This document presents answers to frequently asked questions relating to the 2023/25 NHS Payment Scheme. We welcome enquiries about any aspect of the payment system. Please contact pricing@england.nhs.uk

Last updated: June 2024

What is the correct reimbursement for homecare drugs?

The 2023/25 NHS Payment Scheme (NHSPS) includes rules for the reimbursement of homecare services (drugs, devices and related costs).

Reimbursement of homecare drugs – NHSPS rules

In Section 3.4 (Excluded items), Paragraph 70 of the NHS Payment Scheme states:

Homecare services (drugs, devices and their related costs) are also excluded from core payment mechanisms or prices. For these items and their related costs, local funding arrangements must be agreed by the commissioner and provider, in accordance with the excluded items pricing rule set out below.

This exclusion is because the costs of homecare drugs are not factored into price calculations. As such, providers and commissioners instead need to locally agree the reimbursement of homecare drugs and related costs. This could be including funding in the aligned payment and incentive fixed element (ie have an overall amount assigned to pay for homecare), paying for the drugs separately on a cost and volume basis, or a mix of the two approaches – or any other approach that is locally agreed.

It is important to stress that reimbursement is subject to local agreement between providers and commissioners – not that homecare items are automatically paid for. In addition, please note that homecare delivery changes are also subject to local agreement.

In addition to homecare drugs, the NHSPS includes a list of drugs that have been identified as relatively high cost. These high-cost drugs are also excluded from core payment mechanisms (and so subject to the excluded items pricing rule). These high cost drugs are more likely to relate to specialised services, and so be commissioned by NHS England, rather than by ICBs. For these items, providers and commissioners may agree cost and volume payment arrangements are appropriate.

Implementing the rules – worked examples

What are the payment arrangements for items delivered as homecare that are included on the high cost drugs list?

These drugs are identified as high cost and would usually be passed through. If delivered as part of homecare, they should be paid in line with local payment rules and arrangements as they are not part of the prices.

What are the payment arrangements for items delivered as homecare that are not included on the high cost drugs list (eg aspirin)?

These drugs cannot be passed through as they are not classed as high cost drugs. If delivered as part of homecare, they should be paid in line with local payment rules as they are not part of the prices.

Should optical coherence tomography (OCT) scans be paid for separately to an outpatient ophthalmology attendance?

No – the NHSPS guidance explains that they should not be paid separately (see Annex B). This is because:

Optical coherence tomography (OCT) scans should be submitted to SUS PbR as part of the outpatient attendance That record will group to the procedure-driven HRG, BZ88A, which has an outpatient procedure unit price and is therefore a procedure-driven HRG that is covered by an aligned payment and incentive agreement.

A scan will not necessarily take place on the same day as an outpatient attendance, however under the NHS Payment Scheme and the rules for submitting to SUS, the scan is part of the attendance.

If there is more than one outpatient attendance on the day the scan was requested, and if local systems do not allow identification of which attendance the scan was requested from, follow these steps:

• If the diagnostic imaging occurs on the same day as the outpatient activity, and there is more than one outpatient attendance, the scan should be assumed to be related to the activity it follows, using time to establish the order of events.
• If the scan occurs before any outpatient activity on that day, it should be assumed to be related to the first outpatient attendance that day.

If the diagnostic imaging occurs on a different day from the outpatient activity, the scan can be assumed to be related to the first attendance on the day the scan was requested.

For more details, see Annex B: Guidance on currencies, Section 4 Diagnostic imaging (paragraphs 70 (first bullet point), 72, 76 and 77).

Does the inclusion of a drug in the Annex A high-cost drugs list mean it is available in secondary care only?

No, including items in the list of high-cost drugs in Annex A does not limit it to secondary care only. The list in Annex A does not define local formulary status, and it does not preclude prescribing or dispensing of relevant drugs (eg Rimegepant) in a primary care setting. In secondary care, all items on the high-cost drugs list are subject to the NHSPS excluded items pricing rule (see Section 3.4 of the NHSPS).

As such, reimbursement will be determined by a local agreement between the relevant commissioner and provider.

Primary care is not in scope of the NHSPS and funding and payment for primary care drugs are the responsibility of the relevant commissioner.