Between January and March 2025 we are updating the branding and templates of our clinical policies and associated referral proformas. This is cosmetic only and therefore the content remains the same. The last formal review date of the content of our policies can be found in the document management table within each policy

The policies below assist NHS Cambridgeshire & Peterborough (ICB) to manage lower clinical priority treatments, and various surgical and clinical procedures.

Note the following:

Threshold Policies: 

  • If patient meets the criteria refer direct to the provider.
  • If the patient does not meet criteria then the referrer must apply for Exceptional Funding.

Lower Clinical Priority Policies: 

  • Require prior approval - apply to the Exceptional Cases Team for funding.

NHS Cambridgeshire & Peterborough (ICB) Clinical Policies

Each referral proforma requires the completion of patient details, a patient consent section and whether the patient meets policy criteria or whether exceptional funding is being sought. 

Where it has not been possible to refer a patient for hospital treatment for their condition, a patient leaflet is available to explain why and where further advice is available. Patient Leaflet - non referral for treatment

Additional information about the policies is also available.

Select a policy or policy group below to find out more about each one. 

Weight Management Surgery

Surgical Threshold Policy

Note for GPs:  
The provider for Tier 3 weight management service across Cambridgeshire and Peterborough is as follows:

Patients who meet the referral criteria for bariatric surgery will be referred by the Tier 3 weight management service to the Tier 3 obesity management services.

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral.  Complete Section 2 of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral. 

Policy and Referral Proforma:

Benign Skin Lesions and Laser Treatment for Skin Conditions

Note:  the Basal Cell Carcinoma Pathway Policy has been withdrawn.

Lower Clinical Priority Policies

The lower clinical priority treatments below are not routinely commissioned for cosmetic reasons.  Exceptional case funding is required prior to any Benign Skin or Soft Tissue Lesion Surgery, or Laser Treatment for Skin Conditions.  The GP must complete a referral proforma and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Benign Skin or Soft Tissue Lesions

Policy and Referral Proforma:

Laser Treatment for Skin Conditions

Policy and Referral Proforma:

Bobath Therapy

Lower Clinical Priority Policy

Bobath Therapy for cerebral palsy treatment is not routinely commissioned.  For patients who are considered to be exceptional to the policy clinicians should complete an Exceptional/IFR funding request form  and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Policy:

MSK & PAIN: Carpal Tunnel/Chronic Hip Pain/Dupuytren's Contracture/Foot Care Interventions/Ganglion/Hip Replcmnt/Knee Arthroscopy/Knee Replcmnt/Low Back Pain/Shoulder Pain - Mngmnt of/ Shoulder Rplcmnt/Trigger Finger/ESWT

Surgical Threshold Policies and Lower Clinical Priority Policy

Surgical Threshold Policies:

For patients who meet the policy threshold criteria complete the applicable sections of the relevant referral proforma below and send direct to the Musculoskeletal triage service for onward referral - see instructions on proforma. 

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email on: cpccge-ifr@nhs.net for consideration by the Exceptional Cases Panel.

Carpal Tunnel Syndrome

Policy and Referral Proforma:

Chronic Hip Pain

Policy and Referral Proforma:

Dupuytren's Contracture

Policy and Referral Proforma:

Foot Care Interventions:  Podiatry, Laser, Injections and Surgery

Policy and Referral Proforma:

Ganglion

Policy and Referral Proforma:

Primary Hip Replacement Surgery

Policy and Referral Proforma:

Knee Arthroscopy for Chronic Knee Pain

Policy and Referral Proforma:

Primary Knee Replacement Surgery

Policy and Referral Proforma:

Surgery and Other Invasive Interventions for Low Back Pain

Policy and Referral Proforma:

Management of Shoulder Pain (including referral for surgical assessment)

Policy and Referral Proforma:

Shoulder Replacement for Chronic Shoulder Pain

Policy and Referral Proforma:

Trigger Finger (Stenosing Tenosynovitis)

Policy and Referral Proforma:

 

Lower Clinical Priority Policy:

Extracorporeal Shockwave Therapy (ESWT) for Orthopaedic Indications

Referral for ESWT for orthopaedic indications is considered a low priority and will only be commissioned by the NHS on an individual basis.  Funding through the Exceptional Cases process must be sought prior to referral - clinicians should complete an Exceptional/IFR funding request form  and submit it to the Exceptional Cases Team by secure email on: cpccge-ifr@nhs.net for consideration by the Exceptional Cases Panel.

Policy:

 

Cataracts - Chalazion - Eyelid & Brow - Coloured Filters - Photodynamic Therapy

Surgical Threshold Policies and Lower Clinical Priority Policies

Surgical Threshold Policies

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpccge-ifr@nhs.net to obtain funding approval before referral.

Cataracts

Policy and Referral Proforma:

Chalazion

Policy and Referral Proforma:

Eyelid and Eyebrow Surgery

Policy and Referral Proforma

 

Lower Clinical Priority Policies

Coloured Filters/Tinted Lenses for Reading Difficulties

Treatment using coloured filters/tinted lenses for reading difficulties is not routinely commissioned.  For patients who are considered to be an exception to the policy clinicians should complete the Exceptional/IFR funding request form and submit it to the Exceptional Cases Team by secure email to cpccge-ifr@nhs.net to obtain funding approval before referral.

Policy:

Photodynamic Therapy for Age Related Macular Degeneration

There is a Group Prior Approval form available for this intervention for patients who meet the policy criteria.

For patients who do not meet the criteria the Exceptional/IFR funding request form must be completed and submitted to the Exceptional Cases Team by secure email to cpccge-ifr@nhs.net to obtain funding approval before referral.

Policy:

Cholecystectomy for Gallstones

Surgical Threshold Policy

For patients who meet the policy threshold criteria for gallstones complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma). 

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Policy and Referral Proforma:

CFS ME - DID - rTMS

Lower Clinical Priority Policies

The treatments below are not routinely commissioned.  For patients who are considered to be exceptional to the policy clinicians should complete an Exceptional/IFR funding request form and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME)

Policy:

Treatment for Dissociative Identity Disorder (DID)

Policy:

Repetitive Transcranial Magnetic Stimulation for Depression (rTMS)

Policy:

 

Circumcision

Surgical Threshold Policy

NOTE:  If penile malignancy is suspected then referral should be via a two-week wait pathway for suspected cancer. 

In instances of traumatic foreskin injury it may be appropriate to refer to hospital as an emergency admission for surgery.

For patients who meet the policy threshold criteria for circumcision complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Further information on circumcision in men and boys is available on the NHS.uk web site.

Policy and Referral Proforma:

Earwax Removal - OSAHS/Grommets & Adenoidectomy (Otitis Media) - Nasal Surgery -Tonsillectomy - OSAHS and Snoring

Clinical Threshold Policies and Surgical Threshold Policies

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Clinical Threshold Policies

Referral for Earwax Removal

Policy and Referral Proforma:

Diagnostic Investigations and Treatments for Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS) in Adults

Policy and Referral Proforma

Surgical Threshold Policies

Surgical Treatment of Otitis Media:  Grommets and Adenoidectomy

Policy and Referral Proforma:

Nasal Surgery for Obstruction or Deformity

Policy and Referral Proforma:

Surgery for Tonsillitis:  Tonsillectomy and Adenoidectomy

Policy and Referral Proforma:

Surgery for Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS) and Snoring

Policy and Referral Proforma

Familial Breast Cancer

Position Statement

Referral for breast screening and genetics services will be provided in accordance with the policy criteria.

For patients who are considered to be exceptional to the policy, clinicians should complete an Exceptional/IFR funding request form and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Further information about Familial Breast Cancer and genetic testing 

Policy:

Assisted Conception and IVF Treatment

Clinical Threshold Policy

Policy and Referral Proforma:

Couples who do not meet the criteria and consider they have exceptional circumstances, which suggests that they are likely to gain significantly more benefit than might generally be expected, can be referred to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net, using the Exceptional/IFR funding request form, to obtain funding approval before referral.

Treatments excluded from the Assisted Conception Policy:

Egg, sperm and oocyte storage is available for adolescent/adult men and women preparing for medical treatment or other conditions known to cause premature infertility.  Following cancer treatment, couples seeking fertility treatment must meet the defined eligibility criteria.

Cryopreserved material will be stored for an initial period of 10 years in line with recommendations in The Royal College of Physicians Working Party Report:  'The effects of cancer treatments on reproductive functions'. Guidance on management, 2007, and the Human Fertilisation and Embryology Authority (HFEA), Code of Practice, January 2019 guidance.  Extensions to the initial  period will be by exceptional funding request to the Exceptional Cases Panel.  See  Assisted Conception Policy for further information.

Sperm washing will be provided to men who have a chronic viral infection (primarily HIV), and whose female partner does not, where intrauterine insemination is being considered.  This is a risk reduction measure to limit the transmission of a serious, pre-existing viral conditions such as HIV to the woman and, therefore, potentially her unborn baby.

For further information about the above interventions and conditions please go to the NHS.UK website. 

Gastroscopy (Upper GI Endoscopy) - Endoscopy/Lower GI Endoscopy

Surgical Threshold Policies

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Gastroscopy (Upper GI Endoscopy) Management of Dyspepsia in Primary Care and Referral for Endoscopy

Policy and Referral Proforma:

Lower Gastrointestinal (GI) Endoscopy (Colonoscopy or Sigmoidoscopy)

Policy and Referral Proforma:

Haematuria

Clinical Threshold Policy

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma). 

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

NOTE:  referrals for 2-week-wait Urology should be made using the 2-week-wait form available on SystmOne/EMIS or available below.

Policy and Referral Proforma:

Haemorrhoids (Piles)

Surgical Threshold Policy

For patients who meet the policy threshold criteria for piles (haemorrhoids) complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Policy and Referral Proforma:

Heavy Menstrual Bleeding (HMB) and Female Pelvic Organ Prolapse

Surgical Threshold Policies

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).  

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Management of Heavy Menstrual Bleeding (HMB)

Policy and Referral Proforma:

Management of Female Pelvic Organ Prolapse

Policy and Referral Proforma:

Hernia Surgery

Surgical Threshold Policy

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).    

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral. 

Policy and Referral Proforma:

Hydrotherapy

Position Statement

This position statement covers the use of hydrotherapy in place of land-based physiotherapy.  It is the responsibility of the referring and treating physiotherapist to ensure compliance with this commissioning advice.

Hydrotherapy is not considered to be an essential service, this policy applies only where local provision is available.  Where local provision is not available, patients should receive land-based physiotherapy.

Policy:

Hyperhidrosis

Lower Clinical Priority Policy

Botox treatment for hyperhidrosis is now in tariff and, therefore, the GPA form is no longer required and has been removed from Blueteq.  Prior approval is not required for Botox treatment but the policy criteria are still applicable and patients need to meet the policy criteria.

For patients who are considered to be exceptional to the policy clinicians should complete an Exceptional/IFR funding request form  and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Policy:

Lymphoedema

Lower Clinical Priority Policy

Treatment for lymphoedema is available locally and may be referred through the commissioned pathway.

Treatment provided by a specialist unit in the private sector will require the involvement of an appropriate local service and funding must be sought prior to referral by completing an Exceptional/IFR funding request form  and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net.

Policy:

Neurostimulation

Position Statement

Neurostimulation interventions are not routinely commissioned.  For patients who are considered to be exceptional to the policy clinicians should complete an Exceptional/IFR funding request form and submit it to the  Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

This policy does not apply to neurostimulation for indications commissioned by NHS England or covered by NICE Technology Appraisal Guidance.

Policy:

Open/Upright MRl

Lower Clinical Priority Policy

Routine referral by clinicians in Musculoskeletal Services or Secondary Care, for Open or Upright MRI (MRI is short for Magnetic Resonance Imaging), in all indications, is considered of low priority and will only be commissioned by the NHS on an individual case basis.  

Funding through the individual funding process must be sought prior to referral - Musculoskeletal or Secondary Care clinicians should complete the referral proforma (see below) and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval.

Applicants who receive approval of funding will be forwarded an MRI referral form applicable to the selected commissioned provider.

Policy and Referral Proforma:

Pain Relief Services

Lower Clinical Priority Policy

Treatment in secondary care is via the routinely commissioned pathway. Requests for referral outside the area will not normally be provided under the NHS.  For patients who are considered to be exceptional to the policy clinicians should complete the Exceptional/IFR  funding request form  and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Treatment provided in tertiary centres, such as spinal cord stimulation, is commissioned by NHS England:  NHS Pain Management Specification.

Policy:

 

Post Traumatic Stress Disorder (PTSD)

Lower Clinical Priority Policy

Treatment for PTSD is available locally and may be referred through local pathways.

For patients who are considered to be exceptional to the policy clinicians should complete an Exceptional/IFR funding request form and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Note:  NHS England are responsible for commissioning post-traumatic stress disorder services for veterans from Highly Specialist Veteran's Post-Traumatic Stress Disorder Centres.  The veterans' post-traumatic stress disorder programme provides inpatient treatment for service veterans who have complex post-traumatic stress disorder as a result of multiple traumas whilst in service.

Policy:

Radiofrequency

Surgical Threshold Policy - this policy links to the Low Back Pain Surgical Threshold policy.

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email on: cpicb.e-ifr@nhs.net for consideration by the Exceptional Cases Panel.  

Policy and Referral Proforma:

Sterilisation and Reversal

Surgical Threshold Policy and Lower Clinical Priority Policy

Surgical Threshold Policy

Sterilisation

For patients who meet the policy threshold criteria complete the applicable sections of the referral proforma below and send direct to the secondary care specialist (see instructions on proforma).  

For patients who do not meet the policy threshold criteria treatment is considered of low priority and will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval.

Policy and Referral Proforma:

 

Lower Clinical Priority Policy

Reversal of Sterilisation

Reversal of Sterilisation is not routinely commissioned.  For patients who are considered to be exceptional to the policy clinicians should complete an Exceptional/IFR funding request form  and submit it to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval before referral.

Policy:

 

 

Stop Smoking

Clinical Threshold Policy

This policy covers the pre-operative referral of patients who smoke to a stop smoking service (SSS). It includes patients undergoing elective surgery.  It does not include patients undergoing urgent non-elective surgery.

Note: There is no requirement for a patient to have stopped smoking, but contact with a SSS is mandated prior to surgery.

Policy:

Stop Smoking Service:

Cambridgeshire Peterborough residents can access the free stop smoking service at Healthy You (formerly known as CAMQUIT): 

Web site:  https://healthyyou.org.uk

Telephone number:  0333 005 0093

Self referral using the Healthy You  contact form

Email:  healthyou@healthyyou.org.uk

Text:  Healthyou to 60777

Email address for Health Professionals:  eh.healthyyou@nhs.net or to self refer a patient please use the referral form:  referral form

General NHS advice about stopping smoking and treatments 

Where a within-surgery, pharmacy, hospital or equivalent service is available, refer to a service as per patient choice. 

Temporomandibular Disorder (TMD) and Information on Dental Treatments

Surgical Threshold Policy

Management of Temporomandibular Disorders (TMD) - GP advice

For patients who meet the policy criteria for referral, the dental practitioner will make the referral to secondary care services as per the NHS England pathway - NHS England are the responsible commissioner for Temporomandibular Disorder interventions.

For patients who do not meet the criteria:  application to the NHS England Individual Funding Request Panel can be made for patients who are considered exceptional to the criteria. See below*.

The NHS Cambridgeshire and Peterborough (ICB) policy:

 

*NHS England local area teams are responsible for commissioning dental services this included Dental Implants, Orthodontic Treatment and Wisdom Teeth Removal please refer all exceptional case requests and enquiries to NHS England.

Tongue-Tie

Surgical Threshold Policy

Tongue-tie surgery will be funded for infants 0-4 months that meet the policy criteria.  Complete the applicable sections of the referral proforma in order the make the referral.

For patients who do not meet the policy threshold criteria and for indications other than feeding difficulties, eg speech problems, treatment is considered a low priority and will only be commissioned by the NHS on an exceptional basis.  Funding through the Exceptional Cases process must be sought prior to referral.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval.

Policy and Referral Proforma:

 

Varicose Vein Interventions

Surgical Threshold Policy

For patients who meet the policy threshold criteria for varicose veins complete the applicable sections of the referral proforma below, providing full clinical detail and send direct to secondary care (see instructions on proforma).

For patients who do not meet the policy threshold criteria and who have signs and symptoms as defined by the policy as low clinical priority, treatment will only be commissioned by the NHS on an exceptional case basis.  Funding through the Exceptional Cases process must be sought prior to referral to secondary care.  Complete the relevant section of the referral proforma and submit the proforma to the Exceptional Cases Team by secure email to cpicb.e-ifr@nhs.net to obtain funding approval.

Policy and Referral Proforma

 

NHS England Specialised Commissioning Group Policies

You can access NHS England National Programmes of Care.  Each national programme provides details on NHSE policies relevant to that particular programme of care.

NHS England policies for routinely commissioned treatments.

Generic policy information that includes NHSE Individual Funding Request information - and the process for making an individual funding request application is also available (select the Individual funding policy link located under the 'Key Documents' heading to quickly jump down the page to the Individual Funding Request section).  

NHS England Evidenced Based Interventions (EBI) Guidance in association with the Academy of Medical Royal Colleges

The EBI Programme is overseen by NHS Clinical Commissioners, the Academy of Medical Royal Colleges, The National Institute for Health and Care Excellence, and NHS England and NHS Improvement.

The guidance is addressed to ICBs, to assist them in fulfilling their duties relating to securing continuous improvements in the quality of services for patients and in outcomes, particularly regarding appropriate clinical interventions. This guidance is issued as general guidance under S14Z8 of the NHS Act 2006. The objective of the guidance is to support ICBs in their decision-making, to address unwarranted variation, and to provide national advice to make local clinical decision-making more appropriate.

ICBs are expected to have regard to the guidance in formulating local policies and for clinicians to reflect the guidance in their clinical practice. The guidance does not remove the clinical discretion of clinicians in accordance with their professional duties.