Over a four week period between mid-July and mid-August 2017, Bristol, North Somerset and South Gloucestershire CCGs consulted on a proposal to set out criteria that will mean that patients diagnosed with obstructive sleep apnoea (OSA) are provided with a continuous positive airway pressure (CPAP) device only where appropriate and where alternative treatments have failed.
Following the consultation exercise, the combined Governing Body of Bristol, North Somerset and South Gloucestershire CCGs approved the new policy in September 2017 and it took effect in mid-October 2017.
As part of our consultation principles, we report back on what you said to us about the proposals and what our response was. A summary of this can be found in the ‘You Said, We Did’ report below.
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This report summarises feedback we received during our consultation on proposed changes to the sleep apnoea commissioning policy for Bristol, North Somerset and South Gloucestershire and what we have done as a result.
About the proposal
Bristol, North Somerset and South Gloucestershire CCGs propose to set out access criteria for provision of Continuous Positive Air Pressure (CPAP) machines for patients diagnosed with obstructive sleep apnoea.
Sleep apnoea is a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing leading to regularly interrupted sleep. A CPAP device prevents a patient’s airway closing while they sleep by delivering a continuous supply of compressed air through a mask. Without treatment of the underlying causes of sleep apnoea, treatment with a CPAP device can be life-long.
This proposal is in line with National Institute for Clinical Excellence (NICE) guidance issued in March 2008, outlining a range of management options for treating sleep apnoea, including CPAP machines.
Under this proposal, patients with moderate or severe sleep apnoea will, in the first instance, be supported to try all possible clinically effective management options prior to being issued with a Continuous Positive Airway Pressure (CPAP) device. Patients with mild conditions may receive a device under exceptional circumstances. Patients will be given one device only as they are portable.
There are a number of ways to successfully treat patients with sleep apnoea before the use of CPAP:
- Weight loss to reduce the patient’s BMI (Thomasouli, 2013)
- Avoidance of alcohol, particularly within 6 hours of bedtime (NICE, 2008)
- Stopping smoking (Boldova A., Sep 2014)
- Dental devices to keep the airway clear by moving the jaw forward. These devices are not prescribed on the NHS (Sharples L.D., 2016)
- Avoidance of sedative medicines (NICE, 2008)
- Advising patients on appropriate levels of sleep overnight. Generally adults should have between 7 and 9 hours of quality sleep per day.
The 2008 NICE guidance estimated that 91 new patients a year would be diagnosed and treated with CPAP in Bristol, North Somerset and South Gloucestershire. In 2016/17, 1250 new CPAP machines were issued at a cost of £1 million. This is more than ten times the NICE estimated cost and activity levels.
The new policy proposes that patients will be able to access CPAP treatment where appropriate, but there should be greater emphasis on other management options earlier in their treatment. Patients will be assessed by secondary care clinicians and if they do not meet the criteria within the policy, the consultant may seek funding from the Individual Funding Request Panel where there are exceptional circumstances.
Criteria Based Access [CBA] – Where a CCG has published a policy setting out eligibility criteria. If clinicians are content that the patient meets the criteria, they may proceed to treat without seeking funding approval.
Prior Approval [PA] – Where a CCG has published a policy setting out eligibility criteria. Clinicians, where they feel patients meet the criteria, must seek funding approval from the commissioners prior to treating.
Individual Fund Request [IFR] – Where a CCG has published a policy stating that certain treatments are not routinely funded. Treatment will only be funded via agreement from commissioners in exceptional circumstances
Clinical pathway – A systematic way of treating and managing diseases in the NHS. A clinical pathway outlines the way a patient should be cared for through the NHS system from first presentation, followed by testing and diagnosis and through to completion of treatment.