Clinical Council Achieves – Net Savings of £1.1 million on Cardiac Devices
This collaboration has produced enormous benefits, both for patients and the health system. By working together as a network, we have unlocked significant savings that can be used for future innovation and investment. We have also uncovered resource efficiencies through an aligned, cross-site procurement process. Perhaps most importantly, however, is the pooled expertise of south London colleagues to ensure consistent, evidence based clinical practice for all of our patients.Alice Ward
Cardiovascular Network Manager
The South London Cardiac Operational Delivery Network (ODN) saw an opportunity to leverage an existing regional collaborative, to achieve significant cost reduction impact in Cardiac Rhythm Management (CRM). CRM can be equally as complex from a procurement standpoint, as it is clinically. The South London CRM Clinical Council (part of the ODN) therefore adapted the collaborative procurement strategy accordingly.
The CRM heart care specialism features a range of small, battery powered devices related to the heart’s electrical system. These complex and costly devices are implanted in the patient’s chest by consultant cardiologists and connected to the heart using “leads” (wires and electrodes). After bespoke programming for the patient’s heart, the devices invisibly monitor and regulate heart rhythms around-the-clock to prevent sudden cardiac death or other cardiac-related issues.
Working with NHS Supply Chain’s cardiac specialist team, the ODN had already undertaken – clinician-led engagement to reduce costs and reduce the variation in devices used for percutaneous coronary intervention (PCI). That initiative resulted in over £1.3 million of projected savings per year for the trusts involved, standardised clinical practice, and the preservation of product choice and protection of supplier value-adds.
NHS Supply Chain was invited to bring in their specialist cardiac products group to assist the ODN and use a transparent, evidence based Clinical Council approach to:
- Identify optimal devices for patient care
- Shape clinician consensus
- Deliver a cost-saving procurement exercise.
With an annual CRM spend of £13.1 million the trusts within the South London Cardiac Operational Delivery Network include:
- Croydon Health Services NHS Trust
- Dartford and Gravesham NHS Trust
- Epsom and St Helier University Hospitals NHS Trust
- Guy’s and St Thomas’ NHS Foundation Trust
- King’s College Hospital NHS Foundation Trust
- Kingston Hospital NHS Foundation Trust
- Lewisham and Greenwich NHS Trust
- St George’s University Hospitals NHS Foundation Trust.
The CRM category encompasses devices covered for payment in-tariff, as well as others covered by commissioners under High-Cost Tariff Excluded Devices (HCTED). HCTED was introduced in April 2016 by NHS England Specialised Commissioning and is a nationwide purchase and supply system for specific categories of HCTED*.
Pacemakers covered in the CRM category, are implants that are clinically considered “Low Voltage Devices”. For procurement purposes they are in-tariff. Pacemakers use electrical impulses to keep the heart beating at a steady rate and rhythm and avoid the heart beating too slowly or unevenly. Internal Loop Recorders, a related CRM implant, are also in-tariff. The latter are most commonly used to identify causes of fainting, palpitations, very fast or slow heartbeats, and hidden rhythms that can cause strokes
The most expensive CRM devices are “high voltage” implants which are procured under HCTED. These devices deliver a shock in real time, to correct a potentially life-threatening abnormal heart rhythm – a heart that is beating out of control. They include internal cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy devices (CRT-Ds).
Almost every incumbent CRM supplier in the NHS offers most or all the spectrum of CRM devices. As a result, a CRM procurement exercise typically must reconcile the cost nuances and impacts of both in-tariff and HCTED devices.
In addition, industry typically bundles a bid for device units with an array of value-adds associated with a trust’s cardiac rhythm management service. These are of great importance to trusts clinical and financial leaders. However, they can be difficult to quantify as a line-item in a cost-savings exercise.
This is a therefore complex clinical and procurement challenge for any one trust. For the South London Cardiac ODN, the challenge was magnified over eight trusts and their respective CRM consulting cardiologists and business leaders. If consensus could be reached on the best clinically warranted devices, the ODN could approach the market. The aim was for suppliers to commit to a multi-year agreement for market share, formally backed by the ODN’s clinical leaders. Trusts would commit to competitive device prices with no diminution in any participating trust’s added-value supplier benefits. This arrangement would avoid resource-intensive annual procurements over the course of the agreement.
The ODN invited NHS Supply Chain to bring in their specialist cardiac products group to assist.
The Clinical Council model integrates all stakeholders in a formal, transparent process. Steps include the following:
- Trust clinical directors execute a formal Memorandum of Understanding (MOU) of the parties’ responsibilities.
- Trusts recruit respected consultant “opinion leaders” to the Clinical Council. In addition to cardiologists, the council included physiologists and trust business leaders.
- Clinicians sign a Conflict-of-Interest disclosure.
- NHS Supply Chain gathers trust data and, when necessary, supplier data, cleansing and reconciling the data to create a credible picture of device cost and utilisation.
- Using regional and national comparative data, NHS Supply Chain benchmarks the baseline performance of spend and usage patterns and identifies opportunities for savings.
- Trust finance and procurement leaders verify and sign off on the accuracy of the baseline and, later, savings data.
- NHS Supply Chain facilitates council meetings in which the clinicians review data on current usage patterns and products’ clinical merits. The ODN gathers product specifications that would shape a go-to-market strategy.
- Hospital Episode Statistics (HES) data can be of special benefit to these discussions. Often for the first time, clinicians see objective data comparing severity of illness across trusts. In addition, they see their own practice patterns of device use.
The council evaluated the pros, cons, and impacts of various procurement strategies, considering the starting points of eight trusts – what they already had in place and how each might benefit (or not) from any given change. At their final meeting the council reviewed enhanced data from NHS Supply Chain, which clarified current device usage against the existing National Pricing Matrices (NPM) and modelled the cost impacts – by each trust and for the ODN – of potential market share commitments and added-value options.
On the strength and integrity of this analysis, the Clinical Council made a final commitment to combine market share buying using NPMs, with preserved added-value benefits already being provided by suppliers.
All five incumbent CRM suppliers participated in a forum in which they could present their product portfolios. Throughout the process, suppliers provided their data to NHS Supply Chain to cleanse, reconcile with trust data, and present to the trusts’ clinical, business and procurement leaders for approval and decision-making.
Suppliers were also included in the final phases of contracting. The ODN and NHS Supply Chain worked with individual trusts and suppliers to achieve final agreements on bespoke “tri-partite” contracts to document the various parties’ requirements and agreements.
The South London Cardiac ODN CRM Clinical Council achieved overall net savings of £1.1 million throughout the two-year term, with the option to extend.
Approaching the market via the ODN was an optimal way to achieve this result both for trusts and suppliers. Commitment by CRM clinicians in eight regional trusts to a purchasing contract is a significant change. The formal and transparent Clinical Council process signalled market share commitment to suppliers. In return, suppliers offered savings and protected value-adds for trusts.
Value-adds are common ground between the clinicians and trust financial managers. The Clinical Council acknowledged there would be no network CRM agreement if a participating trust saw a diminution of their respective net benefits.
With NHS Supply Chain’s data and assistance, the Clinical Council created an innovative “Supplier Value Fund” approach that worked for all trusts. Extensive consultations took place including commissioners and suppliers. The Clinical Council voted to award its market share commitment to two of the five incumbent suppliers; internal loop recorders (ILR) were awarded to a single supplier:
- High Voltage – ICD + CRTD – 50% Supplier 1 / 40% Supplier 2 / 10% Open
- Low Voltage – Pacemakers + CRTP – 50% Supplier 1 / 40% Supplier 2 / 10% Open
- Internal Loop Recorders – 90% Supplier 1 / 10% Open.
The decision of the CRM clinicians to keep 10% “open” for innovation means that they retain funds available to acquire any new technology that comes to market for the duration of the contract, regardless of supplier. By doing this, clinicians assured their access to the newest – devices for patient care.
It was agreed prior to the start of the Clinical Council process that the participating cardiology units would see direct financial benefits from the savings achieved through their regional procurement effort. The commitment was made to bring a percentage of savings back to the trusts budgets and to clinical programmes. Clinicians were assured that their trust would be able to apply part of the cost savings to business cases such as additional staff or other division priorities.
The CRM project was one that had many complexities and challenges due to the fact that this was a multi-million pound, multi-trust tender project which had cross over with the national HCTED programme. With stakeholders across several NHS divisions and trusts having to come together and attain a cross functional benefit for the wider Operational Delivery Network (ODN) group, we had to work collaboratively to find a successful outcome for all. Kings Management Facilities (KFM) played a lead role within the Cardiac Rhythm Management project by taking the savings brought to the group and renegotiating parts of the savings with the suppliers in order to give not only King’s College Hospital NHS Foundation Trust but the full ODN group an increased level of savings.Prince Ahmed
Kings Management Facilities Senior Commercial Procurement Partner
To support all parties’ continued compliance, as well as to set checkpoints to validate value to the trusts, industry and NHS Supply Chain oversee the CRM agreement for its multi-year duration. Quarterly contract review meetings with current spend and utilisation data include clinicians, suppliers, and business leaders and are facilitated by NHS Supply Chain.
The success of the Clinical Council approach to clinical and business collaboration on procurements signifies new ways of working. The South London ODN is eager to begin a third Clinical Council project – in intervention radiology. Other clinical specialisms, and other areas of England, are adopting this approach. Work has begun in Devon and Cornwall and in Oxford. They are being supported by subject matter experts and the enhanced analytics of NHS Supply Chain.
A Clinical Council approach to clinical and business collaboration on procurements also supports the development at the national level, of Integrated Care Systems (ICSs). ICSs will consolidate procurement at a regional level, amplifying the potential impact of an initiative such as the South London Cardiac ODN’s sub-regional CRM collaboration model across England.
What you can do now
To understand how we can support your trust to work collaboratively and deliver savings – please speak to your NHS Supply Chain Hospital Care Team.
* The second phase of the NHS England programme is now known as the Specialised Services Devices Programme, or SSDP (formerly known as the High-Cost Tariff-Excluded Devices, or HCTED programme). It is designed to optimise device choice across the identified categories to enhance patient outcomes, improve value and deliver cash releasing and commissioner savings.