In the twelfth of our series of interviews with healthcare industry professionals, Gill Davies, General Manager of biosurgical company ZooBiotic, talks to On Target about her working life.

Who are your target customers? How do you reach them?

Our target customers are predominantly specialist nurses who deal with wound care. That varies from area to area, but primarily it’s the tissue viability nurse, whether in the hospital or in the community.

Podiatry is probably the next target customer. As diabetes increases at a rate of 7–10% per year, there is a greater occurrence of diabetic foot ulcers that may go on to require amputation. This has a massive impact on the patient’s life as well as on NHS costs, and the application of our products may reduce this requirement.

We do not have a sales force: we have nurse advisors. In our three-year commercial history, we have gone from having three clinical nurse advisors for the UK and Northern Ireland to having nine.

More and more, we are contacted by GPs who are treating patients with long-term wound care needs. They have read about us and would like us to send a nurse advisor to help. So our business is driving into the community, which is clearly a crucial role for us: to stop wounds deteriorating before referral to secondary care becomes inevitable.

That is how we reach our customers, and it’s always requested by them: our customer base dictates our activity. The nurse team run large and small workshops on the request of customers, and attend both national and international wound care conferences where they meet new customers and network with our existing customer base.

“Wound care specialists worldwide are looking for a rapid method of debridement (wound cleaning) that keeps the patient out of hospital. That’s where maggots come into their own.”

What happens in your typical working week? What challenges do you face?

I’m generally split between Head Office and visiting key customers, which is crucial for me to keep a handle on what the market is doing and what our customer base needs. When I’m at Head Office, I manage the team there and oversee a multitude of projects. My biggest challenge is a balancing act: prioritising what I’m going to do and when I need to do it, bringing people who are at number 5 on my priority list to number 1.

Then there’s the routine of dealing with e-mails and phone calls. As we are one of very few companies worldwide that produce maggots of medicinal quality, we draw a lot of attention. The BioFOAM dressing that we produce has been recognised on a worldwide scale as probably the best method of delivery. Wound care specialists worldwide are looking for a rapid method of debridement (wound cleaning) that keeps the patient out of hospital. That’s where maggots come into their own.

I also manage the sales and marketing function and have a very good office-based team who support me. We develop new literature and deal with creative agencies. I attend wound-focused study days and conferences, which give me opportunities to network and look at what the competition is doing as well as seek collaboration opportunities. We’ve had a number of large wound care companies approach us to form partnerships, but it’s very important for us at the moment to remain focused on what we’re doing as a small company and get that absolutely right.

Since we’re an SME, I liaise with the Welsh Assembly Government as well as International Business Wales, who are affiliated to the WAG and are a tremendous support for us. We are a flagship company as far as they are concerned, as we are a spinout from the local NHS and have a unique product. I also spend a lot of time working with our R&D Director and our Regulatory Quality Decisions Manager to explore new product opportunities as they are presented to us.

Although we’re a small team of 26 and growing, all ZooBiotic staff are very dedicated to the business. We have what is perceived to be this scrawny little product, but everybody loves working with larvae and is passionate about the company growing and continuing to move forward.

 

Maintaining patient safety in hospital involves various strategies that rely on the full range of medical technologies. Stephen Ramsden, OBE, Chief Executive of Luton & Dunstable Hospital NHS Foundation Trust, talks to On Target about the medtech industry’s role in improving the safety of patients in secondary care.

Stephen Ramsden is a leading figure in the National Patient Safety Agency’s campaign to raise awareness of patient safety within the NHS. As he explains, patients in hospital are at risk of preventable harm on a number of fronts: HCAIs, treatment errors, pressure sores and failure to rescue. He explains that addressing these issues depends partly on effective use of a broad range of medical technologies – from diagnostics and interventional devices to infection control and healthcare IT – and goes on to discuss the market access issues for medtech companies keen to align their products and services with the patient safety agenda.

What are the key areas of the patient safety agenda?

One of the challenges the campaign has faced is that the media and society understand about HCAIs, and the Government has reacted to that by setting targets – but the issues of patient safety that we as a campaign are trying to address are much broader than HCAIs, though we include HCAIs.

One of the most common, but less well-known, elements of the patient safety agenda is the failure to rescue patients who are already sick, leading to avoidable harm or death. The work we’ve done in this area has had the biggest single impact on our hospitals’ standardised mortality rates. When we tried to put in an early warning system accompanied by a new critical outreach team about four years ago, we were shocked to learn how many wards were not regularly observing the vital signs of acutely ill patients – and even when the observations were being taken reliably, they weren’t being acted upon.

We have put a lot of effort into getting observation right at ward level, getting the early warning system implemented, getting an outreach team 24/7, and also improved communications between the ward and the outreach team and the medical staff on take, and that has led to a 50% reduction in cardiac arrests and much better use of our acute care facilities. Monitoring vital signs is an area the NHS must major on if it’s to protect and save our acutely ill patients. In every hospital, to varying degrees, that will be an issue.

Other patient safety issues include HCAIs and medication errors. Also, patients developing pressure sores through neglect in the hospital environment is another big issue – many hospitals don’t even measure that. We could add the complications that arise through surgery errors – they’re not that common, but the effects are traumatic. There’s a whole agenda about addressing these human factors in our hospitals and health organisations to create teamwork and improve communications and awareness of possible risks.

At the Patients Association SUMMIT Conference in October, you said that patient safety needs to become a strategic priority for NHS hospital trusts. What does that imply in terms of how trusts work to develop solutions?

I believe firmly that this is the chief executive’s highest priority: it can’t be delegated, the CE must take it as the most important task and must lead by example. Of course, the strategy would be to get everybody giving it the highest priority – but unless the CE is doing so, it’s hard to expect everyone else to. That’s the journey I’ve been on, and I think I can speak authoritatively and with passion about the unacceptable nature of the safety of patients in our hospitals.

We’ve got to stop accepting the unacceptable. So while it’s a strategic priority, it’s also a change in mindset that we need to achieve in our staff – especially our clinical staff, who are all brought up with the mantra of ‘First do no harm’, but somewhere along the way that’s gone out the window.

I have seen many examples where clinicians have been leading improvements in patient safety, and they’ve changed their mindset completely because of the success they’ve had. For example, in the virtual eradication of central line infections in an ITU or critical care unit. Four years ago, my ITU clinicians believed that it was an inevitable complication of a patient being in an ITU environment that they would have one or two patients acquiring a central line infection every month. Now, not having had one for 12 months, they see it as an unacceptable failure of the system when it does happen.

Going back to the strategic priority: it starts with the chief executive, the board has a role to play, the campaign’s asking the board – by the chairman or the CE writing to tell the staff that patient safety is that board’s highest priority, and a similar commitment to the public with a public declaration that we’re asking them to make if they join the campaign. We’re asking the board to give at least 25% of their time to safety and quality as opposed to finance and targets and governance. We’re saying that safety and quality should receive the greatest amount of time and should probably be the first item on the agenda.

Ideally we would bring a patient or relative into the boardroom to talk about how they or their loved ones have been harmed in their organisation. The impact of that on board directors who are not used to interacting with patients is dramatic. Our Non- Executive Chairman of the Audit Committee, an accountant through and through – when we first had a patient come into the boardroom to tell their story, in the evaluation afterwards he said: “If I’d had this information eight years ago, I’d have changed my behaviour at these meetings.” It really brings the issues home.

So a number of things that are included in our ‘leadership interventions’ from the campaign are tips to the board to give patient safety the strategic priority that it deserves, and to lead by example and be visible around the organisation. So directors (both executive and non-executive) can undertake leadership safety walkabouts and spend an hour on a ward, asking questions and helping staff work through the safety issues on the ward or department: where could a patient be harmed, and what can we do to prevent it happening?

What are the key types of medical technology that contribute to the patient safety agenda? For example, Lord Darzi has drawn attention to the potential of patient ID wristbands and ‘smart’ swabs and sponges.

I think this is the next big agenda – certainly for my own hospital, and I know there are some hospitals that are trailblazing across the country in using these technologies to improve the safety of patients. In addition to the technologies you’ve given, we’re aware in my own hospital of some new developments.

For example, VitalPACs is a product in use in one or two hospitals that uses a PDA to take the observations of patients, so they can be inserted into the computer at the bedside. The observations are then converted into an observation chart, which is coded in a way that mirrors our early warning system: it would immediately trigger an alert if it fell into a red warning, and immediately call for help from the outreach team or the medical staff on take. So you take away that judgement and that lack of reliability in monitoring vital signs. I think that’s a revolution, and we’re going to pilot it in our acute care unit in the next couple of weeks. Things like that, which make use of Wi-Fi and allow you improved communications and more reliable systems, I think will be the order of the day going forward.

The second example I would give, and I don’t believe the NHS has yet found a reliable technological solution to this, is in the whole field of electronic prescribing – so you can use standard order sets that improve the decision making at the most junior medical staff level, and you can then build in the electronic and more reliable communications with the pharmacy to prescribe and then dispense the drugs; you can then audit more properly what’s been going on in terms of medication management. I’m unaware of a reliable electronic prescribing system, at least in this country, though I know there are more in use in the USA at the moment.

How can the medtech industry help to integrate its products and services with strategic patient safety initiatives at trust level? Who does it need to talk to, and what opportunities for sales and partnership are there?

That’s a really important question but quite a difficult one as well, and I suspect – and have some sympathy with industry – that there’s an element of frustration in terms of not being able to target the right people at the right level, both locally and nationally. Therefore my suggestions may not be based in my own experience or awareness of what has worked, but I can at least fl oat them.

I suspect that the most receptive environment will be in those trusts that have become quite high-profile in saying that patient safety is the highest priority, and are willing at a very senior level to engage with sales people and senior personnel from the medtech industry.

I suspect that the most receptive environment will be in those trusts that have become quite high-profi le in saying that patient safety is the highest priority, and are willing at a very senior level to engage with sales people and senior personnel from the medtech industry. For example, I’ve been involved just recently in discussions about the VitalPACs product – I haven’t had any discussions with suppliers of electronic prescribing, but have argued for us to give it a high priority.

Chief executives, medical directors and directors of nursing are probably the three main board directors who would be interested in what technical improvements can be made to improve patient safety – but I suspect it will only be in those organisations where one or more of those directors can be seen to champion the cause of patient safety and has a high profile. The patient safety campaign has a number of examples of hospitals that have led the way in this.

Then there’s a question at national level of what organisations such as the National Patient Safety Agency and the NHS Institute for Improvement and Innovation can do in terms of being receptive to the medtech industry and helping it to best get alongside the patient safety movement – and it really is a movement. I believe those two organisations can and should have a key national role in doing that. PASA and the procurement side of the NHS also have a role to play, but I don’t believe they will be as important as the people who will be making the commitments and the decisions for resources bought at local and national level.

The following anecdote illustrates an important point. When my hospital first embarked on patient safety work five or six years ago, it began because two of my directors were in the USA at an Institute for Healthcare Improvement conference, primarily for clinical leaders, chief executives and medical directors. Visiting the exhibition hall, they were struck by the dominance of patient safety as a theme.

In this country you would see companies that were pushing efficiency improvement or organisational development or maybe aspects of clinical effectiveness – but at least in those days, it was quite rare for me to go to, say, an NHS Confederation conference and see much about patient safety from the suppliers in the exhibition hall.

So I wonder if the medtech industry is missing a trick in terms of taking the risk and pushing themselves not just into clinical conferences but into management conferences, and trying to influence board directors in terms of

 

The NHS is developing a new contracting strategy to increase the capacity of radiotherapy services. Thoreya Swage looks at what this new approach means for the medtech industry, both within cancer treatment and beyond.

The opening up of the UK healthcare market to providers other than the NHS has been much heralded and discussed over the past few years. The threat of competition from independent sector healthcare organisations from abroad and at home, with their slicker and more innovative ways of working, should in theory have shaken up the NHS. However, with the exception of a few cases, it has been difficult to budge NHS commissioners from their comfort zone of dealing with the providers they know to having a dialogue with organisations that have a different background or pedigree.

The Government tried to increase the market share of independent sector organisations in the English healthcare market with the Independent Sector Treatment Programme, set up over four years ago. However, as the DH had to pay a premium to stimulate this market, there were criticisms that it was centrally driven, unwanted and expensive compared to local NHS provision. As a consequence, with the contracts for the first wave of ISTCs coming to an end next year, the companies have little appetite for continuing to provide the services at a lower cost – while the NHS has scant enthusiasm to pay for healthcare that seems to be surplus to requirements.

The cancer challenge

What is needed is another approach to enable the private sector to access the healthcare market. An opening emerged with the publication of the Cancer Reform Strategy in 2007, which identified the need for a dramatic increase in capacity for radiotherapy services. This was quantified as an increase in radiotherapy treatment for cancer patients from the current average of 30,000 fractions per million population to 54,000 fractions per million population by 2016. The Strategy recognised that this meant a requirement for more skilled staff and linacs or linear accelerators (radiotherapy machines) to deliver the service, with investment to support this development across England. It quickly become apparent that current NHS facilities could not meet this future demand, and so the scene was set for a different way of looking at how care could be provided – and in particular, how to enable potential providers from the independent sector to help fill this gap.

Contract bridge

In response to this challenge, the National Cancer Action Team (in conjunction with the Commercial Directorate at the Department of Health) has developed a new methodology for commissioning and contracting for radiotherapy services. At its heart are the following principles:
• Radiotherapy is defined as a discrete service (whether part of a current facility or a separate organisation) comprising radiographers, medical physicists and supporting staff, together with linacs. The service is separate from the multidisciplinary cancer team (which is based in a different organisation), but has clear accountability to it in providing the radiotherapy section of the whole cancer pathway for the patient.
• The methodology allows for the development of different models of service that providers can come up with, as long as these are within defined outputs.
• The methodology is reliant on the principles of the ‘safe patient pathway’ as developed by the Commercial Directorate.

Roads to recovery

The cancer pathway is complex, with a number of sub-pathways (radiotherapy, chemotherapy, surgery etc) that could be followed by a patient. It is made more complex if the different sub-pathways are provided by different providers, with a risk of discontinuity of care as the patient moves from one pathway to another. Figure 1 illustrates the four layers within the safe patient pathway:
• Commissioning (procuring the radiotherapy service and managing the contract).
• Clinical case direction (management of an individual patient by the multidisciplinary cancer team).
• Provision of the radiotherapy service or process (the treatment received by a patient).
• The organisational platform on which the service or process sits (systems to manage and audit clinical care, competencies of the staff providing the radiotherapy service, managing change and innovation, working with partners).

It is essential that at each level there are clear governance arrangements to ensure sound and safe systems of delivery of patient care, with clear lines of accountability between the different levels.

A new landscape

This work resulted in the following tools:
• A high-level radiotherapy pathway to describe the interventions (administrative, technical and clinical) that occur during the patient’s journey for this section of their cancer care.
• A contracting framework toolkit to set out the standards and outputs required of a radiotherapy service.
• A template service specification that can be modified by local commissioners to meet the needs of their local populations. This sits within the NHS standard contract for acute services.

Cancer networks across the country need to get a grip on increasing radiotherapy capacity, and the Cancer Action Team is planning a rollout of the new strategy to support networks in this task.

Opening doors

This situation presents a number of new opportunities, both for radiotherapy services and for the medtech industry.

Defining the radiotherapy service from first principles makes it possible for different models of care to be provided by different organisations. These models could range from providing the whole radiotherapy service (i.e. radiographers, medical physicists and linacs) to working in partnership by providing only staffing or linacs and facilities.

Purchasing the linacs requires major capital investment up front. Here, organisations wishing to provide a radiotherapy service may decide to enter into different agreements with medtech companies over the provision of the linac: buying the machinery outright; leasing the linac and providing maintenance, either in-house or externally; or with another provider responsible for provision and maintenance of the linac within the service.

Access to treatment is another key issue. Cancer networks are in the very early stages of working out how to increase radiotherapy capacity in their localities. A key element of the expansion in radiotherapy services will be ensuring that patients do not have to travel far to receive treatment. The access target is a journey no longer than 45 minutes from the patient’s home.

The cancer networks will have identified gaps in the delivery of radiotherapy services within their localities, and will be looking to develop more locally accessible care. This may mean the establishment of ‘satellite’ services, which could be either an extension of a current wider cancer service into another geographical locality or an independently-run service that has clear sub-contracting and governance arrangements with the local multidisciplinary cancer team.

NHS cancer networks need to expand their radiotherapy services to meet the future demand for cancer care. NHS providers will not be able to fulfill this requirement by themselves, and so the door is open for dialogue with the independent sector.

What medtech can do

The medtech industry has an opportunity to be proactive. Now is the time to think differently and consider developing radiotherapy services in partnership with NHS providers, or even with other independent sector providers (who might, for example, provide staff), as described by the high-level pathway and contracting framework.

Look up the tools that have been developed on the NHS cancer website (see below) and consider how these can help to shape and define radiotherapy services.

For more information on the tools developed, visit: www.cancer.nhs.uk /radiotherapy/commissioning.htm www.supply2health.nhs.uk /default.aspx Dr Thoreya Swage has several years’ experience in the NHS, both as a clinician (psychiatry) and as a senior manager, including Executive Director for a Health Authority, in various NHS organisations covering acute and primary care. She has expertise in commissioning health services, most recently working with the independent sector as part of the Independent Sector Treatment Programme at the DH. She is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

It is worth establishing contact with local cancer networks to find out what their specific issues and gaps in radiotherapy services are. It will also be helpful to understand the patterns of service that are planned for the future in a network locality.

Cancer networks may also welcome discussions with potential providers about the different models of radiotherapy care that could be offered.

Identify potential partners, approach them and start discussions about the shape and form of the radiotherapy service to be provided, and the various business or sub-contracting relationships with respect to provision of staff and equipment, using the contracting framework as a guide.

Look on the NHS procurement portal Supply2health (see below), which allows potential providers to search for clinical service opportunities announced by NHS commissioners.

Looking ahead

This is a very real opportunity for the medtech industry. NHS cancer networks need to expand their radiotherapy services to meet the future demand for cancer care. NHS providers will not be able to fulfill this requirement by themselves, and so the door is open for dialogue with the independent sector.

The new commissioning methodology has potential applications in other therapy areas. For example, the approach could be applied to all aspects of diabetes care, from prevention, initial diagnosis and management to continuing care of inpatients and outpatients, services for complications of diabetes (renal, vascular, ophthalmic etc), obstetrics, paediatrics and end of life care. Thus a whole range of services can potentially be brought into play.

This points to a significant shift in the relationship between the NHS and the medtech industry, as the NHS extends its horizons to commissioning healthcare from a wider range of providers.