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How we designed and set-up new end-of-life services

Dr Matthew Davies talks through the process of developing a service plan, designing specifications and going out to tender

Making the case for change

In 2009, delivery of the national End of Life Strategy had stalled slightly and in June of that year Nene Commissioning was approached by NHS Northamptonshire to become the lead commissioners for countywide end-of-life services. I was asked to be the GP lead for the development of any new services to help deliver this national strategy and was supported by a dedicated management lead.

We began by establishing a clear strategy – to increase choice for patients at the end of their life and to ensure that services were available to enable people to exercise preference over their place of care.

Public health analysis from the Joint Strategic Needs Assessment coupled with market analysis clarified the issues:

• The number of people dying at home (20%) and in hospices (6%) was well below patient preference.

• More people with cancer (26%) were dying at home than those with other conditions (18%).

• There was no single point of access to services and no provision of rapid-response services.

• The local Hospice at Home service was very limited, and our community Macmillan Service only ran on weekdays.

Developing our plan

We undertook extensive engagement with clinical leaders and stakeholders to establish where gaps existed and what could be commissioned differently. We consulted with local GPs and held carers' workshops to establish what a ‘gold-standard' service would look like.

There was close synergy between what clinicians, patients and carers thought needed to improve. This included additional support for families in their own homes to enable them to support their relatives and a need for rapid access to additional services if necessary.

Service design then started in earnest, together with the building of a business case to secure additional funding. I led the service design in collaboration with other GPs and hospital consultants, while a multi-disciplinary project team produced the business case.

The business case was approved in October 2009, and as a result of the market analysis and the identification of both provider intentions and market reform levers, it was agreed that a formal procurement was necessary in the form of an open-market tender.

Service specifications were developed for inclusion in the tender documentation and the formal procurement process commenced. The official procurement process took us to April 2010, with the new services planned to start in December 2010.

In leading the procurement of these new services, we undertook six steps to move us from service review to implementation:

• identifying the drivers for change

• generating clinical leadership and stakeholder engagement

• developing and producing a robust business case

• designing clinically led service specifications

• procuring services

• implementing services.

Stakeholder engagement is critical to ensure you gather the views of all the people involved in delivering and receiving services. Once areas that need to be improved have been identified, focus on collecting ideas and suggestions from the public, patients, carers and local providers.

Hold events and workshops and invite stakeholders to participate in shaping the new services. This helps with introduction of new market entrants as local people feel they have had their ideas listened to, and it promotes ownership of the new services.

Designing service specifications

Developing specifications for a package of services needs strong clinical leadership.

We decided we wanted to deliver the following:

• a care co-ordination centre available 24 hours a day, seven days a week, providing a single point of access

• a rapid-response service available seven days a week to provide specialist care within 60 minutes of request

• personalised care support to help families keep their relatives at home if that is their preferred place to die

• primary care link nurses working in the two local hospitals to help identify patients who want to go home to die, with a full package of support to enable this to happen.

The developed clinical pathways were written up and clinical key performance indicators (KPIs) developed and included in the specification. These KPIs included:

• all patients who have a care plan to co-design their bespoke patient care/ management plans with professionals

• all carers to be offered a referral for a carers' assessment

• the rapid-response service clinical (home) visit to be undertaken within 60 minutes of the time the call is received from the co-ordination centre.

Other performance KPIs were taken from the Carson Standards already nationally available, for example:

• all calls must be answered within 60 seconds

• no more than 0.1% of calls engaged

• no more than 5% of calls abandoned.

However, we felt it was vital to ensure that clinical quality was being measured and not just the process. For example, outcomes needed to be measured such as the percentage of patients with a care plan documenting their preferred place of death and the type of interventions carried out to support patients to stay at home.

Procuring the services

• Due to the complexity of procurement rules, it is best to get support for the technical process including advertising through the national procurement website:

• As lead clinician, I was directly involved in the assessment and scoring of the bids at the invitation-to-tender stage. This involved designing crib sheets based on the requirements in the specification, including what we would expect best practice to look like so we could assess objectively against the specification.

• The scoring of the bids is time consuming and took us five full days spread over a month.

• I was also a member of the interview panel where I led on clinical areas of questioning and challenge with a second GP colleague from Nene Commissioning.

I was able to assure myself and colleagues about clinical quality by focusing on a number of questions, including:

– How will the service guarantee patients receive appropriate symptom control?

– How will the service ensure patients are able to have the opportunity to express their preferred place of care and death?

– How did the service provider anticipate it would meet the needs of carers?

• Locally, this was the first time that GPs had been such an intrinsic part of the procurement process. This has led to GPs being involved in other service tenders and procurement.

Avoiding conflicts of interest

No GPs involved in the procurement and tendering exercise were involved in or linked to any potential providers of the new services, and this therefore removed the issue of conflicts of interest.

The procurement process in itself was also very robust, with the panel comprising eight people who independently scored the applications against a set of pre-determined questions recommended by national procurement rules. Under these rules, scores are aggregated for each bidder and the preferred provider is the organisation which scores highest.

Measuring how services are performing

The new package of services commenced in December 2010. The different elements are delivered under one contract with subcontracting arrangements in place to deliver personalised care support.

To date, on average 30 people per month are referred to the primary care link nurse, of which at least 20 are able to go home. Some 300 hours per week of personal support has been fully used – with an additional 250 hours available from 1 April, 2011.

We feel we have commissioned and procured a gold standard service that delivers value for money by recycling funding that would otherwise have been spent in hospital to provide a community-based service to support those who would prefer to die at home.

Dr Matthew Davies is vice chair of Nene Commissioning and a GP in Daventry, Northamptonshire

How we designed and set-up new end-of-life services