Improving quality of life for adults with chronic pancreatitis

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 brittle diabetes. This highly specialist treatment requires providers with appropriate experience and 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.

The challenge

Chronic pancreatitis is a condition where the pancreas has become permanently damaged from inflammation and stops working properly. 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 – may be considered. This causes brittle diabetes unless the Islets of Langerhans (which make insulin) are transplanted back into the patient – a procedure known as Total Pancreatectomy with Islet Autotransplantation (TPIAT). This is a major surgical procedure, 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.

Our approach

The NHS England and NHS Arden & GEM partnership adopted a holistic approach to procurement with individual stages (pre-process, process and contract award, contract and provider management) conducted as part of a whole cycle rather than in isolation.

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 Commissioning Oversight Group approval for strategic decisions.

Understanding the market
To inform our procurement strategy, we needed a better understanding of market dynamics, potential providers and procurement options. We achieved this through a soft market testing exercise and desktop research. Our final report and process design options were presented to decision-makers, with an analysis of advantages and disadvantages for each option.

Determining centre allocation
We developed a detailed ‘Centre Allocation Strategy’ examining the risk and benefits associated with several options including an 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 (including location) to commissioning two, three or four centres.

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

Procurement strategy
The procurement process was designed in successive stages with bespoke questionnaires developed in consultation with the project group. We discussed questions weightings, quality requirements and adopted proportionate word limits for responses, linked to the question’s importance.

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 how to use ‘Award’, simulating an evaluation process to ensure understanding.

The outcomes

Thanks to meticulous planning, and regular and open communication, the TPIAT service was successfully awarded to four centres with proven expertise covering the North, South, Midlands/East and London regions.

These high-quality providers are:

• Delivering patient centred care with a focus on maximising the patient’s experience
• Providing specialist multidisciplinary care for eligible patients referred by pancreatic centres
• Ensuring that patients access hepatobiliary surgical, diabetic, pain management, anaesthetic, gastroenterological, psychological and islet isolation expertise
• Effectively monitoring patients post-operatively in the medium and long term
• Maintaining a national database of TPIAT cases to generate evidence-based guidelines for the management of patients
• Operating a rolling programme of clinical audit and cross-centre collaboration.

The service is now fully established, and NHS England is anticipating approximately 40 surgical cases a year which will be evenly spread across the centres. A consortium of the centres has been set up to maintain oversight of the service, bringing clinical teams together to provide the highest quality of care to patients.

Formal evaluation of quality of life is undertaken using regular assessments by a medical psychologist. Centres also undertake post-surgery satisfaction surveys with patients showing excellent self-reported outcomes.