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Clinical Affairs Committee Chair Dr Elizabeth MacPhie experienced service design in action in 2017-18 when her local Clinical Commissioning Group in Lancashire put out to tender for an integrated MSK service (including MSK physiotherapy, the equivalent of a Tier 2 assessment service, community pain service, rheumatology and chronic fatigue syndrome). Here, she shares her top tips for colleagues who go through a similar process.


Avoid a tender process if possible
Probably the most important learning from this whole process is the need to maintain a close relationship with commissioners.  It’s essential to understand the pressures they are under and the local politics so as to avoid a tender process if at all possible.  Explore if there are alternative ways in which services can be redesigned.

The tender process utilised an enormous amount of resource that, if our Foundation Trust hadn’t been successful in winning the contract, would have been completely wasted.  The bid was led by our Transformation Team – a team of five working on a number of projects, with dedicated support from finance. 


During the tender process we had regular meetings between the Transformation Team and clinicians and we held three half-day engagement events attended by stakeholders, including patients. Each of these ‘competitive dialogue days’ was attended by a team of 10, with representation from the Transformation Team, clinicians (at least three at each session), contracts and finance. There was a considerable amount of time that went into writing the submissions that were required before each session, and then for the final tender submission itself.

Take the opportunity to get things done
We benefited from pushing forward on a number of separate initiatives that came about as a result of the tender. For example, proposals for an extended scope physiotherapy role to be piloted, and our biosimilar switching work were identified as new ways of working – things likely to strengthen our case. Within the staffing model for the new service we included three new posts within the rheumatology team: Nurse Consultant, GPwSI and pharmacy technician.

Choose your partners carefully
It was clear from the start that we would need to work in partnership with another provider to deliver the MSK and physiotherapy elements of the service.  We were fortunate that many providers were keen to partner with us as they recognised that they would struggle to deliver the rheumatology element.  We decided to partner with a provider that was already delivering the majority of physiotherapy locally and were reassured that they had experience elsewhere in the country of running an MSK model.

They also understood the local politics and had a good understanding of the Estates and local GPs, which was helpful.  We also partnered with the acute Trust, recognising that an important part of the model was the onward referral pathway to specialist pain and orthopaedic services. Throughout the tender journey our partners were involved in all meetings and discussions to ensure we were all aligned with the vision for the service. 

Get involved, it’s your service
We realised early on that it was very important to have representation from the rheumatology team to ensure that the interests of the service and our patients were heard and to also ensure that the model proposed would benefit our patients. We also appreciated that there was much to be gained by this service redesign to streamline the patient pathway across the MSK disciplines. We recognised that many patients were referred to more than one discipline; diagnosis of an inflammatory arthritis was sometimes delayed if patients were not referred straight through to rheumatology and working alongside other disciplines provided an opportunity to support some of our patient groups, particularly those with an element of chronic pain. This was our chance to rectify some of these anomalies.

Meet regularly and ring-fence time
It was a real challenge to find the time within the job plan particularly for the regular meetings. But I was fortunate that it was acknowledged early on by the Transformation Team that clinical input into the bid was extremely important. Following discussions with our Network Director, I was allowed to drop a clinic in order to engage with the tendering process and provide vital clinical input into discussions. Deadlines for submissions for the competitive dialogue sessions were often very tight with sometimes only a week’s notice.

An external advisor can be helpful
Our Transformation Team recognised that there were a number of well-established integrated MSK models and employed an external advisor as part of our bid team. This individual brought valuable insight into the challenges their service had faced and how they had overcome them. Our external advisor attended the competitive dialogue sessions and provided additional assurance to the commissioners that we were learning from other successful services. 

Learn to speak the commissioner’s language
It’s very important to understand what the priorities are for commissioners and understand their language. We were provided with a service specification that identified nine pillars of care and all of our presentations were focused around these. It was also important to understand the specific details of the contract and what was and wasn’t included, as well as the key performance indicators. These are all things which sometimes as a clinician we don’t focus on but at the competitive dialogue sessions it was critical to speak the commissioner’s language as many round the table weren’t clinicians.

Engage with stakeholders including patients
Throughout the tender process we held a number of engagement events with stakeholders. These proved invaluable to demonstrate to commissioners that we were listening to our stakeholders and taking on their views. It showed we were keen to partner with the third sector and that we were involving patients with the re-design of our service.


Keep patients informed
It was a very difficult time for the service and we acknowledged that there was a risk we might not win the contract. We realised that our patients were our best advocate and keeping them informed of what was happening was very important. I met every couple of months with our patient support group and they very much appreciated being part of the discussion.

Regularly update the team, and be honest
Probably the most important lesson I learnt was the importance of keeping the team updated with what was happening and to be open and honest. We had several members of staff, both clinical and non-clinical, who were anxious about their job security and this was important to acknowledge. The team really appreciated this transparency and felt assured that their worries and concerns were recognised.

For more background on Dr MacPhie’s experience, or if you have any questions on service design, commissioning or delivery in your area, contact the policy team.