26th May 2016
by Edward Sheppard

Lord Carter’s review and potential savings is the biggest and strongest procurement initiative the NHS has embarked for many years. It has received high profile publicity with savings in temporary staffing, estates and supplies identified in line with the Five Years Forward plan of NHS England (Interim Report June 2015).

As a tax-payer this is welcome news; as a patient, the situation is more concerning because there appears to be risks to the services one may receive. As a long term supplier to the NHS, my fundamental question is how will procurement recognise the importance of clinical value?

Value to the Clinician

The NHS employs professional buyers in their various procurement departments who endeavour to organise the clinicians to determine what is needed before seeking the best value supply.

In principle this process is logical, methodical and engaging with the front line to give medical and nursing teams exactly what they need to provide patient services.

In practice, this often misses the best value option and the local departments are forced to make their own arrangements if only to deliver the service patients expect. This applies especially to busy clinics like ENT and Ophthalmology and Day Surgery Theatres.

In ENT, a ubiquitous instrument is Crocodile Forceps used in otology, which is one of the most common referrals to NHS hospitals.

Sterile single-use Crocodiles are preferred because they don’t get lost or damaged with high repair or replacement costs. However, the cheaper ‘better value’ options suffer from short shaft lengths, poor jaw opening, sizes that will not fit ear specula, particularly in paediatrics any of which make them less useful to the clinician.

Cheap Overlooks Waste

What does a surgeon do if the available single-use instruments are not fit for purpose?

This is a familiar decision for many when faced with scissors that do not cut, forceps that will not grip and clamps that do not hold. The solution is open another pack and immediately double the price the NHS pays for one procedure tray.

It may not stop there: work DTR Medical undertook a few years ago amongst Welsh A&E Departments indicated up to three suture trays are opened, tripling the costs!

Single-use instruments will be disposed of in sharps bins and be processed as clinical waste. Excessive trays increase the amount unnecessarily which is environmentally wasteful and costly. Sometimes cheapness is too much of a compromise and value comes from confidence in opening the first pack.

The Future is Overlooked

Public procurement rules focus the NHS on buying what has been used historically and routinely re-tendering these items every few years usually for minimal extra return. This is especially the case for disposables and single-use purchases. There is a significant burden on buyers which over emphasise the lowest price and no volume commitment.

With so much effort spent on current or past usage, there is no time left to look towards the future. There is talk of “Horizon Scanning” and Re-Engineering Services and Patient Pathways” lead by new clinical practice.

Making change is often where the value lies, but procurement teams are kept in the dark; “The computer says no” or they have no purchase history means they have yet to see the clinical need and resulting value.

Otologists are starting to use endoscopes in ear surgery in place of microscopes because the view of the procedure site is superior making it easier to operate. This change requires different instruments and surgeons have suggested to us they need sterile single-use suction tubes and tips to help them.

This is very new and used by a few innovators who see the value in change and DTR Medical has been delighted to introduce a range of Ear Endoscopy Suction to meet this need. How long will it be before procurement are aware of this movement?

Location, Location, Location

Bundling current demand from all departments makes sense to the NHS, but it also contributes to a loss of value. In the case of general surgical instruments, like Scissors and Forceps, they are used in wards, outpatient clinics, primary care, day surgery and main theatres, but are the needs the same?

The answer is obviously no; a surgeon performing procedures in main theatres needs to have a high level of confidence in their tools. A nurse attending to a dressing in a clinic wants a quick and easy pack to do their job. The NHS has the tendency to push these requirements together with the result being no one sees the value.

In maternity, there has been a recent trend toward home delivery (Daily Mail 2016). The NHS already buys sterile single use packs for use in labour wards which works for this location. If a pack has poor quality instruments it is easy to get another from stores quickly.

However, for home births, how many packs does the midwife need to carry in case one is inadequate?

For the professional, the wrong instrument in the wrong location is a source of stress, adds extra risk, and the value of single-use is negated by inconsistent quality.

Recognition is a Good Start

There are signs that the NHS recognises the struggle between cost and value and this is a good sign, even if it will take time to integrate.

Of course, there is a place for bulk purchasing of sterile single-use trays used widely in hospitals, clinics and GP practices. There are experts who provide this service, but at the market prices, it is impossible for them to give the precision clinicians need some times. Non-stock requisitions by departments will be seen negatively by most NHS buyers because it creates extra work, and may break contract commitments.

But a non-stock requisition also provides an insight into the value clinical teams place on their sterile single-use instruments today and into the future?

DTR Medical Ltd is registered in England & Wales. Company No. 4394278. Registered office: 17 Clarion Court, Enterprise Park, Swansea, SA6 8RF. VAT No. 800410205. DTR Medical is a registered trademark of DTR Medical Ltd.

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