Managing medicines: Commissioning

Last updated: Sunday, July 11, 2021

Commissioning is the process of planning, agreeing and monitoring services. From the hospital perspective it is often seen as being concerned with paying for the services that your Trust provides. It is a complicated subject and this is just a simple introduction.

Basically, the services that your hospital offers are either commissioned nationally by NHS England or locally by your CCGs. The precise arrangements are managed via contracts between the provider (e.g. your Trust) and the responsible commissioner. If you're feeling brave, there are two diagrams from the King’s Fund showing how providers of NHS services are regulated, commissioned, and funded.

ⓒCrown copyright 2017
NHS England is responsible for commissioning a range of specialised services (e.g. for patients with cystic fibrosis). The details of these services are published in what is known as The Manual. All other services are commissioned locally by CCGs following NICE guidance or after negotiating a local arrangement. You can read more online about NHS England’s commissioning role, while details of your local arrangements are often published on a CCG’s website.

For every hospital intervention, a national tariff (previously called ‘Payment by Results tariff’ or PbR) specifies a set price for each episode of patient treatment e.g. a hip replacement operation. These tariff prices cover the majority of acute healthcare in hospitals and usually incorporate the costs of routine medicines. However, there is a list of selected High Cost Drugs excluded from the tariff which require separate reimbursement by the responsible commissioner (NHS England or your CCG). These are sometimes termed ‘PbR excluded’ or ‘ex-tariff’ drugs. An example is adalimumab.

NHS England publish a list of the medicines that they commission on their website (‘NHS England Drug List’). If the drug is not listed by NHS England, it will probably be commissioned by your CCG but you can ask your CCG pharmacist if they commission it and will reimburse the Trust.

Individual Funding Requests

The commissioner is responsible for deciding whether or not a treatment will be routinely funded for defined groups of patients. An individual funding request (IFR) is a request for a commissioner to fund healthcare for an individual who falls outside the range of services and treatments that they have agreed to routinely commission and fund. NHS England have a video that explains IFRs. The requests generally fall into 3 categories:

  • The patient has a rare condition. 
  • The patient has a more common condition but a case is made that the usual pathway doesn’t work for them (they are an exceptional case).
  • The patient and clinician want to use a treatment that is not routinely used (perhaps because it is new or not licensed for use in the UK) and therefore not routinely commissioned.

ⓒCrown copyright 2017

In terms of 'rare', NHS England defines it as ‘the patient’s clinical presentation is so unusual that they could not be considered to be part of a defined group of patients in the same or similar clinical circumstances for whom a service development should be undertaken’ and for which there is no existing treatment policy/pathway. CCGs tend to follow the same principles – i.e. almost unique and there is unlikely to be another case so as not to create a precedent.

The principle of exceptionality is another key consideration for assessing IFRs, typically demonstrating that:

  • The patient is significantly different to the general population of patients with the condition in question; AND 
  • They are likely to gain significantly more benefit from the intervention than might be normally expected for patients with that condition. 

It is important that IFRs are directed to the correct commissioner to avoid delays in patient care. Senior pharmacists often work with other healthcare professionals to make the case for an IFR.

  • Does your hospital have a contract with NHS England for providing a range of specialised services? 

  • Find out the arrangements for processing IFR requests in your hospital.