Feature / Raising the bar

Earlier this year, the Medicines and Healthcare products Regulatory Agency (MHRA) included unique bar code identifiers in a recall notice for the first time. Although some hospitals do not yet have the ability to use the identifiers, the recall of the metal-on-metal hip replacements was hailed as a milestone in the health service journey to introduce bar codes.

The Department of Health’s e-procurement strategy, issued last year, included a decision to adopt the GS1 bar code standards in the NHS. Not only would it help the speedy execution of safety recalls, but also make procurement more efficient, it said.

For example, as items are ‘scanned out’ for use with a patient, an inventory management system can log this and automatically reorder the items when stock levels reach a set threshold. Also, with a standard bar code for each product, price comparison is easier.

The inability of hospitals to compare like-for-like products and thus ensure they are paying the lowest price is one of the issues raised by several Department procurement reviews, including the recent interim report by Lord Carter.

All trusts were due to submit their GS1 adoption strategies by June, but this has proved too difficult for most and they have been given more time to complete their plans. However, the Department now has more than 40 board-approved GS1 adoption strategies – 12 of these trusts have been shortlisted to bid to become one of six demonstrator sites.

The shortlisted trusts are benefiting from external support to develop implementation strategies. This has been funded by the Department to the collective tune of £1m. And the six trusts that become demonstrators will then receive a share of a £12m-£15m pot to help them implement their strategies over two years. Most of the money is earmarked to aid business and cultural change, rather than systems redesign.

Glen Hodgson, head of healthcare at GS1 UK, says that within the two years of the demonstrator project, the trusts must deliver all three key enablers of the GS1 strategy (ability to identify patient, product and place) and three primary applications (purchase to pay, inventory management and product safety recalls). ‘They will be expected to have completed the implementation of all six within the 24 months,’ he says. ‘That’s critical. They need the suppliers on board to do that.’

Implementation strategies must be with the Department by the middle of November and about a month later the six demonstrators will be announced. Implementation will begin in January.

Significant potential

Daniel Godfrey, solutioning consultant at NHS Shared Business Services, says widespread implementation of the e-procurement strategy and GS1 standards have significant potential to help meet a number of key ambitions for the NHS, particularly around the delivery of safer, more affordable care and in achieving significant savings through consistent approaches to procurement.

‘GS1 standards represent one of the foundations of Lord Carter’s review of operational productivity in NHS providers,’ he says. ‘We need good data to identify and measure real savings opportunities. GS1 standards can help NHS organisations identify the best price for the products they need and control their stock levels effectively.

‘NHS Shared Business Services is working with the Department of Health, our strategic partners at GS1 UK and several potential demonstrator sites, which are determined to get there quickly and lead the way. It is not a quick fix and there is a lot of work needed to fully embed GS1 standards within the NHS as a whole. But if successful, there is a huge potential benefit for the NHS in finance, efficiency and better patient care.’

However, Mr Hodgson says that some trusts are already moving to a more advanced use of GS1 data. ‘Not all of the six trusts will start with a blank sheet of paper. Some have made significant progress already and have been looking at applied benefits,’ he says.

Broadly speaking, these applied benefits fall into three main types:

• Near real-time patient tracking, which reduces clinical time spent looking for patients
• Patient pathway monitoring, including patient-level costing and providing information to draw a direct link from patient activity to outcomes
• Accurate information on the individual elements of patient care, including better apportionment of high-cost equipment usage.

Derby Teaching Hospitals NHS Foundation Trust is one of the shortlisted trusts and, together with Portsmouth Hospitals NHS Trust, was recently awarded a global GS1 healthcare award for its implementation of the bar code system.

Derby director of finance and performance Kevin Downs says GS1 bar codes are the critical building block for its hTrak system. This collects data via GS1 bar codes and links it to inventory management software and an information system to analyse activity by procedure.

The system is currently in use in 19 theatres, including general surgery and ophthalmology, as well as radiology, day surgery and two cardiac cath labs. The trust intends to add further areas in the next few months. This will include the remaining 16 theatres, a ward trial and, it hopes, A&E. ‘GS1 has allowed us to take our work up to a different level,’ Mr Downs says. ‘We have a GS1 licence to create our own bar codes, so we can issue them for our staff and for coding and comorbidities.’

In theatre, the trust is able to scan who is in the theatre as well as the products as they are used on the patient.

Mr Downs continues: ‘In addition to producing a consumables cost sheet, for every procedure we know who’s in theatre and the role they are playing so we can produce a cost sheet for every procedure.’

It also helps track and trace instrumentation and implants, should the trust receive a product recall request, as well as improving patient safety by identifying out-of-date stock prior to use on the patient.

The trust plans to develop scanning for comorbidities, with healthcare resource groups (HRGs) or OPCS codes given their own bar code. It is encouraging the Department and the Health and Social Care Information Centre to adopt standard bar codes for HRGs or OPCS codes. “They should be national – it shouldn’t be up to each hospital to develop their own bar codes for an arthroscopy or any other procedure,’ says Mr Downs.

Safety implications

Patient safety is one of the key benefits offered by a standard bar code system allied to inventory management software and a data warehouse. As in the recent national hip prosthesis recall, if there is a problem with an implant or a set of surgical instruments, the trust can find out at the touch of a button which patients had the implant or were operated on using the instruments.

‘We believe that when GS1 is implemented in every product, the NHS will be able to develop a system that can track the care that is being provided to each patient, who is doing it, when, where and with what,’ says Mr Downs.

This is similar to the detailed information that shop chains such as Boots and Sainsbury’s collect through customers using loyalty cards.

Portsmouth Hospitals NHS Trust is also shortlisted in the demonstrator project and it too is looking for applied benefits (see box overleaf), leading to significant cultural changes in its approach to inventory management. Mr Downs says the next step is to extend the system to the pharmacy department, with the pharmaceutical industry already a major user of GS1.

‘A nurse on a ward or a district nurse in the community could scan the drug, the dosage and when it was given to the patient,’ he says. ‘That information would flow into the e-prescribing database and also to the electronic patient record.’

Although there is a lot to be said for GS1’s role in collecting accurate, timely information, this alone will not necessarily bring more efficient, higher-quality services. The Derby trust has put time into maximising the use of the data. Aside from the benefits of more efficient procurement, the collection of activity and cost data at procedure level can help inform discussions with clinicians about variation.

‘Through hTrak, we know clinical directors can have a detailed discussion at procedure code level about clinical variations,’ says Mr Downs. ‘The information is untainted by any apportionment introduced by finance. It is untouched from the time it was collected. It says: “This is the procedure and this is what it cost” – which gives it total credibility with the surgeons.’

The information can be cut in many ways – time taken or the consumables used, for example. In one case, for a particular procedure, most surgeons had eight staff in theatre, while one of their colleagues had an additional healthcare assistant. At a high level, it’s an adverse variation, but looking into the data they discovered that the larger team was able to cut minutes off the theatre time for each patient. Over a four-hour session they saved enough time to operate on an additional patient – reducing waiting lists, using theatre time more efficiently and potentially increasing the trust’s income.

But if the NHS is gearing up for GS1, what about suppliers? GS1 reports increasing interest from NHS suppliers in becoming compliant with its standards, though trusts say suppliers, particularly smaller ones, have some trepidation over the move to GS1.

The industry will welcome GS1 with open arms, according to Ray Hodgkinson, public affairs at the British Healthcare Trades Association (BHTA), which represents companies that make or sell healthcare products. ‘The industry has been pressing for a number of years for bar coding to be adopted within the NHS as well as local authorities,’ he says. ‘Suppliers are supportive and believe the technology provides significant efficiency and cost savings to both customer and supplier. It also improves safety for patients.’

Implementation support

The BHTA is working with GS1 to support adoption. ‘Suppliers are ready and manufacturers already use bar codes for internal purposes – manufacturing, inventory management and accounting,’ says Mr Hodgkinson. ‘Small and medium enterprises find it more of a challenge. That’s why we have the close relationship with GS1, so that support is readily available.

‘The issue for industry is that it needs clarity from the public sector side – for example, a date by which to be ready for adoption. The Department of Health is not clear and keeps wavering.’

He adds: ‘I believe that by adopting bar coding across the NHS and at primary care level this would be the single most significant cost saving the government can achieve. Savings experienced in many sectors can be between 5% and 7%. That would be a significant figure for the taxpayer.’

GS1 UK’s Mr Hodgson acknowledges there is a risk that some trusts will sit on their hands while the demonstrator project is running, perhaps in the hope that some funds will become available for wider implementation across the NHS. But he insists the demonstrators do not mean there will be a pause in implementation elsewhere. Nor will there be a ‘ta-da’ moment after 24 months – change will happen organically. Most trusts have adopted GS1 standards in some form and, once the demonstrators begin to show what can be achieved – which could happen early in the new year – he believes there will be rapid take-up of GS1 standards.

He believes momentum is swinging behind the adoption of GS1 standards. As well as the current government’s support for the NHS e-procurement strategy stipulating the use of GS1 barcodes, the recent MHRA recall highlighted one of its benefits. A forthcoming EU directive on serialising medicines to ensure authenticity will solidify GS1’s position as the unique identifier of choice for drugs in UK pharmacies. And the Department has hinted it may set a deadline on compliance for trusts and suppliers.

‘We are not yet at the tipping point, but we will get there in the next 12 to 18 months,’ says Mr Hodgson. ‘My best estimate is that the vast majority of trusts and suppliers will have fully implemented GS1 standards by 2020. That’s not a long timescale and some will move faster.’

Clearly, there is work to be done, but GS1 and the Department are hoping that early benefits shown in the demonstrator sites will tip the balance and get all trusts to hasten their adoption of GS1 bar codes and use them to improve efficiency and patient care.

Code benefits

Portsmouth Hospitals NHS Trust (pictured) has so far implemented GS1 standards in a 27-theatre complex, as well as cardiology, audiology and across six wards.

The trust uses GTINs (global trade item numbers) to identify each product – but GS1 bar codes contain GTINs and more besides.

For example, in cardiology most products must also have batch or lot numbers, expiry dates and, increasingly, products must also be serialised – uniquely identifying each individual instance of the product. GS1 bar codes include all this information.

This has helped the trust streamline its ordering and inventory processes, according to Jackie Pomroy, head of supply chain at South of England Procurement Services, which is hosted by the Portsmouth trust.

‘An immediate benefit is that they use the products with the shortest life remaining first, meaning less wastage of expired products. Also, by scanning the batch or lot numbers they easily prevent the use of recalled products, improving efficiency and, most importantly, patient safety,’ she adds.

Following its implementation, stock has been reduced by 20%, waste cut to less than 1%, recalls are handled more efficiently and inventory data is more accurate and visible across the trust, she says. The return on investment was calculated as being 8.5:1.

The trust is working with its top 30 suppliers and between January 2014 and May 2015 the correct use of GS1 standards by these suppliers increased from 37% to 65%. Other suppliers are beginning to use GTINs to identify their products.