Health and Social Care Committee
Access to medical technologies in Wales
Evidence from Cwm Taf University Health Board – MT 1
Cwm Taf Local Health Board
Ynysmeurig House
Navigation Park
Abercynon
Rhondda Cynon Taf
CF45 4SN
Dear David,
Cwm Taf Health Board has considered your enquiry regarding access to medical technologies in Wales. Our response is detailed below which follows the terms of reference identified in your letter of 23rd July 2013.
1. To examine how the NHS assesses the potential benefits of new or alternative medical technologies;
There are a number of routes in which NHS organisations can address the above. It is important to note that this question can be investigated from different perspectives:
1) The NHS can be utilised as a beta testing site for new technologies, particularly the smaller equipment. This gives the NHS the opportunity to critically review any new / alternative technologies before they come on the market and help in finalising the design before release, marketing etc.
2) The NHS can be utilised to formally “confirm” and “validate” the proposed application of the device in clinical practice.
3) The NHS can be utilised to validate “alternative” uses of the device which have hitherto, not been associated with the device post its release.
4) The NHS is the gateway to patient access and opinion and there is more scope to develop this re: new / alternative medical technologies.
5) Current Procurement rules can limit how the NHS assesses the potential benefits of new or alternative medical technologies.
How can these be achieved:
a) NHS organisations can agree to be potential sites for the evaluation of all new devices. NICE through its Medical Technologies Evaluation Programme have developed a process whereby they put equipment / device evaluations out to tender, for interested parties to bid for. One organisation in Wales that looks to submit responses to the NICE evaluation calls is CEDAR. Engagement with CEDAR can identify NHS sites with an interest and expertise in new technologies and who can help them undertake the “clinical” evaluation of these new technologies.
b) The NHS can undertake research (in partnership with academia) to provide the evidence base for the use or alternative use of a device in clinical practice. In Wales, the Welsh School of Primary Care Research and the South East Wales Trials Unit (SEWTU) have a strong history of supporting such research. This can be accessed by the NHS as a research partner.
c) Forming links with Industry through research is an important mechanism to help address the above bullet point. For example there is the Knowledge Economic Skills Scholarship (KESS) scheme. This scheme funds the undertaking of research by academia and often in association with an NHS organisation. As part of the funding scheme an Industry partner has to agree to provide financial input (approx. £3,000 - £5,000) where there must be financial input by Industry. Research studies at PhD and MSc level can be developed to evaluate the utility of medical devices developed by industry partners.
d) Direct links at specialty (Departmental) level with Industry, being cognisant of the opportunities for clinical disciplines to assess / evaluate new technologies as part of the procurement process or as part of a research opportunity where a new technology has its intended functionality assessed or an alternative use identified which requires an evidence base for its use in clinical practice.
e) Recognition of and full engagement with the appropriate NHS professionals to review, investigate, evaluate and document all potential benefits of new technologies, to include Pathology, Clinical Engineering, Occupational Therapy and Radiology, etc.
2. To examine the need for, and feasibility of, a more joined up approach to commissioning in this area;
With the development of shared services, notably procurement, this may be possible. However, for Medical technologies, this may prove problematic as increasing the number of stakeholders, where their requirements due to clinical service provision, may be different and this could prove difficult.
a) One company may not be able to provide technologies where “one size will fits all”. This can result in the purchasing of equipment that meets no ones needs fully, as a compromise. There is an increasing evidence base that recent large procurements of clinical services and equipment across the UK have failed or have over-run considerably, due to the complexity and time resources required to manage on a large scale, often negating the perceived benefits of large commissioning projects.
b) Large commissioning projects could lead to the monopolisation of the provision of a device and its associated consumables. This may have financial benefits but increases the clinical risk considerably as the scale of any failure in the continuation of service provision would be much larger and more difficult to rectify quickly. This does occur and In the last 5 years there have been a number of failures in service provision due to issues with medical technologies companies products.
c) A joined up approach to commissioning may be possible if a multi-company approach is taken where the manufacturers work together themselves in responding to a call, and provide the appropriate equipment, meeting the requirements of all stakeholders included in the commissioning. The benefit of this approach is that the manufacturers decide amongst themselves who can provide what for each stakeholder to meet the requirements / specification. This approach may not be attractive commercially to the companies as they would all wish to have the “lions share” of a contract.
3. To examine the ways in which NHS Wales engages with those involved in the development/ manufacture of new medical technologies;
There are several ways in which this can be / is being achieved:
a) The recent development and launch of Health Research Wales in May 2013 will facilitate the engagement of the NHS, HEI and Industry partners. HRW provides a central portal (and brand) through which Industry can gain access to appropriate NHS sites with an interest and expertise in various technological fields. It is anticipated that the use of a sign-posting portal will help the development of partnerships and input into technology development at an earlier stage.
b) Development of strong partnerships between the NHS and Academia facilitates the engagement between suitable partners and scientific / clinical specialties. This has been enhanced through the development of University Health Board status and the development of South East Wales Academic Health Science Partnership (of which Cwm Taf HB is a member organisation) and its Industry working group. SEWAHSP also has Industry membership through organisations such as MediWales.
c) Developing direct partnerships with each of the NHS organisations and Industry partners such as MediWales and diagnostic companies, will help facilitates the development and manufacturing of new technologies driven by the NHS.
d) One area that I think should be developed is “patient led” device development. Developing devices that the Patients consider would be helpful to them, their condition and quality of life, at the “idea” stage, rather than having NHS professionals and Academics assuming the position on making the decisions and developing devices on their behalf.
e) There are a number of schemes that encourage and support (financial and legal) the direct development of new/alternative technologies. One such scheme is the Health Technologies Challenge. This scheme is being directed and co-ordinated through the South East Wales Academic Health Science Partnership (of which Cwm Taf HB is a member organisation) and SARTRE (Prof Lars Sundstrom). The scheme takes a direct approach by asking Clinicians for clinical problems / ideas which they post on a website accessed by other clinicians and academics. The ideas are then voted upon by the web fraternity and the “best” idea(s) for potential development are pursued in terms of developing a project team and providing pump priming financial support.
f) The Welsh Government has the Department for Business, Enterprise, Technology and Science (BETS), which also helps facilitate and develop opportunities for partnership building between the NHS, Academia and Industry, providing an economic viewpoint on the development and manufacturing of new medical technologies.
4. To examine the financial barriers that may prevent the timely adoption of effective new medical technologies, and innovative mechanisms by which these might be overcome.
a) The financial barriers can be divided into two areas:
i) Funding resources required to support the validation / evaluation of new technologies, the safe and effective delivery / implementation and future monitoring of new technologies.
What would help:
1) Greater flexibility between “budgets” where a reduced spend in one specialty as a result of a given development can be used to support the new development managed by another specialty.
Recognition that investment (even pump priming) in staff resources can result in the following:
a) Taking a more scientific / evidenced based approach where choosing / implementation of all such technologies is managed by the appropriate professionals to avoid “waste” and prevent the use of technologies that are not fit for purpose.
b) Allows time for greater engagement / co-ordination between all the stakeholders with clear lines of accountability, to ensure informed decisions are taken between those managing and using any devices.
c) Development of clear documentation to ensure that devices are used appropriately to optimise the financial and clinical benefits and reduce any clinical risk.
ii) Purchasing the medical technologies is often a barrier, even when the case for the clinical and financial benefits are clearly made. This is particularly the case when “Capital” is required and replacing equipment takes priority over “new technologies”.
What would help:
1) Each NHS Organisation could have an annual budget set aside and separate from the Capital replacement budget, specific for purchasing new technologies.
2) Allow carryover of ring-fenced funding (badged as development funding) between financial year(s), to reduce the risk of impulse / rushed (and perhaps inappropriate, untested) purchases. Choosing the appropriate Technology and purchasing can be complex, requiring sufficient time to ensure an informed decision is taken. Having time limited budgets currently hamstrings the NHS and can lead to poor purchasing decisions to beat the financial year deadline.
3) Removing the “Capital” limit of £5,000 will allow more flexibility in the use of non-capital funding. This level of Capital is now outdated due to the costs of devices / equipment.
4) Ensure standardisation of manufacturer, equipment (hardware/IT) and consumables across an NHS Organisation. This provides inherent resilience and allows for economies of scale in terms of purchasing power with the manufacturers. Putting all eggs in one basket can be a risk, but at a single NHS organisational level this may be managed contractually via risk transfer.
Many thanks,
Mr Chris Hopkins,
Cwm Taf Local Health Board