Specialised commissioning: Where are we today?

Suzy Heafield

Associate: Medicines & Therapeutics

Arden-GEM CSU

Pharman National Forum, Gateshead

30th April 2015

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Context of today’s NHS

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Context for today’s NHS

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The NHS is one of the most valued institutions in the country. There have been significant improvements in the outcomes for patients and the public over the last decade.

Financial constraintRising

expectationDemographic pressures

The challenge for the NHS is to improve against the backdrop of that context. And that means it can’t stay the same if it is to be sustainable as a nationally tax-funded system, free at the point of use, available to those in need. The ongoing challenge of sustaining and improving outcomes, quality, and tackling inequalities, within constrained resources, will be with us for many years.

However there is a challenging backdrop…

Past failures e.g. Winterbourne, Stafford

Comparative outcomes

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Commissioning - how the money flows

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Parliament

Department of Health

NHS England incl. Area Teams152 Local Authorities

Public Health England

211 Clinical Commissioning Groups*

Public Health

Community services

Mental healthDistrict general

hospital servicesPrimary

careSpecialised

services

£2.7 billion £66 billion £26 billion

£1.8 billion screening/immunisation programmes delivered in primary care

* Supported by 17

Commissioning Support Units

Health & Justice

Armed forces

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Medicines Utilisation in Practice

Medicines still most common therapeutic intervention and biggest cost after staff, but:30 to 50% not taken as intended

Patients have insufficient supporting information5 to 8% of hospital admissions due to preventable adverse effects of medicinesMedication errors across all sectors and age groups at unacceptable levelsRelatively little effort towards understanding clinical effectiveness of medicines in real practiceThe threat of antimicrobial resistance

Data source: HSCIC: Hospital Prescribing: England, 2013-14

2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/140

2000

4000

6000

8000

10000

12000

14000

16000

Primary careHospital & community health sectorTotal

Gro

ss s

pend

£m

NHS Drug Spend £bn

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Defining what is “Specialised”

4 Key Factors• The number of individuals who require provision of service• The cost of providing the service or facility• The number of persons able to provide the service or

facility• The financial implications for Clinical Commissioning

Groups (CCGs) if they were required to commission the service or facility themselves

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• 60% of all medicines in development are specialist• NHS England responsible for specialised commissioning and

estimates show that this may account for approximately £2.4billion of medicines spend annually (40-50% of hospital medicines spend)

• Drug costs associated with specialised commissioning increasing at greater rate than overall secondary care drug costs

Analytical Overview – Specialised Commissioning

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What’s happening in 2015/16?

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The tariff arrangements

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• Twist or stick?

• Enhanced tariff option (ETO)• CQUIN payments (up to 2.5%)• Reduced deflator (3.5% vs 3.8%)• Enhanced marginal rate emergency tariff (30 to 70%)• 70/30 risk share on bottom line (including PbRE drugs)

• Default tariff rollover (DTR)• No CQUIN • Full deflator• No enhanced emergency tariff• Pass through on drugs but no update on 14/15 excluded drugs list

Tariff

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• Allocated budgets based on 14/15 plan = stated base value (SBV)• Plus SBV adjustment (contract variations agreed pre Dec 14)• Plus adjustment for NICE TAs

• Budgets based on tariff exclusion categories• Reporting through minimum dataset• If overspent then Trust pays 30% of spend over SBV• If underspent then Trust keeps 30% of spend under SBV

What ETO means for medicines

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Drug GroupNice impact

£’000

Allergen Immunotherapy 1,237 Drugs affecting the Immune response 6,420 Hormone antagonists (abiraterone and enzalutamide only) 11,084 Immunomodulating drugs - lenalidomide/thalidomide 3,504 Immunomodulating drugs - MS 26,804 Other Chemotherapy 1,332 Paroxysmal nocturnal haemoglobinuria 14,721 Protein kinase inhibitors 11,305 Drug totals 76,409

NICE uplift

For specific allocations and other Monitor documents go to:https://www.gov.uk/government/publications/tariff-arrangements-for-your-201516-nhs-activity

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• Blueteq

• QIPP opportunities

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Staying within the SBV

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• Applies to ETO and DTR Trusts • Already used for CDF applications in 3 of 4 regions• Provides assurance that excluded medicines being used in line with

policy• Will be used initially for:

• MS drugs• Hepatitis C drugs• Cancer drugs (where used in CDF and routine commissioning)

• Use will be extended as new policies are published/ issues are identified

Blueteq

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• A web based clinical decision support tool • Clinicians complete an online proforma to confirm the patient

meets NICE/ NHS England commissioning policy criteria• Approval is automatic if the patient is eligible• Clinicians are directed to consider an IFR if not eligible• Priority is to ensure NEW patients meet initiation criteria but

moving forward clinicians will be asked to complete a continuation form to confirm patient receiving expected benefit

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What is Blueteq?

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• Ensuring cost effective use and delivery of medicines• Examples include:

• Therapeutic tenders – use of most cost effective therapeutic alternatives, e.g. HIV drugs, antifungals

• Use of outsourced outpatient pharmacies or homecare to deliver medicines

• Reducing waste by reviewing duration of supply, e.g. oral chemotherapy

• Reducing waste by vial sharing/ dose rounding

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QIPP Opportunities

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Prioritisation

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Development of a prioritisation framework

• What do we mean by a prioritisation framework for NHS England?Almost every public body faces difficult decisions, which balance the demand for services against the resource available to provide those services. A prioritisation framework describes the principles that we use to underpin our decision making in allocating finite resources

• Why do we need these?It is difficult to make robust, fair and consistent resourcing decisions without clearly setting out core principles

• Consultation closed on 27th April

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A prioritisation framework is needed in making decisions (1)Fair process, based on evidence and transparently

Service development

Service development

Service development

Service development

Service development

Prioritisation Framework

Set principlesApplied consistently to all

proposals for service developments

Following a well defined, structured governance

processFair

TransparentHelps NHS England to

decide between competing options for service

development

Given resource constraints, NHS England cannot meet

every potential treatment for every

patient

Service development

Service development

Service development

Service development

Service development

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2

3

4

5

Available resources

Se

rvic

es

will

be

de

velo

pe

dS

erv

ice

s w

ill n

ot

be

de

velo

pe

d

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A prioritisation framework is needed in making decisions (2)To replace the interim ethical framework

Currently NHS England makes prioritisation decisions based on 3 elements:

Clinical Reference Groups (CRGs)

Develop the clinical policies and service specifications

Interim Ethical Framework and Generic Policies

Clinical Priorities Advisory Group (CPAG)

Reviews all proposed policies and specifications and makes

recommendations to NHS England about which treatments

and services should be commissioned including priorities

for investment

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• Transparency• Patient and public voice• Evidenced based

General principles:

• Clinical effectiveness• Benefit to patientsIt works:

•Takes account of rare conditions•Likely to address health inequalities•Can be offered to all patients in the same group•Promotes parity between physical and mental health

Its fair and equitable:

• Offers value for money• Affordable

Is a reasonable cost to the public:

The new principles to aid the prioritisation That have been proposed by NHS England

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Applying the principles in practiceThe new clinical policy production process

Phase IEnvironmental

scanning

Phase IIPlanning

CRGs and others consider potential developments

Understanding what are the new developments on the horizon

Phase IIIClinical Build

Evidence is reviewed and the clinical case established, a policy is proposed

Phase IVImpact &

Consultation

Impact analysis (clinical, financial), engagement and consultation plans developed.

Phase VGovernance

CPAG recommendations and Specialised Services committee approval. Publication and implementation

Pa

tien

t an

d p

ub

lic voice

e

mb

ed

de

d

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Outcomes based commissioning

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Principles of Medicines Optimisation

http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

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• Strategic advisory group to NHS England and other CRGs• Advises on commissioning of medicines• It’s about

• Applying principles of MO • Commissioning through evaluation• The evidence base for outcomes of care with NHS England

Commissioned medicines• Alignment of measuring / monitoring medicines through outcome

metrics• Consistency of use across England of specialised medicines

MO CRG – what is it?Rebalancing culture from cost to outcomes

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• Measuring outcomes of care with specialised medicines• Understanding variation in uptake of specialised medicines by populations• Incentivisation principles to support health economies in achieving best

value for money in medicine choice and supply• Commissioning pharmacists - working together across healthcare

boundaries• Improving patient experience - improving efficiency in handling

chemotherapy - eliminating waste• Specialised medicines - an up to date national list • Transparency on specialised medicine product prices

MO CRG Work programme

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• Relies on availability of outcomes data• SACT data• IvIg database• Hepatitis C data

• Data is the most powerful tool we have

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Examples of Outcomes Based Commissioning

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Key Facts… Chemotherapy Commissioning

£1.6 Billion 12% of Spec Com Budget

80% Drugs 20% Delivery

70% of Drug Spend NICE Approved

147 NHS Providers

Annual £ Growth of 8%

SACT Data - 150,000+ patients

1,200 Different drug regimens in use across

England

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SACT & Improving Value

SACT essential for the effective commissioning of Chemotherapy services• Is prescribing in line with National Algorithms?• Real World Outcomes – are we getting Value? If not….• Benchmark providers against clinical quality indicators• Support financial and capacity planning• Linkages to other datasets

We will use contract levers to ensure data collection

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IvIg database & Improving Value

Outcomes data essential for the effective commissioning of immunoglobulin• IvIg spend ~£120m p.a. and increasing • Is prescribing in line with policy?• Payment will only be made if entered on database• Real World Outcomes – are we getting Value? If not….

We will use contract levers to ensure data collection

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Hepatitis C & Improving Value

Outcomes essential for the effective commissioning of Hep C services• Significant number of drugs coming to market – high cost• Trial data suggests high cure rate (SVR)• Real World Outcomes – are we getting Value? If not….

We will use contract levers to ensure data collection

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The future

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Where appropriate, there are strong reasons for devolving specialised services

To restore pathway integrity for patients• To help ensure that specialised care is not commissioned independently from the rest

To enable better allocation or investment decisions• Giving CCGs and their partners the ability to invest in upstream or more effective services

To move towards population accountability • To lay the groundwork for ‘place based’ or population budgets and clearer accountability

To improve financial incentives over the longer term• Avoiding specialised care where appropriate and reducing unwarranted variation

To focus NHS England on services that are truly specialised• Helping improve focus and the quality of specialised commissioning

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Level 1

Centralised – full national control of budgets and contracting• Budget and accountability rest with NHS England• Will include all highly specialised services and other services requiring national planning (e.g

specialised burns; specialised infectious diseases)

Level 2NHS England + CCG co-commissioning

• Budgets and accountability rest with NHS England but CCGs collaborate as networks—perhaps a transitional position

Level 3CCGs individually or in networks

• Budgets and accountability rest with individual CCGs

Beyond ‘one size fits all’– three different tiers of commissioning

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Principles of specialised collaborative commissioning

• The new collaborative arrangements will be co-designed with CCGs• CCGs will be able to choose how much involvement they have in collaborative

arrangements• It is not expected that CCGs will be required to invest additional resource in

setting up or delivering the new arrangements• NHS England will provide a range of development support for CCGs to

implement the arrangements• National standards, policies and specifications will be utilised within locally

designed service models and pathways.

Collaborative commissioning

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Plan today for tomorrow

“There will be no delegation ofcommissioning functions to oversight groups in 2015/16 and NHS England will retain legal and financial responsibility for the commissioning of all specialised services”.

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• A better patient experience through more joined up services

• Improved health outcomes

• Improved equitable access to high quality sustainable services.

Patient benefits

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• Realising benefits for patients and the system from consolidating services and redesigning pathways to deliver more joined up care

• Agreeing the most optimal footprints for commissioning services and pathways for their local populations

• Setting priorities for how and where services are delivered, and which local services are prioritised first

• Supporting the transformation agenda through CCGs and NHS England working together to deliver transformed pathways and QIPP schemes for improved value.

Opportunities for CCGs

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Anyquestions?

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