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Dr Eslam Al-Abadi sets out to clarify the process of proposing the development of new treatment pathways via the Preliminary Policy Proposal (PPP) Process. In England, accessing medicines not supported by NICE care pathways is an ongoing challenge for our members. While PPPs are not a guaranteed success, at the very least participation will show that clinical needs are not being met.


Many patients in paediatric and adolescent rheumatology are without recognised treatment pathways. There's a clear case of postcode lottery access to treatment; doctors in Scotland and Wales can discuss requests with those who fund care and report a favourable outcome of per patient discussions, while doctors in England have to ask hospitals to absorb the costs.


This is highly unlikely in most cases due to a lack of specific budget; the other option is to submit an Individual Funding Request to NHS England, which has lately become a frustrating process that almost always results in rejection on grounds that the patient is not exceptional.


We've identified this as a priority, and want to clarify the process by which members can propose the development of new treatment pathways. This process begins with a Preliminary Policy Proposal (PPP), a submission to NHS England for the development of new commissioning policies.


The proposal sets out a proposed clinical intervention, the indication, the intended population and a list of published clinical evidence. PPPs are considered by NHS England’s Clinical Panel, which decides whether they progress to policy development phase.


The service development process has three phases:


  • The ‘clinical build’, where new or amended clinical commissioning policies and new or amended service specifications are proposed and developed. Policy propositions need to be underpinned by a clinical evidence review; NHS England’s specialised services Clinical Panel challenges and confirms whether there's a sound evidence base.

  • NB: service specifications do not normally require an evidence review and therefore are not normally considered by the Clinical Panel

  • The ‘impact analysis’ phase, which identifies the financial and operational impact of moving from current pathways of care to those proposed. These suggestions are then subject to stakeholder testing and public consultation

  • The 'decision' phase. For submissions which are cost-neutral or cost-saving, the approval decision is based on a clinical benefit assessment. For those which require additional investment and where's there not enough funding to cover all proposed interventions, assessment is on likely relative clinical benefit and value for money

  • Using this information, NHS England carries out a twice-yearly prioritisation process to determine which services will be routinely commissioned


No proposal is guaranteed success, but the process is worthwhile, as it shows a clinical need is not met, and the Clinical Reference Group (CRG) can then continue lobbying for a satisfactory arrangement.


Steps to follow:


  • Identify a patient group lacking a pathway to a recognised or new treatment

  • Contact the relevant CRG

  • CRG sends you the application form

  • You supply the application form

  • Once approved, you'll be sent a PPP submission form. When you've completed it, you'll discuss with the Clinical Panel to ensure the application stands a chance at the next stage

  • NICE will then review the evidence and perform an impact analysis, and there will be stakeholder and public consultation by NHSE

  • A decision on funding will be made based on clinical benefit and relative value for money


For more information, you can refer to NHS England's Specialised Commissioning Service Development Policy or look at an application form sample.