Published: 20/03/2003, Volume II3, No. 5847 Page 28 29
The NHS plan promised£300m by 2004 to replace outdated equipment. But all the new cancer scanners delivered so far have been funded through Lottery money. And the NHS is still poorly equipped compared with its European counterparts. Alison Moore reports
An industrial tribunal involving Godfrey Charnley, an orthopaedic surgeon from Derriford Hospital, Plymouth, made headlines last month when he claimed that NHS managers refused to buy him an instrument known as a curette - and told him to use a sterilised dessert spoon instead.
Mr Charnley lost his case after witnesses - including a heart surgeon - told the tribunal that dessert spoons are routinely used in operations, and are perfectly good instruments. But many patients and staff may feel the story shows that something is wrong with the state of NHS equipment.
The NHS plan, published in July 2000, promised that£300m would be spent on equipment to improve cancer, renal and heart disease services by 2004. The plan promised 50 MRI scanners, 200 CT scanners, 80 liquid cytology units for cervical screening, 45 linear accelerators for delivering radiotherapy, 3,000 automated defibrillators in public places and 450 haemodialysis stations.
The Department of Health says£208m worth of equipment has been delivered through central programmes since April 2000. But in two key areas - MRI scanners and linear accelerators - all the equipment delivered so far was funded under the National Lottery's New Opportunities Fund.
This is despite Labour's assurances that Lottery money would not be used instead of general taxation. In April 1997, Campbell Robb, spokesman for then shadow health secretary Chris Smith, told HSJ: 'It will be extra and additional things that are provided, to what is provided by taxation' ('Suspicion greets Labour's Lottery health proposal', news, page 7, 1 May 1997).
The NOF Living with Cancer fund has provided 34 MRI scanners and its cardiac, stroke and cancer programme another four. This accounts for the 38 MRI scanners delivered to date, and NOF funding will pay for 19 more by December 2004. Another 50 will be provided by the DoH. It is a similar situation for linear accelerators, where the NOF has funded the 55 provided so far and the DoH has yet to deliver the 45 it has promised.However, the department has funded 117 CT scanners with 83 to come and 692 defibrillators with 2,308 to come.
On haemodialysis, the DoH says that it has wholly or partly funded 350 new stations through the capital modernisation allocation and 100 more will be provided by December 2004. The investment to date has cost around£28m, but further investment on a similar scale may be needed since, according to the DoH's own figures, the demand for haemodialysis is rising by 8-9 per cent per year.
The liquid cytology units have been put on hold, pending a National Institute for Clinical Excellence review, which is not expected to report until August.
The DoH says a range of criteria have been used in deciding where the equipment will go.One aim has been to address historic imbalances where some regions have been better equipped than others.
Though its figures are not broken down by region, several large hospitals in the north have been given multiple pieces of equipment - for example, Weston Park in Sheffield has three linear accelerators and Christie Hospital in Manchester four.Another has been the age of equipment to be replaced. For example, the recent investment has ensured that all CT scanners are no more than 10 years old.
It is striking how important NOF funding has become to the NHS - despite early assurances that it would always provide extra money and not become a replacement for taxation. Since the NOF was set up in January 1999, it has provided more than£1.7bn worth of spending to health, education and environmental projects, with current spending around£450m a year. Its cancer diagnosis and treatment fund has had£93m to distribute and its cardiac, stroke and cancer programme£213.5m.
In some cases, these programmes are replacing old equipment. Six out of the 16 most advanced MRI projects are replacing existing scanners, while 10 are providing new ones. The NHS has to agree to replace equipment when necessary, but the policy direction for the distribution of NOF funding is set by the Department of Culture, Media and Sport, which says it works alongside the DoH to identify areas of need.
The investment by both the NOF and the government has made a difference. The government said in July 2002 that by the end of 2001 the NHS had 86 per cent more MRI scanners, 50 per cent more CT scanners and 20 per cent more radiotherapy machines than in 1997. But this will not bring the UK up to the level of our European neighbours. Figures calculated before the recent NOF and DoH purchases suggest the UK has four MRI scanners per 1 million population, compared with 10 in Germany, six in Italy and eight in the Netherlands. It has seven CT scanners per 1 million population, compared with 20 in Germany and Italy and 15 in the Netherlands.
The DoH says it is on track to meet its commitments under the NHS plan, and the remaining MRI and CT scanner allocations will be made soon.However, it takes up to a year for some of this equipment to be built, so it may be the end of 2004 before it is eventually installed. And even when scanners and linear accelerators are in place, there are barriers to their optimal use - staff shortages, for example.
Much equipment may still be outdated. The Audit Commission's Radiology report last August found that 41 per cent of equipment in radiology departments was older than Royal College of Radiologists recommendations. This alone would cost£510m to replace.
A number of trusts have looked at more innovative ways of funding large pieces of equipment. Since the Treasury removed its opposition to leasing in the 1990s, these have included leasing arrangements or mini-private finance initiatives, either with or without staffing.
Trusts also need to fund smaller pieces of equipment - and ideally to have a planned replacement programme. Capital allocations to strategic health authorities and primary care trusts have noticeably increased and the government is committed to increasing them by more than 10 per cent for the next three years. Some estates managers are also hoping that money from the national IT budget could be used to move from conventional x-rays to fully digitised systems.
But Kingston Hospital trust chief executive Helen Chalmers says routine equipment replacement has to be weighed against many other needs, especially compliance with legal requirements on, for example, fire and health and safety. 'I do not think we in the NHS are always as good as we should be on planned replacement of equipment, ' she says.
This can mean that equipment replacement falls further and further behind - and more of the available cash has to be spent on emergency replacements or repairs as equipment reaches the end of its life.
One area in which trusts have been forced to spend significant amounts of money is in upgrading anaesthetic equipment to prevent patients being given a potentially fatal mix of gases.
The Royal College of Anaesthetists was keen to see these anti-hypoxic guards used across the country after the death of a London child who was accidentally given the wrong mix. 'A lot of trusts took a very big financial hit to do that, ' says RCA president Dr Peter Simpson. 'Risk management and the flagging up of risks has done an awful lot for equipment replacement.Most trusts now have a planned replacement programme.'
However, less vital pieces of equipment may not be being replaced at a similar rate. In an article in HSJ (Out of order, pages 26-28, 17 August 2000), Dr Colin Connolly highlighted many trusts' inadequate equipment inventories.
This makes it difficult to get an exact picture of the situation, but Dr Connolly says: 'The problem for the NHS is 25 years of massive underinvestment.With the smaller stuff... much of it is so old it is unbelievable. Some of it is quite critical, especially in operating theatres with things such as suction pumps.'
The DoH's investment strategy, issued in the wake of the NHS plan in November 2000, said previous under-investment had led to 'the use of poor quality, obsolete and unreliable equipment which leaves us lagging behind our European neighbours'.
That position is improving: but is it improving rapidly enough?
Broken promise: old scanners put patients at risk
Old equipment can malfunction and suddenly leave a hospital trust in the lurch.This happened to Maidstone and Tunbridge Wells trust last year.
An old MRI scanner at Pembury Hospital was decommissioned when it was discovered it had not been working adequately for more than six months. A thousand scans had to be re-examined to ensure patients had not been at risk during this time and arrangements made for patients to be treated elsewhere.
A mobile scanner was set up at Maidstone Hospital,16 miles away, because of difficulties in siting one at Pembury.Meanwhile, the trust had to find close to£1m to purchase a new scanner. Five months after the scanner was closed, the New Opportunities Fund agreed to pay.
Lottery winner: RUH Bath's funds boost
The New Opportunities Fund has been a saviour for Royal United Hospital Bath trust. It has funded some substantial pieces of equipment - a linear accelerator was replaced recently and next summer the trust will be getting a simulator that controls the dosage given by linear accelerators.
A CT scanner has been replaced and director of facilities Stephen Holt is hopeful that a new MRI scanner can be bought as well.The trust has also benefited from the 'action on'programmes run by the NHS, which has funded new equipment such as an x-ray machine for the fracture clinic.But smaller items have to come out of the facilities budget - and with competing demands from other areas, such as ward refurbishment, expenditure has to be justified.
The trust expects to spend just under£1m on medical equipment this year, using risk assessment to decide which equipment to replace.'We look at what would endanger patients if we did not replace it, ' says Mr Holt.Like many other trusts, it has a major programme to replace anaesthetic equipment - expected to cost£600,000 over four years.