On 28 June 2019, the British Journal of Nursing (BJN) and Ontex held a round table on the procurement of disposable continence pad devices. The aims were to demystify the process surrounding formulary development and procurement, and to describe how nurses can establish good working relationships with finance, procurement departments and commissioners when formulating a tender.
The panel included a continence service lead and advanced clinical nurse specialist, a director of continence services, a clinical governance lead who was formerly a nurse consultant in continence, a continence care nurse, a continence care nurse manager, a clinical evaluation and implementation manager at the NHS Supply Chain and a senior category manager at the NHS Supply Chain. Panel members came from England and Wales, and represented both the acute and community sectors. Topics discussed included:
Are formularies for disposable continence products effective?
The panel agreed that, in their experience, the inclusion of items on formulary was decided by nurses, within a set budget, based on the clinical needs of a patient population with moderate to severe incontinence. Community formularies are more extensive than acute ones.
The dual aims are to streamline the formulary to avoid confusion, but with sufficient choice to meet individual patient needs. In short, the formulary should include a whole range of continence products, but avoid duplication and unnecessary variety. It was agreed that if a patient requires a product that is not on formulary, a case would be made to include it. However, such occurrences are rare.
In some areas, the formulary covers the acute, community and private sectors, such as day centres and residential settings. This is ideal for continuity of care. In Wales, they are in the process of introducing a national formulary. The panel thought it extremely unlikely this could be achieved in England.
The panel briefly discussed paediatric requirements, noting that patients in some regions do not have access to a paediatric nurse for continence assessment, or even a paediatric service.
Need for specialist assessment
Key to successful implementation of the formulary is effective assessment: only then can the right product be assured for the patient, based on their needs at that time. Some panel members stated that they have transferred this role from district nurses (DNs) to dedicated continence nurses/advisors. This gives DNs more time to devote to complex care.
Expert evidence-based assessment ensures that the device used is cost-effective, as selection is based on clinical need. For example, the decision about whether a patient requires one, three or six pads a day is a clinical one, although the maximum number of pads that can be used per day varies between regions. This approach also promotes correct application and fitting. Panel members related how specialist assessment (and re-assessment) has produced significant cost-savings by optimising product use.
Although the panel said that, in their experience, assessment and product selection focused on patient need, they knew of regions where this was interpreted very conservatively, with only high absorbency pads allowed onto formulary or where a maximum of three pads per day could be prescribed. In such cases, continence specialists can use Association for Continence Advice (ACA) guidance for provision of containment products to guide formulary development and prescribing criteria.
Educating and supporting generalist nurses
The provision to generalist nurses of clinical education on product use was considered highly important.
‘It is vital generalist nurses receive education on the correct application and fitting of continence pads’
One panel member described how DNs and healthcare assistants (HCAs) in her trust undergo a 7-day shadowing programme and attend a study day to help them meet the relevant competency framework. The DNs and HCAs are then appraised every 2 years.
To ensure good patient outcomes are achieved within budget, only three products are permitted on a single prescription, which is processed by the continence service. If a DN requests more or asks for a product not on formulary, a specialist from the service will liaise with them to assess whether there is a clinical need for this.
Re-assessment following hospital discharge
The panel commented that the prescription of continence products is often not given priority in the acute setting, creating problems at discharge.
A panel member said that specialist nurses in her community continence service provide advice and education to staff in acute care, in order to aid assessment and prescribing. This, combined with prompt home delivery of stock following discharge and encouraging patients to liaise with their GP or DN when a different product is required, has reduced re-assessment waiting times from 16 to 2 weeks.
Within the Welsh area represented by a panel member, all patients are re-assessed within 5 days of discharge, which has achieved cost savings by avoiding wastage and poor continence care. Asked how this focus on post-discharge re-assessment affects referrals, the clinician said her team has a varied skill-mix (from clinical nurse specialists to support workers), enabling de facto triage.
Additions to the formulary and need for product innovations
As stated above, the addition of an existing product to a local formulary is approved on the basis of clinical need. In Wales, innovative products are trialled by a Welsh health board to generate clinical and economic data before they are approved for use in clinical practice.
Another panel member commented that, in her experience, suppliers have issued redesigned versions of existing products or changed information on the packaging without prior notice. Although there is no requirement for companies to consult about changes in product design, sudden alterations can be confusing or unsettling for patients. In one instance, an unannounced alteration in the icons on the packaging caused uncertainty among patients about the product's level of absorption.
The panel said they would like to see more innovation in faecal products, specifically in the form of a light absorbency all-in-one product with a faecal indicator. The need for an disposable product that can curb the effects of explosive diarrhoea was also raised. In addition, the panel wanted more environmentally friendly products.
Larger sizes for bariatric patients are also required. Panel members confirmed that these products are mostly available as a ‘special item’, to prevent routine ordering. These orders are closely monitored.
Asked how they heard about innovative new products, the panel said it was either direct from the company in the form of a launch announcement or via a nursing journal or conference. They said it was important for companies to announce the launch of a new product in order to increase awareness and stimulate debate, even if it was likely to be too expensive to include in a formulary in the first instance. Clinicians could then share this information with patients, who might want to consider purchasing the products themselves.
The panel said they would like to see companies liaise with clinicians and patients more when developing new products.
Suppliers
All panel members said that products on their formularies are supplied by a single company. The whole of Wales has a single supplier (Ontex). As this is not feasible in England, each trust formulary has its own supplier, resulting in regional variations. Panel members said they are free to purchase from another supplier if the main distributor's range does not include a product that meets an individual patient's needs—for example, if there is a fitting issue.
Efficient tendering
The panel outlined the vital importance of having a systematic and well-scheduled process for the tender, as well as good ongoing communication with managers, procurement staff and financial services. Failure to do this can result in clinical leads being overlooked during decision-making, which can lead to poor patient experiences.
It is important to get the process right from the start. Relationship building is key. This involves getting to know the procurement lead and senior managers, with a view to explaining things to them from the nurses' and patients' perspectives, and challenging them when required. In addition, feedback from patients can be relayed to the stakeholders. To maintain the momentum, it is important to stay in regular contact with the stakeholders throughout the tender process.
‘Relationship building is key to getting the process right. Getting to know the procurement lead and senior managers will enable continence nurses to explain things to them from the nurses' and patients' perspectives, and to challenge them when required. To maintain the momentum, stay in regular contact with the stakeholders throughout the tender process’
For community continence services, it is important to know what data the clinical commissioning group (CCG) requires and how to present it. Much of this can be derived from internal reports and audits.
Practical tips
The top tip is to start early, ideally by developing relationships with the key stakeholders a year in advance. Begin by identifying what needs to be in the tender, including delivery service specification, IT requirements and educational provision. In other words, the process for implementation should be mapped out at the outset.
The panel also thought that it is helpful for health professionals who are new to the tender process to go through the entire procedure with someone who has experience of it. For example, this might give an insight into the additional services that could be offered, such as online ordering or freephone numbers. Even small details, such as the size of pallets for transportation, can be useful. One panel member said that additional requirements suggested for their 2020 tender are environmental issues and education for social services staff.
When making a business case for what needs to be included in the tender, identify the potential benefits in terms of clinical efficacy and cost effectiveness. The tender should stipulate that the contractor must prove that they are able to provide a service that will enable the clinical provider to achieve its desired patient outcomes.
The follow-up support and service to be provided by the company, such as the number of training days, is another important consideration, especially if it is a new contract covering a large geographical area.
Finally, it is worth checking the extent of information provided on the potential supplier's website and whether it has an app. The panel commented that apps can be useful for activating orders when re-assessing a patient in their own home. For example, Ontex has a learning hub on its website, as well as a central location for ordering forms and fitting guides. It also has an app.
‘It is helpful to check how much online information the supplier offers. For example, Ontex has a learning hub, ordering forms and fitting guides on its website. It also has an app’
Evaluating bidders' products
One panel member described how, in her region, the stakeholders decide what to include in the tender and determine the weighting. Each continence nurse lead then selects three products from a shortlist to trial. The products are rated for clinical efficacy, with the best performing ones added to the tender. The contract is awarded based on price and clinical effectiveness, with a 50:50 or even 40:60 ratio.
Another panel member commented that, in contrast to previous tenders, she was able to trial a bidder's products in patients' homes, in a care home and in a school. They also used questionnaires to assess the supplier's reporting style.
Following the trials, they tested the products' absorbency in their office, and invited patients attending clinics to view them and give feedback. After the contract was awarded, there were no phone calls from patients in response to the change, in marked contrast to previous experiences.
‘One potential new supplier gave permission for their products to be trialled in patients' homes, in a care home and in a school. After the contract was awarded, there were no calls from patients in response to the change’
When finalising the contract, it is worth double checking the absorbency bracket specified for individual pads, as similar products can fall into different Rothwell brackets or the level of absorbency of different products in the same band can vary markedly. Such inconsistencies can result in products being priced incorrectly within contracts, causing significant extra local expenditure; they can also cause patient dissatisfaction with performance.
These inconsistences reflect the challenge of assigning different levels of product tolerance to the various Rothwell bands. It is vital, therefore, that the NHS Supply Chain and companies work together to ensure tolerance levels and associated Rothwell bandings are reported accurately to clinicians. This reinforces the need for health professionals and procurement to work together as a team when developing contracts.
Finally, many patients find it unsettling and disturbing having to switch products as a result of a tender. One panel member suggested sending out a standard letter explaining the legal requirements of the tender process, with confirmation that it is ultimately designed to ensure the cost-effective prescription of effective products.
NHS Supply Chain perspective on product evaluation
The tender process principles described above are also used by the NHS Supply Chain to generate information on clinicians' and suppliers' requirements in relation to purchasing and distribution.
In terms of evaluating products, the Supply Chain has a nationally available evaluation framework that covers the full range of products included in the disposable and washable area. All awarded suppliers and products undergo due diligence, which includes checking compliance with all relevant market standards, adherence to the technical specifications, and financial and non-financial evaluation.
Given the lack of consistency in table-top product benchmarking and the ensuing need for a more controlled environment for these evaluations, NHS Supply Chain is considering producing standardised guidance for clinicians on product evaluation.
Going forward, all products will be subject to evaluation throughout the framework. The Supply Chain now has a clinical team, with health professionals who understand the needs of both patients and clinicians, to ensure the products it distributes to the NHS are of high quality and offer value for money.
Is it possible to standardise the tender process in England?
Although NHS Supply Chain has a standard template to generate and collect data from health professionals (which can be ‘bespoked’ to reflect individual customers' needs), there is no standard template for use at trust or CCG level for tendering purposes. It was suggested that the standard template used by shared services in Wales to tender for a national supplier could be adapted for use elsewhere. Even so, this would need to be adapted to reflect local patient needs.
The panel pondered if digital apps, or similar, might provide a means of standardising the tender process in England. For this to work, health professionals would need to focus less on local particulars and more on the wider community.
Patient engagement
Due to the taboos surrounding incontinence, it is difficult to get patients to join forums to discuss this topic. However, one panel member holds a patient engagement group in her hospital, with patients being invited back to discuss their care and products. Feedback is acted on, with one example being the adaptation of a disabled toilet.
Another panel member was considering talking patients through the entire procurement journey, so they can say what they want from it. She wondered whether this might lead to a few surprises.
Conclusion
This round table set out to describe how continence nurses can more effectively manage the tendering process of absorbent continence products. The panel identified that, in practice, the prescription of absorbent pads is generally based on clinical need and therefore cost-effective. This requires specialist assessment, with generalist nurses ensuring that continence devices are applied properly and fit well. Ongoing education is required to support generalists in this.
To ensure the tendering process meets clinical objectives, the panel advised that continence nurses should identify the key stakeholders—managers, procurement staff, commissioners and financial services—at the start of the process, and make every effort to maintain ongoing communication with them. In this way, the stakeholders are more likely to consider nurses' perspectives and needs during decision-making. It is also vital to present a good business case for the various components of the tender, identifying how the clinical benefits can translate into cost savings. Potential future developments could include more standardisation of the tendering forms and process, to reduce regional variation. Online media, including apps, could play a role in this.