What is commissioning?

Yorkshire & the Humber Office What is commissioning? Paul McManus Pharmacist Advisor Yorkshire and the Humber Office North of England Specialised Commissioning Group North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

The commissioning cycle • Where do medicines fit in? • Who are the commissioners? • Medicines’ optimisation North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Commissioning in the NHS is the process of ensuring that the health and care services provided effectively meet the needs of the population North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Outputs • Needs assessment • Service specification • Designation of service • Commissioning policies • Contractual framework - currencies/tariffs • Information • Quality measures/CQUIN • Innovation North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

It depends… • Community supply • Funded from PCT prescribing budget • Clinical and financial risk typically managed through ‘formulary’/D&TC/APC/local prescribing schemes • Traditional role of Medicines Management (MM) teams North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Payment by Results (PbR) is the payment system in England under which commissioners pay healthcare providers for each patient seen or treated. • Hospital supply /home delivery • Funding managed as part of contractual agreement • ‘In tariff’ – medicine costs included in contract payment to provider • ‘Excluded from tariff’ – medicine costs passed on to commissioner • Other funding arrangements – e.g. Cancer Drugs Fund (CDF) • Clinical governance managed by provider • Conflicts – e.g. ‘compassionate’ supplies, CDF, ex-clinical trials • Shift in focus for MM teams to manage high-cost medicines North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Medicines’ commissioning • Response to PbR and ‘excluded’ high-cost medicines • Inappropriate introduction of new medicines by Individual Funding Requests (IFRs) • Local-decision making • National Prescribing Centre • Secretary of State directions April 2009 North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Local decision-making “You have the right to drugsand treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you.” “You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you, they will explain that decision to you.” North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Local decision-making NHS standard contract 2012/13 Where a Variation would have a cost implication for the Commissioners, including for the avoidance of doubt and without limitation, additional activity, new treatments, drugs or technologies, then: • the Provider shall provide a full and detailed cost and benefit analysis of the requested or proposed Variation; and • the Co-ordinating Commissioner shall, after consultation with the Provider, in its absolute discretion have the right to refuse or withdraw the requested or proposed Variation; and • the Commissioners shall have no liability to the Provider for any costs arising from the requested or proposed Variation should the Provider implement it other than in accordance with this Agreement. North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Local decision-making • Population focused • Commissioning policies • IFRs only for ‘exceptions’ to policies • Aligned with commissioning cycle • Horizon scanning • Opportunities to link commissioning with procurement North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Who are the commissioners? Pre-April 2013 • Primary Care Trusts • Specialised Commissioning Groups Post-April 2013 • Clinical commissioning groups (“GP consortia”) • NHS Commissioning Board North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Health and Social Care Act 2012 “3B Secretary of State’s power to require Board to commission services (1) Regulations may require the Board to arrange, to such extent as it considers necessary to meet all reasonable requirements, for the provision as part of the health service of— (a) dental services of a prescribed description; (b) services or facilities for members of the armed forces or their families; (c) services or facilities for persons who are detained in a prison or in other accommodation of a prescribed description; (d) such other services or facilities as may be prescribed. (2) A service or facility may be prescribed under subsection (1)(d) only if the Secretary of State considers that it would be appropriate for the Board (rather than clinical commissioning groups) to arrange for its provision as part of the health service. (3) In deciding whether it would be so appropriate, the Secretary of State must have regard to— (a) the number of individuals who require the provision of the service or facility; (b) the cost of providing the service or facility; (c) the number of persons able to provide the service or facility; (d) the financial implications for clinical commissioning groups if they were required to arrange for the provision of the service or facility. North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

New responsibilities • CCGs become the commissioners of some non-tariff high cost medicines, for example: • Anti-TNFs • Ranibizumab • “For CCGs, sound policies around medicines are crucial to ensuring patient safety and good care. It also makes financial sense as £13bn of the NHS budget goes on prescribing.” • “CCGs wishing to ‘aggregate brain power’ should fund specialist teams or committees covering a very large population area to evaluate and make recommendations on new or expensive medicines and devices” Commissioning Excellence, May 2012 North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

New responsibilities • Direct commissioning by NHS Commissioning Board for ‘prescribed’ services • National policies, for example for: • Cystic fibrosis • Pulmonary hypertension • Renal replacement • Transplants • Immunoglobulins • HIV? • All cancer? North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Impact on procurement • Procurement is a key consideration • Home delivery • Tenders • Focus on total medicines’ expenditure • Consideration of service costs • Optimising investment in high-cost medicines • Business planning for new medicines North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Some challenges • Maintaining focus on medicines’ optimisation • Working with a national commissioner • Hackett report • ‘gain’ sharing between providers and commissioners • Patient access schemes and other ‘discounts’ • confidential price agreements • impact on community pharmacy • Value based pricing North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

Yorkshire & the Humber Office What is commissioning? paulmcmanus@nhs.net North of England Specialised Commissioning Group comprises the former North East SCG, North West SCG and Yorkshire and the Humber SCG

What is commissioning?