Principles for the Commissioning of
Health and Healthcare Policy
Document Reference:
CLPOL-1
Document Title:
Principles for Commissioning of Health and Healthcare
Policy
Version:
0.1
Supersedes:
n/a
Author:
Dr Anthony Sudell
Authors Designation:
Consultant in Public Health Medicine
Consultation Group:
Clinical Policy Working Group
Date Ratified:
26.11.2014
Review Date:
26.11.2017
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
Page 1 of 12
Version Control
Version Date
0.1
Author
Anthony
09/07/14
Sudell
Status
Comment / Details of Amendments
Draft
Draft policy
Circulation List
Clinical Policy Working Group
Equality Impact Assessment
The policy has had an equality impact assessment undertaken on 7.1.2015 by the
Equality and Diversity Lead.
There are no identified negative impacts for people who identify with a protected
characteristic.
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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Contents
1
POLICY STATEMENT................................................................................................ 4
2
PRINCIPLES .............................................................................................................. 4
3
APPROPRIATE .......................................................................................................... 4
4.
EFFECTIVE ................................................................................................................ 6
5.
COST EFFECTIVE ..................................................................................................... 6
6.
ETHICAL .................................................................................................................... 7
7
EQUALITY ................................................................................................................. 8
8
MONITORING & REVIEW .......................................................................................... 8
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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Principles for the Commissioning of Health and Healthcare
1
POLICY STATEMENT
1.1
This document sets out the principles underlying the commissioning decisions
and policies of the NHS Chorley & South Ribble Clinical Commissioning Group
(referred to hereinafter as "CCG").
1.2
This document and each commissioning policy is a separate public document in
its own right.
2
PRINCIPLES
2.1
In developing local commissioning policies, the CCG will only commission
interventions which fulfil all of the following criteria:

Appropriate

Effective

Cost effective

Ethical
3
APPROPRIATE
3.1
The CCG defines an appropriate intervention as one which meets one or more of
the following criteria:

It has the intended outcome of preventing, diagnosing or treating a medical
condition. (See definitions in appendix 1)

It enhances dignity at the time of death.

It has the intended outcome of preventing unwanted pregnancy.

It provides part of such services or facilitates for the care of pregnant
women, women who are breastfeeding and young children as may be
reasonably required1

It is considered by the commissioning organisation to be essential to meet
the requirements of primary or secondary legislation, or to avoid being in
contempt of Court.
3.2 In relation to specific conditions, especially when there is more than one treatment
option, the commissioning organisation may take a view that:
1
s.3(1)(d) of the NHS Act 2006.
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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
The appropriate treatment option is one which addresses the underlying
problem, rather than the symptoms of that problem.

The appropriate treatment option is one which is simple and non-invasive.

The appropriate treatment option is one which preserves certain other
bodily functions.

The timing of a particular treatment is inappropriate, e.g. in relation to
development, reproduction, weight loss etc.

A particular service is appropriate only if it is commissioned from a particular
service provider or providers.
3.3
Services which fall within the defined remit of another public sector commissioner
are not appropriate to be commissioned by this CCG.
3.4
The CCG categorises appropriate interventions as follows:

Category 1 (“Must Do’s”) Interventions are:a) Those for which the intended outcome is to:
o preserve life;
o prevent or relieve major pain, disability or physical discomfort; (See
definitions in appendix 1)
o directly address the distress or disability associated with a
diagnosed mental health condition; or
o maintain dignity at the time of death.
o achieve pregnancy, in the circumstances defined as appropriate
(Category 1) in the commissioning organisation's extant fertility
services policy.
o correct an unacceptable appearance as defined as appropriate
(Category 1) in the commissioning organisation's extant cosmetic
services policy/policies.
b) Healthcare services or facilities which are reasonably required for the
care of pregnant and newly delivered women, women who are
breastfeeding and young children.

Category 2 (“Could Do’s”): Interventions are those which fall within the
overall definition of “appropriate” but for which the intended outcome or
purpose is other than those in category 1.
3.5
The CCG will commission category 1 interventions provided the principles of
effectiveness, cost effectiveness and ethical delivery are met.
3.6
In the light of competing demands for NHS resources, the CCG will only consider
routinely commissioning interventions in category 2 if they have made a formal
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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decision that their financial position permits them to do so. The default position is
that their financial position does not permit them to do so. It is a matter for the
discretion of the CCG as to whether or not they will routinely commission any
category 2 interventions as part of current or future commissioning rounds.
3.7
Any new procedures for which there is no budgetary provision in the current
financial year may be placed in category 2 until such time as the budget can be
prioritised.
4.
EFFECTIVE
4.1
The CCG defines an effective intervention as one which is capable of achieving
its intended outcome, and of doing so without causing undue harm.
4.2
The CCGs’ default position is that the intervention is not effective.
4.3
The CCG will move from their default position if, following consideration of the
content and quality of the available evidence, they consider that the intervention
is effective.
4.4
The CCG will not commission an intervention for which there is evidence that it is
of no benefit, simply because it is the only treatment available.
4.5
The CCG will only commission an intervention for which evidence of
effectiveness is unavailable within the context of their research governance
frameworks.
5.
COST EFFECTIVE
5.1
The CCG will consider the cost effectiveness of an intervention only if they have
judged that the intervention is effective, in accordance with section 3.
5.2
The CCG defines a cost effective intervention as one which represents good
value for money in comparison with other possible uses of that money.
5.3
The CCGs’ default position is that an effective intervention is also is costeffective.
5.4
The CCG may consider an intervention not to be cost effective if it does not meet
any national or local cost effectiveness criterion that may be in force at the time.
5.5
The CCG will move from their default position if, following consideration of the
content and quality of the available evidence, they consider that the intervention
is not cost effective.
5.6
The CCG recognises that the costs, expected benefits and expected dis-benefits
of a particular treatment may vary from patient to patient and therefore the CCG
may adopt a policy to commission a service only for those patients for whom the
balance between costs and net expected benefits is the most favourable
5.7
In comparing two possible treatment options the CCG may consider the relative
and marginal costs and benefits, and will decide which service to commission
accordingly. (See detail in appendix 1)
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NHS Chorley & South Ribble Clinical Commissioning Group Policy
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5.8
NB: When adopted, these principles will be in force with immediate effect (or as
agreed by the Clinical Policy Committee) for the development of new policies.
However existing polices based on previous sets of principles will remain in force
until their review date, or until superseded by new policies. The sets of principles
on which they were based shall remain on the record and shall continue to give
validity to those policies.
6.
ETHICAL
6.1
The CCG defines ethical healthcare as that which is provided justly and fairly
according to need, and in accordance with the values of society and of relevant
professional bodies such that the health of the population is maximised within the
resources available. A healthy population is one in which health and wellbeing
are prevalent in a fair and sustainable fashion.
6.2
The CCGs’ default position is that the intervention can be delivered ethically.
6.3
The CCG will commission interventions based on the health and healthcare
needs of their resident population, as assessed by the CCG. In doing so, they will
seek to reduce health inequalities within the population.
6.4
The CCGs' commissioning policies, in line with the Equality Act 2010 will not
discriminate on the basis of age, disability, gender reassignment, marriage or civil
partnership, pregnancy and maternity, race, religion or belief, sex, sexual
orientation. The CCG will also not discriminate on social disadvantage, lifestyle,
occupation, financial status or family status (including responsibility for
dependents).
6.5
The CCG will also apply the human rights principles of Freedom, Respect,
Equality, Dignity and Autonomy when developing and applying commissioning
policies ensuring that they demonstrate a positive duty to meeting peoples’
human rights in line with the Human Rights Act 1998 and the NHS Constitution
2009.
6.6
All commissioning policies will be subject to robust equality analysis and if there
is robust evidence that these factors affect the effectiveness of an intervention,
the CCG may take this into account in their commissioning policies.
6.7
Where there are specific equality issues in
relation
to
the
application/implementation e.g. exceptions will be referred to the CCGs' funding
request panel for consideration.
6.8
The CCG will not commission a service simply because that service is
commissioned by another Commissioning Organisation or Commissioning
Organisations.
6.9
NB: When adopted, these principles will be in force with immediate effect (or as
agreed by the Clinical Policy Committee) for the development of new policies.
However existing polices based on previous sets of principles will remain in force
until their review date, or until superseded by new policies. The sets of principles
on which they were based shall remain on the record and shall continue to give
validity to those policies.
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NHS Chorley & South Ribble Clinical Commissioning Group Policy
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7
EQUALITY
7.1
In applying this policy, the CCG will have due regard for the need to eliminate
unlawful discrimination, promote equality of opportunity, and provide for good
relations between people of diverse groups, in particular on the grounds of the
following characteristics protected by the Equality Act (2010); age, disability,
gender, gender reassignment, marriage and civil partnership, pregnancy and
maternity, race, religion or belief, and sexual orientation, in addition to offending
background, trade union membership, or any other personal characteristic.
8
MONITORING & REVIEW
8.1
The policy and procedure will be reviewed periodically every three years. Where
review is necessary due to legislative change, this will happen immediately.
Date of adoption:
27 November 2014
Date of review:
Not later than 27 November 2017
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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Appendix – Definitions:
The CCG defines a medical condition as any illness, injury or impairment in which
there is an abnormality in the structure or function of the body or mind.
-----------------------------------------------------------------------------------------------------------------The CCG defines treating as providing a healthcare service with the intention of curing
a medical condition, halting or delaying its progress, reducing its impact, relieving
symptoms, or delivering alternatives to impaired biological functions.
-------------------------------------------------------------------------------------------------------------------The CCG defines an abnormality in the structure or function of the body or mind as a
situation where either:
a) a part of the body or mind is unable to deliver its purpose, or
b) a part of the body or mind is preventing another part from delivering its
purpose, or
c) there is a threat that (a) or (b) will happen imminently, or
d) the structure or function is so far removed from the usual range that the
commissioning organisation considers it to be exceptional and intolerable.
(This definition does not apply to an abnormality of appearance which may be defined
separately in policies for cosmetic services.)
-------------------------------------------------------------------------------------------------------------------The CCG defines major pain, disability or physical discomfort; in the context of
category 1 of appropriateness, as a situation where that pain, disability or physical
discomfort:

Is the dominant feature of the condition, and

Is of a level of severity that would lead most people to seek healthcare for
that feature of the condition alone, and

Is preventing usual activities, or is significantly disrupting the sleep pattern,
and

Is present for all or most of the time, and

Is not primarily related to certain activities which could be avoided, and

Has a plausible basis, and

(for surgical interventions) either is likely to be permanent, or if short term is
not relieved by medication, and

Is recognised by the clinicians providing treatment as the main feature that
will be addressed by any intervention.
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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On rare occasions an extreme odour that prevents social contact may be regarded as a
disability in this context.
A treatment intention of enabling the patient to be employable (or to benefit from
education) may be sufficient to place a patient into Category 1 of appropriateness, as
the CCG recognises education and employment as important determinants of health. It
is unlikely that such an intervention will have employability as its only treatment
purpose, and therefore the intervention is likely already to be in Category 1 for reasons
other than employability. However, a treatment intention of enabling the patient to have
a particular employment will not normally be sufficient to place an intervention in
Category 1 of appropriateness, and a policy that did place such an intervention into
Category 1 may discriminate against people without that particular career aspiration.
-------------------------------------------------------------------------------------------------------------Cost effectiveness
The CCG regards cost effectiveness as a relative concept. Therefore if two equally
effective treatment options for the same condition would satisfy the cost effectiveness
principle compared with doing nothing, then this principle would determine that the less
costly option would be commissioned. Similarly if a slightly more effective treatment
was very much more costly than the alternative, then the CCG would consider the
marginal costs and marginal benefits in determining which one if would commission.
This is shown in the examples below.
In all of these examples assume that the cost effectiveness criterion (threshold) that is
in force is that one unit of benefit shall cost not more than £100
Example 1
Treatment A
Treatment B
Difference
Expected average benefit
10
15
5
Cost
£1,100
£1,800
£700
Cost per unit of benefit
£110
£120
£140
In Example 1, neither option would be commissioned as they both cost more than
£100 for each unit of benefit
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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Example 2
Treatment A
Treatment B
Difference
Expected average benefit
10
15
5
Cost
£1,200
£1,600
£400
Cost per unit of benefit
£120
£107
£80
In Example 2, neither option would be commissioned as they both cost more than
£100 for each unit of benefit. As both treatments cost more than this threshold, then
the difference (marginal analysis) is not relevant.
Example 3
Treatment A
Treatment B
Difference
Expected average benefit
10
12
2
Cost
£900
£1,500
£600
Cost per unit of benefit
£90
£125
£300
In Example 3, Treatment A may be commissioned as it costs less than £100 for each
unit of benefit, but treatment B would not be commissioned as if costs more than £100
for each unit.
Example 4
Treatment A
Treatment B
Difference
Expected average benefit
10
12
2
Cost
£600
£1,000
£400
Cost per unit of benefit
£60
£83
£200
In Example 4, although both options come below the £100 threshold in absolute
terms, the additional benefit from treatment B is above the threshold, and therefore
the difference would not be considered cost effective and only option A would be
commissioned.
Principles for the Commissioning of Health and Healthcare Policy
NHS Chorley & South Ribble Clinical Commissioning Group Policy
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Example 5
Treatment A
Treatment B
Difference
Expected average benefit
10
15
5
Cost
£800
£1,250
£450
Cost per unit of benefit
£80
£83
£90
In Example 5, both options come below the £100 threshold in absolute terms, and the
additional benefit from treatment B is also comes below the threshold. Therefore the
CCG may commission that additional benefit, and may commission treatment B.
Although in absolute terms treatment A is more cost effective, treatment B and the
difference between A and B are both below the cost effectiveness threshold and
therefore may be commissioned.
Please note, that if the cost effectiveness criterion (threshold) was raised to £115,
then in example 1 Treatment A would be commissioned, and in Example, 2 Treatment
B would be commissioned.
In terms of discrimination within the ethical principle, the CCG considers that it is
legitimate to decide not to commission a service for people with condition X, provided
that such a decision is otherwise in accordance with these principles. Such a decision
would not discriminate against people with condition X.
However if a service was commissioned to treat unrelated condition Y, but policy was to
deny access to that service to people with condition X, than that policy may
discriminate against people with condition X unless there was a rational reason why the
treatment was not appropriate, effective, cost effective or ethical specifically in people
with condition X.
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NHS Chorley & South Ribble Clinical Commissioning Group Policy
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