This was a winding up, showcase of achievements conference for a project to bring Universities, NHS Trusts and commercial companies together to work in partnership to take forward innovations for the health sector. It was a long day with many talks - some of them more intersting and understandable than others, and I do not have time to outline all I learnt. However there is one talk well worth blogging to the stroppy women out there because this is useful information for those of us looking to change the way the NHS works.
The talk was by a charming and articulate man called Dr Chris Herbert, from a Government agency aiming to get innovations into the NHS. You can find his talk on the website linked to below.
Chris re-iterated the oft quoted observation that the NHS is a slow adopter of medical technology. Too right! but then he began to unravel the NHS system and you can see why - and of course by seeing what is making the NHS tick we can on the one hand challenge the system to change but on the other, have strategies to effect change whilst the systems are still in place as they are.
Chris's talk in a nutshell:
There are three levels of procurement in the NHS:
- the national level ( now a private company called DHL)
- regional level (Regional Collaborative Network. the Regional level do no not buy anything they just set up framework contracts for hospital trusts to buy into)
- and local or Hospital Trust level
The Hospital level is where it is at and here there is also complexity and further levels to penetrate.
The Hospital procurement process runs along the following lines: a need is identified, a solution is sought and suppliers identified, then a long procurement process ensues (he did not go into detail here!) which can last around 18 months to 2 years. The key decision maker in the process is the Directorate Manager and his/her only criteria for decision making is COST.
Directorate mangers have only an annual budget which they must spend or lose on the one hand but not overspend on the other. This is a very territorial system therefore with your fiefdom defined by the size of your budget. A purchase which has cost savings but outside of their own budget is of no interest to the directorate manager.
The key drivers to the 'not best but cheapest' criteria for decison makers are the Government tools of Commissioning and Payment by Results.
Commissioning has been dealt with in a previous blog around PCT commissioning. Basically the needs of a population are identified and priorities set from these and then health services are bought in to supply these health needs and priorities.
Payment by Results is a mechanism for calculating what is paid to hospitals for the work they do. In maternity services, say in the delivery suite, there is a fee paid for a normal birth, a fee paid for forceps and a fee paid for ceasareans. The fee set is said to be the average cost for these procedures. This is a strong force in driving down costs because you won't want your costs per procedure to be higher than the fee you receive! In fact you will aim for the reverse!
This has implications for those of us wanting to promote normal birth and choice and innovation in maternity care. Trusts get more money for doing lots of Ceasereans than they do for normal births, water births etc. This has been an issue in our local PCT area as it is a driver for the medicalised high tech birth. This payment by results also discourages innovation and innovative practices because if you are on a set fee you will want to do what is easiest and fastest - there is far more risk costwise for innovation.
So in sum, the key levels of procurement are national level, regional level and hospital level. At hospital level the key decision making is at directorate level and their over riding criteria is cost (against a one year budget allocation!). And the drivers in this system are the systems of thecommissioning process and Payment by Results.
So how do you introduce innovation and innovative practice into this scenario - not without difficulty it is clear, however Dr Herbert had a few pointers:
Directorate managers say they are in favour of innovation - but as you see the drivers mean that their practice penalises it, so
- Plan strategically
- Look at how to maximise chances of take-up over a wide area
- Intervene early in the process of procurement to enable things to move forward
When looking at an innovation or new practice ask yourself the following:
- Will it solve a problem the Trust has?
- Will it fit the current practice (if it does not then it won't be adopted because changing current practice cost s time and effort that cannot be afforded)
- What is the tariff (in the Payment by Results) for the procedure or service you want to innovate? (You need to show cost benefits or at least neutrality for your innovative practice)
- Identify data and evidence to support you innovation.
- The key to procurement is hospital uptake so start with them - get to the clinicians and end users.
- Do a trial help set up a tiral - even if there have been research trials done globally they will want to do a trail in their hosital
- Help staff write their business plan to get the money/go-ahead from the management (directorate and remember cost)
- Remember it is not all over until the fat lady sings - until there is a contract signed then nothing has changed
- Once you have got a hopsital or two under your belt then you can start to tackle the strategic health authority. Look for tender calenders on their websites and start negotiating - remembering that price is the big issue - not quality.
It makes me wonder why I do it! But do not be de-moralised - we can change things because the other great driver in current Government policy is patient satisfaction and patient choice. So it really is time to get stroppy because policy is on our side.
Good luck to you all!
For all the conference papers for the day (20th October in Harrogate) and slides go to the White Rose Health Innovation Partnership website: www.wrhip.org