Procedure that requires prior approval prior to referral
Application form: - Surgery for painful big toe (hallux valgus/bunions)
GP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐ No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service to enable full consideration of this funding request? / Yes ☐ No ☐
Is this a patient/guardian led application? / Yes ☐ No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐
Routine: Decision needed in 4 to 6 weeks. / ☐
Procedure requires prior approval. Surgery for patients with asymptomatic bunions is not normally funded, regardless of cosmetic appearance.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration.
The policy statements are available at: http://www.fundingrequests.cscsu.nhs.uk/berkshire-east/cosmetic-and-other-surgeries-berkshire-east/.
Clinical Criteria required for consideration of treatment / Please Tick
1. Has this patient been assessed and treated via the local MSK service if available?
Please attach the MSK referral information to the case file. / YES ☐ NO ☐
2. Indicate which foot it is proposed to treat? / Right ☐ Left ☐
3. How long has the patient been managing with the symptoms?
4. Has the patient tried all appropriate conservative management for a minimum of 3 months which have failed?
Please specify which have been tried:
☐ Avoiding high heels shoes
☐ Wearing roomier footwear with soft leather uppers
☐ Use of oral analgesia for pain management
☐ Use of bunion pads or ice packs
☐ Use of customised footwear
☐ Orthoses for appropriate patients
☐ Treatments for ulceration
Please provide details of outcomes or why they were not appropriate: / YES ☐ NO ☐
5. Has the patient been counselled on appropriate conservative management? / YES ☐ NO ☐
6. Does the patient suffer from severe deformity (with or without lesser toe deformity) that causes significant functional impairment?
Please indicate which apply to this patient due to severe deformity:
☐ Work-related issues – Light duties because of the condition
☐ Work-related issues – Off work/missed work/ unable to work due to condition
☐ Domestic activities
☐ Carer activities
Please provide specific details for all those selected above: / YES ☐ NO ☐
7. Does the patient suffer with severe pain that causes significant functional impairment?
Please indicate which apply to this patient due to severe pain:
☐ Work-related issues – Light duties because of the condition
☐ Work-related issues – Off work/missed work/ unable to work due to condition
☐ Domestic activities
☐ Carer activities
☐ Transferred pain to second metatarsal or the ball of the foot
Please provide specific details for all those selected above: / YES ☐ NO ☐
8. Has the patient been appropriately counselled to understand the outcomes of surgery and possible complications? / YES ☐ NO ☐
9. Patient’s Body Mass Index:
BMI / kg/m2
Height / cm
Weight / kg
10. Is the patient a non-smoker? / YES ☐ NO ☐
Please note: The term bunion refers to any enlargement or deformity of the 1st metatarsophalangeal (MTP) joint, including enlarged bursae, overlying ganglion, gouty arthropathy, and hallux valgus, as well as bony masses that can develop secondary arthritis. They often also cause marked lesser toe deformities.
South, Central and West Commissioning Support Unit June 2017 TVPC47 BE