Contracting for supply of Enteral Feeds

What is it?

Enteral feeding is used where someone has a functioning GI tract, but has a swallowing or eating disorder which makes it impossible to meet nutritional requirements orally e.g. MND, MS, post CVA.

Most are fed through a PEG tube (percutaneous endoscopic gastrostomy), though some are via a nasal tube.

Can of worms

• Feeds are usually given through a pump (supplied free by Provider – training needed)

• Common problems: buried bumper, blocked tubes, overgranulation of stoma site, medicines administered through the tube (specials!), infection,

• Increase in hospital admissions if no access to timely expert advice

• Change in carer (in care home)

Why QIPP?

• Check your enteral feed primary care prescribing costs – each monthly script costs on average £150 to £250

• Also check what’s being paid for ‘ancillaries’ – supplies delivered direct to the patient or carer by the contractor

• Then check primary care sip feed costs

Why QIPP?

• For Norfolk this was c. £ 4 million per year for sips & enterals in primary care, and c. £300k per year for ancillaries

• Value for money?

• Feeds VAT free as FP10, ancillaries usually VAT free (but only if claimed for)

Contracts

• Specialised contracts like these are usually managed by the Trusts – so the incentive to save costs in primary care is not often considered

• Contract monitoring is often also managed by the Trusts (lots of primary care NHS re-organisations over the years!)

Contracts

• Fear of possible change of status quo from patients, clinicians and commissioner

• Up to date specification was needed e.g. improved clinical support in community, electronic patient data & invoices.

Contracts

• NHS has specialist enteral feeding group which provides advice to Commissioners

• Advised to re-tender as the same Provider had held the contract for many years

• Process started after talking to Trusts and engaging help of procurement hub

• First had to establish database of patients & feeds & equipment used – took about two months

Writing the Specification

• Aim to meet future needs as far as possible e.g. increase in patient numbers, care in community, needs of different patient groups (paed/adult) etc.

• Explore the options: flat pricing, off FP10, rebates, split paeds/adult

• Don’t re-invent the wheel – find out what others have done – what worked/what didn’t

• Get it agreed with the clinicians & patients

• Get the weightings right to meet the need

Form a Committee!!!• Nutrition Committee established to evaluate

offers, select supplier & manage future contract monitoring

• Members drawn from patients, Primary & Secondary care

• Made an advisory sub-committee of Area Prescribing Group

Keep calm

• It’s hard work

• Potential change in supplier for the needs of such a specialised patient group isn’t easy

• It may cost more initially (e.g. time)

• Not everyone will agree about ‘savings’

What happened?

• Significant reduction in primary care costs

• Maintained lower costs to Trusts

• Option for further savings in primary care

• Most importantly – increased clinical provision in the community – 4WTE nurses from 1.8 WTE (cost met by Provider)

• Shifted balance of contract management from Trust only to Trust & Primary Care – shared responsibility