Saving lives while also saving money

The Cooksey report acknowledges the NHS is poor at translating clinical research into practice. Yet its recommendations, based on fundamental misunderstandings, are unlikely to stop patients being denied modern standards of care.

Cooksey describes innovation as ‘so vital to improve the treatment of patients as well as contain the costs of healthcare delivery’.

He is right. However, effort is needed not just on harnessing future innovation, but also on implementing existing proven innovation. There are products and techniques already proven to save lives and money which are seriously underused by the NHS. The systems for research, procurement and assessment of new products are not capturing these ‘no-brainers’.

Cooksey places great store in NICE’s role in uptake of innovation, saying it ‘sits at the interface between health technology assessment and clinical practice’. However, this misunderstands the reality of NICE’s role.

DH officials told Deltex Medical that NICE only looks ‘at the most significant new and existing technologies’, and with a ‘NICE appraisal potentially costing over £200,000 it is a tool we need to use selectively’.

NICE technology appraisals guide difficult and often high-profile decisions on whether the extra clinical benefit of a treatment merits the extra cost. NICE does not issue guidance on ‘no-brainer’ technologies that deliver clinical benefit at reduced cost. Cooksey is a missed opportunity to address the implementation of ‘no-brainers’ which could transform our health service.

The story of how Deltex Medical, a small entrepreneurial British medical device company, has pioneered a life-saving and money-saving technology is an example of the struggle that many companies face in securing NHS uptake of proven, common-sense innovation.

Reducing surgical complications, reducing length of hospital stay

Since 1989 Deltex Medical has pioneered oesophageal doppler monitoring (‘ODM’) through its CardioQ™ monitor, which determines the amount of blood being pumped around the body — ‘circulating blood volume’. Reduced circulating blood volume (‘hypovolaemia’) causes inadequate oxygen delivery around the body, leading to complications including organ failure and sometimes death. Hypovolaemia, akin to severe dehydration, affects virtually every patient having surgery because of the combined effects of pre-operative starvation, the impact of anaesthetic and trauma from the surgery itself.

Using the CardioQ, doctors can optimise the circulating blood volume and dramatically reduce post-operative complications, allowing patients to make faster, more complete recoveries. The clinical benefit translates into economic benefit — average hospital stays are reduced by three days.

The CardioQ is one of the fastest growing new technologies in the NHS; however, at current adoption rates, it will be decades before all 750,000 patients undergoing major surgery each year benefit from it. Doctors’ business cases to implement CardioQ are being scaled down or rejected on financial grounds, despite the CardioQ costing far less than treatment for complications suffered through not using it.

Clinical research

The British Journal of Surgery recently published results from a major trial of the CardioQ in bowel surgery at the Freeman Hospital in Newcastle, funded by the Royal College of Surgeons. It showed that when doctors used the CardioQ, they entirely or almost entirely eliminated serious post-operative complications, emergency post-operative admissions to critical care units and emergency readmissions to hospital. It found that patients were fit to go home three days earlier than non-CardioQ patients.

The CardioQ is now a core part of the Freeman’s ‘enhanced recovery’ programme for bowel surgery, which delivers amongst the lowest mortality and readmission rates and the shortest lengths of stay in the UK.

This was the seventh study of the CardioQ in peer-reviewed medical journals since 1995. An independent meta-analysis (systematic review of evidence) in 2006 concluded that ODM reduces post-operative complications and lengths of hospital stay; it is highly unlikely that any amount of new evidence could change that conclusion.

Government-funded study

An earlier government-funded study at Worthing Hospital also showed improved outcomes and reduced hospital stays in 2004, yet nothing has been done nationally to action its results. The trial appears to have been a waste of £44,000 of taxpayers’ money; estimates of the cost of not implementing its results range from £350 million to over £1 billion each year.

A DH spokesperson said last year, ‘We do not know if [the research] has fed into NICE guidance in this area.’ Unfortunately, as noted earlier, NICE has not looked at and will not look at ‘this area’. DH has instead offered the olive branch of a review of ODM by the new Centre for Evidence-based Purchasing (‘CEP’).

We are optimistic about the CEP findings, particularly as CEP should report after a full health technology assessment commissioned by the US government. However, it is unclear what teeth CEP has. There are no requirements upon the NHS to give regard to or provide funding for CEP approvals as there are for NICE. Cooksey refers to NICE 74 times, but not once to CEP.

Ewan Phillips is the managing director of Deltex Medical Limited