Commissioning through Evaluation

Background

NHS England’s Commissioning through Evaluation (CtE) programme enables a limited number of patients to access treatments that are not funded by the NHS, but nonetheless show significant promise for the future, while new clinical and patient experience data are collected within a formal evaluation programme.

There are two main phases to the programme:

  • Phase 1 – an agreed number of patients are recruited to a CtE scheme within just a few selected centres across England. The National Institute for Health and Care Excellence (NICE) helps to identify the total number of patients who need to be recruited to the scheme to support data analysis. It is important to note that schemes may end earlier than expected, if enough patients have been recruited to support this analysis. Equally, the number of patients to be recruited may be increased, if, for instance, a scheme fails to recruit enough patients in a particular group. The closure of each scheme depends on the point at which sufficient patients have been recruited to complete data analysis. Only then does a scheme enter the second phase.
  • Phase 2 – the analysis phase will vary in length, depending on the evaluation measures agreed by clinicians and patients at the start of each scheme. For example, it may be important to test whether the expected benefits of a treatment have been both achieved, and maintained, at 12 and 24 months; or there may be a need to evaluate whether a treatment, such as a novel cancer treatment, has halted the disease process, or improved overall survival, at three and six months.

NHS England receives advice from NICE on the need for, and the length of, follow-up measures, as well as the number of patients who would need to be assessed at the various points of follow-up in order for the analysis to be completed.

This approach ensures that each CtE scheme provides valuable new data, beyond that already available from clinical trials, or where there is no clinical trial data, to inform future commissioning policy decisions.

Whilst any patients already being treated as part of a CtE scheme will continue to receive appropriate follow-up care, no new patients will be funded by NHS England during the subsequent analysis phase.

During the analysis phase, NHS England’s published policy position for the treatment concerned will continue to apply which will mean that the procedure will not be routinely available within the NHS.

Once the CtE evaluation report is available, or if other significant clinical trial information becomes available more quickly, NHS England’s published policy for the treatment concerned will be reviewed and a decision will be made with regard to whether NHS England will or will not make the treatment available within the NHS.

Full details of the Commissioning through Evaluation approach can be found in the Methods: Commissioning through Evaluation document,

CtE scheme updates

There are currently two active schemes within NHS England’s CtE programme. It should be noted that schemes will only cease once planned patient recruitment numbers have been reached, therefore it is not possible to provide a definite scheme stop date in relation to a number of the schemes.


Selective Dorsal Rhizotomy (SDR): This is a procedure that aims to increase mobility in children with cerebral palsy by selectively cutting nerves in the spine to improve spasticity (muscle stiffness).

Phase one was completed at the end of March 2016, with 140 patients receiving Selective Dorsal Rhizotomy (SDR) surgery at five SDR centres across England. An evaluation (phase two) in partnership with the National Institute for Health and Care Excellence (NICE) has now been completed, which monitored the clinical outcomes of all 140 patients. Following an extension of the evaluation period between spring 2017 and summer 2018, the final evaluation report has new been published and available here:

Commissioning through Evaluation: Selective Dorsal Rhizotomy

NICE has now completed its independent evaluation report for the SDR scheme.

The final reports have been considered by the SDR Steering Group Public Health Lead and independent clinical lead who have concluded that based on the new evidence of two year follow up data, there are no changes required to the current policy for the treatment of spasticity in cerebral palsy (children aged 3-9 years). A link to the current policy can be found here:

Selective dorsal rhizotomy for treatment of spasticity in cerebral palsy

In June 2018 a commissioning decision to continue with the treatment was taken to reduce the delay between the policy being published and access to treatment, the service will continue to be made available at the former five CtE sites listed below:

North Region: 
Leeds Teaching Hospitals NHS Trust
Alderhey Hospital NHS Trust

South Region:
Bristol University Hospitals NHS Foundation Trust

Midlands and East Region:
Nottingham University Hospitals NHS Trust

London Region:
Great Ormond Street Hospitals NHS Foundation Trust

The former five CtE participating centres have already gone through a selection process and have known clinical experience of the procedure. Therefore, these centres are well placed to provide the interim provision pending a formal new selection process to identify substantive providers. The selection process to identify substantive providers will be linked to a formal nationally led procurement intervention to be completed in Summer 2019.


Selective Internal Radiation Therapy (SIRT): This is a form of radiotherapy using radioactive beads to treat cancerous tumours in the liver.

A total of 10 centres participated in the SIRT CtE scheme:

  • Cambridge University Hospitals NHS Foundation Trust
  • Kings College Hospital NHS Foundation Trust
  • Leeds Teaching Hospitals NHS Trust
  • Newcastle upon Tyne Hospitals NHS Foundation Trust
  • Nottingham University Hospitals NHS Trust
  • Oxford University Hospital NHS Trust
  • The Christie NHS Foundation Trust
  • The Royal Free London NHS Foundation Trust
  • University Hospitals Birmingham NHS Foundation Trust
  • University Hospital Southampton NHS Foundation Trust

NICE has now completed its independent evaluation of the SIRT CtE scheme.  The evaluation will support a planned review of the currently published NHS England clinical commissioning policy statement for the use of SIRT.


Percutaneous Mitral Valve Leaflet Repair (Mitraclip): This procedure is used to treat mitral regurgitation in patients with heart failure.

The Commissioning through Evaluation (CtE) Scheme has now closed and the reports can be found below:

Percutaneous mitral valve leaflet repair for mitral regurgitation: Commissioning through Evaluation Report

NICE independent evaluation report for the mitral valve leaflet repair scheme.


Patent Foramen Ovale (PFO) Closure: This procedure is intended to reduce the risk of recurrent stroke. The Commissioning through Evaluation (CtE) Scheme has now closed. The NICE Evaluation Report has now been published.

NHS England is currently reviewing the latest evidence of clinical effectiveness together with the CtE Evaluation Report to develop an updated clinical commissioning policy. In the meantime, the currently published  PFO Policy Statement remains extant.


Left Atrial Appendage Occlusion (LAAO): This procedure may be considered to reduce the risk of stroke in patients with atrial fibrillation and who cannot take the standard treatment of blood thinning medication. The Commissioning through Evaluation (CtE) Scheme has now closed. The NICE Evaluation Report has now been published.

NHS England has reviewed the latest evidence of clinical effectiveness and the CtE Evaluation Report and has published an updated clinical commissioning policy.


Stereotactic Ablative Radiotherapy (SABR): SABR is a more precise delivery of radiotherapy, applying high doses of radiation whilst causing less damage to surrounding healthy tissues.

Centres participating in this scheme are:

Oligometastic Disease

  • Barts Health NHS Trust
  • Guy’s and St Thomas’ NHS Foundation Trust
  • Leeds Teaching Hospitals NHS Trust
  • Mount Vernon Cancer Centre (North and East Hertfordshire Foundation Trust)
  • Newcastle upon Tyne Hospitals NHS Foundation Trust
  • Nottingham University Hospitals NHS Trust
  • Oxford University Hospital NHS Trust
  • Royal Surrey County Hospital NHS Foundation Trust
  • Sheffield Teaching Hospitals NHS Trust
  • South Tees Hospitals NHS Foundation Trust
  • The Christie NHS Foundation Trust
  • The Clatterbridge Cancer Centre NHS Foundation Trust
  • The Royal Marsden Foundation Trust
  • University College London Hospitals NHS Foundation Trust
  • University Hospitals Birmingham NHS Foundation Trust
  • University Hospitals Bristol Foundation Trust
  • University Hospitals of Leicester NHS Trust

Re-irradiation of pelvis and spine

  • Barts Health NHS Trust
  • Guy’s and St Thomas’ NHS Foundation Trust
  • Leeds Teaching Hospitals NHS Trust
  • Nottingham University Hospitals NHS Trust
  • Mount Vernon Cancer Centre (North and East Hertfordshire Foundation Trust)
  • Oxford University Hospital NHS Trust
  • The Royal Marsden NHS Foundation Trust
  • University Hospitals Birmingham NHS Foundation Trust

Hepatocellular carcinoma

  • Barts Health NHS Trust
  • Guy’s and St Thomas’ NHS Foundation Trust
  • Leeds Teaching Hospitals NHS Trust
  • Mount Vernon Cancer Centre (North and East Hertfordshire Foundation Trust)
  • Oxford University Hospital NHS Trust
  • The Royal Marsden NHS Foundation Trust
  • University Hospitals Birmingham NHS Foundation Trust

A number of new potential CtE schemes are under consideration by NHS England. Updates regarding existing, and any new, schemes will be provided here in due course.