Managing medicines: Commissioning

Last updated: Monday, July 08, 2024

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 majority of services that your hospital offers are either commissioned nationally by NHS England or locally by your integrated care board (ICB). The precise arrangements are managed via contracts between the provider (e.g. your trust) and the responsible commissioner. 

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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 ICBs 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 ICB’s website. NHS England has plans to delegate responsibility for commissioning of a number of specialised services to ICBs as outlined in their document: Roadmap for integrating specialised services within Integrated Care Systems

High cost drugs

For every hospital intervention, the NHS Payment Scheme (previously called the National Tariff or Payment by Results (PbR) tariff) 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 payment scheme which require separate reimbursement by the responsible commissioner (NHS England or the local ICB). These are sometimes termed ‘PbR excluded’ or ‘ex-tariff’ drugs. 

You can find a list of all the excluded high cost drugs in the latest NHS Payment Scheme prices workbook, available as a spreadsheet published on the NHS England website each financial year. An example is adalimumab. 

NHS England publish a separate list of the medicines that they commission on their website (NHS England High Cost Drugs Commissioning List). If the drug is included in the NHS Payment Scheme workbook list of high cost drugs, but is not on the NHS England High Cost Drugs Commissioning List, it will probably be commissioned by the local ICB. If a drug is high cost, but isn’t on either of these lists, it may need an individual funding request (IFR) and/or Chief Pharmacist approval. Commissioning is complicated so it’s best to check with a senior pharmacist before supplying any medicine that seems expensive or unusual – better to be safe than sorry!

Individual funding requests

The commissioner (i.e. NHS England or the local ICB) 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.

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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. ICBs 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.