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PH3611- Clinical module > Commissioning > Flashcards

Commissioning Flashcards

1
Q

Setting the scene

A
  • 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)
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2
Q

Why do we need to commission at all

A
  • 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
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3
Q

Why do we need to Commission at all

A
  • 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
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4
Q

Why do we need to commission at all

A
  • 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
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5
Q

Why do we need to commission at all

A
  • 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
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6
Q

Structure of the NHS in England

A
  • Commissioners
  • Providers
  • Influencers
  • Evolving structures
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7
Q

Commissioners

A
  • 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
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8
Q

Providers

A
  • NHS foundation trusts
  • NHS acute trusts
  • Ambulance trusts
  • Mental Health Trusts
  • Specialist Centres
  • Community Healthcare trusts
  • Third sector
  • Any qualified providers
  • GP services
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9
Q

Influencers

A
  • DoH
  • NICE
  • Health and wellbeing boards
  • NHS England
  • NHS Improvement
  • Local Authorities
  • Healthwatch
  • Clinical senates
  • Regional Medicine Optimisation Committee
  • Social media
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10
Q

Evolving structures

A
  • 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
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11
Q

What is commissioning

A
  • 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
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12
Q

The commissioning cycle

A
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13
Q

A simple way of looking at commissioning

A
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14
Q

Applying this process to medicines

A
  • 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
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15
Q

National commissioning of medicine- NICE

A
  • 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
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16
Q

National commissioning of medicine- NICE

A
  • 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
17
Q

Local commissioning of medicines- CCGs

A
  • 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
18
Q

Medicines commissioning policies

A
  • 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
19
Q

Medicines commissioning policies

A
  • 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
20
Q

Prioritisation

A
  • 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
21
Q

Prioritisation

A
  • 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)
22
Q

Formularies

A
  • 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
23
Q

Your local area prescribing committee

A
  • 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
24
Q

Area prescribing committee

A
  • 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
25
Q

Area prescribing committee

A
  • 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
26
Q

Managing exceptions

A
  • 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
27
Q

Individual Funding Requests (IFRs)

A
  • 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
28
Q

IFR panels

A
  • 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)
29
Q

IFR Panels

A
  • 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
30
Q

Consultation and public engagement

A
  • 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
31
Q

Why should pharmacist care

A
  • 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
32
Q

Why should pharmacists care

A
  • 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
33
Q
A
  • Is it safe
  • Does it work
  • Is it better for the patient
  • Does it improve outcomes
34
Q

Answer

A

PH3611- Clinical module (28 decks)

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