Meeting of Bristol Clinical Commissioning Group To be held on Tuesday, 2 July 2013 commencing at 1.30 pm in the BAWA Centre Title: Replacement of the Commissioning Advisory Forum Agenda Item: 9 1 Purpose To propose and seek agreement of the CCG to the replacement of the Commissioning Advisory Forum [CAF] with new treatment policy review arrangements. 2 Background The CAF was established in 2007 in order to support the commissioning decision-making process; identifying local priorities and to develop local commissioning policies for the commissioning of drugs and health care interventions that are not routinely funded across BNSSG. With the commencement of the CCGs on 1 April 2013 and NHS England taking responsibility for many areas of work previously considered by the CAF, a review of the CAF system was undertaken. This paper summarises the key recommendations from that meeting. 3 Discussion of issues Within that ethos, the CAF enabled clinicians to bring forward proposals for new service developments in order to support any funding application put forward to the annual funding round as well as allowing PCT Commissioners to bring forward policies in order to manage access to low priority treatments. The CAF s role in reviewing new treatment and service requests from Clinicians meant that the committee would examine the proposals including the clinical evidence to support such treatments and consider whether they could recommend the development of the services to the local CCGs. Each proposal from a clinician would lead to a policy being drawn together to either allow access to all patients, a restricted group of patients or only allow the treatment to be given in exceptional circumstances. As the financial picture of the NHS has become more challenging in recent years, the CAF was less able to support initiatives which would require significant investment and therefore the link to the annual funding round diminished. However, this is seen as a key area in providing commissioning support to CCGs in future annual funding processes. If you need this document in a different format telephone the PCT on 0117 900 2632 Page 1 of 8
The CAF also considered whether to recommend the adoption of policies restricting access to established treatments which are considered to be lower priority. The list of these policies is known as the Interventions Not Normally Funded list or INNF list. It should be noted that the CAF did not have powers to award funding to new service developments and if funding was needed, this would need to be secured through the normal annual funding rounds. Proposals that are cost saving or self-funding were able to be implemented if both the CAF and CCGs had approved the development. The CAF Committee comprised: A GP from each of the three Clinical Commissioning Groups [CCGs] in the BNSSG area, and The Medical Director, Pharmacy Director and Commissioning Manager from both UH Bristol Trust and North Bristol Trust, and a representative from Weston Area Health Trust A Commissioning Manager from each of BNSSG PCTs and A Medicines Management lead, and Public Health Consultants. Key Proposals In considering this issue, it is clear that the conflicting needs of service developments, including new technologies, new medicine uses and policy developments could no longer be effectively managed through one CAF style process. Therefore, it is recommended that each area should be considered by separate bodies. New Uses of Medicines: Previously, proposals for new uses of drugs were considered by the CAF. However, there was traditionally a number of overlaps in the responsibilities of CAF and the Joint Formulary Group and this made the process for having new drug uses confusing for providers. The Executive Summary of the Joint Formulary Group Annual Report for 2012/13 is reproduced in Appendix 1 for information. With the commencement of the CCGs, the remit of the Joint Formulary Group has been reviewed and Public Health support via the Core Offer has been secured, the Joint Formulary is now seen as the vehicle to take forward new drug commissioning. The first recommendation is that the consideration of commissioning drugs should be removed from the remit of the CAF successor and in future all drugs will be considered by the Joint Formulary Group. Discussions have taken place regarding this chance of remit for the Group and changes to that groups Terms of Reference will be taken forward by the Medicines Management team. New Interventions: Historically the CAF was first developed mainly in order to consider the clinical evidence around new service development proposals from the Acute Trusts. This Page 2 of 8
ensured that there was a method to review the evidence and to inform the annual financial planning round whether a proposal was clinically effective. However, with the challenging financial position that developed, this element became a lower priority for the Acute Trusts and the PCTs. However a process to review and agree priorities for new service developments is needed by the Trusts and CCGs in order to assess the benefits of proposals. A process is also needed to review new service development proposals ahead of the annual funding process and to ensure that the clinical evidence supports such new developments. New service developments will include proposals where the Trusts are developing a new surgical intervention but it will be used on an existing patient group and will not change the HRG to which they are coded. This group will require the Trusts to consult over all new service developments at the new interventions group, and that if they do not the provider will be liable for any additional financial impact arising from this. This will ensure that the CCGs will have an enhanced level of control over new service developments. The enhancement of the Healthy Futures programme across BNSSG could allow joined up working ensure wider consideration of such proposals. Discussions will take place with the Healthy Futures team to explore this. It is proposed that subject to discussions with the Healthy Futures programme, this body will meet twice per annum. Clinical Policy Review Group - Over the last four years, over 100 clinical policies managing access to treatments for planned care procedures have been agreed and implemented through the CAF process. With persistent pressures on planned care budgets, and an on-going need to review and renew the established policies, it is proposed that a new Policy Review Group be established. The Clinical Policy Review Group will replace the CAF, the remit of the group will be to: Undertake a programme of review of the current BNSSG CCG policies to ensure that they remain appropriate, measured and effective, particularly to confirm that the evidence supporting their initial adoption remains valid. This review will also mean greater exploration of what alternatives for the patients are available if an intervention is not the option in future and wider consideration needs to be given to costs and effects of policies being adopted. Review the evidence to support new policy developments and balance the conflicting demands of evidence to support treatments (which are often long established) against capacity and resource restrictions Review the impact of new policy developments on activity, capacity and resources six months following the implementation of the agreed policies. (Note: implementation of new policies need to be agreed contractually with the Page 3 of 8
Acute Trusts and they are allowed one month following the signing of contract variations to implement fully) These activities above will result in recommendations to the BNSSG CCGs around existing and proposed policies and the CCGs will receive these reports jointly from the CCGs Individual Funding Request Leads and the Individual Funding Request Manager of the SWCSU. This group will comprise: Individual Funding Request Leads from each of BNSSG CCGs, with a far greater input from primary care colleagues being desirable, Public Health colleagues (this support is included in the Core Offer), secondary care clinicians with experience of the area being discussed, and public engagement. It is proposed that this group will meet quarterly initially and be administered by the Individual Funding Request team of SWCSU. A Terms of Reference will be developed upon acceptance of this proposal. The TOR will state that the Policy Review Group will make recommendations to the CCGs and they will continue to be approved, or rejected, by the BNSSG CCG Boards. 4 Financial Implications There are no financial implications to this proposal. Each development and policy considered by the new groups will consider the financial impact separately. 5 Legal implications There are no legal issues raised in this paper 6 Risk implications, assessment and mitigation There is no risk envisaged in implementing this recommendation. 7 How have service users, carers and local people been involved? No service users have been specifically consulted on this change but it is proposed to secure wider pubic engagement in the Fora going forward. In addition, there has been wide consultation with former CAF members in developing these proposals. 8 Implications on equalities and health inequalities. There is no impact. 9 How does this fit with Bristol CCG s Annual Work Plan or Strategic Objectives? This proposal allows the CCG to have an open and transparent process for reviewing and adopting new policies and interventions. Page 4 of 8
10 Recommendation(s) The Clinical Commissioning Group is asked to: Agree the proposed solution for the replacement of the Commissioning Advisory Forum [CAF], including: o that all proposals for the new uses of medicines and drugs be considered by the Joint Formulary Group, o that a New Interventions Review Group be established jointly with the Healthy Futures programme, o that a new Clinical Policy Review Group be established across BNSSG CCGs to consider and review policies governing access to planned care treatments. Niall Mitchell IFR Manager SWCSU 21 June 2013 Claire Beynon Head of Thresholds Management SWCSU 21 June 2013 Appendices Appendix 1 BNSSG Joint Formulary Group Annual Report Executive Summary Page 5 of 8
Appendix 1 BNSSG Joint Formulary Group Report 2012/13 Executive Summary This report outlines the work undertaken by the BNSSG Joint Formulary Group (JFG) during the period April 2012 March 2013, on the back of a significant change in process for managing the entry of new medicines into the BNSSG Joint Formulary, implemented in December 2011. The JFG is an operational and decision making subgroup of the BNSSG Drugs and Therapeutics (D&TC) and is responsible for developing, and updating the Joint formulary. It seeks to harmonise working across the sector, reduce duplication of work and deliver benefits in terms of quality, safety and efficiency of medicines use across both primary and secondary care. The JFG membership includes both primary and secondary care NHS staff, comprising of Secondary Care Clinicians, GPs, Pharmacists, nursing, and Public Health. The aim of the Joint Formulary (JF) is to promote safe, effective, and economic prescribing in both primary and secondary care. The BNSSG JF covers prescribing in primary and secondary care, and covers approximately 900,000 population. Obtaining agreement across the interface between primary and secondary care and the subsequent prescribing within the JF promotes a seamless approach to prescribing which will benefit all patients who require medicines, and reduces the need for medicine switching programmes. The BNSSG Joint Formulary group manages all new medicine applications to the JF which up until December 2011, was the remit of the individual trusts D&TCs. This was a significant change in process for all members of the JF. There are many benefits of operating a centralised approach to managing the entry of new medicines within BNSSG; the two significant ones being reducing duplication of work within the area and local clinicians having a consistent set of medicines to prescribe from. The group also manages the Traffic Light Status (TLS) of Formulary medicines (i.e. agreeing where appropriate prescribing responsibility should lie) and also the co-ordinating and signing off of Shared Care Protocols for those medicines that have been given amber status i.e. medicines appropriate for specialist initiation, that may be continued by primary care under appropriate written guidance. The BNSSG JF is hosted on the internet, with access to all, including the public. The website can be viewed at www.bnssgformulary.nhs.uk. The JFG considered 47 New Drug Requests (NDR) between April 2012 to March 2013. New Drug Requests TLS Red 17 Approved TLS Amber 4 TLS Green 6 TLS Blue 1 Awaiting e sign off 3 Page 6 of 8
Rejected 14 Withdrawn after consideration 2 NBT submitted 27 NDR of which 6 were rejected and 2 were withdrawn after consideration. UHB submitted 10 applications of which 5 were rejected. WAHT submitted 1 application which was approved. AWP submitted 1 application which was rejected. Primary Care / Dermatology Nurses submitted 5 applications of which 2 were rejected. There were 3 joint applications between NBT and UHB which were approved In December 2012, NICE produced the guidance Developing and updating local Formularies, which included a number of recommendations. This document has been evaluated from a BNSSG Joint Formulary perspective, and it is encouraging to note that we are working well within these recommendations. Nevertheless, there are areas that need to be worked on including formalising an appeals process, improving clinical engagement, and attendance at meetings, and ensuring that our local decision making process is robust considering the current NHS structure changes. It has also been made apparent that identification of the appropriate funding stream for the drug needs to be identified early on in the process. Drugs that would be funded via the PbR excluded non NICE drugs budget have been identified as an area that needs managing, in order to streamline reimbursement of these medicines. A request has been made that this budget is managed in the same manner as the NICE College budget. A further need is for a BNSSG Paediatric Joint Formulary to be produced in the same way as the adult formulary. Work is underway to try and address this within the 2013-2013 period. Page 7 of 8
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