Why can’t clinicians choose their own tools?

[Originally posted on my LinkedIn page]

As an NHS doctor I have frequently been disappointed by the lack of quality electronic patient record systems provided for us to use on the front line. In most hospitals, electronic patient records simply don’t exist, so we’re still illegibly scrawling in manila folders balanced on a knee in 2016. In the few hospitals where there are electronic records, the systems are cumbersome, take longer to use than doing it on paper, are eye-wateringly expensive, and are designed for a manager to crunch numbers rather than for a doctor to care for their patients.

How did we end up in this situation? Part of the problem is the lack of quality clinician-designed systems available on the market, which is what my company, PatientSource addresses. The other part of the problem is the bizarre way tools for clinicians are purchased by the NHS.

Let me illustrate with an example:

Let’s say you are a barber and you are in need of some electric clippers…

 

What should happen:

The sane way forward would be for the barber to look at the various models of clippers available, find the one which he thinks will produce the best results according to his professional knowledge of cutting hair, and then go out and buy that model from whichever shop or online store was selling it the cheapest. Done.

 

How the NHS might do it:

Now, let’s apply some institutional habits to the same situation…

As a barber you’re not in control of the budget for barber’s tools. So you have to speak to your Financial Manager and make a “business case” to explain why spending the money on the clippers will result in savings or income greater than the cost of the clippers. Instead of spending the next couple of days doing what you’re good at (cutting hair), you spend it writing that business case. You attend a series of meetings over several weeks to discuss your business case for the clippers, which are facilitated by an external procurement consultant who is probably paid more per day than the clippers cost. All the while you are still without any clippers.

There is much anxiety from your Financial Manager over your proposal to buy clippers. What if buying clippers is the wrong decision? What if we buy the wrong model of clippers? What are the other barbers in the area doing and what model of clippers did they buy? After much deliberation (during which you are still not able to cut hair effectively) your Manager decides that since the barbers down the road recently bought some clippers, it must be a safe decision to buy some too.

The Manager takes your business case to the Company Buyer. The Company Buyer is responsible for buying everything for the company. He knows absolutely nothing about clippers, but knows everything about the buying process, and has detailed procedures in place for buying things, whatever those “things” may be.

The Company Buyer draws up a specification based upon his understanding of clippers from your business case. The specification states that the item to be purchased must:

  • Be capable of cutting hair
  • Be supplied by an ISO9001 certified company
  • Be supplied by an ISO14001 certified company
  • Be supplied by a company with at least £2m on their balance sheet, and a AA+ credit rating
  • Be something which at least three other barbers have bought in the recent past
  • Ideally be capable of automatically generating reports about the number of haircuts it is used in, the colours of the hair cut, the gauges of the hair cut, and the lengths chopped off

 

The Company Buyer invents a scoring matrix, which awards points to each of the items on the specification based upon his understanding of the intended impact of this purchase:

 

Specification Item Score
Be capable of cutting hair 1 point
Be supplied by an ISO9001 certified company 1 point
Be supplied by an ISO14001 certified company 1 point
Be supplied by a company with at least £2m on their balance sheet, and a AA+ credit rating 1 point
Ideally be capable of automatically generating reports about the number of haircuts it is used in, the colours of the hair cut, the gauges of the hair cut, and the lengths chopped off 2 points
Be the cheapest option available 5 points

The matrix will be used as the basis of choosing the ideal product. An economy item has been added to the bottom where being the lowest price is rewarded with many points. Meanwhile, the barber is still without any clippers.

 

Next, the Company Buyer advertises widely their intention to purchase a “trichological-profile shaping device”, inviting would-be suppliers to fill in a lengthy application form which among other things assesses their product, sales channels, features and prices.

Although there are probably some thirty suitable models of hair clippers available which the barber would have considered, the Company Buyer’s advertisement only receives five bids:

Applicant Company Item Sales Channel Price
Pillocks PLC Hair Clippers Poundyland £65
Brosch PLC Sheep Shearers Argoose £256
Barber Innovations Ltd Next-Generation Faster Hair Clippers Tresco £75
Carpitar PLC Nail Scissors Tresco £178
Gelite Ltd Beard Electric Razor Argoose £418

 

Of these applicants, there are problems with some of them. For a start, the company will only buy through two preferred sales channels: Argoose and Tresco. So the Hair Clippers by Pillocks PLC is off the table, so won’t be scored or considered.

 

Now, Barber Innovations Ltd is a new company with a new modern technology product the “Next-Generation Faster Hair Clippers”. It has been proven in lab studies to help a barber deliver a haircut in half the time and give a much better shape with better client satisfaction. The device also has three times the lifespan compared to standard hair clippers. However there is a problem… since they are a new product they haven’t yet supplied three other barbers to date, they are deemed too risky and are thus eliminated.

 

The three remaining bidders are scored:

 

Applicant Company Item Sales Channel Price Score
Brosch PLC Sheep Shearers Argoose £256 4
Carpitar PLC Nail Scissors Tresco £178 8
Gelite Ltd Beard Electric Razor Argoose £418 4

 

These three remaining bidders are brought in to demo their products and presented to the barber as “a courtesy”. The barber is invited to give his opinion on the shortlisted candidate products:

“None of them are what I asked for!” exclaims the barber.

“Only the Beard Electric Razor has any use to me.”

 

Nevertheless, many months and thousands of pounds have been spent getting this far in choosing a product. So the Company Buyer “takes on board” the barber’s feedback, and weighs this against the bidders’ scores. Carpitar PLC’s Nail Scissors scored so highly that even the barber’s feedback couldn’t detract from their score.

So the barber ends up being given nail scissors to do his job!

 

 

The parallels:

It sounds ridiculous, but this is the approximate practice many NHS Trusts use when choosing electronic medical record systems!

Clinicians are not empowered to choose the electronic medical record system they will use for caring for their patients. They able to indicate the need for such a system, however once the need has been demonstrated, the decision making power is taken away from them.

Purchasing is run through standard procurement procedures by non-clinical procurement teams where small companies and innovative products are eliminated based upon their lack of a track record to date. Companies which do not supply through a Trust’s approved “Framework” are not considered, even though their offerings might be ideal. Final decisions are made by people who have never read nor written a medical record in their life.

 

Fortunately this is starting to change. Expensive failures like the National Programme for IT have demonstrated that clinician input is vital throughout.
After all, who in their right mind would think of giving a barber some nail scissors?!

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