1. Contracting for supply of Enteral Feeds

2. 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.

3. Can of worms

4. 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)

5. 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

6. 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)

7. 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!)

8. 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.

9. 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

10. 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

11. 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

12. 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’

13. 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