Local modifications template
All information submitted via this template may be made publicly available. It must not include
information identifying individual patients, and should not include information that is
confidential to third parties, unless consent has been obtained.
Please note the guidance on submission dates for applications of local modifications in
2015/16, shown below. Update: For local modifications for 2016/17 to be granted and take
effect on 1 April 2016, providers should submit an application in accordance with section
7.3.4 of the National Tariff 2014/15 to Monitor by 30 September 2015.
Title
Descriptive title of local modification.
Key words
Please include key words or phrases that will help others to identify
whether this local modification could be relevant to their local health
economy.
BACKGROUND INFORMATION
Overview
Overview of the proposed local modification, including a summary of
relevant background information.
Type of local
modification
State either ‘local modification agreement’ or ‘local modification
application’.
Services covered
Commissioner(s)
Services covered by the proposed local modification along with all
associated currency codes, including the circumstances and areas in
which the local modification would apply.
Where a local modification covers a range of activity within a particular
specialty, please describe the scope of the services covered by the
local modification.
Commissioner(s) party to the local modification (organisation code and
name).
Commissioning model in use, for example:
Commissioner
model





Single NHS Commissioner
Group of NHS Commissioners
Joint commissioning – NHS and LA
Delegated commissioning under Section 75
Other
Provider
Provider party to the local modification (organisation code and name).
Duration
Proposed duration of the local modification. The duration of local
modifications is limited to one year.
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Start date of local
modification
End date of local
modification
Date local modification takes effect; in the case of local modification
applications, this cannot be before the start of the following financial
year, except in exceptional circumstances.
Date local modification ends.
SERVICE DELIVERY MODEL
Service delivery
model
Current price for
each relevant
currency
Current annual
costs and revenue
Describe how the services are to be provided to patients. This should
include the care setting within which the services are delivered and the
relevant patient pathways.
Nationally determined price for the currencies covered by the proposed
local modification.
Please provide a brief summary of any applicable national variations
(eg market forces factor).
Details of current annual costs and revenue of the services for which
the local modification is sought.
LOCAL MODIFICATION DETAILS
Modified prices
Provide details of the proposed modification to the nationally
determined price (ie the national price after any applicable national
variations), for each currency covered by the local modification. Include
details of how the nationally determined price was calculated.
As explained in Section 4 of the guidance on locally determined prices,
different modified prices may be proposed for different levels of activity.
For example, the modified price may be higher at low levels of activity.
Patient numbers
Projected patient volumes for affected services in the year for which the
local modification is proposed.
Incremental annual
revenue
Projected total monetary value of the proposed local modification, ie
change in provider revenue based on price uplift and expected volumes
for affected services.
Rationale for local
modification
Rationale for proposed local modification, including explanation of
proposed price uplift.
Allocation of
financial risk
Explanation of allocation of financial risk agreed under the local
modification and how risks may be mitigated and shared.
Process for
reaching
agreement
Provide details of the constructive engagement process undertaken to
agree the local modification.
Alternative models
considered
Provide details of alternative service delivery and payment approaches
considered prior to pursuing a local modification (including any
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consideration given to procuring the service).
ADDITIONAL CONSIDERATIONS
Quality of care
Description of the impact of the proposed local modification on quality
of care patients receive.
Wider impact
Description of wider health economy impact of the proposed local
modification, for example impact on choice and competition, provider
capacity and capabilities and sector efficiency.
Evaluation
Description of planned evaluation approach for the proposed local
modification.
Additional points
Add any additional information required to clarify the approach agreed
and any further considerations regarding the impact of the new
approach.
CONTACT DETAILS
Contact details
Contact details for queries about this local modification (can be a
named individual or a generic email address).
By submitting this template the co-ordinating commissioning officer (for local modification
agreements) and provider’s responsible officer (for local modification agreements and
applications) confirm compliance with the rules set out in the national tariff.
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