Key documents

Service Development Policy and Methods

This service development policy sets out NHS England’s approach for making decisions about which new treatments and interventions to routinely commission, and the approach used for updating existing service specifications, or creating new ones.

It is intended to ensure that funding is allocated fairly and appropriately, with due regard to the competing demands on NHS England’s available funding.

The service development process has three phases:

  1. Clinical build: This phase is where new or amended clinical commissioning policies and new or amended service specifications are proposed and developed. Policy propositions are will need to be underpinned by a clinical evidence review.  NHS England’s specialised services Clinical Panel challenges and confirms whether the proposition has a sound evidence base. Service specifications do not normally require an evidence review and therefore are not normally considered by the Clinical Panel.
  2. Impact analysis: This stage identifies the financial and operational impacts of moving from current pathways of care to the pathways proposed in the draft policy proposition or service specification proposition. The proposed policy or service specifications then are also subject to stakeholder testing, and public consultation.
  3. Decision: For policy propositions and service specification propositions which are cost-neutral or cost-saving, the decision on whether to approve is based on an assessment of its clinical benefit. For propositions which require additional investment and where there is not sufficient funding available to cover all interventions being proposed, the policy propositions are assessed on their likely relative clinical benefit and relative value for money. Using this information, NHS England carry out twice a year a relative prioritisation process to determine which services will be routinely commissioned.

NHS England can rapidly assess policy propositions, for example where there is an urgent clinical case and it would not be appropriate to wait for a decision to be made through the full service development process.  In these circumstances a policy statement can be put in place to provide an interim commissioning position which allows interim access to the service, or to make it clear that there is no access to the service until a full assessment has been carried out. The policy may then be considered in full through the normal service development process.

The service development policy document, and supporting methods documents set out the policy and process for these in more detail.

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:

Individual Funding Requests

Individual funding requests (or IFRs) are made to NHS England by clinicians when they believe that a patient’s clinical circumstances are exceptional and because of this, they would benefit from a treatment that isn’t usually available on the NHS. Applications are considered by an independent panel made up of doctors, nurses, public health experts, pharmacists, NHS England representatives and lay members.

More information about IFRs and how decisions are made is available in our patient guide and process map.

NHS England’s policy and standard operating procedure, which are used for decision making in the case of IFRs, are below.

These documents were consulted on with the public, and a range of other stakeholders, between October 2016 and March 2017. The aim of the revised IFR documents is to make sure there is a timely and consistent approach to managing requests.

You can read the detailed consultation response, which provides a summary of the key themes identified and how these have shaped the new policy and supporting documentation.

Healthcare professionals wishing to submit an IFR should send the completed application form and any supporting documents to: england.ifr@nhs.net.

Terms of Reference for the Specialised Commissioning Oversight Group (SCOG)

SCOG is a decision-making group within NHS England, established in order to deliver the key priority of creating sustainable, clinically effective and affordable specialised services. It has operational oversight of specialised commissioning and holds to account the national and regional specialised commissioning teams in NHS England in delivering high quality specialised services within budget. SCOG also receives recommendations from the Clinical Priorities Advisory Group (CPAG) on the introduction of new clinical commissioning policies  and other service developments.

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

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:

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.

Operating Model

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

The Manual is a technical document describing the 146 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).

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.

Identification Rules

The Identification Rules (IR) is a mechanism by which healthcare activities can be identified as specialised. The data flows used to support the commissioning process consist of both standard and non-standard flows of various quality and content. It is therefore not possible to have one single identification method for prescribed activity. There are two products that exist and are required to be used in tandem in order to identify specialised service activity:

Other NHS England Commissioning Policies

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.