The news comes at a time when the NHS is charged with making financial savings of £20billion by 2015, leading to calls for improved data collection and procurement activities to ensure the availability of vital technologies moving forward.
The worrying figures were revealed in the new National Audit Office report, Managing high-value capital equipment in the NHS in England, which also accuses the health service of failing to get real value for money for high-value capital purchases.
It adds: “NHS trusts do not have the means to know if they are making best use, or getting best value out of their high value equipment. Equally, they do not have the means to determine if they are getting value for money from purchasing or maintenance. There are significant variations in levels of activity between trusts, and a lack of comparable information about performance and costs. In these circumstances the planning, procurement, and use of high value equipment is not achieving value for money across all NHS trusts.”
According to the document, over the past five years NHS trusts have spent £50m a year purchasing MRI, CT and linac machines and the current value of equipment in hospitals and specialist centres is around £1billion.
This increasing demand has been driven by a focus on reducing waiting times and increasing clinical application of the technologies, including the ability of scanning equipment to allow early diagnosis and provide timely intervention within key areas such as cancer, stroke and major trauma.
As the widespread roll-out of devices has been confined mainly to the past decade as applications improved and prices became more affordable, it is only now that, after a typical 7-10-year lifespan, they are coming up for renewal. Were all trusts to replace existing machines on a like-for-like basis, they would collectively need to find £460m in three years at a time when spending, particularly capital spending, is being severely curtailed.
There are significant variations in levels of activity between trusts, and a lack of comparable information about performance and costs . In these circumstances the planning, procurement, and use of high value equipment is not achieving value for money across all NHS trusts
The report states: “The significant investments made during 2000-2007 purchasing replacement and additional machines present the challenge in future years as to how the costs of replacing machines will be met as they reach the end of their useful life. More immediately, the NHS faces the challenge to make better use of existing capacity in the current financial climate, as the Government aims to deliver up to £20billion of efficiency savings in the NHS by the end of 2014-15. Furthermore, in its 2010 Comprehensive Spending Review, the Government announced a 17% reduction in capital spending for the NHS over the next four years, from £5.1billion in 2010-11 to £4.6billion in 2014-15.”
The report claims that, without major changes to procurement systems, the NHS could find itself unable to keep up with demand and see patient outcomes deteriorate.
Key issues highlighted include a lack of comprehensive data on cost, efficiency and utilisation of equipment, and no formal collaboration on price.
NHS trusts do not have the means to know if they are making best use, or getting best value out of their high value equipment
According to the document, the number of diagnostic scans carried out on NHS patients using MRI and CT machines has increased three-fold in 10 years. For radiotherapy, the number of treatment sessions has increased two-and-a-half times over the same period. Over the same time, the workforce supporting delivery of scanning and radiotherapy has increased, but shortfalls of up to 7% still remain in some trusts.
While trusts do report their average costs per scan, they do so in different ways. As such the report shows that, in 2008/09, the average cost per CT scan ranged from £54-£268 between trusts; while MRI scans ranged from £84-£472. In terms of radiotherapy use of linac machines, the Department of Health has developed a dataset to enable comparisons to be made about efficiency and utilisation. No similar approach exists for CT and MRI.
The report states: “This [report] points out that trusts are not collaborating to get the keenest prices on purchasing or maintenance of machines. One quarter of purchases in 2009/10 were made outside existing framework agreements and opportunities were missed to secure lower prices by grouping together requirements for new machines.”
Other issues include:
- A lack of independent procurement advice on how needs can be met
- No mechanism to determine if a trust has the appropriate type of maintenance for CT and MRI machines
- A wide variation in opening times of between 40-100 hours a week for MRI and 40-90 hours a week for CT scans between trusts
- A wide variation in the time taken for scans to be performed, with the proportion of patients waiting under two weeks for referral for MRI varying from 20%-93%, while CT waits vary from 33%-98%
- No systematic means for trusts to assess how efficiently they use their MRI and CT machines
One quarter of purchases in 2009/10 were made outside existing framework agreements and opportunities were missed to secure lower prices by grouping together requirements for new machines
The report states: “Greater savings and efficiencies for the NHS can be secured if trusts plan their decision-making in the light of capacity required beyond individual trusts, for example cancer networks, which typically cover 1-2 million people. However, it is not clear what the future of such supra-trust structures are. Cancer networks have guaranteed funding until 2012, but the issues of purchase and maintenance of new equipment will persist far beyond that time frame. Whatever NHS structures develop, we consider there is more scope for trusts to act together in the following ways in the interests of patients and value for money.”
It goes on to make a number of recommendations for improvements to the system so as to ensure that, where necessary, trusts can afford to replace existing machines and upgrade as new technologies appear. The recommendations include:
- The NHS Commissioning Board should set standards for accurate and comparable data in the use of high-value capital equipment
- The Department of Health and NHS Commissioning Board should design tariff prices in a way that incentivises efficiency of use of machines and recognise that trusts may need to find several hundred million pounds to replace machines over the next 10 years
- The introduction of a means by which trusts can objectively determine the right specification for their needs and be assured they are gaining VFM from procurement decisions
- Boards should participate in benchmarking activity to compare prices with other trusts and look for opportunities to group their demand for machines with other organisations to secure savings
- The management of trusts should be able to demonstrate to boards that they have appraised the value of using framework agreements for the purchase of new machines and demonstrate, if they have not used framework agreements, that they have secured a lower price when purchasing machines
- GP consortia should work together to assess levels of demand expected across a wider locality when considering purchase of new machines, and establish the extent to which they might combine plans with other consortia to fund the capacity needed to meet demand
Greater savings and efficiencies for the NHS can be secured if trusts plan their decision-making in the light of capacity required beyond individual trusts
It also calls on individual trusts to assess the costs and benefits of purchasing, leasing and outsourcing when replacing machines, stating: “As around half of machines are due to be replaced within three years, trusts need to plan their procurement now so they can manage the risk of incurring higher costs, for example, extra maintenance costs or not achieving savings through aggregating requirements with other trusts seeking to replace their equipment to a similar timescale. Trust boards should also scrutinise their existing deals for maintenance of machines by assessing current arrangements against, for example, the Department of Health’s NHS Procurement Diagnostic Tool.”
It adds: “Trusts should look critically at the arrangements they have for meeting the demand for scans and for radiotherapy and consider whether they have sufficiently robust planning and flexibility in place to minimise the need for overtime. They can do this by collecting the right data to measure demand and capacity, examining trends and expected patterns in scanning and radiotherapy treatment and checking that they are using a combination of staff skills and extended hours in the most efficient way to maximise use of equipment for the convenience of patients. Planning should also focus on recruitment and retention of staff, including physicists, technologists and engineers.”
The report has been welcomed by representatives from industry, who claim they are working hard to improve the technology behind the machinery to enable trusts to do more for less.
Andy Brown, NHS Supply Chain’s managing director of diagnostics, said: “Around 75% of NHS trusts are utilising our framework and are enjoying lower acquisition costs and equipment cost savings. Naturally trusts get the benefit of Supply Chain’s national pricing and we are already providing services to support a number of the recommendations in the National Audit Office report.
The replacement of old equipment will provide a significant challenge for trusts and our range of frameworks to plan, aggregate, purchase or lease and maintain high-end equipment will be invaluable
“The replacement of old equipment will provide a significant challenge for trusts and our range of frameworks to plan, aggregate, purchase or lease and maintain high-end equipment will be invaluable. We welcome the opportunity to work with the DH and NHS Commissioning Board to further develop these recommendations.”
And Lucy Hutchins, head of planning services as Asteral, a leading provider of Managed Equipment Service (MES) agreements, added that full analysis of existing equipment would be one of the first tasks for trusts. She said: “I welcome the report as we work closely with a number of trusts and know that many do not have a clear and detailed understanding of utilisation across their equipment portfolio.
Up-to-date and accurate information of this nature allows trusts to decide whether to start attracting patients to bring equipment up to capacity, or whether alternative items of equipment could be used to perform certain procedures to alleviate over utilisation
“An analysis of equipment utilisation needs to consider a number of factors including the different examinations performed, the time they take, the type of patients undergoing the exam, and any preparation time required.
“Up-to-date and accurate information of this nature allows trusts to decide whether to start attracting patients to bring equipment up to capacity, or whether alternative items of equipment could be used to perform certain procedures to alleviate over utilisation. To do this effectively, a good understanding is required of all technology available so that trusts can make their decision based on actual clinical and financial requirements, rather than being equipment led.”
WHAT DO YOU THINK OF THE REPORT’S FINDINGS AND HOW CAN THE NHS ENSURE IT HAS THE TECHNOLOGY AVAILABLE TO CONTINUE IMPROVING PATIENT OUTCOMES?