In the next few years, biomedical engineers will have a crucial role in helping to redesign the health service to deliver more for less. Among the challenges will be to provide medical device management across healthcare boundaries, as the Government presses ahead with its strategy for integrated care, supported by remote monitoring technologies. LOUISE FRAMPTON reports.

The electro-biomedical engineering (EBME) sector faces significant challenges ahead in delivering effective medical device management within a changing healthcare landscape - in which hospitals are coming under pressure from increased demand and rising expectations, coupled with financial constraints. At the same time, biomedical engineers will need to get to grips with changes in the way care is going to be delivered, as the Government promotes a move towards the provision of 'integrated care'. These are some of the issues recently addressed by expert speakers at the EBME Innovations Seminar.

"This is a period of rapid change for the biomed sector," commented Professor Nick Bosanquet, professor of health policy, Imperial College, and consultant director for the think tank Reform. "In the past, the perception of biomedical engineers has been one of 'fitters with oily rags' - they have been hidden away at the end of long corridors like rabbits in warrens. "They related to machines rather than the people in the organisations, around them. As long as the equipment was alright they felt they had done their job. But now the biomed sector is becoming a communication business, in which the customers are the healthcare professionals and even patients."

He added that biomedical diagnostics used to be "a very secret world, with high priests in white coats". However, today, there are a vast number of appliances being used within the healthcare system, leading to information overload. He warned that there is a rising risk of misuse of technology and misinterpretation of information, as well as potential benefits. Furthermore, this journey for biomedical engineers is taking place within a changing healthcare environment.

Funding pressures 

"Although healthcare spending is reported to be 'ring fenced', in reality the incomes of many Trusts are actually falling - partly due to the increase in competition and redesign of services. Just recently, in North London, cancer surgery has been concentrated on three sites, which means some centres that are already struggling financially will be losing activity and income. Tariffs are going down, so the Trusts that biomedical engineers are working with are losing income all the time," he continued.

Prof. Bosanquet pointed out that there will also be increasing pressure on the top tier of Foundation Trusts as a result of the formation of a much tougher commissioner - NHS England (previously the NHS Commissioning Board).

"NHS England has produced a manual for supplying specialised services, which sets out the services that NHS England is going to contract for. Many are within the diagnostics and biomedical engineering area - for example, there are already around 50,000 PET/CT procedures performed each year and this is set to increase. NHS England will be commissioning these services, as well as other specialist services, and this will involve high usage of diagnostics," said Prof. Bosanquet. This, he asserted, will have major significance for all those working in the biomedical engineering sector. There will be a much tougher approach to commissioning and spending.

"Previously, this was a 'blank cheque' business - now there are budgets. For the first time, it will be possible to work out the costs of delivering services and there will be a much tougher agency setting much tougher financial discipline in high tech areas," he commented.

The move to clinical commissioning groups (CCGs) will also bring changes, according to Prof. Bosanquet: "There are 210 commissioning groups, which will commission £60 bn worth of services, and these will have to deal with the problems of district hospitals that are under pressure - there are a number of hospitals on the 'danger list' for quality, high mortality and financial deficit. While CCGs are effectively being handed these problems, they do not have accurate information on activity or spending levels in their areas, so they are going to be very tense and anxious for the first year or two, as they establish solvency."

The sector is facing greater uncertainty, but there is one date in the diary that will be key in shaping the future for the sector - 15 May 2015 (the date of the next election). The next important date, according to Prof. Bosanquet will be 15 June 2015 - when the treasury will have calculated public spending availability for the next five years.

"All the problems that are being 'shoved forward', at the moment, will have to be reviewed and will come into sharp focus. There is likely to be significant changes in funding and incentives to deal with the fact that we have run out of younger tax payers.

"In the long term, we cannot spend more on public services than we can afford. Unfortunately, this is something that we have been doing for the past 30 years - we have been borrowing to pay for additional public services. You have not seen anything yet in terms of financial pressures - there is a lot more to come," he warned.

He went on to add that there is wider scope for dispersed technology, with greater access by more people - in the home, GP surgeries, clinics and pharmacies.

"We are moving away from a patriarchal, feudal system in which doctors control the output of diagnostics and biomedical technology, to one where there is access by many," Prof. Bosanquet asserted. One example of how diagnostics has spread to more people is the move from doctor-controlled, hospital-based pregnancy testing to an open system where 'stick testing' is available from any pharmacy. This will be an increasing trend across other areas of diagnostics, he predicted.

Quality issues

There are also issues of quality to be addressed, which will create pressures, according to Prof. Bosanquet. The Francis report (which investigated failures at the Mid Staffordshire NHS Foundation Trust), revealed that there were problems with diagnostics and the use of equipment - staff showed poor understanding of the use of medical devices and patient monitors were turned off.

The health service is also set to face increasing pressures from rising expectations. For example, the Department of Health recently announced that millions more people will be protected against disease through improvements to the UK's immunisation programme. All children aged two - around 650,000 in total - will be offered a nasal flu vaccine from September 2013; a rotavirus vaccination programme will also start in July 2013, when children under four months will be vaccinated; and there will be a shingles vaccination programme for people aged 70, with a catch-up programme for those aged up to, and including, 79, from September 2013.

"What is not mentioned is the cost. This is an example of the constant rise in expectation, which adds to the financial pressures on the health service. Demand pressures on the health service are also increasing - particularly from people with long-term medical conditions - this means more diagnostics, more monitoring and more biomedical services," said Prof. Bosanquet.

Service redesign

The next challenge, he added, is to increase job satisfaction among healthcare professionals and staff: "It used to be a source of pride to work in the health service - now, in many hospitals, 50% of staff say they wouldn't like their friends or relatives to be treated at their hospital. This is a terrible situation. We are short of local leaders. When I was a student, I worked as a nursing assistant and what was clear was that there was a cadre of ward sisters who knew what was going on and effectively run the hospital. They had scores of experience between them and enormous expertise.

"Today, we need more of these people - there is a much higher turnover of staff, work is more intensive, the average length of stay is now four days and patients are getting a lot more treatment and diagnostics while they are there; they have more co-morbidities and yet staff are less experienced, on the whole, and more anxious about what they are doing.

"Therefore, biomedical engineers need to work with champions on the design, layout and use of biomedical technology to raise productivity - they need to be involved in every step of the care pathway. What this means is that the biomedical engineering sector needs to have a much greater focus on customer relationships (with healthcare professionals, managers and patients), rather than machines."

He went on to point out that biomedical engineers will have an important role in the integration of care (between primary and secondary care) through IT and diagnostics - with the twin aims of improving outcomes, while reducing the cost of the service.

"Biomedical engineers can produce results; they need to look at how the service is delivered to maximise the use of limited staff time and improve services for patients," he commented, adding that rigorous staff training will need to be more central to the commissioning of biomedical engineering services in the future. "A machine is only as good as the person using it," he pointed out.

Citing Tim Kelsey, National Director for Patients and Information, Prof. Bosanquet concluded: "We are entering an entrepreneurial future - one in which biomedical engineering and informatics are converging. Clinical data is required in a form that is accessible for staff and patients, while information is needed on cost and utilisation rates.

"The interaction between biomedical engineering and IT will be an important driver and biomedical engineers will be key partners for the health service, with regards to sustaining technology for healthcare professionals. In the next few years, biomedical engineers will have a crucial role in redesigning the health service to deliver more for less - we have what it takes to make a really creative contribution to this new phase."

Integrated care technology

Providing further insight into the impact of the Department of Health's changing strategy for healthcare delivery, Wayne Moore highlighted some key considerations for biomedical engineers. Initially trained as a biomedical technician in the Royal Airforce, Wayne Moore has worked in the medical device industry for over 20 years and is now developing the integrated care service offering for TBS GB.

An important trend, for EBME departments, in his view, is the move towards regional centres of excellence - this, he pointed out, will promote the rationalisation of medical devices, including spares and consumables. However, it will also 'widen the net' in terms of patients, resulting in increased distances for the delivery of postoperative after care and a greater number of post-operative consultations.

He added that the health service is placing greater emphasis on preventative care and people will increasingly have responsibility for managing their own care, using supporting technology.

"Historically, telecare has been somewhat disjointed, but there is renewed interest in using remote monitoring technologies for telecare and telehealth, following the Department of Health's 3million Lives campaign. The aim is to reduce the impact of managing long-term conditions on the health service. CCGs are being targeted to drive this technology," Wayne Moore commented.

He went on to point out that the need for improved integration between health and social care has been high on the agenda, in recent years, but there is very little detail on what this integration actually means. Technology exists to support the integration of acute, primary and social care, but issues need to be addressed in terms of communication between the various software packages used by the different care sectors.

"Software is being sold to GP surgeries, which enables them to link together, but this doesn't talk to the acute care sector software. Social care also has its own software. In short, none of the software technologies are able to communicate with each other," said Wayne Moore. This is a key barrier to effective integration, which needs to be addressed.

He suggested that the introduction of CCGs should enable greater integration and improved resource planning. However, the centralisation of care pathways will fundamentally change how products are sourced, maintained and managed. "Instead of purchasing large volumes of monitors, we will have to look at a rental model, so that individuals in the telehealth or telecare environment can use the devices for as long as they need them. When they are no longer required they can be allocated to another individual," Wayne Moore explained.

He went on to point out that one third of beds used in hospitals are occupied by individuals who are not patients, but people waiting to go home - a key issue that also needs to be addressed.

"We need to aim for quicker allocation of product, quicker decision making and easier funding provision to deliver improvement. Some hospitals are now developing rapid discharge teams - however, they will need support to make this happen," Wayne Moore commented.

"A patient with congestive heart failure (CFH), may have post-operative care needs, and require help to develop the techniques to improve their lifestyle and improve outcomes. Support may be offered for these patients in their homes to enable them to manage their condition more effectively," he explained.

"When a patient is discharged, remote monitoring devices are installed at their home, along with access via a web portal or mobile phone to a contact centre. They are shown how to monitor their blood pressure, heart rate and weight, and, as their vital signs and habits improve, they are moved on to a condition management programme. They receive helpful prompts and assistance in developing methods to adjust their lifestyle and, when they no longer require the equipment, it is withdrawn. This enables the throughput of service users to continue at a fixed cost, by employing an 'equipment library' approach," he continued.

He pointed out that the integration of care will ultimately mean that EBME departments will have to consider: how assets are tracked, as equipment moves between care settings, how user training is provided and how equipment is serviced and scheduled. The biomedical engineers' scope will broaden and EBME departments will have to engage with external agencies in the community - it will not always be the prescribing agency that they deal with, when problems arise with equipment.

"If we carry on as we are, hospitals will continue to lose equipment into the community and patients' homes, where there are no proper quality systems or training," Wayne Moore concluded. 
  

Delivering improvements

John Sandham, chairman of the medical devices website www.ebme.co.uk and chair of the EBME Seminar, went on to discuss the need to deliver improvements in the management of medical devices - including procurement. A recognised expert in medical devices management, John Sandham has been instrumental in changing the device management processes of many NHS Trusts and has a track record in delivering safe, cost saving improvements, as well as ensuring National Health Service Litigation Authority (NHSLA) and Care Quality Commission (CQC) compliance.

"We need to review current practice and consider whether there is a different way," he commented, pointing out that poor medical device management is both harmful and expensive.

"Poor acquisition leads to variation, which can ultimately lead to patients being seriously harmed, while poor training and maintenance can also lead to the same outcomes," John Sandham continued.

Research shows that this is a major problem in the health service. In 2010, the World Health Organization (WHO) highlighted the problem of adverse events occurring in the operating theatre, due to misuse of medical devices, and concluded that variation was a significant contributing factor. These are problems that effective equipment management could prevent.

"Improved medical device management can help avoid harm, help avoid deaths and help avoid costs," said John Sandham. He pointed out that WHO research shows that 30%-50% of additional costs are due to poor medical devices management and between 20% and 40% of equipment remains underutilised. Often modifications to equipment are required due to poor selection and acquisition, while around 30% of unplanned costs are also due to poor acquisition. Furthermore, users are not being properly trained in the use of equipment.

"Biomedical engineers are frequently called to fix equipment when there is nothing wrong, because staff don't know how to use it. The potential lifetime of equipment is also greatly reduced because it is being misused and mishandled. Recently, I visited a large acute Trust which had £1.2 m worth of equipment in the EBME department and this is not uncommon. At other Trusts I found equipment which had been awaiting repair for over two years. Poor management of devices is widespread - not just in the NHS but worldwide," John Sandham continued.

The National Audit Office (NAO) has also raised concerns about equipment management and called on Trusts to introduce a standardisation policy to deliver safe devices management and financial savings. The results of a survey, reported by the NAO, showed that only 12% of Trusts had a documented policy on standardisation of medical equipment (NAO 1999).

There has been a slight improvement across the UK, since the publication of this report, John Sandham revealed. However, there are still significant problems that need to be addressed - in 2004, the National Patient Safety Agency (NPSA) identified that "uncontrolled purchasing and device management, in the absence of competency-based training, were contributing factors in causing incidents."

"We know that patients continue to die because of incorrect use of infusion pumps, and equipment variation and training are linked. It is nearly a decade after the NPSA's original report and we still haven't solved this issue," he commented.

More recently, in 2011, the WHO stated that a number of studies have shown that around 46% of adverse incidents are due to misuse of medical equipment - an indicator that staff are using equipment without proper training. As mentioned earlier, by Prof. Bosanquet, the Francis report also highlighted equipment deficiencies as a key issue at the Mid Staffordshire NHS Foundation Trust.

"There are a number of facts emerging from these reports - devices are not always well designed. When selecting a medical device, the acquisition process should consider training. How easy is the product to use? Is it right for the business of the organisation? Does it meet the European standards of manufacture? All these factors need to be considered," said John Sandham. "Most importantly, we know that variation leads to death. In terms of improving medical device management, there is a lot of work to be done. Biomedical engineers need to step up and consider how they can improve safety and drive down costs in the future."

This issue is not going to go away, he warned, pointing out that the use of technology will continue to expand - in the future there will be increasing use of remote monitoring equipment, as the health service seeks to manage the rising numbers of patients with chronic and agerelated conditions in the community.

"People will need more technology, not less, and EBME departments will have to manage this. Furthermore, they will need to ensure that NHS managers understand the risks involved. Ultimately, every Trust should have a medical devices management policy and it should be a living document - someone needs to be managing and implementing it," he concluded.

About the event

The www.ebme.co.uk seminar brings together manufacturers, suppliers, and customers with an interest in medical equipment. The directors of the EBME Seminar have over 50 years of experience in the healthcare industry. This annual, independent, educational event brings together healthcare professionals that are responsible for the management of medical equipment. These medical equipment healthcare professionals are involved in areas such as procurement, maintenance, user training, and managing inventories.

An exhibition also takes place alongside the seminar programme - providing a showcase for innovative solutions, including a variety of patient monitoring equipment, medical and diagnostic devices, as well as software designed to improve medical device management.

To register for your free place at this event, please visit https://www.ebme.co.uk/seminar/registration

This article was originally published by our official media partner The Clinical Services Journal.