Commissioning

Question 1

Give a good working definition of commissioning in a healthcare setting.

Answer 1

“The act of committing resources, with the aim of improving health, reducing inequalities, and enhancing the patient experience.”

Question 2

In the NHS, what groups act as commissioners?

Answer 2

NHS England, CCGs, Public Health England and Local Authorities.

Question 3

What services does NHS England commission?

Answer 3

o	Specialised services.
o	Pharmacy.
o	Dentistry.
o	Optometry.
o	GP services.

Question 4

What services do CCGs commission?

Answer 4

o	Planned care.
o	Rehabilitation services.
o	Urgent care.
o	Community health services.
o	Mental health services.
o	GP services.

Question 5

What services do public health England and local authorities commission?

Answer 5

o Population health.
o Screening services.
o Substance misuse services.

Question 6

Give some examples of providers of services in the NHS.

Answer 6

• NHS Foundation Trusts – independent.
• NHS Acute Trusts.
• Ambulance Trusts.
• Mental Health Trusts.
• Specialist Centres.
• Community Healthcare Trusts.
• Third Sector – private providers supporting the NHS.
• Any qualified providers.
• Increasingly, GP services.

Question 7

Give some examples of influencers in the NHS.

Answer 7

• Department of Health.
• NICE.
• Health and wellbeing boards – non-governmental and hold the health economies to account.
• NHS England.
• NHS Improvement.
• Local Authorities.
• Healthwatch.
• Clinical Senates.
• Regional Medicines Optimisation Committees – like NICE but regional.
• Increasingly, and perhaps alarmingly, social media.

Question 8

The 2010 re-organisation was intended to be transformational, in reality, it has proved to be more evolution than revolution. Which groups were created with this re-organisation?

Answer 8

• Sustainable transformation programmes.
• Vanguards.
• Accountable care organisations.
• Integrated care organisations.

Question 9

What processes are followed when commissioning medicines?

Answer 9

• Establish the need for the medicine.
• Plan who will need it.
• Specify who will have access to it.
• Monitor the implementation and usage.
• Start the cycle again and refine…

Question 10

Describe the nature of NICE clinical guidelines.

Answer 10

Clinical Guidelines are not mandatory but must be considered when prioritising healthcare resource allocation.

Question 11

Describe NICE technology appraisals.

Answer 11

Technology appraisals provide 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. This timeframe can, in exceptional circumstances, reduce to 30 days.

Question 12

What are medicines commissioning policies?

Answer 12

Essentially a statement of what a CCG will undertake to fund in respect of a medicine however cannot override national policy or NICE guidance and must be compliant with the local commissioning policies.

Question 13

What is the default commissioning policy for any CCG?

Answer 13

Not routinely funded.

Question 14

What considerations/assessments are medicines subject to before they are considered for commissioning?

Answer 14

All medicines are assessed for safety, efficacy, cost and patient preference. Cost-effectiveness and affordability are also key considerations.

Question 15

What factors are considered when prioritising medicines to be commissioned?

Answer 15

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 16

What information should formularies contain?

Answer 16

A formulary should tell everyone what medicines are commissioned in the local area alongside any restrictions and are a key feature of complying with NHS Constitutional requirement.

Question 17

Describe the role of the area prescribing committee.

Answer 17

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 18

Describe the RAG rating of medication.

Answer 18

• Red – Hospital only prescribing.
• Amber – May be prescribed in primary care with restrictions.
• Green – No restrictions.

Question 19

Some medicines may require prescribing support documentation, outline what this may be.

Answer 19

• Patient Decision Aids (PDAs).
• Effective Shared Care Agreements (ESCAs).
• Rationale for Initiation, Continuation and Discontinuation (RICaDs).
• Safety support documents.

Question 20

What are individual funding requests (IFRs)?

Answer 20

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.

Question 21

What must the individual funding requests panel consider?

Answer 21

• There is an evidence base to support the use of the treatment.
• The “rule of rescue” 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 (and if it is, to consider the request in those terms).