Threshold

Norfolk and Waveney CCG will fund patients for referral to secondary care if they meet at least one of the following criteria:

a) Ulceration secondary to venous stasis.

b) Bleeding varicose vein or if the patient is at high risk of re-bleeding. (i.e. there has been more than one episode of minor haemorrhage or one episode of significant haemorrhage from a ruptured superficial varicosity.)

c) Significant and/or progressive lower limb skin changes such as varicose eczema, or lipodermatosclerosis with moderate to severe oedema proven to be caused by chronic venous insufficiency (itching is insufficient for referral).

d) High risk significant superficial vein thrombosis  (previously known as superficial thrombophlebitis), with a hard, painful, red vein affecting the saphenous vein (great or small saphenous) or above the knee (these patients should be referred to the appropriate service that deals with thrombosis).

e) If the patient is severely symptomatic (not covered by the above criteria) and this is affecting activities of daily living and/or instrumental activities of daily living*. - ALL below must apply:

• Symptoms must be caused by varicosity and cannot be attributed to any other comorbidities or other disease affecting the lower limb.
• There must be a documented unsuccessful six-month trial of conservative management**
• BMI <30 or documented evidence of attempts to lose weight for at least 1 year in line with NICE obesity guidance
• Evidence that symptoms are affecting activities of daily living and or Instrumental activities of daily living.
• In the opinion of a vascular specialist, these symptoms can be reversed or significantly improved with treatment.

* Activities of daily living include: functional mobility, eating, bathing and personal care. They can be measured using the Barthel activities of daily living index, Instrumental activities of daily living include more complex tasks such as care of others, community, mobility, health management and meal preparation. ** Conservative management should include advice on walking and exercise, avoidance of activities that exacerbate symptoms, leg elevation whenever sitting.

Cases for Individual Consideration

On a case to case basis, patients might be eligible for intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.