Specialised commissioning: Where are we today?

Suzy Heafield

Specialist Medicines Pharmacist

NHS England: West Midlands

Pharman National Forum, Birmingham

22nd October 2015

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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 (Five Year Forward View)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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• Need to improve patient outcomes, quality and value by:• Finding new and innovative ways to deliver services

to patients.• Extracting more value from the money spent in the

NHS, including from medicines

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The Challenge

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Medicines Utilisation in Practice

Medicines still most common therapeutic intervention and biggest cost after staff (15% of NHS budget) but:

30 to 50% not taken as intended5 to 8% of hospital admissions due to preventable adverse effects of medicinesRelatively little effort towards understanding clinical effectiveness of medicines in real practice

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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From “Manage” to “Optimise”

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Medicines Management

Medicines Optimisation

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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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1. Patient experience- What are organisations and clinicians doing to ensure they really understand the patient experience?

2. Evidence based – We think we do this well, but do we really understand the evidence base, e.g. trials and the cohorts used? Do we adhere to NICE guidance and monitoring schedules? Do we understand biosimilars?

3. Medication safety - How good are we at implementing safety alerts? Are we sure clinicians get the message or are they waiting for their organisation to initiate the change?

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Medicines Optimisation –can we do better?

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4. Improved patient outcomes – what outcomes should we be measuring?

5. Measurement and metrics – Do we really know if we are getting any better?

6. Patient centred - Are all of our decisions centred around the patient, including those we don't have resource to see?

7. Making medicines optimisation part of routine practice - All the above suggest we have some way to go before we can be confident we have really moved clinical practice to be delivering MO

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Medicines Optimisation –can we do better?

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Medicines Optimisation in Specialised Services

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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 is responsible for specialised commissioning • Estimates show that this may account for approximately

£2.4billion of medicines spend annually (40-50% of hospital medicines spend) and is increasing at ~10% p.a.

• 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 happened in Specialised Services in 2015/16?

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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 (measurement and metrics)• 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

NOTE: This does not include Hepatitis C

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Improving Value Schemes

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

with policy (evidence based)• Used initially for Hepatitis C drugs, MS drugs• Use is being 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 (monitoring outcomes)

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What is Blueteq?

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

• CMU 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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Other QIPP Schemes

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Outcomes Based Commissioning

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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

Medicines Optimisation CRGRebalancing 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• Transparency on specialised medicine product prices (Carter review)• Embedded commissioning pharmacists - working together across

healthcare boundaries• Improving patient experience - improving efficiency - eliminating waste, e.g.

chemotherapy standardisation• Specialised medicines - up to date national list

MO CRG Work programme

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• Relies on availability of outcomes data (measurement and metrics; monitoring outcomes)• Systemic Anti-Cancer Therapy (SACT) data• Immunoglobulin 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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Immunoglobulin 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 new drugs 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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Policy Development and Individual Funding Requests

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• National (instead of regional) approach to be adopted during 2015/16 to ensure equity

• Patients must be “exceptional” for IFR to be considered• If a cohort of similar patients then considered for policy development• Clinically Critically Urgent treatment policy for situations which may

be life threatening or major loss of function• Suggested reading:• https://

www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/06/how-to-reach-decision-trtmnt-pats.pdf

Individual Funding Requests

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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

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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:

Principles to aid Prioritisation

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• 40 new NHS England policies published in July 2015• “Turnkey”:

• Interventions that have been prioritised for evidence review• Evidence reviews currently under way• Will be prioritised for commissioning during 16/17 based on

prioritisation principles

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New Commissioning Policies

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The (not too distant) Future

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Co-commissioning

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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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• How do we get clinicians more involved in Medicines Optimisation?

• How can we get patients more involved in Medicines Optimisation?

• How can we ensure Medicines Optimisation is part of routine practice?

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Improved clinical and patient engagement

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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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