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:
- 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.
- 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.
- 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.
- Service development policy
- Infographic showing the service development process
- Methods document on National Service Specifications
- Methods document on National Clinical Policies
- Ethical framework for priority setting and resource allocation.
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:
- Clinical commissiong service specification work programme
- Clinical commissioning policy work programme
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
NHS England’s policy on the conditions, processes and criteria used for decision-making in the case of Individual Funding Requests (IFRs).
- Interim Commissioning Policy: Individual funding requests
- Interim Standard Operating Procedures: The Management of Individual Funding Requests
- Application form for IFRs
Where a treatment or service is not routinely offered by the NHS, a healthcare professional may submit to NHS England an Individual Funding Request (IFR). As of January 2016, improvements have been made to the administrative processes for managing IFRs. These changes have made been as a result of the experience gathered over the past 3 years, since NHS England took on responsibility for the IFR process, and have been made following engagement with a range of stakeholders, including the NHS England Patient and Public Voice Assurance Group. The aim of the revised IFR process is to ensure a more timely and consistent approach to managing IFRs for NHS England prescribed services.
An amended standard operating procedure for the management of individual funding requests has been published to reflect the changes.
A single point of entry system for clinicians to submit all IFR applications has also been implemented with the aim of providing a clear route for submission of requests. Healthcare professional wishing to submit an IFR should send the relevant completed documentation to: firstname.lastname@example.org.
- 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
- 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
- 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