Adherence to Evidence Based Medicine Programme Evidence Summary Pack (Version 2) Vasectomy Local commissioners working with local people for a healthier future

About the AEBM Programme Enfield Clinical Commissioning Group, along with our North Central London colleagues, wants to the secure the greatest health impact it can with its resources by adhering as closely as possible to the clinical evidence base available. There is considerable national and international evidence that many procedures offered routinely by the NHS are of limited clinical benefit to patients in some or all circumstances. Therefore there needs to be careful consideration as to whether or not a procedure is going to be of any benefit to an individual patient before deciding to undertake it. To do this we must use the best and most up to date clinical advice and evidence to ensure we have the best chance of delivering a benefit to each individual patient who is put forward for treatment. This  evidence published by the National Institute for Health & Care Excellence(NICE) as well as available evidence published by the Royal Colleges and other Clinical Commissioning Groups. This will also ensure the best value from the services we commission. To ensure this decision making process is applied consistently, Enfield Clinical Commissioning Group along with the other Clinical Commissioning Groups in North Central London, adopted a common policy concerning these procedures that have limited clinical effectiveness in 2012 based on the best available evidence at that time. As the clinical evidence base moves on we are now undertaking a further review to ensure that we are using the best and latest clinical evidence in our decision making. We are also looking at the range of procedures where the evidence base now suggests we need to make changes to the guidance for individual patient situations to avoid the risk of undertaking procedures that have little or no benefit to patients or even where the undertaking of the procedure could result in a risk of harm. Clinical Leaders at the Clinical Commissioning Group with the full support of the Governing Body are leading this review. Enfield Clinical Commissioning Group will engage widely and consult formally on the proposals which emerge, while continuing to work closely with partner Clinical Commissioning Groups in North Central London.

About the Evidence Pack This evidence pack summarises the evidence that the Clinicians working on the AEBM Programme have reviewed prior to the commencement of the consultation process. Due to the nature of many of the documents reviewed it is not possible to repeat the evidence in its entirety. The first version of these Evidence Packs only contained highlights of the information and clinical evidence reviewed and based on feedback from our public this was seen as an oversight and therefore a more comprehensive summary is now being provided. These packs will be made available along with the underpinning documents that were used. The purpose of the Consultation is to enable clinicians, patients, our public and other stakeholders to contribute to the debate including identifying additional evidence that may have been missed by the clinicians working on the programme during the pre-consultation phase. The views of all participants in the consultation along with any additional evidence that comes to light during the consultation programme will be taken through further clinical review at the end of the consultation programme. We would like to thank all who have contributed during the extensive pre-consultation phase (that lasted from September 16 through to March 17) and all who are now taking the time to contribute during the formal consultation phase.

About the Approach Taken In preparing these Evidence Packs we undertook an extensive review of available clinical data and evidence and looked in detail at the evidence used (or at least reviewed) by other Clinical Commissioning Groups during similar exercises. The span of this work included (but was not limited to) the following: NICE BMA Royal Colleges All London CCGs CCGs outside of London including Cambridge, Berkshire, North Staffordshire and many others Guidance documents available from relevant stakeholder websites We then collated the evidence including eligibility criteria that CCGs had reviewed (although it is noted not all may have gone on to implement the changes) and then added in local data such as activity and spend, trend analysis and benchmarking. This collated data and evidence was then reviewed by a wide range of clinicians including secondary care representatives before being summarised into these Evidence Packs for use during the consultation. The purpose of these Evidence Packs is to provide a summary of the extensive clinical review that was undertaken prior to the commencement of the Consultation Period but we recognise that further evidence might come to light during the consultation process and this is the reason for undertaking the consultation before any decisions are made to ensure we have used all of the available evidence in our final decision making processes.

Enfield CCG Evidence Summary NICE Guidance: No related guidance Guidance taken from: Royal College of Obstetricians & Gynaecologists (RCOG). Male and female sterilisation. Evidence-based Clinical Guideline No 4. London: RCOG Press; 2004. Except when technical considerations dictate otherwise, a no-scalpel approach should be used to identify the vas, as this results in a lower rate of early complications. Division of the vas on its own is not an acceptable technique because of its failure rate. It should be accompanied by fascial interposition or diathermy. Clips should not be used for occluding the vas, as failure rates are unacceptably high. Vasectomy should be performed under local anaesthetic wherever possible. Most men will tolerate vasectomy under local anaesthesia. As local anaesthesia is both safer and less expensive than general anaesthesia, vasectomy should be performed under local anaesthesia wherever possible. Recovery from local anaesthesia is quick and anaesthetic complications are rare. There are no controlled studies comparing vasectomy under general anaesthesia with local anaesthesia, although a retrospective questionnaire survey of 115 men suggested that postoperative pain was higher after general anaesthesia. This may be because the more difficult cases were performed under general anaesthesia. The number of days to full recovery was the same in both groups. There are contraindications to vasectomy under local anaesthesia. A general anaesthetic is necessary if there is: • a history of an allergy to local anaesthetic • a history of fainting easily • patient refusal of local anaesthesia. Vasectomy should be delayed when the following conditions are present: • Scrotal skin infection, active sexually transmitted disease, balanitis, epididymitis or orchitis; there is an increased risk of postoperative infection, systemic infection or gastroenteritis; there is an increased risk of postoperative infection, intrascrotal mass; this may indicate underlying disease. Caution is needed when the following conditions are present and specialist referral may be necessary: • previous scrotal injury • large varicocele or large hydrocele; the vas may be difficult or impossible to locate. Specialist referral with availability of general anaesthesia may be necessary with the following conditions: • cryptorchidism, inguinal hernia, coagulation disorders.

Enfield CCG Evidence Summary NICE Guidance: No related guidance Guidance taken from: Royal College of Obstetricians & Gynaecologists (RCOG). Male and female sterilisation. Evidence-based Clinical Guideline No 4. London: RCOG Press; 2004. Except when technical considerations dictate otherwise, a no-scalpel approach should be used to identify the vas, as this results in a lower rate of early complications. Division of the vas on its own is not an acceptable technique because of its failure rate. It should be accompanied by fascial interposition or diathermy. Clips should not be used for occluding the vas, as failure rates are unacceptably high. Vasectomy should be performed under local anaesthetic wherever possible. Most men will tolerate vasectomy under local anaesthesia. As local anaesthesia is both safer and less expensive than general anaesthesia, vasectomy should be performed under local anaesthesia wherever possible. Recovery from local anaesthesia is quick and anaesthetic complications are rare. There are no controlled studies comparing vasectomy under general anaesthesia with local anaesthesia, although a retrospective questionnaire survey of 115 men suggested that postoperative pain was higher after general anaesthesia. This may be because the more difficult cases were performed under general anaesthesia. The number of days to full recovery was the same in both groups. There are contraindications to vasectomy under local anaesthesia. A general anaesthetic is necessary if there is: • a history of an allergy to local anaesthetic • a history of fainting easily • patient refusal of local anaesthesia. Vasectomy should be delayed when the following conditions are present: • Scrotal skin infection, active sexually transmitted disease, balanitis, epididymitis or orchitis; there is an increased risk of postoperative infection, systemic infection or gastroenteritis; there is an increased risk of postoperative infection, intrascrotal mass; this may indicate underlying disease. Caution is needed when the following conditions are present and specialist referral may be necessary: • previous scrotal injury • large varicocele or large hydrocele; the vas may be difficult or impossible to locate. Specialist referral with availability of general anaesthesia may be necessary with the following conditions: • cryptorchidism, inguinal hernia, coagulation disorders.

Enfield CCG Criteria Summary NCL CCG ORGANISATION CRITERIA AVAILALE NOTES Enfield CCG N Barnet CCG Haringey CCG Islington CCG Camden CCG NCL CCG ORGANISATION CRITERIA AVAILABLE NOTES Harrogate and Rural District CCG Y It should be noted that whilst a criteria or evidence exists on the Website of a CCG we may or may not have had the opportunity to confirm whether the policy, proposed threshold or evidence has been enacted or remains in place once enacted. We are simply identifying other CCGs who have undertaken a similar exercise to add their evidence to our own. This caused some confusion with the first version of these Evidence Packs. Scarborough and Ryedale CCG Kent and Medway CCG Vale of York

Spend & Activity Data including Trend Analysis and Benchmarking Local commissioners working with local people for a healthier future

Enfield CCG Activity & Spend Data 26 Cost 2015/16 £19,189

Enfield CCG Activity & Spend Trend Analysis

Enfield CCG Benchmarking Data Spend Standardised Per 1,000 Population   Enfield CCG NCL CCGs BHR CCGs WELC CCGs Vasectomy - Male Sterilisation £18.5 £11.2 £22.2 £25.7

For Further Information contact communications@enfieldccg.nhs.uk or call 0203 688 2814