Getting it right first time and reducing variation in the NHS

Source: NHE March/April 2019

Mike Hutton, author of the recently-published Getting It Right First Time (GIRFT) national report on spinal services and consultant spine surgeon at The Royal Devon and Exeter NHS Foundation Trust, looks at how reducing unwarranted variation in NHS procurement could make a multimillion-pound difference.

If you went online looking to buy a new set of headphones, would you buy the ones that cost £20 or the ones that cost £200, even if they did exactly the same job?

Of course, it’s impossible to say without knowing all the facts. Yet NHS procurement managers are faced with sourcing and negotiating for clinically-assured, high-quality products worth hundreds of millions of pounds – often without the information they need to get the best possible deal.

It is a common theme of the eight GIRFT national reports to date that millions of pounds could be saved every year if trusts stopped paying vastly different prices for what is essentially the same thing.

Data collected using the Purchase Price Index and Benchmark Tool (PPIB) suggests that £42m a year is spent on implants in spinal surgery. Yet the evidence we saw repeatedly when we visited 127 trusts across the country for this report was that most do not understand the cost of the implants they are procuring, and many are not working effectively to secure best value for the NHS.

Poor information is at the heart of these decisions. Such is the scarcity of accurate procurement data that we needed to sift through more than 120,000 receipts and purchasing orders simply to understand the scope of procurement variance across the NHS in England.

We found, for example, that some trusts pay £150 each for one of the most commonly used implants in spinal surgery – the polyaxial pedicle screw – while others spend £650, even though there is little demonstrable peer-reviewed evidence to suggest one has a better outcome for patients than another. If, as is the case in France, we had a nationally set figure for these screws – say £200 each – it is estimated the NHS could save £4.6m a year on just that item alone.

Of course, if surgeons prefer to use the £650 screws because they think they are better for patients, they should be able to back this up with evidence.

The means for gathering that evidence already exists in the British Spine Registry (BSR), yet the opportunity to make better-informed procurement decisions is being lost – best estimates show that between 94% and 68% of spinal activity (depending on the procedure) is still going unrecorded on the BSR. The GIRFT report recommends that all surgical interventions are logged going forward, with best practice tariffs for providers that comply. Only then can we begin to judge whether certain brands of implants really do justify their price tag.

And while we acknowledge that the seemingly-inflated price of an implant can sometimes mask its true cost – if, for example, implant manufacturers fund support staff, research posts, or other services not otherwise available to a cost-conscious trust – the ultimate value of that can only be determined if both industry and the NHS are more open and transparent about the size and scale of these benefits.

Only once the full facts and figures are at our disposal can we decide whether we can afford those £200 headphones, or whether we should be buying them in the first place.

Procurement efficiencies are just one of a number of potential financial opportunities identified in the GIRFT spinal services report. There are also opportunities to make efficiencies and savings of £27m annually by tackling length of stay, increasing the use of day case surgery, and better planning of paediatric scoliosis services.


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