Whither procurement?

Or should I say wither procurement?

It was always going to happen – those ‘I told you so moments’ as top down NHS restructure led to cracks in the system. Alas, however well-meaning Andrew Lansley’s Healthbill was, the execution and interpretation of the changes were always going to lead to trouble as the NHS struggles to achieve savings of £20bn over the next four years.

A good example is procurement. As I witness changes in procurement strategy and behaviour I can’t help thinking of that hilarious scene in the iconic 60’s movie, The Italian Job. The incompetent would-be villains have a practice run to open a bullion van but overdo it with the explosives. As the van is blasted to smithereens, the head honcho says  “You're only supposed to blow the bloody doors off!"

Some trusts and Clinical Commissioning Groups (CGGs) are viewing procurement as a blunt instrument of torture, aiming at sweeping cost cuts without considering the implications of squeezing suppliers till they, at best, bleed, at worst, expire. I was passed a document recently from a Hospital Trust advising a supplier that ‘in addition to and savings initiatives driven by our procurement department, we are also applying a 2% settlement discount on all invoices presented during 2012/13’.Take note – this isn’t an early payment settlement, this is basically chopping 2% of the bill, and it’s quite likely that the bill will be paid late too. Hardly ethical practice. This supplier, like many others, had also been advised that there will be an additional 5% reduction in terms or no deal. Like many independent suppliers working with the public sector, this supplier’s margins are virtually zero so what can they do? Operating in a specialist clinical device sector, this company could go out of business and the NHS will lose access to some exceptional intellectual property and equipment vital to enhance some patients’ quality of life.

The procurement mantra should be ‘value’, not ‘cheap’, and short term savings are not necessarily translated into long term value.

Effective procurement needs a robust strategy, experienced operatives and clear tender process. The ‘various procurement organisations and initiatives’ (to quote a recent procurement conference promotional literature) do not generate the clarity needed. It is highly time-consuming and expensive to complete an NHS tender process and if each Trust or CGG uses a different document, suppliers are at risk of re-inventing the wheel with alarming regularity.

Speaking of experienced operatives, a quick glance of the interim job ads display an air of desperation. As the disassembled Primary Care Trusts created an unprecedented brain drain, the newly formed procurement teams are, in some cases, sadly lacking essential expertise. Here is one of many of those ads:

I am urgently seeking a Commissioning Project Manager for a 4 month contract in London. Essential skills include:
- NHS experience
- Masters degree or equivalent managerial level experience or qualification
- An understanding of the NHS policy framework
- Understanding of procurement and contracting rules in the NHS
- Experience of working successfully with clinicians particularly GPs

The ad continued with other worthy attributes such as stakeholder engagement, bla bla.

But where would such a candidate have gained such experience? In the NHS. So this organisation will either be re-employing someone who was made redundant earlier or they will be pinching an expert from another procurement body. Same old same old.

No-one can argue that savings must be made for the NHS to remain a sustainable, free to all, health service. But efficiency savings should be as the name suggests – efficient. Working smart, not just cheap, is the way forward.

Liverpool Care Pathway – one man’s meat is another man’s poison.

This is a debate this isn’t going away any time soon. And now the government is including a change to the NHS Constitution which will, in effect, change the law regarding the way that the Liverpool Care Pathway can be applied.

The suggestion is that relatives must be involved in decisions regarding ‘end of life’ care for terminally ill patients. I have a strong personal view about this having nursed my beloved husband through to what I would describe as a ‘good death’. Peaceful, without pain and in my arms. You could say that we were fortunate, as a pharmacist and stroppy mare, I was intimately involved with every decision about pain relief and care and no, the Liverpool Care Pathway was not included.

The regime is designed to relieve suffering and of course includes pain relief but controversially may involve the withdrawal of food and water. This sounds horrific but must be viewed in the context of a terminally ill individual who may be incapable of taking on board sustenance.

As the news of this proposed change in the NHS constitution was announced I listened to an interesting radio debate on the subject. Two callers, both recently bereaved, spoke with passion and knowledge about their recent experiences of supporting a much loved relative through their final hours, one with a highly positive view of the LCP, and one vehemently against. They both spoke angrily about ‘dying with dignity’ – a phrase that makes my hackles rise at every mention. How can anyone describe what dignity means? Surely a ‘good death’ – i.e. – at peace, in comfort and hopefully without pain – is what we should want.

I remember a recent news item about an old lady suffering from pneumonia. The nursing home advised her niece that there was little chance of recovery and they would adopt the LCP to ‘ease her passing’. The niece was having none of it and knowing what a feisty lady her aunt is, insisted that antibiotics should continue and there should be no talk of dying. Two years later, the sprightly old dear was enjoying a game of scrabble as she celebrated her 90^th birthday.

Discussing care of a relative who is unable to speak for themselves doesn’t always work in the patient’s favour. There is a real risk (and no doubt plenty of examples can be found) where an elderly or infirm individual may be seen as a burden and a terminal care pathway seen as a blessed relief, not for the patient, but for their beneficiaries. Harsh but true.

So to get off the fence, what is my view of the LCP and a change in the constitution? Care pathways for terminally ill patients are normally designed specifically for that patient, discussed with the patient, or if that’s not possible, with their relatives. The LCP is one solution in a complex tool box full of options for a clinician to do their best for the patient. To focus this debate on only one method of terminal care is unhelpful and confusing.

As the former secretary of state for health famously kept saying – ‘nothing about me without me’ – in a perfect world, these life changing, and possibly life ending, decisions must be made with an informed balance. Doctors, nurses and therapists can only do what they believe to be best for an individual state of circumstances. The views of a patient and/or relative must be sought and the discussion must be recorded on the patient’s notes along with the way forward which has been agreed.

This will protect not only patients, but their clinicians too.