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Community spirit

Community spirit
8 December 2016

Supporting patients closer to home is the key to reducing hospital admissions, so a CSU came up with a procurement programme to boost local and community services

Supporting patients closer to home is the key to reducing hospital admissions, so a CSU came up with a procurement programme to boost local and community services

Community health services have an increasingly important role in the delivery of NHS services. They cover a wide range of out-of-hospital care, from community nursing support for children and families, to treating people with long-term and complex conditions.
Supporting people closer to home is widely recognised as a positive move, providing better care, reducing hospital admissions and costs. However, access to community-based services can be variable and there are significant challenges to overcome to deliver integrated, coordinated care that focuses on the needs of individuals.

Fragmented community services
This was the case in Nottinghamshire, where community services were fragmented, meaning patients experienced inconsistent levels of care and a lack of coordination between providers, and would often have to travel far from home to get the treatment they needed. With many contracts spanning a range of services from children in care to end-of-life support, there was a need to radically rethink how these services were commissioned and delivered.
This sparked a £247.38 million procurement programme to deliver community services across the area for up to seven years (five years, with the option to extend for a further two), bringing together NHS Arden & GEM commissioning support unit (CSU) and six Nottinghamshire clinical commissioning groups (CCGs) in a collaborative programme with Nottinghamshire councils, Nottinghamshire Healthcare NHS Foundation Trust and Nottinghamshire Hospice.
Ensuring patient needs and locally focused services were at the heart of the procurement programme involved an ambitious collaborative approach across a wide range of stakeholders. Combined with meticulous planning and the use of innovative technology, the procurement process has resulted in better, more integrated services as well as delivering cost savings, and the approach could be used in other areas.

A collaborative approach
Collaboration, partnership working and integrated care are terms that are becoming synonymous with the redesign of services in the NHS, and rightly so. But it is for all of us who work in the NHS to find ways to improve services and work together more effectively and efficiently, to deliver value for money. Innovative approaches to procurement have a key role to play.
The Nottinghamshire project is an ideal example. The project brought together healthcare commissioners, local authorities, procurement experts, an NHS foundation trust and a charity – uniting 10 separate lots including adult integrated care teams, end-of-life support, short term rehabilitation, integrated community children’s and young people’s healthcare services and children-in-care services.
The principal aim of the programme was to commission coordinated, patient-centred and locality-focused services that could be provided in community settings closer to home. This would involve designing new models of integrated care, focusing on patient needs at every level, in line with the NHS Five-Year Forward View.1
Central to the procurement process was the need to commission for outcomes, including creating financial incentives to deliver high-quality care. The main objectives included:

  • Joining up health and social care services more effectively in line with the ‘We Care’ and ‘Better Together’ programmes.
  • Developing outcome-based commissioning to achieve better outcomes through more integrated, person-centred services and ultimately providing better value for money.
  • Making best use of innovative procurement tools and techniques.
  • Integrating to create more efficient and effective services.
  • Laying the foundations for effective ongoing contract management and collaborations.
  • Involving patients and other stakeholders to enable them to influence the process and make key decisions.
  • Sharing learning and best practice from the process to inform future procurement projects.

The scale and complexity of the project required a joint vision, meticulous planning, innovation and exemplary collaboration to ensure successful delivery. Stakeholder engagement was critical throughout the process. This involved building a culture of trust and transparency across all organisations, as well as involving patients to ensure their needs were at the heart of service delivery.

Enabling decision-making
Multiple stakeholders can add an additional layer of complexity which has the potential to slow down progress. However, with the right processes and governance structures from the outset, we have seen multi-faceted procurement programmes such as this proceed efficiently, particularly where there is a shared vision firmly established among those involved.
At the pre-procurement stage of the Nottinghamshire project, the team began by defining the service scope before identifying an effective collaborative procurement strategy. This included establishing governance structures that would enable quick decision-making at every clinical and management level, as well as clear and effective project management. This included:

  • A commissioning board reporting to the CCGs’ governing bodies comprising senior members and clinicians from all organisations and patient representatives.
  • A steering group with representatives from patient organisations gathering monthly to discuss and prepare documentation such as tender questions and award criteria for board approval.
  • Task and finish groups responsible for development of specific service specifications and outcome measures.
  • A conflict of interests guardian and close management of risks through a risk register.

Delivering a robust procurement process
Ensuring stakeholders were involved throughout the process helped to keep the programme focused on delivering outcomes and gave clear direction to potential providers about the importance of ongoing collaboration.
Arden & GEM CSU designed a two-stage procurement process consisting of a pre-qualification questionnaire, allowing only providers with the necessary capacity to be invited to tender. The invitation was tailored to include questions on patient engagement, innovation and service integration.
The BravoSolution e-tendering portal was used for tender submissions and communication with the bidders, ensuring transparency and equal treatment for all interested parties. Further engagement was held during the process at bidders’ participation events to clarify the partners’ expectations and allow providers to raise questions before submitting their final offers.
Bidders were also required to deliver presentations and address real-life scenario questions to test their awareness of the practicalities of service delivery. The process was designed to ensure that stakeholder engagement would go beyond the procurement exercise, by including questions on ongoing patient and public involvement, co-production and consultations prior to service commencement and for future service development.
Importantly, the evaluation panel included members from a range of cross-functional areas that included clinical, quality, commissioning, finance and HR experts, patient representatives, parents, carers and a young person.
Thanks to the effectiveness of the procurement, which was delivered in just 17 months, the contract was awarded in October 2015. This was followed by a smooth transition into the mobilisation and contracting stages, with the new services in place by 1 April 2016.

Involving service users
Patients were involved at every step of the procurement process from inception to scoring, using innovative technologies for engagement and support. Effective pre-procurement involvement ensured that the patients, parents, carers, service providers, third-sector representatives and clinicians’ voices were heard when developing the model, the outcomes and service specifications.
Stakeholders influenced the commissioning process through ongoing engagement with the commissioners. Instant feedback was also provided via smart surveys or through the BravoSolution e-procurement portal at market participation and co-production workshops.
During the engagement events, children, young people and their families had the opportunity to share their personal stories and the difficulties they had faced while accessing a fragmented service for children with complex needs.

Making the most of innovative technology
Across the Arden & GEM procurement portfolio, we are increasingly using technology to improve consistency, provide a clear audit trail and deliver efficiencies. This was particularly the case in the Nottinghamshire project.
For example, as well as the innovative engagement techniques and use of the BravoSolution e-procurement portal, we managed the whole tender evaluation process for this project, including moderation meetings, via an electronic evaluation tool (Award), making sure that each mark was justified.
By making the most of technology, the project has resulted in services that use the latest innovations in personalised care and remote patient treatment. In the pre-procurement stage, patients expressed the desire for fewer trips to the doctor, while health professionals wanted real-time patient information and tools to teach patients. It was therefore specified that successful bidders should deliver remote care-planning and videoconferencing tools to link doctors and patients.
Bidders took this on board and have implemented educational videos, online rehabilitation instructions (Recap Health) and messaging applications (Florence Telehealth) in their service delivery plans.

Using the learning
With a complex project of this size, the project team was keen to capture the learning and experience to improve future procurement. The team has taken a proactive approach to gathering feedback, creating a benefits log and sharing experiences.
This included:
l Feedback surveys showing a positive satisfaction rate of 70%
l Lessons-learned sessions for the project team
l Bidders’ debrief sessions to help unsuccessful bidders improve future submissions
l Dedicated e-bulletins, events and case studies to keep patients, staff and GPs updated.
There have been a number of key learning points across the project, ranging from project initiation to collaborative working with the provider after the contract award.
Key challenges that were overcome included managing the high number of clarification questions through a daily question log, and gaining exact information for the service reconfiguration by working closely with service providers and our partners.
As well as sharing learning with stakeholders involved with this project, the team has welcomed the opportunity to keep other organisations informed about the approach, so that even greater collaboration can be encouraged in future projects.

Realising the benefits
As well as delivering a better quality, locally focused service that considers the needs of individual patients, the project has resulted in significant cost savings.
Over the full seven-year contract, it will deliver a saving of £12.04 million, with further savings and improved quality expected through contract management and monitoring, service improvement and incentives.
Furthermore, this collaboration has enabled the CCG to move to outcome-based commissioning, where a proportion of the contract value is dependent on achievement of pre-determined performance and quality outcomes.
By combining 10 procurements into one procurement approach and making use of the latest technologies, we were able to deliver efficiencies, economies of scale and value for money throughout the process.
As the requirement for complex procurements involving numerous partners and stakeholders looks set to increase, this approach has demonstrated how strong collaboration and management can help develop community services that are fit for the future. l

Warren Simms is the associate director of procurement and market management at NHS Arden & GEM CSU, which provides commissioning support services to more than 60 CCGs, NHS England, local authorities and a range of care providers.

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