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Re: Primary care trust commissioning of varicose vein intervention – New guidance needed? Dear Miss Griffin, Many congratulations for your detailed study on the national variability of commissioning in the treatment of varicose veins.1 Your data clearly present a ‘postcode lottery ’ in both the selection of patients meeting the criteria for treatment and whether they receive endove-nous laser therapy (ELT) or a surgical procedure. We agree that new NICE guidelines are imperative to assist primary care trusts in their referrals, but this should not lead to one national treatment for all. All patients with symptomatic varicose veins require an expert opinion from a consultant vascular surgeon. Decisions on those patients appropriate for treatment should be at this stage, along with planning for inter-vention. ELT is commonly used as first-line treatment, as it is not associated with potential surgical morbidity; however, at present, there are no long-term data on the outcomes of ELT.2 ELT also provides a poorer cos-metic result, often leading to further referrals and subsequent treatment.3 We agree with your recommen-dation for a first-line national decision in the commissioning of varicose vein surgery; however, com-missioners should not be prescriptive in the treatment modality. Treatment should be at the discretion of a vascular specialist making the decision in partnership with the patient and taking into account the patient’s values, expectations and concerns. References 1. Griffin KJ, et al. Primary care trust commissioning of vari-cose vein intervention—new guidance needed? Phlebology 2014; 29: 505–510. 2. van den Bos RR, et al. Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Sur