GP Guidance on Referral Thresholds for Low Priority Procedures. December 2009

Transcription

1 GP Guidance on Referral Thresholds for Low Priority Procedures December Introduction 2. Hip pain from osteoarthritis total hip replacement 3. Assessment of Pain, Functional Limitations 4. Knee pain from osteoarthritis total knee replacement 5. Pain Functional Limitations 6. Hand surgery for carpal tunnel syndrome, Dupuytren s contracture, trigger finger and ganglions 7. Foot surgery for bunions 8. ENT surgery grommets, adenoidectomy, tonsillectomy 9. Hysterectomy for heavy menstrual bleeding 10. Minor surgery skin excisions 11. Varicose vein surgery 12. Circumcision 13. All cosmetic surgery 14. Cataract surgery 15. Inguinal hernia repair 16. Epidural and facet joint injections for chronic back pain Appendix 1 Letter for patients where a GP does not refer Appendix 2 Letter for patients where a GP is referring

2 1. Introduction This document summarises the guidelines for GPs where assessing patients for some low priority procedures. All of these procedures are subject to Low Priority Guidelines from the Bedfordshire and Hertfordshire Priorities Forum. The full guidelines can be found at The PCT is asking all GPs to establish first their patient meets the criteria in these guidelines before they can refer to out patients. 1

3 2. Guidance for Primary Care- Hip Pain The initial non-surgical management of hip pain due to osteoarthitis should be provided by a package of care which may include weight reduction, adequate doses of Paracetomol and Paracetomol/weak opoioid combination or nonsteroidal anti-inflammatory drugs (NSAIDs) changing activity, exercise, introducing walking aids, other forms of physical therapies and other therapies such as acupuncture (within the context of a package of care). Referral should usually only be considered when other pre-existing medical conditions have been optimised, and there has been evidence of weight reduction to an appropriate weight. Patients who are overweight (BMI ) or obese (BMI >30) should be encouraged and supported to reduce their BMI below 25. Referral criteria for immediate or urgent referral to orthopaedics services should be based on NICE referral guidance NICE recommendations state that the threshold for immediate referral to orthopaedic services is when there is evidence of infection in the joint. Symptoms that are suggestive of a rapid deterioration in the joint or persistent symptoms which are causing severe disability necessitate urgent referral to orthopaedic services. Referral criteria for routine referral to orthopaedic services Candidates for elective THR should have; - Moderate-to-severe persistent pain not adequately relieved by an extended course of non-surgical management - AND Clinically significant functional limitation resulting in diminished quality of life - AND Radiographic evidence of joint damage 2

4 3. Assessment of Pain, Functional Limitations Variable Definition Pain level - Mild Pain interferes minimally on an intermittent basis with usual daily activities Not related to rest or sleep Pain controlled by one or more of the following; NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol - Moderate Pain occurs daily with movement and interferes with usual daily activities. Vigorous activities cannot be performed Not related to rest or sleep Pain controlled by one or more of the following; NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol - Severe Pain is constant and interferes with most activities of daily living Pain at rest or interferes with sleep Pain not controlled, even by narcotic analgesics Previous non-surgical treatments (should be offered before surgery considered) -Correctly Done -Incorrectly Done NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses during 6 months with no pain relief; weight control treatment if overweight, physical therapies done NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses or less than 6 months with no pain relief; or no weight control treatment if overweight, or no physical therapies done Functional Limitations - Minor Functional capacity adequate to conduct normal activities and self care Walking capacity of more than one hour No aids needed - Moderate Functional capacity adequate to perform only a few or none of the normal activities and self care Walking capacity of about one half hour Aids such as a cane are needed - Severe Largely or wholly incapacitated Walking capacity of less than half hour or unable to walk or bedridden Aids such as a cane, a walker or a wheelchair are required 3

5 4. Guidance for Primary Care Knee Pain The initial non-surgical management of knee pain due to osteoarthitis should be provided by a package of care which may include weight reduction, activity modification, patient specific exercise programme, adequate doses of Paracetomol, Paracetomol/weak opiod combinations or non-steroidal antiinflammatory drugs (NSAIDs) and exercise, joint injection, walking aids (contralateral hand), other forms of physical therapies and other therapies such as chondroitin or acupuncture (within a package of care). Referral should usually only be considered when other pre-existing medical conditions have been optimised, and there has been evidence of weight reduction to an appropriate weight. Patients who are overweight (BMI ) or obese (BMI >30) should be encouraged and supported to reduce their BMI below 25. Referral criteria for immediate or urgent referral to orthopaedics services should be based on NICE referral guidance 1 NICE recommendations state that the threshold for immediate referral to orthopaedic services is when there is evidence of infection in the knee joint. Symptoms that are suggestive of a rapid deterioration in the joint or persistent symptoms which are causing severe disability necessitate urgent referral to orthopaedic services. Referral criteria for routine referral to orthopaedic services Candidates for elective TKR should have; - Moderate-to-severe persistent pain not adequately relieved by an extended course of non-surgical management - AND Clinically significant functional limitation resulting in diminished quality of life - AND Radiographic evidence of joint damage 4

6 5. Pain, Functional Limitations Variable Definition Mobility and Stability - Preserved Preserved mobility is equivalent to minimum range of mobility and movement from 0 o to 90 o stable joint Stable or not lax is equivalent to an absence of slackness of - Limited mobility and/ or stable joint more than 5mm in the extended joint Limited mobility is equivalent to a range of movement less than 0 o to 90 o unstable or lax is equivalent to the prescene of slackness of more than 5mm in the extended joint Symptomatology - Slight Sporadic pain Pain when climbing/ descending stairs Allows daily activities to be carried out (those requiring great physical activity may be limited) Medication; aspirin,paracetamol or NSAID to control pain with no side effects - Moderate Occasional pain Pain when walking on level surfaces ( half an hour, or standing) Some limitation of daily activities Medication; aspirin,paracetamol or NSAID to control pain with no/ few side effects - Intense Pain of almost continuous nature Pain when walking short distances on level surfaces or standing for less than half an hour Daily activities significantly limited Continuous use of NSAIDs for treatment to take effect Requires the sporadic use of support systems (walking stick, crutches) - Severe Continuous pain Pain when resting Daily activities significantly limited constantly Continuous use of analgesics narcotics/ NSAIDs with adverse effects or no response Requires more constant use of support systems (walking stick, crutches) Radiology - Slight Ahlback grade I - Moderate Ahlback grade II and III - Severe Ahlback grade IV and V Localisation - Unicompartmental Excluded patello-femoral isolated - Bicompartmental Unicompartmental plus patello-femoral - Disease affecting all three compartments of the knee Tricompartmental 5

7 6. Guidance for Primary Care Hand Surgery Carpal Tunnel Syndrome The initial management of carpal tunnel syndrome should be non-surgical: injections and splints. Nerve conduction studies are routinely unnecessary. Referral for consideration of surgical treatment should be considered only if the patient has: Severe symptoms uncontrolled by conservative measures - particularly in pregnancy; or Mild to moderate symptoms that have not responded to 4 months of conservative management in primary or secondary care (injection and splints); or Neurological deficit, i.e. sensory blunting or weakness of thenar abduction. Palmar Fasciectomy for Dupuytren's Contracture Simple nodules in the palm are not an indication for referral. Referral letters should indicate the degree of functional impairment and loss of extension. Surgical treatment will only be considered if: The loss of extension results in significant functional disability interfereing with activities of daily living for the patient And one of the following: Patient has loss of extension in one or more joints exceeding 25 degrees; or Patient has at least 10 degree loss of extension in 2 or more joints; or Finger tips cannot comfortably be pushed to within 2.5cm of the table when the back of the hand is placed on the examination table. It should be noted that fixed flexion of the metacarpo-phalangeal joints is usually correctable whatever the degree of fixed flexion, but fixed flexion of the interphalangeal joints is often difficult to correct. Trigger Finger Surgical treatment will only be considered if the patient has: Failed to respond to conservative measures (e.g. up to 2 hydrocortisone injections); or Fixed deformity Ganglions Surgery for ganglia offers limited benefit, and the majority of ganglia cause cosmetic problems only. Referral for surgery should be considered only where: There is diagnostic uncertainty Functional impairment due to the lesion (such as pain, interference with mobility or dressing); or Significant psychological distress, perhaps due to the location and the size of the lesion 6

8 7. Guidance for Primary Care Bunion Surgery Hallux valgus, also known as bunions, can result in pain with limitation of function and mobility, mainly due to pressure from shoes over the medial prominence of the metatarsal head. While conservative management such as orthoses may not always improve the longterm outcome, surgical intervention can give significant improvements in patient symptoms and clinical parameters, but is not without risks. Patients presenting with hallux valgus should be evaluated according to symptomatology: Mild: Occasional pain not interfering with walking or other activities of daily living (ADL). Symptoms controllable with analgesia and conservative management Moderate: Frequent pain, eg on walking, limiting exercise. Interferes with other ADLs. Some relief with analgesia and conservative management Severe: Very painful on minimal activity eg walking less than half an hour. Unable to exercise or unable to carry out other ADLs. Poorly controlled by analgesia and conservative management Patients with mild to moderate symptoms should be advised to try the following conservative measures: Wide fitting footwear Over the counter conservative treatments eg padding/toe separators OTC analgesia If no improvement, consider Referral to chiropody for further advice It is appropriate to refer for consideration of surgery if: Angle of deviation greater than 15 o ; or Severe pain and impairment of function; or Moderate pain and impairment of function and no relief using above basic conservative measures; or The patient is diabetic The patient has neuropathy affecting the feet Patients should not be referred to surgery for cosmetic reasons without symptoms. 7

9 8. Guidance for Primary Care - ENT Surgery Grommets and / or Adenoidectomy In the majority of children individual episodes of acute otitis media will resolve spontaneously. Referral for an ENT opinion should take into account concerns raised by the child s parent, school or health visitor. Referral for an ENT opinion is advised if: They have hearing loss suggestive of sensori-neural deafness (urgent referral); If there is reasonable suspicion of hearing loss plus delays in speech or language, poor educational progress, social or behavioral problems or other disability such as Downs Syndrome or cleft palate (should be seen soon); The child has persistent hearing loss detected on two occasions separated by 3 months or more; NICE guidelines suggest a threshold of 25 dbhl or worse in the better hearing ear. Frequent episodes of acute otitis media (6 over the previous 12 months); The otoscopic features are atypical and accompanied by a foul smelling discharge lasting for more than 6 weeks suggestive of cholesteatoma (urgent referral). Tonsillectomy Referral for consideration for tonsillectomy should be considered for: Patients with 5 or more episodes of acute sore throat (which are likely to be tonsillitis) in the preceding 12 months documented by parent or doctor, and which have been severe enough to disrupt normal behaviour or day-to-day activity, should be referred to specialist services (if symptoms have arisen over less than 12 months, then a 6 months period of watchful waiting is advised); or Patients who have had a least one episode of quinsy. The patient or parent should be made aware that spontaneous improvement may occur, particularly if the symptoms have arisen over a relatively short period of time. 8

10 9. MANAGEMENT OF HEAVY MENSTRUAL BLEEDING IN PRIMARY CARE INITIAL ASSESSMENT History A history of heavy menstrual bleeding over several cycles should be obtained Impact on quality of life should be assessed Symptoms suggestive of other pathology should be sought including o Intermenstrual or post-coital bleeding, pelvic pain or pressure symptoms, dyspareunia, sudden change in blood loss o Risk factors for endometrial cancer: tamoxifen, unopposed oestrogen treatments, polycystic ovary syndrome, obesity Examination Abdominal and pelvic examination should be performed Speculum examination of cervix and vulva should be performed if indicated Initial investigations Full blood count Thyroid function tests only if symptoms/signs of hypothyroidism Consider endometrial biopsy for persistent intermenstrual bleeding and in patients over 45, after treatment failure or ineffective treatment If the uterus is palpable or there is a pelvic mass, consider imaging. Ultrasound should be considered the first line diagnostic tool for the identification of structural pathology in heavy menstrual bleeding and available on a direct access basis to GP s. NICE CG27 any woman with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin should have an urgent ultrasound scan. If the scan is suggestive of cancer, or if ultrasound is not available, an urgent referral should be made Suspected malignancy Fibroids > 3 cm or multiple fibroids causing distortion of uterine cavity Fibroids < 3cm with no distortion of uterine cavity No structural or histological abnormality suspected PHARMACEUTICAL TREATMENT 1 st line Levenogesterol-releasing intra-uterine system (Mirena ). Trial of at least 6 cycles 2 nd line Tranexamic acid: 1g TDS or QDS from onset of menstruation for up to 4 days. Trial of 3 cycles NSAID s. From 2-3 days before menstruation until heavy bleeding stops. Trial of 3 cycles Combined oral contraceptive. Trial of 3 cycles 3 rd line Norethisterone. 15mg PO days 5-26 of cycle Injected progestogen. Intramuscular injection every 12 weeks or subdermal implant Treatment should be discussed as per NICE guidance Clinicians should bear in mind BHPF minimum criteria for surgical invention (page 2) 1 st, 2 nd and 3 rd line pharmaceutical treatments failed, declined or contra-indicated Consider ultrasound if not already done URGENT referral to Gynaecology Routine referral to Gynaecology Prior management should be clearly documented in referral 9

11 10. Assessment and Management of Patients in Primary Care with Skin Lesions Background This is written to help clinicians in primary care make the most appropriate decision regarding the care of patients who may benefit from minor surgery (skin excision). Good practice in this area is informed by national and local guidance Does this patient have the type of lesion I can treat under GMS additional services? If you think the patient has a seborrhoeic keratosis, solar keratosis skin tags / wart / verucca or some popillomas (not an exhaustive list) and you have tried conservative therapy whenever appropriate you may want to then consider treating the patient in your practice using cryotherapy or cautery or curettage Does this patient have a lesion which may be a skin cancer? National guidelines state that if the patient has a lesion suspected of being skin cancer, the patient should be seen by an appropriate specialist before treatment. Please do not excise skin lesions in primary care which you believe may be malignant. The exception to this is if the lesion is a low risk BCC and you are accredited as a GP with a special interest (GPwSI) associated with a named hospital skin cancer MDT Does the patient have a non malignant skin lesion which gets infected or causes physical irritation / interference with normal functioning? Types of lesion which come into this category include skin tags, epidermoid (sebaceous) cysts and lipomas. Assuming conservative treatment where appropriate has failed you may wish to treat the patient under GMS (e.g. cautery of skin tags) or by excision of the lesion under the Minor Surgery Directed Enhanced Service Does the patient have a lesion which they want to have removed for cosmetic reasons? We are not able to offer removal of skin lesions for cosmetic reasons under the NHS and if appropriate you could consider referring the patient privately for excision of the skin lesion. If there was a compelling clinician reason to remove the lesion under the NHS (e.g. documented significant psychological distress) the case should be referred for consideration by the PCT individual funding request panel. 10

12 11. Guidance for Primary Care Varicose Vein Surgery Treatment for varicose veins may improve quality of life. Studies indicate that this improvement is more likely to be short-term rather than long-term. Longitudinal studies have not yet been able to assess long-term benefits. After surgery, 20-30% of patients develop recurrent varicose veins within 10 years. For many, treatment for varicose veins will be for purely cosmetic reasons. However, untreated, some varicose veins may bleed, thrombose or progress to skin changes and venous ulceration. However, there is a chance of complications associated with, either during or following, surgical interventions. Unfortunately, there is no way of predicting which limbs with varicose veins will subsequently develop venous ulceration, and it would not be clinically appropriate to operate on the 30% of the population with varicose veins in order to prevent 1% developing an ulcer. There is little evidence on the cost effectiveness of surgery and sclero-therapy compared to other elective surgical procedures. Referral to a specialist service is advised only for patients suffering from one or more of the following: bleeding from a varicosity that has eroded the skin if they have bled from a varicosity and are at risk of bleeding again if they have an ulcer which is progressive and/or painful despite treatment. if they have an active or healed ulcer and/or progressive skin changes Including varicose eczema, lipodermatosclerosis, moderate to severe oedema that may benefit from surgery, or in the opinion of the clinician is at high risk of significant future complications: recurrent superficial thrombophlebitis 11

13 12. Guidance for Primary Care Circumcision Circumcision is a surgical procedure that involves partial or complete removal of the foreskin (prepuce) of the penis. Circumcision should only be funded by the NHS for medical reasons, and not for religious or social reasons. Medical indications for referral for specialist surgical assessment for circumcision are: phimosis in children with spraying, ballooning and/ or recurrent infection; adult phimosis; recurrent balanitis; balantitis xertotica obliterans; paraphimosis; suspicion or evidence of malignancy; dermatological disease (such as lichen planus or eczema) which is unresponsive to other treatment; where biopsy is required; occasionally for selected patients with urinary tract infections (normally referred by a paediatrician). 12

14 13. Guidance for Primary Care Cosmetic Surgery Prior funding approval should be sought for all cosmetic treatments and surgery. Conditions resulting from trauma, burns or problems resulting from medical treatment which need plastic surgery will usually be funded buy the NHS. Treatments and surgery that are judged to be cosmetic will not normally be funded. The Bedfordshire and Hertfordshire Priorities Forum Guidance No.1 gives specific guidance for the following procedures: Abdominoplasty / Apronectomy Laser removal of abnormally placed hair Bat / prominent ears Benign skin lesion Botulinum toxin Blepharoplasty Breast Augmentation Breast Reduction Revisions of mammoplasty Gender dysphoria Hair Loss Male breast reduction Inverted Nipples Congenital vascular abnormalities (e.g. congenital naevi and port wine stains). Repair external earlobes Face lift or browlift (rhtidectomy). Labioplasty Liposuction Male pattern baldness Mandibular or maxillary osteotomy Removal of redundant fat or skin Rhinoplasty Scar revision Skin resurfacing or dermabrasion Tattoo removal. Thread veins or telangiectasias Forms for the IFR panel can be obtained from the IFR team: Individual Funding Requests Team Tel: Hertfordshire PCTs Fax: (safe haven) Charter House Welwyn Garden City enh-pct.ifr@nhs.net Herts AL8 6JL Please the completed form to enh-pct.ifr@nhs.net attach electronic copies of any correspondence or reports you believe to be of relevance alternatively the form can be faxed to

15 14. Guidance for Primary Care Cataract Surgery Referrals to the ophthalmologists should be based on reduced visual acuity, plus impairment of lifestyle plus willingness to have surgery. Referral of patients with cataracts to ophthalmologists should therefore be based upon the three following indications: 1. Reduced visual acuity documented to be at least 6/9 or worse in the affected eye (corrected) 2. AND impairment of lifestyle such as; the patient is at significant risk of falls OR the patient s vision is affecting their ability to drive OR the patient s vision is substantially affecting their ability to work OR the patient s vision is substantially affecting their ability to undertake leisure activities such as reading, watching television or recognising facies 3. AND willingness to have cataract surgery: The referring optometrist or GP has discussed the risks and benefits and ensured the patient understands and is willing to undergo surgery before referring Exceptional cases that do not meet the above criteria can be considered at the PCT individual case panel, e.g. those with significant functional disability from cataract but no visual acuity loss. 14

16 15. Guidance for Primary Care Inguinal Hernia Surgery Not all symptomatic or minimally symptomatic hernias will progress to a state that will require surgical intervention; clinicians should consider offering watchful waiting as a treatment option. In a few cases the risk of surgery may outweigh the benefit, and this should be discussed with the patient. Patients who smoke should be encouraged to stop smoking at least 8 weeks before surgery to reduce the risk of surgery, the risk of complications and chances of recurrence of the hernia. Where surgical intervention is required, open inguinal hernia repair should be the preferred option. Open hernia repair should be undertaken as a day case where it is clinically appropriate to do so (i.e. in uncomplicated primary hernias). 15

17 16. Guidance for Primary Care on Referral for Pain Management of Low Back Pain with Facet Injections or Elective Epidural Injection. Low back pain can be divided into those with a specific cause (e.g. fracture, infection, trauma), or nerve root compression lasting longer than 4-6 weeks or causing progressive neurological symptoms or neurological claudication) and those with no pathophysiological cause found (nonspecific/mechanical back pain). This guidance applies to those patients with non-specific back pain and the recommendations below do not apply to patients with neurological claudication or progressive neurological symptoms. Facet joint, trigger point and sclerosant injections have not been shown to be effective long term. However facet joint injections have been shown to be effective for short to mid-term relief in a subset of patients with facet joint disease and very poor mobility. In these patients, relief from injections can provide sufficient time to initiate a multi disciplinary pain management programme and rehabilitation. Patients likely to benefit from injections in this context must fulfill the following criteria: - Pain is not directly central - Pain radiating to legs but not below knee - Pain may be unilateral or bilateral - Pain is aggravated by extension of the back Facet joint injections should only be considered as part of a multidisciplinary treatment in this specific subset of patients and can only be provided as part of the outpatient tariff. Due to lack of evidence for long term relief it cannot be otherwise routinely recommended. Epidural injection Based on the current state of the literature there is insufficient evidence to support or refute the use of injection therapy, regardless of type and dosage, for patients with sub acute and chronic low back pain without radicular pain. 1. The main approach for back pain is the current, widely supported active approach directed at reassurance and self management. 2. Bedfordshire & Hertfordshire Priorities Forum would not routinely fund the use of epidurals expect in exceptional circumstances 3. Such patients with exceptional circumstances may include patients with severe radicular pain where all other appropriate treatment has been shown to be ineffective 4. For those patients who are exception, a prior approval must be sought from the PCTs using the Individual funding request (IFR) route 16

18 Appendix 1 Charter House Parkway Welwyn Garden City Hertfordshire AL8 6JL Tel: Fax: Dear Patient, You have been given this letter by your GP because they have advised you that at the moment you do not need referral to hospital for an outpatient assessment. There is guidance that doctors use to help them decide at what point particular treatments are of most help to patients. In recommending when procedures should be carried out, the guidance also considers the cost of the procedures and weighs this up against how effective the treatment is likely to be. All the guidance is based on evidence from scientific studies into the effectiveness of treatment. NHS Hertfordshire (Primary Care Trust) is responsible for planning and funding healthcare services. To help with this, we have local guidance for a range of treatments. All of our local guidance can be found on the internet at The condition that you have consulted your GP about is included in this list. Recently, we have asked your GP to help us to use our guidelines to target resources at those treatments that can make the most difference to patients. Please do feel free to talk to your doctor about this. You may also want to speak to someone in the PCT about your particular case and get some more information about this new way of doing things. If so, please contact our PALS team who will be happy to talk to you. You can contact them on by phoning or or by ing the team at: pals@hertspcts.nhs.uk. Kind regards Jane Halpin Deputy Chief Executive & Dr Mike Edwards PEC Chair 17

19 Director of Public Health NHS West Hertfordshire Dr Tony Kostick PEC Chair NHS East & North Hertfordshire 18

20 Appendix 2 Charter House Parkway Welwyn Garden City Hertfordshire AL8 6JL Tel: Fax: Dear Patient, You have been given this letter by your GP because they are referring you to outpatients to be assessed for a particular operation or procedure. There is guidance that doctors use to help them decide at what point particular treatments are of most help to patients. In recommending when procedures should be carried out, the guidance also considers the cost of the procedures and weighs this up against how effective the treatment is likely to be. All the guidance is based on evidence from scientific studies into the effectiveness of treatment. NHS Hertfordshire (Primary Care Trust) is responsible for planning and funding healthcare services. To help with this, we have local guidance for a range of treatments. All of our local guidance can be found on the internet at Recently, we have changed the way we check that that existing guidance on effective treatments is being used. We are doing this to make sure that we target resources at those treatments that can make the most difference to patients. Once you have been assessed in outpatients, if your hospital doctor thinks you might need one of a number of operations or procedures covered by guidance, they will apply on your behalf for approval. This application is considered by our medical staff and checked against the guidance. On some occasions the procedure proposed is not approved by the PCT. This is because, based on the information provided by the consultant, these 19

21 guidelines do not recommend the procedure be carried out. Alternatively, it could be that not enough information is provided by the consultant. We are writing to you at this stage to let you know that this process is currently in place and may be applied to your case. Your consultant should discuss with you any specifics that are relevant to you at the time you are seen. Please do feel free to talk to your doctor about this. You may also want to speak to someone in the PCT about your particular case and get some more information about this new way of doing things. If so, please contact our PALS team who will be happy to talk to you. You can contact them on by phoning or or by ing the team at: Kind regards Jane Halpin Deputy Chief Executive & Director of Public Health Dr Mike Edwards PEC Chair & GP NHS West Hertfordshire Dr Tony Kostick PEC Chair & GP NHS East & North Hertfordshire 20