Improving quality of life for adults with chronic pancreatitis

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Summary Overview

For individuals experiencing severe pain due to chronic pancreatitis, complex surgery to remove the pancreas can be the only option to improve quality of life. However, this procedure also removes the cells that produce insulin which then need to be transplanted back into the patient to avoid severe diabetes. This highly specialist treatment requires providers with appropriate expertise.

NHS England partnered with NHS Arden & GEM’s procurement team to engage with the market and design an effective procurement strategy. Our public procurement project resulted in successfully appointing four centres who are now delivering the highest quality of care to patients.

Project

The challenge
Chronic pancreatitis is a condition where the pancreas has become permanently damaged from inflammation and stops working properly (Appendix 1). The most common symptom is repeated episodes of severe pain in the abdomen, which can last for several hours or days.

For individuals experiencing severe pain, surgery to remove the whole pancreas – a total pancreatectomy – is considered. This causes brittle diabetes unless the Islets of Langerhans (which make insulin) are transplanted back – a procedure known as Total Pancreatectomy with Islet Autotransplantation (TPIAT). This is a major surgical procedure with potential operative complications, a prolonged surgical recovery and an intensive post-operative regimen that includes the management of diabetes and lifelong enzyme therapy. However, for patients it can provide significant pain relief and a restoration of quality of life.

NHS England wanted to establish a national TPIAT provider network, delivering the highest quality of care to adult patients with severe chronic pancreatitis. The main goal was to select providers with the necessary experience in complex pancreatic surgery, islet isolation and transplantation and to ensure access to services for patients. NHS England partnered with NHS Arden & GEM’s procurement team to engage with the market and design an effective procurement strategy.

Our approach

We adopted a holistic approach to procurement with individual stages conducted as part of a whole cycle rather than in isolation (Appendix 2). Our success was achieved through meticulous planning, regular and open communication to deliver the following areas:

Collaborative working and governance
Our diverse, multidisciplinary project group comprised: commissioning, procurement, finance, contracting, performance and supplier management, clinical leads, an expert in transplantation, a Patient and Public Voice member, and a public health advisor. We promoted collaboration and openness, to build trust and achieve common objectives.

We implemented the ‘right ‘governance processes – going beyond ‘light touch’ but avoiding unnecessary bureaucracy – which contributed to the smooth flow of activities from one procurement stage to another. We reported to a Senior Responsible Officer and held monthly project group meetings to test assumptions and gather expert opinions. We communicated with NHS England directors to ensure project sponsorship and sought approval from NHS England Specialised Commissioning Oversight Group for strategic decisions.

Robust pre-tendering stage
a. Documentation
We developed a simple set of documents including a project initiation document and checklist for commissioners, detailing key approvals required at critical stages of the procurement cycle.

b. Engagement
In 2018, NHS England published a TPIAT policy which detailed the service requirement, incorporating public consultation responses from a range of stakeholders including patients, patient groups, medics and academics.

Extensive market engagement, research and analysis were undertaken including:

  • A soft market testing questionnaire which provided a chance to engage with potential providers and inform them on evolving opportunities
  • A dedicated market engagement event which provided an opportunity for commissioners and providers to interact, exchange questions and clarify aspects of the service.

c. Centre allocation strategy
We developed a detailed ‘Centre Allocation Strategy’ examining the risk and benefits associated with several options. We concluded that four centres provided the best balance of access for patients and adequate volume to maintain expertise.

d. Tailored process and questionnaires
The process was designed in successive stages with bespoke questionnaires developed in consultation with the project group. We discussed question weightings, quality requirements and adopted proportionate response word limits linking to questions importance.

Smooth execution
The entire tendering process was managed online, using:

  • ‘Bravo Solutions’ for uploading tender documentation and submitting bids
  • ‘Award’ for online evaluation and moderation meetings.
    We trained evaluators on the principles of public procurement, how to apply these and use ‘Award’, simulating an evaluation process to ensure understanding.

Overcoming obstacles

Understanding the market
To inform our procurement strategy, we needed a better understanding of market dynamics, potential suppliers and procurement options. We achieved this through a soft market testing exercise and desktop research. Our final report concluded that TPIAT is a developing market and that some providers were willing to expand service delivery and invest in facilities. Considering this intelligence, several process design options were presented to decision-makers, with an analysis of advantages and disadvantages for each option.

Determining centre allocation
Based upon the number of projected cases, the TPIAT policy stated the optimum solution would be to commission up to four centres nationally. We undertook a thorough examination of this recommendation, ensuring it was robust and realisable, including analysis of:

  • Patient needs, population and anticipated number of cases
  • Geographical, financial, medical and policy considerations
  • Expertise, capacity, accessibility, collaboration and networks
  • Scenario models: from commissioning one centre nationally to commissioning two, three or four centres.

Our strategy concluded that having four centres provided the best balance between patient accessibility and maintenance of centre expertise through case volume.

Consolidating expert view
Consolidating expert views (including finance, procurement and commissioning) during the process and moderation meetings was sometimes challenging. We handled this with soft skills and techniques when managing meetings (e.g. pressing ahead due to time constraints when needed or breaking for short pauses in case of impasse) and technical skills for disagreements about legal or procurement requirements.

Contracting
We knew commissioning four centres had the potential to cause delays in the contracting phase, as different contracting teams would have different processes and timescales. To minimise delay, we engaged with local service specialists and contract managers during the procurement process. Immediately after the standstill period, we facilitated discussions about procurement outcomes. This minimised the time period over which contracts were signed and sped up overall contract conclusion.

Outcomes, achievements and benefits

A network of experienced service providers
The TPIAT service was successfully awarded to four centres with proven expertise covering the North, South, Midlands/East and London regions. We anticipate approximately 40 surgical cases a year which will be evenly spread across the centres, with providers expected to work collaboratively to address any fluctuations.

These high-quality providers are:

  • Delivering patient centred care with a focus on experience and maximising access to a holistic service
  • Providing specialist multidisciplinary care for all eligible patients, following referral from pancreatic centres
  • Effectively monitoring patients post-operatively in the medium and long term to recognise surgical complications
  • Maintaining a national database of TPIAT cases to generate evidence-based guidelines for the management of patients with end stage chronic pancreatitis
  • Operating a rolling programme of clinical audit and cross-centre collaboration
  • Providing high quality information for patients, families and carers in appropriate and accessible formats.

Patient outcomes and impact
Across the four providers, six surgeries have been reported to date, with a further 18 patients undergoing assessment.

Formal evaluation of quality of life is undertaken using regular assessments by a medical psychologist. This captures a full picture of the effects of surgery including diabetes management, experience and management of pain, assessment of diabetic complications and annual ultrasound examinations.

Centres also undertake post-surgery satisfaction surveys with patients showing excellent self-reported outcomes (Appendix 3 and 4).

Contracting and outcomes monitoring
During the procurement process we recorded feedback and internal notes for contract managers around service aspects that may require further improvement and monitoring.

Providers and contract managers meet with the NHS England managers monitoring service mobilisation and outcomes at regular meetings and reporting on:

  • The quality indicators and methodology specified in the contract
  • The minimum dataset specified through the contract
  • Patient and treatment outcomes in accordance with agreed audit requirements.

To ensure consistent quality of care across the country, centres use identical protocols throughout the entire service pathway. Outcomes are monitored by collating data from all centres to produce a national database submitted to the Collaborative Islet Transplant Registry.

Feedback from key stakeholders
We sought feedback from project group members and national leads at every stage of the procurement process, adjusting our approach when necessary. After contract award, we collected feedback from project participants which was very positive (Appendix 5), with the entire team commended by NHS senior leaders on their dedication, hard work, expert guidance and project steer.

Learning and continuous improvement

Embedded pre-tendering process stage
The project clearly embedded a centre allocation strategy, market analysis report and procurement strategy to support commissioning. This helped to inform the procurement approach and develop options, risks and benefits analysis which enabled NHS decision-makers to make informed and effective choices. This approach has been replicated across our subsequent programmes.

Developing procurement skills
It was clear from submissions received that some providers needed support and training on how to structure and submit responses. We provided extensive written feedback to suppliers including areas for improvement. For our next project we implemented an ‘in the commissioner’s shoes’ training session for providers. We have also organised sessions on how to write successful responses and shared case studies.

Balancing ‘standard’ and ‘bespoke’
We utilised available standard documents and questionnaires but also reviewed and revised these to create a process and questions which were tailored to the project and our objectives. Most importantly, the procurement was not a process that the procurement function developed ‘for’ our customers – it was a process that we collaboratively designed and carried out which was key for its success.

Downloads: Total Pancreatectomy with Islet Autotransplantation

 

 

Finalist : 2020 HCSA Procurement Excellence Award  and  Highly Commended: 2020 HCSA Procurement Excellence Award

 

Name: Marie-Louise Allred
Job Title: Marketing and Communications Manager
Organisation: NHS Shared Business Services

For further information:
Email: marielouise.allred@nhs.net