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)
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
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
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
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
6
Q
Structure of the NHS in England
A
- Commissioners
- Providers
- Influencers
- Evolving structures
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
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
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
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
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
12
Q
The commissioning cycle
A
13
Q
A simple way of looking at commissioning
A
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
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
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
