Neli Garbuzanova explains how early strategic use of procurement can benefit specialised commissioning
Those of us working in the NHS are all too aware of the need to provide quality services within stretched budgets. As public servants, the way we spend taxpayer money is subject to public and legal scrutiny, and we must ensure that we make the best use of resources for our patients and communities. But finance is only part of the story. Most decisions in the NHS are led by clinical considerations, and the public expectation for service quality is high. Decisions about funding are often emotive, and the pressure is on the NHS to find fair and workable solutions. Yet, as with any other sector, healthcare budgets are finite.1
So, how can we make sure that people receive good quality health care, particularly when it comes to specialised commissioning, which may benefit only small numbers of people? Increasingly, strategic use of procurement techniques is helping to answer that question.2
Procuring in a unique context
NHS England specialised services are usually for patients with rare, complex, and often life-threatening conditions requiring expert care. The number of patients is smaller compared with other services: usually it does not exceed 500 patients per year and can be fewer than 10 patients for some highly specialised services, such as auditory brainstem implantation (ABI) surgeries.3 The treatments and interventions are often new or just emerging from innovative research, and suitable providers may be limited. For these and other reasons, the costs of treatment can be significant. In this context, reducing costs or achieving economies of scale may not always be achievable or even desirable. However, cost efficiencies can be realised, for example, in some cancer or drug treatment services. For example, procuring proton beam therapy for certain types of cancer delivered cost savings and is improving access to treatment for patients.4
NHS England specialised commissioning undertakes regular reviews of its priorities, and has a legal duty to fund certain new medicines and devices recommended by NICE.5 For proposed new treatments that require more investment, NHS England uses a prioritisation process to decide on the costs and benefits and where NHS resources and funding will be directed (see this video explaining how the relative clinical benefits and costs of proposed new treatments are independently assessed by the Clinical Priorities Advisory Group).6 The procurement process traditionally begins after these priorities are established by decision-makers, relevant stakeholders have been engaged and consulted, and policies and service specifications have been adopted. The procurement options and risks are assessed, and a compliant procurement process is advised on and designed, with the aim of extracting the best value for each individual service.
However, learning from recent specialist projects has shown that there is much to be gained from involving procurement specialists at the embryonic stage, enabling a more holistic approach.
… there is much to be gained from involving procurement specialists at the embryonic stage …
Pre-procurement—plan, research, and design
Procurement includes a number of different ways of obtaining services and supplies. In NHS England specialised commissioning, procuring cutting‑edge healthcare services can be associated with higher risks compared with procuring routine or already well‑established services—such as the inherent risks of complex and novel interventions like brain or in‑utero surgery. Designing and running a successful procurement process that is right for the service in question can be significantly enhanced by a more detailed approach to pre‑procurement activities that includes:
- advance planning
- identification of needs
- service and quality standards
- clear governance structures
- multidisciplinary working
- deep-level research
- knowledge of the supplier base.
Advance planning and thorough identification of needs are key stages in each procurement project. Realistic yet ambitious project plans allow the participants to engage with and commit to the project and spend enough time at each procurement step. The process of defining the needs and what is required to satisfy them is also critical, because it will set out the scope of the future procurement steps. For example, the number of patients requiring a particular intervention or treatment would be one of the factors to consider when deciding on the number of centres required.3,7
Research and engagement
Investment in pre-procurement research, market consultation, and testing pays dividends later. This is particularly true when commissioning a service for the first time or when seeking to solve a problem without a clear understanding of the options that might be available.4 For example, pre-procurement questionnaires and market engagement events provide the opportunity to interact with potential suppliers and test the art of the possible. In return, potential providers have an opportunity to feed back their suggestions, take part, and identify if the opportunity is right for them. Sometimes ‘in a commissioner’s shoes’ sessions are organised with providers to discuss past procurements and some of the challenges commissioners have experienced, such as evaluating incomplete responses or responses that do not address all points of a question. These help providers to compare ‘good’ and ‘bad’ practices, and to ensure that high-quality responses are received.
Design in collaboration
Within the flexibilities of the law for procuring healthcare services, processes are designed that consider the specifics of the service, including accessibility, continuity, and availability.8 When procuring a service for airborne high consequence infectious diseases (HCID; see case study in Box 1),7 for example, market engagement was crucial in informing the number of centres nationally, thus ensuring that there would be equitable access to HCID services across the country. Engagement also helps to determine the market size and to design an appropriate procurement process model.
Box 1: Case study—high consequence infectious diseases7
In 2015–16, NHS England established the HCID programme. NHS Arden & GEM was responsible for procuring a network of HCID centres that would provide a national system of service readiness for patients with airborne diseases such as severe acute respiratory syndrome and MERS, with the ability to cope with small numbers in a safe, managed environment.
To deliver national coverage and ensure equitable geographic access to services it was essential to develop a lotting strategy, which would:
- minimise travel times for patients
- co-locate adult and paediatric services.
Following the publication of a prior information notice, we held a virtual market‑engagement session to allow interested organisations across the country to learn more about the service requirements and talk to service commissioners. This enabled us to agree the most appropriate lotting and procurement approach, and a one-stage open procurement process was implemented.
We worked with stakeholders from both specialised services and public health to assist in the development of documentation and evaluation of tender submissions and ensured that the service specification was clear.
The entire procurement was delivered over a 5-month period, with four providers selected to deliver a high-quality, affordable, and family-centred service. Units are able to mobilise quickly to treat adults and children with a confirmed HCID diagnosis and to prevent spread.
The network has been operational since April 2018, and selected providers have already successfully dealt with four cases: three of confirmed monkeypox and one of confirmed MERS.
HCID=high consequence infectious diseases; MERS=Middle East respiratory syndrome
During these pre-procurement activities, and when designing a procurement process, a multidisciplinary approach should be adopted, with procurement personnel serving as both procurement subject matter expert and project facilitator. The approach sees procurement specialists working alongside clinicians, finance experts, and commissioners at an early stage. Procurement teams can spot and advise on potential problems with specifications or service delivery models, improving future processes and ultimately the way services are designed and delivered. Detailed research enables understanding of what can be achieved so that procurement effort is focused on the right areas from the outset. Adopting extensive and strategic pre-procurement engagement approaches, including soft market testing and analysis, allows testing of the assumptions on the size, capacity, and capabilities of the market.
Setting clear organisational and project governance structures at the outset is beneficial, particularly for specialised commissioning. This contributed to the success of the ABI project (see case study in Box 2),3 which was a highly specialised service enabling children to hear for the first time. By reporting to an internal governing group, we gained acceptance from key decision‑makers and stakeholders. The group scrutinised the work, endorsed the procurement approach, and approved the final outcome.
Box 2: Case study—auditory brainstem implantation3
ABI is a pioneering brain surgery for children aged 5 years and under who are profoundly deaf and unable to use conventional hearing aids or implants. NHS Arden & GEM worked with NHS England’s highly specialised commissioning team to establish a new specialist ABI service to enable approximately nine children per year to receive this life-changing surgery.
The aim was to select two paediatric ABI centres to establish the new service and ensure that appropriate outcome reporting, monitoring, and clinical governance structures were in place. Concentrating and accumulating clinical expertise within a multidisciplinary team was key.
The procurement process considered results from the extensive pre-process engagement and consultation—which included lead clinicians and patient and public representatives—and the narrow provider base available. Suitably qualified providers were invited to bid for the two contracts in an open process organised in multiple stages.
To run the procurement process effectively, a project group panel was established bringing together commissioning leads, patient and parent representatives, procurement, clinical, finance, quality, and information governance expertise. Independent clinical input was provided by a European professor who was an international expert in this area. To make the process as robust and inclusive as possible the project group panel supported every stage, including drafting service-specific procurement questions and undertaking the evaluation and moderation.
A high-quality, affordable, and family-centred ABI service has been established at Guy’s and St Thomas’ NHS Foundation Trust and Manchester University NHS Foundation Trust. Concentrating expertise and experience in two centres is expected to improve clinical effectiveness, service delivery, patient experience, and, consequently, outcomes.
ABI=auditory brainstem implantation
From process design to effective execution
During the formal procurement phase, developing clear documentation is critical, drawing on all the learning from the previous phase. This allows potential providers to make an informed and timely choice about their suitability, and improves the quality of submissions received.
For some projects, an online evaluation system is used for accessing and scoring the proposals, with conference calls for some of the less complex moderation discussions. For more complex discussions, however, face‑to‑face meetings ensure the evaluation process is managed effectively.
Where possible, patient representatives are involved in scoring and moderation. This can include help with developing the questions as well as scoring and participating in discussions, as was the case in the ABI procurement.3 Patient representative involvement allowed for richer analysis and discussions, and ensured that the patient’s voice was heard in a complex procurement that affected a small number of people. In our experience, those involved appreciate the opportunity to be part of the decision making for selecting the providers, and enjoy the process. As the patient representative said at the end of the process to procure ABI: ‘It is easy to complain about how slowly NHS wheels turn, but this process made it clear to me that for these decisions that can lead to life‑changing outcomes, it is vital to be completely thorough.’3
Reaping the benefits
Ideally, the benefits identified at the start of a project will eventually be matched or even exceeded by those realised as a consequence of the procurement process. Smooth transition from procurement to contract and supplier performance management are important to ensure continuity of process.9 Without this, the benefits can be easily lost during the life of the contracts. Ongoing support is crucial, not only for measuring success, but also for developing a deeper understanding of these niche conditions and treatments and continuing to commission best-value solutions for patients and the wider health service.
In a typical procurement, the projected benefits are first captured in the initial reports and project initiation documents, which are then translated into the procurement documents, questionnaires, and moderation discussions. Clear benefits-realisation strategies need to be established as early as possible, and tracked to the end of the process through to contract management. In the NHS, a strong relationship between procurement and contracting should be the norm.
Procurement is much more than simply obtaining services and goods.10 It encompasses the steps leading to the design of the best process to obtain these services and the activities needed after the process is run and complete. It is a tool to meet an organisation’s strategic aims. When it comes to securing the best possible solution to a complex condition, a holistic approach to public procurement—with advance planning, strong governance, and multidisciplinary working—can deliver safe and high-quality specialised surgeries and interventions.
Practical tips for successful procurement
- Map and engage relevant stakeholders, and do not shy away from those perceived as difficult
- Establish clear governance structures at key stages of the procurement project
- Identify the project aims and benefits, and reiterate and monitor these during and after the process
- Keep in mind that designing a process is not a one-off activity delivered by the procurement function; it is joint work involving a multidisciplinary team and end users
- Develop clear documentation and maintain good record-keeping; keep clarifying and testing assumptions before finalising any documentation—anything that you understand may be unclear to others
- Ensure procurement and contracting departments collaborate to deliver the ultimate project benefits
- Review and learn from each project.
- The King’s Fund. The NHS budget and how it has changed. The King’s Fund, 2019. Available at: www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget
- PricewaterhouseCoopers. Strategic use of public procurement in promoting green, social and innovation policies—final report. European Commission, 2017. Available at: op.europa.eu/en/publication-detail/-/publication/6a5a4873-b542-11e7-837e-01aa75ed71a1/language-en;
- NHS Arden & GEM. Improving access to pioneering brain surgery for deaf children. www.ardengemcsu.nhs.uk/showcase/case-studies/case-studies/improving-access-to-pioneering-brain-surgery-for-deaf-children (accessed 29 October 2019).
- NHS Arden & GEM. Procuring an international proton beam therapy service for NHS England. www.ardengemcsu.nhs.uk/showcase/case-studies/case-studies/procuring-an-international-proton-beam-therapy-service-for-nhs-england/ (accessed 29 October 2019).
- NHS England. Specialised services. www.england.nhs.uk/commissioning/spec-services (accessed 17 October 2019).
- NHS England, NHS Improvement. Making decisions about which new treatments to fund. YouTube, 2017. Available at: www.youtube.com/watch?v=b1exxrBDUEU
- NHS Arden & GEM. Establishing a high consequence infectious disease (HCID) service. www.ardengemcsu.nhs.uk/showcase/case-studies/case-studies/establishing-a-high-consequence-infectious-disease-hcid-service (accessed 29 October 2019).
- HM Government. The Public Contract Regulations 2015 as amended. Available at: www.legislation.gov.uk/uksi/2015/102/contents (accessed 29 October 2019).
- Chartered Institute of Procurement & Supply. Procurement and supply cycle. www.cips.org/en/knowledge/procurement-cycle/ (accessed 29 October 2019).
- Chartered Institute of Procurement & Supply Australia. The definition of procurement. Melbourne: CIPS Australia, 2006. Available at: www.cips.org/Documents/CIPSAWhitePapers/2006/Definition_of_Procurement.pdf