Service specifications and clinical commissioning policies help to ensure equitable provision and standards of care for the patients for whom NHS England holds direct commissioning (funding) responsibilities. They are developed by clinical reference groups (CRGs) made up of clinicians, commissioners, public health experts, patients and carers who use their specific knowledge and expertise to advise NHS England on the best ways to provide specialised services.
Service specifications define the standards of care expected from organisations funded by NHS England to provide specialised care.
Clinical commissioning policies define access to a service for a particular group of patients.
Where an interim commissioning position may be needed, for example while a full commissioning policy is being developed, or until NICE Technology Appraisal guidance becomes available, a policy statement may be published.
The process by which these documents are developed is detailed in the Methods below:
Where potentially promising new treatments are not currently funded by NHS England the Commissioning through Evaluation programme enables a limited number of patients to access certain treatments as part of a formal evaluation programme. The process by which these schemes are run is described in the Methods below:
Details of the current service specification and clinical commissioning policy work programmes can be found below:
NHS England has developed a framework for how it makes relative prioritisation decisions for new investments in specialised services. The framework was developed through stakeholder engagement and public consultation.
Two public consultations were held. In 2015 the public consultation Investing in Specialised Services proposed a number of principles to guide prioritisation, and it described the characteristics of a proposed process for decision making. NHS England’s response to consultation (June 2015) confirmed that NHS England had adopted the principles from 2015/16 and it described further work that would take place to develop a method for prioritisation for 2016/17. Published documents relating to this consultation are:
- Specialised Services report
- Annex E – Public Consultation period engagement report
- NHS England response publication document
- PPVAG Response – Prioritisation Consultation April 2015
- CPAG Response Investing in Specialised Services Consultation
In April 2016 NHS England held a second public consultation called Developing a Method to Assist Investment Decisions in Specialised Services. This consultation set out a method that it was proposed would be used by the Clinical Priorities Advisory Group when making recommendations on investment decisions for 2016/17. NHS England’s response to consultation (June 2016) confirmed that the method would be adopted for 2016/17 and it described how learning from that year’s commissioning round would inform the development of the method for future years, including through further stakeholder engagement where appropriate. Published documents relating to this consultation are:
Collaborative commissioning guidance
Developing a more collaborative approach to the commissioning of specialised services sets out the vision and next steps for how Clinical Commissioning Groups and NHS England can work together to develop better outcomes and better experience of care through a more collaborative approach to the commissioning of specialised services for 2015/16 and beyond. The guidance document is supported by a suite of tools and resources to help with implementation.
Individual Funding Requests
- Application forms for Individual Funding Requests
- Individual Funding Requests: NHS England’s policy on the conditions, processes and criteria used for decision-making in the case of Individual Funding Requests.
- Interim Standard Operating Procedures: The Management of Individual Funding Requests: This document sets out the process for managing Individual Funding Requests
- Individual Funding Requests – A guide for patients and service users: A guide for patients to explain the Individual Funding Request and Clinically Critically Urgent process
- How do I reach a decision about treatment for my patient?: A Guide for clinicians on decision making in specialised commissioning at NHS England: Refreshed guidance and advice for clinicians on accessing treatments in clinically critically urgent situations
- Standard operating procedure for funding requests for Clinically Critically Urgent treatment outside established policy: Guidance outlining how NHS England will manage funding requests for designated specialised treatments that are considered by the referring clinician as potentially clinically critically urgent.
Launch of the National Clinical Utilisation Review: Guide for Clinical Commissioning Groups
The Clinical Utilisation Review (CUR) is an internationally recognised health technology adopted as national NHS policy in 2006. NHS England concluded a national CUR software supplier procurement framework in July 2015 to support the 2015/16 CUR CQUIN. The framework enables providers to engage with approved suppliers working to the agreed NHS England specification.
To support the 2016/17 CQUIN process the CUR framework is being targeted at realising the evidence based benefits of this technology in services commissioned by Clinical Commissioning Groups (CCGs). This useful guide for CCGs outlines the full framework and provides details on two launch events being held on 7 and 8 September 2015.
Commissioning Intentions provide a basis for constructive engagement between NHS England and providers of specialised services, to inform business plans and contracts. They are intended to drive improved outcomes for patients, and transform the design and delivery of care, within the resources available.
Commissioning Intentions 2017/2018 and 2018/2019 For Prescribed Specialised Services serves as notice to all providers of specialised services in England of changes and priorities for the coming two years. This is supported annually by technical guidance that specifies in more detail which specialised services are commissioned by NHS England, and which are the responsibility of Clinical Commissioning Groups.
Commissioning Intentions for 2017/2018 and 2018/2019 build on those for previous years:
- Commissioning Intentions 2016/17 for Prescribed Specialised Services
- Commissioning Intentions for 2015/16
- Prescribed Specialised Services Commissioning Intentions 2014/15-2015/16
Specialised CQUIN Engagement
NHS England will invest almost £600m through the Specialised CQUIN scheme in the next two years. We are committed to securing improvements for patients and supporting providers to do so. The Specialised CQUIN scheme for 2017/18 and 2018/19 reflects much detailed work with the 42 Clinical Reference Groups, with over 300 clinical leaders of specialised services from trusts and other providers across the country, to identify where opportunities for sustainable and affordable quality improvement lies.
To ensure that the proposals are both well specified and appropriately stretching, NHS England carried out an engagement exercise with organisations to test the Specialised CQUIN definitions alongside those for the CCG indicators. The majority of comments were, as requested, about specific indicators. Many of the comments asked for clarification, and therefore almost all 24 Specialised CQUINs have benefited from some revision to clarify the CQUIN goal, purpose, what is needed, and/or the payment mechanisms. In some cases supplementary information has been added E.g. for GE3 Medicines Optimisation and for GE4 Redesign of Locally Priced Services. For GE1 Clinical Utilisation Review, for a number of sites undertaking pilots in 2016/17, we will write separately to explain how the earlier conclusion of the contracting round can address local arrangements where pilots will not be concluded at the point of contract signature in December.
In a few cases, the engagement process has helpfully pointed to the need to a revision to the substance of a scheme, and/or to the payment mechanisms. Principal changes of substance in response to the engagement are as follows:
- GE3 Hospital Medicines Optimisation: extensive clarification of aim and requirements; corresponding increase in the target payment from 0.6% to 1.0% of relevant high-cost drug expenditure; moderation of some payment milestones to ensure they are achievable.
- BI2 Severe Haemophilia Haemtrack: payment linked to the number of patients (rather than expenditure) – to recognise that the costs of improving adherence lie principally in offering support to patients.
- CA2 Chemotherapy Dose Banding: doubling of the incentive payment (to 1% of relevant spending) in wake of evidence submitted regarding the likely costs of implementation.
- CA3 Optimising Palliative Chemotherapy: shift to a more precise payment mechanism based upon assessment of implementation cost plus a further 50% uplift to provide a CQUIN incentive in line with the principles of the specialised CQUIN scheme.
- WC4 Paediatric Networked Care: recognition in the payment mechanism that cost of change will depend upon the size of the network supported by each Paediatric Intensive Care unit.
- IM2 CF Adherence HealthHub: detailed specification of requirements to comply with the pilot protocol.
A provider specific CQUIN package, with the number of CQUINS commensurate with the financial value of the scheme will form an element of contract offers. We will continue to provide practical guidance and support including Frequently Asked Questions for provider clinical teams via the NHS England local team through the course of finalising contracts and beyond, and work together to ensure successful implementation and benefit realisation is achieved over the two years.
The Engagement exercise concluded on 11 October 2016.
Final version of the PSS CQUIN scheme and its associated Guidance have now been published.
The Operating Model for Specialised Services Commissioning sets out how a single, national system ensures patients are offered consistent, high-quality specialised services across the country.
The Manual is a technical document describing the 149 prescribed specialised services. It describes the rationale and which elements of specialised services are directly commissioned by NHS England and which are commissioned by Clinical Commissioning Groups (CCGs).
- Indications for NHS England drugs list
- NHS England drug list changes
- List of prescribed specialised services directly commissioned by NHS England as at April 2016
Chemotherapy supportive drugs were recognised as an integral part of a chemotherapy regimen when the chemotherapy procurement bands were introduced into the tariff payment system. The drugs incorporated into these payment bands were those that were routinely used during the administration of chemotherapy and are a recognised part of the chemotherapy regimen. So, as examples, anti-emetics, low molecular weight heparin, G-CSF (listed exclusion) are routinely given as part of some chemotherapy regimens. Drugs which are given to patients outside a chemotherapy regimen to correct or treat cancer/chemotherapy-related complications such as infections and blood dyscrasias, for example, antibiotics and epoetin, are not considered supportive drugs in this context. The accompanying table provides a definitive list of supportive drugs that will be routinely reimbursed by NHS England when given as part of a chemotherapy regimen.
The purpose of the Identification Rules (IRs) document is to provide comprehensive guidance to health care provider and commissioner organisations so they can identify and separate specialised services activity from standard inpatient and outpatient activity, as well as identify which services are commissioned by NHS England and those that are commissioned by Clinical Commissioning Groups.
A supporting document, Identification rules for prescribed specialised services: Guide for trust information managers has been written to provide tailored support and guidance to trust information managers, to share some of the knowledge gathered in the testing phase of the IRs and minimise any potential disruption that this reporting change may impose.
Specialised commissioning is supported by a range of NHS England generic commissioning (listed below) policies that are to be applied consistently and cover a range of areas.
- Commissioning Medicines for Children in Specialised Services
- In-Year Service Developments
States NHS England’s position on requests for the recurrent funding of new services.
- Implementation and Funding of NICE Guidance
Sets out how NHS England will respond to the implementation and related funding of new guidance from the National Institute of Clinical Excellence (NICE)
- Experimental and Unproven Treatments
Sets out the circumstances in which NHS England may wish to fund a treatment or intervention which is either considered experimental or not to be of proven effectiveness
- On-going Treatment Following a NHS CB Funded Trial
Sets out NHS England’s policy on access to treatment following the completion of a trial which it has explicitly funded
- On-going Treatment Following Non-Commercially Funded Clinical Trials
Sets out NHS England’s policy on access to treatment following the completion a non-commercially funded trial
- On-going access to treatment following a trial of treatment
Sets out NHS England’s policy with regard to the funding of a patient’s treatment at the end of a ‘trial of treatment’ which it does not normally commission.
- Patients changing responsible commissioner
States NHS England’s policy on when it will accept responsibility for existing funding commitments made by patients’ previous commissioning bodies e.g. Primary Care Trust or Clinical Commissioning Group
Policy on choices for elective referrals for which NHS England is responsible.
- Defining the boundaries between NHS and private healthcare
This policy defines the boundaries between privately funded treatment and entitlement to NHS funding, under a range of circumstances.
- On-going Access to Treatment Following Industry Sponsored Clinical Trials or Funding
Sets out NHS England’s policy on access to treatment following the completion of industry sponsored clinical trials or funding
- Clinical Service Derogation of Commissioned Specialised Services
Sets out the circumstances under which clinical providers may apply for a derogation, or temporary delay, in meeting key service requirements in full, as described in the service specification, or other mandatory commission requirements
- Commercial Service Derogation of Commissioned Specialised Services
Sets out the circumstances under which commercial providers may apply for a derogation, or temporary delay, in meeting key service requirements in full, as described in the service specification, or other mandatory commission requirements