Varicose veins are often thought to be "only" a cosmetic problem. However research over the last decade or so has shown this to be wrong. Some 20% of patients with varicose veins will go on to get leg ulcers if left untreated. Others will get swollen ankles, skin damage, discomfort, phlebitis or rarely bleeding.
A year ago, the National Institute of Health and Care Excellence (NICE) recognised this and issued clinical guidelines stating that everyone with varicose veins causing any symptoms, or anyone with a leg ulcer that hadn't healed within 2 weeks, should be referred to a vascular service for assessment (http://www.nice.org.uk/guidance/CG168).
Unfortunately from what our patients tell us, these NICE Clinical Guidelines appear to have made very little difference to patients who have varicose veins and symptoms or leg ulcers. General Practitioners and Private Medical Insurers still seem reticent to refer such patients to a vascular service and many tell us they have been told to wear compression stockings instead, contrary to the advice given by NICE.
Moreover, for the lucky few that do get a referral from their GP or get their Private Medical Insurers to agree to fund the required assessment, many patients do not get to a proper "vascular service" such as The Whiteley Clinic, as it is defined in the NICE Guidelines, but rather end up seeing a single doctor in a room who performs a scan themselves, without a team of specialists around them.
Furthermore, many such doctors who "do veins" do not offer a "full range treatment" as they have to be a "vascular service" as defined by NICE, resulting in a large proportion of patients still being treated by stripping when NICE has clearly stated this is third best after endothermal treatment (laser or radiofrequency) and failing that, foam sclerotherapy.
Therefore it is a welcome sign that NICE has now issued Varicose Vein Quality Standards QS67 (http://www.nice.org.uk/guidance/QS67/chapter/List-of-quality-statements). There are 3 stated quality standards.
Firstly "people with varicose veins that are causing symptoms or complications (including ulceration) are referred to a vascular service" - a vascular service being defined as "a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound assessment and provide a full range of treatment".
Secondly "people with varicose veins who are seen by a vascular service are assessed with duplex ultrasound".
Finally "people with confirmed varicose veins and truncal reflux are offered a suitable treatment in this order: endothermal ablation, ultrasound-guided foam sclerotherapy, surgery, compression hosiery".
The quality standards call for data to be collected locally and so it can be seen what proportion of patients in each area get the recommended service compared to those that don't.
This is very commendable - but it is highly unlikely that GP's will collect data on how many patient they fail to refer with varicose veins and symptoms, or that district nurses seeing patients with ulcer will collect data on patients that they don't refer for a full assessment by a vascular service, never mind private health insurers collecting data on how many claims they turn down for assessment of varicose veins.
Even if we could find out this information about the proportion of patients who don't get referred, a great many doctors, clinics and hospitals currently providing varicose veins surgery do not fulfil the criteria of a "vascular service" as defined by NICE.
As such, it is highly unlikely that credible data will be forthcoming for many years. Thus in the interim, patients with varicose veins and leg ulcers and their relatives need to know the guidelines and they need to insist that they are treated as recommended. This means being referred and not being fobbed off and, when referred, making sure it is to a specialist team providing a vascular service as defined. Furthermore they need to make sure they are having a duplex scan by a specialist member of the team and finally that they are being offered a full range of treatments - which will usually be endothermal ablation or foam sclerotherapy and should rarely, if ever, be stripping or compression stockings.
In conclusion, despite clear recommendations from NICE that would reduce the burden of complications from chronic varicose veins and leg ulcers, it appears that the NHS and Private Medical Insurers are not currently offering these recommended referrals and treatments to all patients and many patients seem to have to fight just to get the NICE recommended care.