12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
13. Mr L had a vasectomy in September 2023 and then wanted a vasectomy reversal done soon after to alleviate severe testicular pain.
14. The ICB’s Prior Approval Policy says vasectomy is regarded as irreversible, therefore vasectomy reversal is not routinely funded by the ICB. To be considered for vasectomy reversal, a patient needs an IFR.
15. We know NHS England will only provide funding in response to an IFR if it is satisfied that the case meets the following criteria:
• there is evidence that the patient presents with exceptional clinical circumstances • there is a basis for considering that the requested treatment is likely to be clinically effective for this individual patient • it is considered that the requested treatment is likely to be a good use of NHS resources.
16. This is confirmed in the ICB’s Individual Funding Requests Commissioning Policy.
17. In its complaint response, the ICB says both IFR applications did not provide any evidence of exceptional clinical circumstances, so they did not progress to the IFR panel for consideration.
18. Mr L saw a urologist in November 2023, two months after the vasectomy. They said it was too soon to consider a vasectomy reversal. They advised pain control as first step (amitriptyline or gabapentin) and then a referral to the pain management team as a second step. An ultrasound scan showed his testes were normal.
19. Mr L got a second opinion from a second urologist in December 2023. They recommended pregabalin. They felt this would be preferable to the co-codamol and morphine he was taking. If this did not work, a referral to the pain management team or a spermatic cord block could be considered as the next step.
20. Mr L’s GP submitted the first IFR in December 2023. Reasons given for exceptionality were that Mr L had tried alternatives, he was still in ongoing pain, and he could not work due to the pain. The ICB declined it in January 2024. It said there was no evidence of exceptional clinical circumstances and Mr L did not follow the two steps as advised by the urologists (pain control and referral to pain management team). It said pain after a vasectomy is common and rarely lasts longer than a year. It had only been four months since the vasectomy at this point.
21. Our adviser noted that long-term pain could be considered an exceptional clinical circumstance. But it had only lasted for four months at this point. They said the declining of the first IFR was justified as other treatments had not been explored and the period of four months since vasectomy was short.
22. Mr L’s GP submitted the second IFR in May 2024. Reasons given for exceptionality were pain and significant mental health issues. This was only eight months after the vasectomy. The ICB declined it two days later. Again, it said there was no evidence of exceptional clinical circumstances. It said Mr L had not tried the pregabalin that had been prescribed by the second urologist or been seen by the pain management team. He had been referred in April 2024 but was advised there is a six-month waiting list for an appointment.
23. Mr L said in his complaint to us that he did not try the pregabalin because his GP had advised him not to. And Mr L was worried he might get addicted to it. We cannot see evidence the GP made this clear in either IFR.
24. Again, our adviser noted that long-term pain could be considered an exceptional clinical circumstance. But it had still only been eight months since the vasectomy at this point. They said the declining of the second IFR was justified as the period since the vasectomy was still short, the pain referral had not taken place, and other non-surgical treatments had not been exhausted.
25. According to the treatment algorithm for post-vasectomy pain syndrome, other non-surgical treatment options could include a trial of non-steroidal anti-inflammatory drugs, tricyclic antidepressants, acupuncture, pelvic floor physical therapy, scrotal support, radiofrequency ablation (a treatment in which radio waves are sent through a precisely placed needle to heat an area of the nerve) and spinal cord stimulation (a treatment that uses a mild electric current to block nerve impulses in the spine).
26. Our adviser said if pain had been present for over a year and non-invasive treatment options had failed, the IFR could have been supported, in line with the policy. But this had not happened.
27. We can see that Mr L was provided with detailed information prior to the vasectomy in September 2023. This included information on the risk of long-term pain (1 in 10 men). It also stated reversal is rarely available on the NHS.
28. On review, we think the ICB acted correctly, considered all the available information and its decisions are supported by the evidence. This indicates the ICB acted in line with its own policies when it declined the two IFRs.
29. We do not mean to diminish or downplay the pain Mr L was experiencing because we know it was severe. Because the pain had not been long-term (more than a year) at the point of the IFRs and there were still lots of treatment options that Mr L had not explored yet, we cannot say the ICB made a mistake.
30. We understand this is not the outcome that Mr L was hoping for. But we hope he feels reassured by our view that the ICB’s considerations of the IFRs were fair. We hope he feels we have considered his complaint carefully and explained our decision clearly. We wish him well for the future.