Commissioning

Question 1

Setting the scene

Answer 1

• Commissioning, as a topic is vast
• We will be looking at a sub set of commissioning
  
  • Commissioning of healthcare services
  • Specifically medicines
  • In England (And more specifically in Birmingham)

Question 2

Why do we need to commission at all

Answer 2

• There are competing priorities at the heart of any healthcare system
• Demand is growing fast
  
  • The population is getting older, and therefore sicker
  • Advances in medical sciences mean we can understand the disease better and therefore treat more. And prevent more
  • Technological advances are driving forward what is technically possible

Question 3

Why do we need to Commission at all

Answer 3

• There are competing priorities at the heart of any healthcare system
• The ability of the healthcare system to afford everything is diminishing
  
  • New technologies are more expensive
  • The sheer number of treatable patients grows
  • Gross Domestic product (GDP) does not grow as fast as demand

Question 4

Why do we need to commission at all

Answer 4

• To an extent, socialism meats capitalism
• The NHS is essentially a socialist ideology - everyone gets access to the same treatment regardless of their ability to pay
• The basic tenets of medicine support this
• But the infrastructure that supports the delivery healthcare is heavily capitalist and profit driven

Question 5

Why do we need to commission at all

Answer 5

• The NHS has a large number of duties but two are relevant to this session
  
  • To commission certain specified health services
  • To perform its functions for each financial year so as to ensure that its expenditure meets the (assigned budget)
• In summary, the NHS is required to commission for the health needs of its population in a resource-constrained environment
• So it is all about buying the services people want or need within a restricted, annual budget

Question 6

Structure of the NHS in England

Answer 6

• Commissioners
• Providers
• Influencers
• Evolving structures

Question 7

Commissioners

Answer 7

• NHS England
  
  • Specialised services, pharmacy, dentistry, optometry, (GP services)
• Clinical Commissioning Groups
  
  • Planned care, rehabilitation services, urgent care, mental health services, community health services
• Public Health England and Local Authorities
  
  • Population health, screening services, substance misuse services

Question 8

Providers

Answer 8

• NHS foundation trusts
• NHS acute trusts
• Ambulance trusts
• Mental Health Trusts
• Specialist Centres
• Community Healthcare trusts
• Third sector
• Any qualified providers
• GP services

Question 9

Influencers

Answer 9

• DoH
• NICE
• Health and wellbeing boards
• NHS England
• NHS Improvement
• Local Authorities
• Healthwatch
• Clinical senates
• Regional Medicine Optimisation Committee
• Social media

Question 10

Evolving structures

Answer 10

• The 2010 re-organisation was intended to be transformational
• In reality, has proved to be more evolution than revolution
• As such, continues to develop in search of revolution
  
  • Sustainable Transformation Programmes
  • Vanguards
  • Accountable Care Organisations
  • Integrated Care Organisations

Question 11

What is commissioning

Answer 11

• There are many different definitions of commissioning
• The DoH defines commissioning in the NHS as
  
  • Process of ensuring that the health and care services provided effectively meet the needs of the population
  • It is a complex process with responsibilities ranging from assessing population needs, prioritising health outcomes, procuring products and services and managing service providers
• A good working definition is
  
  • The act of committing resources, with the aim of improving health, reducing inequalities, and enhancing patient experience

Question 12

The commissioning cycle

Answer 12

Question 13

A simple way of looking at commissioning

Answer 13

Question 14

Applying this process to medicines

Answer 14

• The principles for commissioning medicines are not really very different
  
  • Establish the need for the medicine
  • Plan who will need it
  • Specify who will have access to it
  • Monitor the implementation and usage
  • Start cycle again and refine

Question 15

National commissioning of medicine- NICE

Answer 15

• A lot of commissioning work is already undertaken by NICE
• Technology appraisals and clinical guidelines proved detailed guidance about the place of medicines in care pathways
• Technology Appraisals are legally mandated and must be implemented within 90 days of publication; supported by an NHS constitutional right
• Can, in exceptional circumstances, reduce to 30 days
• Clinical Guidelines are not mandatory but must be considered when prioritising healthcare resources allocation

Question 16

National commissioning of medicine- NICE

Answer 16

• NHS England is responsible commissioner for a number of medicines
• Where assessed by NICE, NHS England must comply
• For all other medicines, NHS England generally publishes a commissioning policy outlining it’s approach to commissioning the medicine
• Undertaken by NHS England specialised commissioning
• By definition, the number of patients is relatively small

Question 17

Local commissioning of medicines- CCGs

Answer 17

• CCGs have a duty to consider all other medicines that are not nationally mandated or commissioned by NHSE SC
• CCGs can either choose to publish a commissioning policy for a particular medicine or may assess the medicine through a local medicine committee
• Both methods are valid and each has its uses; in practice, most medicines decisions are taken by the medicines committee

Question 18

Medicines commissioning policies

Answer 18

• Essentially a statement of what a CCG will undertake to fund in respect of a medicine
• Cannot override national policy or NICE guidance
• Must be compliant with the local commissioning policies
  
  • Must be prioritised alongside other requests for investment
  • Should demonstrate clinical and cost-effectiveness
  • Should only be constrained to cohorts that can be rationally defined on clinical grounds
  • Should allow equal access for everyone in the cohort

Question 19

Medicines commissioning policies

Answer 19

• The default position for any CCG is not routinely funded
• All new medicines come to market with efficacy and safety data but often without evidence of superiority over existing treatments
• Many medicines are clinically effective but disproportionately expensive
• All medicines are assessed for safety, efficacy, cost and patient preference. Cost effectiveness and affordability are also key considerations

Question 20

Prioritisation

Answer 20

• Decisions about medicines are not taken in isolation
• Formulary committees have a small discretion to commit expenditure but, in general, any decision to commit funding has to be taken as part of the prioritisation exercise
• Prioritisation generally means looking at all of the requests for new funding and ranking them in order of importance
  
  • Must do’s from NICE or other national policy take precedence
  • Everything after that is ranked in priority order and as much as possible commissioned within funding constraints

Question 21

Prioritisation

Answer 21

• It’s a complex process
• How do you compare very different requests e.g. if £500,000 is available, would you spend it on a medicine that reduces symptoms in severe dermatitis or on a new scanner that allows clinicians to more accurately diagnose rare brain tumours
• There are lots of factors to consider in prioritisation, for example, the strength of clinical evidence, clinical effectiveness, cost-effectiveness, health impact, nature of the condition, affordability, population covered, fit with strategic objectives and clinical priorities (local and national)

Question 22

Formularies

Answer 22

• All CCGs are required to publish a formulary online
• A formulary should tell everyone what medicines are commissioned in the local area alonside any restrictions and are a key feature of complying with NHS constitutional requirement
• You can look at the formulary that affects you
• The formulary is owned and managed by the BBCS&E area prescribing committee

Question 23

Your local area prescribing committee

Answer 23

• Covers the geographical area of birmingham, Solihull, Sandwell (south Staffordshire)
• Comprises 5 CCGs:Birmingham CrossCity, Birmingham South

Central, Sandwell and West Birmingham, Solihull, South Staffordshire

• Comprises of 7 trusts:University Hospitals Birmingham, Heart of England, Sandwell and West Birmingham, Birmingham Women’s and Children’s, Birmingham and Solihull Mental Health, Birmingham Community Healthcare and the Royal Orthopaedic

Question 24

Area prescribing committee

Answer 24

• The main role is to consider applications for inclusion on the formulary
• Each medicine application has a sponsor who must address the safety, efficacy, cost of the medicine, place in therapy, patient preference, cohort to be treated and where treatment will be prescribed
• APC will consider the evidence presented and either accept for inclusion or reject the application

Question 25

Area prescribing committee

Answer 25

* Accepted applications with be RAG rated and may have other conditions imposed * RAG rating- RED, AMBER, GREEN * RED: Hospital only prescribing * AMBER: May be prescribed in primary care with restrictions * GREEN: No restriction * Restrictions may include requiring prescribing support documentation

Question 26

Managing exceptions

Answer 26

* It is not uncommon for a medicine to be denied any commissioning status and subsequently excluded from a local formulary * Commissioners are always mindful that blanket commissioning policies are unlikely to be lawful and may end up in Judicial Review * All commissioners, therefore, will have an exceptions policy to support patients who have a clinical need but for whom the medicine is not routinely commissioned

Question 27

Individual Funding Requests (IFRs)

Answer 27

* Clinicians can apply, in exceptional circumstances, for a medicine to be commissioned for an individual patient * The clinician will need to justify why they think the treatment is the only current option and crucially, why they contend that the patient's circumstances are exceptional * In such cases, commissioners have to ascertain that there is a current commissioning policy to consider against and then will convene and IFR panel to consider the case

Question 28

IFR panels

Answer 28

* IFR panels must consider whether * There is an evidence base to support the use of the treatment * The rule of recuse is being applied * That the patient is exceptional and not part of a definable cohort * That the request for treatment is not covered by the experimental and unproven treatments policy (if it is, to consider the request in those terms)

Question 29

IFR Panels

Answer 29

* The panel is a formally recorded meeating * The patient, through the clinician, has a right of appeal * Appeals can only challange the process that led to the decision, not the decision itself * IFR panels follow a very specific policy and protocol to mitigate the risk of legal challange through judicial review

Question 30

Consultation and public engagement

Answer 30

* Commissioning is not done in isolation by the NHS * Commissioners have a duty to ensure that the views of their population are sought though consultation before implementation * Clinical commissioning policies are normally implemented after a 4-6 week consultation period * National formulary decisions are generally taken by committees with patient representation. Local representation is agreed by currently vacant

Question 31

Why should pharmacist care

Answer 31

* Commissioning plays a huge part of a pharmacist daily working life * Community pharmacy services are contracted nationally by DoH and PSNC but management of the contract is undertaken by NHSE * Community pharmacy enhanced services are commissioned by NHSE and CCG's

Question 32

Why should pharmacists care

Answer 32

* Understanding the commissioning framework is a core role for hospital pharmacists as use of medicine outside of the commissioning framework can lead to financial consequences for the hospital * Primary care pharmacist have a key role in ensuring that prescribers are aware of what they should not be prescribing but more importantl , what they should be prescribing when and to whom

Question 33

Answer 33

* Is it safe * Does it work * Is it better for the patient * Does it improve outcomes

Question 34

Answer

Answer 34