The NHS: Putting Patient's Safety First?
Written by Shane Tickell
While the Francis Report was voluminous and in parts failed to give clear direction on next steps, the most recent Berwick Reportwas criticised for being ‘soft’ and ‘over simplistic’ but in its digestible 46 pages, it distilled the key issues that the NHS continues to face in putting patient safety first. At its most basic, it said learning and leadership must be wholeheartedly addressed.
But perhaps the difficulty in adding further detail to the report, which was said to be ‘light on practical solutions’, comes partly with a wider inability for people to describe what makes a good leader, a leader that encourages learning, is visionary, adaptive and responsible. To me all of these attributes come down to one key quality that every leader must exert ‘courage’.
As it stands, those who progress to lead a division or an organisation have traditionally obtained their status by being forward thinking, devising a plan, implementing the plan and claiming the success following the activity.
But what happens when, and increasingly in the NHS, plans change? This could be due to internal factors, such as resourcing issues or organisational changes or even external factors such as a large-scale medical emergency, a problem with a national helpline, or an ageing population.
Good leaders in my mind are those who have the courage to step up and say ‘this isn’t working, this needs to change’ or ‘things were different when we first started on this path, let’s reassess what we are doing’. This is irrespective of whether they devised the plan, signed it off, or oversaw it. The point is that great leaders are those who have the courage to take responsibility and move things forward regardless of whether they could be considered ‘wrong.’
Salford Royal NHS Foundation Trust is a clear example of where this has been achieved. Five years ago the trust was criticised for having some of the highest unnecessary death rates in the country. The trust realised its mistake and went public. Today it has the lowest mortality rate outside of London. In March, the hospital’s chief executive, David Dalton explained:“The nurses have to deal day-to-day with patients – and they know what works. We set about building a different culture – one which would allow nurses to look at the system and say how we could improve it.”
The Berwick Report focuses on the need for the NHS to become a ‘learning organisation.’ In virtually every industry, we expect our leaders to have all the answers and to radiate the conviction of being all knowing. I disagree with the term ‘born-leader’ and despite often being put on a pedestal, leaders like everyone else, must continue to learn, to improve and to ultimately succeed in making a change.
I read recently that in his retirement, Bill Clinton makes it a rule to say ‘I made a mistake’ or “I didn’t know that” once a day. Even if a scenario doesn’t naturally occur, he will go out of his way to engineer one. He does this, as he believes this will help him to learn and look at situations from a different perspective. However, if he had changed the direction of his manifesto or political strategy during his presidency, he would have no doubt been ridiculed by the opposition the media and the nation alike.
The point here is that, those who lead should be respected for making the best decisions based on the best knowledge that they have at the time, whenever that time is. When things become challenging and circumstances change, this gets tough but having the courage to adapt a strategy or situation is likely to have far better results and can be far more rewarding.
In a recent article,Jan Filochowski, CEO at Great Ormond Street Hospital echoed these thoughts:“You'll always make mistakes ... it's about correcting them before they become really big.” He highlighted that there needs to be a change in NHS culture that does not see failure as an end point.
It takes boldness and bravery to take a step back and admit that decisions made early on might not have been the right ones but it takes courage to change and adapt in order to stop a strategy failing completely.
About the Author
Shane Tickell CEO, IMS MAXIMS
The challenges to vaccine distribution affecting everyone
While it is comforting to know that vaccines against COVID-19 are showing remarkable efficacy, the world still faces intractable challenges with vaccine distribution. Specifically, the sheer number of vaccines required and the complexity of global supply chains are sure to present problems we have neither experienced nor even imagined.
Current projections estimate that we could need 12-15 billion doses of vaccine, but the largest vaccine manufacturers produce less than half this volume in a year. To understand the scale of the problem, imagine stacking one billion pennies – you would have a stack that is 950 miles high. Now, think of that times ten. This is a massive problem that one nation can’t solve alone.
Even if we have a vaccine – can we make enough? Based on current projections, Pfizer expects to produce up to 1.3 billion doses this year. Moderna is working to expand its capacity to one billion units this year. Serum Institute of India, the world’s largest vaccine producer, is likely to produce 60% of the 3 billion doses committed by AstraZeneca, Johnson & Johnson and Sanofi. This leaves us about 7 billion doses short.
Expanding vaccine production for most regions in the world is complicated and time-consuming. Unlike many traditional manufacturing operations that can expand relatively quickly and with limited regulation, pharmaceutical production must meet current good manufacturing practice (CGMP) guidelines. So, not only does it take time to transition from R&D to commercial manufacturing, but it could also take an additional six months to achieve CGMP certification.
The problem becomes even more complex when considering the co-products required. Glass vials and syringes are just two of the most essential co-products needed to produce a vaccine. Last year, before COVID-19, global demand for glass vials was 12 billion. Even if it is safe to dispense ten doses per vial, there is certain to be significant pressure on world supply of the materials needed to package and distribute a vaccine.
It is imperative drug manufacturers and their raw material suppliers have clear visibility of production plans and raw material availability if there is any hope of optimizing scarce resources and maximising production yield.
It is widely known by now that temperature is a critical factor for the COVID-19 vaccine. Even the regions with the most developed logistics infrastructures and resources needed to support a cold-chain network are sure to struggle with distribution.
For the United States alone, State and local health agencies have determined distribution costs will exceed $8.4 billion, including $3 billion for workforce recruitment and training; $1.2 billion for cold-chain, $1 billion vaccination sites and $0.5 billion IT upgrades.
The complexity of the problem increases further when considering countries such as India that do not have cold-chain logistics networks that meet vaccine requirements. Despite India’s network of 28,000 cold-chain units, none are capable of transporting vaccines below -25°Celsius. While India’s Serum Institute has licensed to manufacture AstraZeneca’s vaccine, which can reportedly be stored in standard refrigerated environments, even a regular vaccine cold chain poses major challenges.
Furthermore, security will undoubtedly become a significant concern that global authorities must address with a coordinated solution. According to the Pharmaceutical Security Institute, theft and counterfeiting of pharmaceutical products rose nearly 70% over the past five years. As with any valuable and scarce product, counterfeits will emerge. Suppliers and producers are actively working on innovative approaches to limit black-market interference. Corning, for example, is equipping vials with black-light verification to curb counterfeiting.
Clearly, this is a global problem that will require an unprecedented level of collaboration and coordination.
Disconnected information systems
While it is unreasonable to expect every country around the world will suddenly adopt a standard technology that would provide immediate, accurate and available information for everyone, it is not unreasonable to think that we can align on a standard taxonomy that can serve as a Rosetta Stone for collaboration.
A shared view of the situation (inventory, raw materials, delivery, defects) will provide every nation with the necessary information to make life-saving decisions, such as resource pooling, stock allocations and population coverage.
By allowing one central authority, such as the World Health Organization, to organize and align global leaders to a single collaboration standard, such as GS1, and a standard sharing protocol, such as DSCSA, then every supply chain participant will have the ability to predict, plan and execute in a way that maximises global health.
Political influence and social equality
As if we don’t have enough stress and churn in today’s geopolitical environment, we must now include the challenge of “vaccine nationalism.” While this might not appear to be a supply chain problem, per se, it is a critical challenge that will hinge on supply chain capabilities.
In response to the critical supply issues the world experienced with SARS-CoV-2, the World Health Organization, Gavi, the Vaccine Alliance and the Coalition for Epidemic Preparedness Innovations (CEPI) formed Covax: a coalition dedicated to equitable distribution of 2 billion doses of approved vaccines to its 172 member countries. Covax is currently facilitating a purchasing pool and has made commitments to buy massive quantities of approved vaccines when they become available.
However, several political powerhouse countries, such as the United States and Russia, are not participating. Instead, they are striking bilateral deals with drug manufacturers – essentially, competing with the rest of the world to secure a national supply. Allocating scarce resources is never easy, but when availability could mean the difference between life and death, it becomes almost impossible.
Global production, distribution and social equality present dependent yet conflicting realities that will demand global supply chains provide complete transparency and an immutable chain of custody imperative to vaccine distribution.
The technology is available today – we just need to use it. We have the ability to track every batch, pallet, box, vile and dose along the supply chain. We have the ability to know with absolute certainty that the vaccine is approved, where and when it was manufactured, how it was handled and whether it was compromised at any point in the supply chain. Modern blockchain technologies should be applied so that every nation, institution, regulator, doctor and patient can have confidence in knowing that they are making an impact in eradicating COVID-19.