Effect of clinical engagement on value, standardisation, decision-making and savings in NHS product procurement

Annual procurement of products and services spending in the NHS was around £27 billion, with £6 billion spent on healthcare products used in delivering healthcare before the COVID-19 pandemic (UK Government, 2018). Since then, healthcare spending has grown a great deal (£193.8 billion) and procurement spending has increased (£32.1 billion) (Department of Health and Social Care, 2023). The procurement function within NHS organisations is seen as central to driving efficiencies and service effectiveness (Sanderson et al, 2015). This comes with an increasing onus on clinicians, including nurses and allied health professionals (AHPs), to accept procurement outcomes to realise efficiency savings, with or without their previous engagement.

Procurement is the term used to describe several processes associated with the acquisition of goods (Chartered Institute of Procurement and Supply, 2021), and involves managing both internal and external stakeholder relationships. Procurement within the NHS is facilitated by three main procurement routes: nationally via NHS Supply Chain (NHSSC); external to a healthcare provider organisation through hubs; or internally within NHS trusts through direct agreements with suppliers (Boiko et al, 2020). Procurement within the NHS involves a complex set of actors and, more recently, is influenced by clinical procurement professionals (CPPs), which is a collective term that encompasses clinical procurement specialist nurses and AHPs employed within procurement.

Figure 1 provides an overview of the evolution of centralised NHS procurement of non-clinical and clinical products and services since 2000. This illustrates the correlation between key government policy initiatives to achieve savings and optimise healthcare delivery as well as the changing landscape of NHS procurement from local to centralised national procurement strategies. The chronological exploration shows how the focus and architecture of NHS procurement has come full circle since the inception of the NHS Purchasing and Supply Agency, set up as a centre of excellence in procurement with public sector funding, to the current Target Operating Model, which echoes the NHS Purchasing and Supply Agency aims of procurement. There has been limited change in concept other than organisational leadership and branding.

Despite public investment in centralisation and the ‘top slicing’ (Department of Health (DH) 2017a) of NHS trusts for the provision of the operating models, there is no mandate for the NHS to use these procurement services. Funding for the operating model is now top sliced from the tariff at the outset by NHS England, with trusts purchasing products from NHSSC at the buy price; before this, trusts would pay an oncost to cover operating costs (DH, 2017a).

This has resulted in NHS trust procurement teams having several routes for product procurement in addition to those offered by NHSSC. Therefore addressing ‘unwarranted variation’ (DH, 2016) and achieving savings, standardisation and value in the procurement of healthcare products have become more complex, leading to fragmented approaches determined on a trust-by-trust basis.

The year 2015 marked a key point for national procurement that underpins the national procurement landscape and activity today. This is centred around Lord Carter's review, Operational Productivity and Performance in English NHS Acute Hospitals, which identified potential savings of £5 billion could be made and found ‘unwarranted variation’ across service provision nationally (DH, 2016: 1). The publication of the Carter review coincided with the expiration of the 10-year contract with NHSSC, which was seen as an opportunity to restructure the model for NHS procurement through the Procurement Transformation Programme (PTP) (DH, 2017a). The PTP was underpinned by a philosophy of reducing variation across the NHS through the procurement of high-quality products that met health service needs. The Future Operating Model (DH, 2017b: 1), introduced to deliver the PTP (DH, 2017a), predicted annual savings of £615 million would be made through centralised procurement via NHSSC (DH, 2017b) under the management of Supply Chain Coordination Ltd.

The GP's role in procurement within the NHS was precipitated by the Health and Social Care Act 2012, which created clinical commissioning groups (CCGs), which gave GPs the procurement decision-making responsibility for commissioning services for the population within their CCG. The prominence of clinical engagement in procurement was driven by Carter's review (DH, 2016) and the Getting It Right First Time (GIRFT) programme, which is a clinically led programme that aims to deliver higher quality healthcare at a lower cost and with a reduction in variation (GIRFT, 2021).

Clark and Nath (2014) confirmed the association between clinical engagement and financial savings and better clinical outcomes for NHS organisations. The Royal College of Nursing's (2015) Small Changes, Big Differences campaign added that value could be achieved through engaging nurses in procurement, shifting the focus from financial savings to achieving value through a patient-centric focus on safety, clinical outcomes and standardisation of products.

Since Carter's review (DH, 2016), the realities of clinical engagement in healthcare procurement have become synonymous with forced change, poor or no clinical engagement and poor-quality products driven by price, predominantly because the PTP introduced the Nationally Contracted Products programme (DH, 2017a). There is also a perception of inequality between the value of the voices of nurses and AHPs in product procurement and those of doctors, who are believed to get what they want (Donohoe, 2019).

A review was undertaken to critically evaluate the procurement and supply chain management literature related to the research objectives, using a systematic process of appraisal and analysis (Aveyard, 2019). The evidence base is limited and tends to focus on orthopaedics and high-value products as opposed to the breadth of products required by the NHS.

There is a scarcity of literature that looks at the role of clinical staff (including nurses, doctors and AHPs) in procurement and with a specific focus on the role of clinicians in procurement impacting value, savings and standardisation. Evidence related to value is limited to value-based procurement (VBP), which centres around efficiencies to the health system as a whole (Pennestri et al, 2019) with the added consideration of the whole-life cost of products used and aligned with the patient pathway (Mangan and Bradley, 2021). The VBP literature reflects an undertone relating to the financial instability of healthcare provision and the need for savings to be achieved through procurement activity, shifting from price-based solutions to those based on value achieved through VBP.

Standardisation has been perceived as an opportunity to create savings and achieve value. However, Mannion and Exworthy (2017) asserted that in healthcare ‘standardisation has been associated with a one size fits all approach’, which has developed over recent years and resulted in opposition and workarounds to bypass standardisation. This is also true in the author's experience. Furthermore, an explorative study by Budgett et al (2017) identified that clinical collaboration led to increased standardisation.

The limited evidence available relating to the results of clinical involvement in procurement and the associated benefits regarding value, savings and standardisation, coupled with the wealth of the author's experience within clinical procurement in both the public and private sectors, have defined the focus of this research. This article reports on the findings of an empirical study that was undertaken to address the gap in the research by examining whether clinical engagement in the procurement of healthcare products in the NHS is necessary to achieve value, savings and standardisation.

Method

A multi-method qualitative case study design was used, including a survey (51 participants) and eight semi-structured interviews, which were conducted between September 2022 and February 2023. The research aimed to capture the national perspective of clinicians, CPPs and procurement professionals working in the public and private sectors, procuring healthcare products on behalf of the NHS.

Ethical approval

All procedures were performed in compliance with institutional guidelines and ethical approval was sought and granted for this research from the University of Birmingham.

Survey

The survey had three aims: to scope the procurement landscape; to understand participants' experiences of clinical engagement in procurement; and to identify areas for deeper investigation in the semi-structured interviews.

Convenience sampling was used to capture a broad perspective from a large number of national participants with limited time and resources. The survey was designed by the author so a pilot was undertaken for validity and reliability. The survey was created using Qualtrics XM online survey software. It included open and closed questions to capture breadth and depth of experience.

Survey participants were recruited via procurement networks and social media. Taking part was voluntary and informed consent was a prerequisite for participation for both surveys and interviews. The survey questions are not included here because of publication space constraints.

Sixty-eight participants completed the survey; 17 incomplete responses were removed, leaving a total of 51 completed surveys for analysis. Analysis of survey responses is an automated function of the Qualtrics software. Not all questions were answered by all participants as skip-logic was used to filter responses by specific participant. As the number of participants varied for each question answered, percentages were calculated manually for accuracy and analysis.

Interviews

Semi-structured interviews formed part of the second element of the research design and were intended to elicit a deeper understanding of the role of clinical engagement. The topic guide was piloted during the first interview. Interviews were conducted virtually via a videoconferencing platform, Microsoft Teams, to minimise resource use and financial impact as the participants provided national coverage and interviews were conducted by a single researcher.

Interviewees were selected from the larger cohort of survey participants using purposive sampling, taking into account role, length of time working in procurement and experience of procurement activity, with and without clinical engagement with positive and negative outcome; they were they chosen so a range of experiences would be collected. The interviews were limited to a maximum of 1 hour; they were audio recorded then transcribed, after which they were deleted. The transcriptions were saved securely in line with ethical approval.

Eighty per cent of survey participants agreed to be contacted for interview. Eight out of 13 participants contacted agreed to be interviewed; one who was unable to complete the survey came forward for interview. Participants reflected the six roles that had been identified as pertinent to obtaining a global perspective of clinical engagement on the procurement of healthcare products. To maintain confidentiality, they were allocated a personal identification number; codes are used to indicate role and workplace in interview extracts below (Table 1).

Interview analysis

Analysis was undertaken using the principles of reflexive thematic analysis (Braun and Clarke, 2022). Transcriptions were initially reviewed to highlight and code relevant areas, using NVivo software, followed by further review enabling ‘refining, defining and naming’ (Braun and Clarke, 2022: 36) then concluding with the final themes identified.

Findings

Survey results

Only a high-level summation of survey results is being shared in this article as publication space is limited.

Figure 2 highlights that participants were predominantly procurement professionals (38.78%), with 26.53% being clinicians working on behalf of a category tower service provider, hub, integrated care service or NHS England. Regarding primary employer, the majority of participants worked for Supply Chain Coordination Ltd or a category tower service provider (contracted by Supply Chain Coordination Ltd) (64.59%).

Procurement of healthcare products with and without clinical engagement

All participants were asked to identify specific procurement projects or activities in which they had been involved, with and without clinical engagement and with successful and unsuccessful outcomes. A successful outcome was defined as a procurement activity that obtained the right products that met the specification and provided value in terms of quality for the clinical teams using them as well as longevity of adoption. An unsuccessful outcome was one where these criteria were not met. This question was designed to enable the researcher to potentially identify and discern product groups where clinical engagement was important.

The broad categories of ward-based consumables, wound care, patient equipment, surgical consumables, intravenous (IV) therapy consumables, implantable devices, theatre products and prostheses were successfully procured with clinical engagement. However, ward-based consumables were also successfully procured without clinical engagement, which suggests this was not a central factor here. However, regarding IV therapy consumables, participants reported unsuccessful procurement of these without clinical engagement. Therefore, clinical engagement may well be a central factor with this product group. The lack of clinical engagement in the procurement of non-clinical consumables led to negative outcomes; this is discussed below relating to the purchase of 9V batteries for syringe drivers.

As some findings around the necessity of clinical engagement with a number of product groups were inconclusive, a supplementary question was included in interviews to gain greater insight into product procurement both with and without clinical engagement. However, all participants found this question difficult to answer:

‘It's really muddy, isn't it?’

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The majority of participants agreed that any clinical product would require clinical engagement with varying degrees of involvement, depending on the type of product and how it was to be used and by whom:

‘I would probably say the majority of products, I probably wouldn't say all… there is no one size fits all. It depends what you're buying, it depends how something is used in the organisation and it sometimes even depends on the individuals who it's going to have an impact on.’

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There was also a sense of like-for-like products being procured that are familiar to clinical end users; these items could be dealt with directly by procurement without the need for engagement. There was a sense from participants of being realistic regarding the need for clinical engagement and differentiating between products directly used in clinical practice and ruling out building fixtures and fittings, which fall under estates and facilities. However, the results showed that a lack of clinical engagement could have a negative outcome regarding non-clinical consumables. In this case, this related to the procurement of 9V batteries, which were used in syringe drivers for patient pain management.

The 9V battery, deemed a non-clinical item, had been procured from a new supplier to save money. Compatibility with the syringe drivers had not been considered in the procurement exercise, which led to patient risk and also to clinicians adopting their own workarounds to address the deficit:

‘It took a lot of ensuring that we got the proper batteries because, otherwise, you're putting patients' whole, sort of, existence in jeopardy as they would be in pain and unnecessary discomfort ’cause you couldn't get the driver to work… We used to buy the right batteries.’

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In this scenario, clinical engagement may not have been required; staff with expertise in the product, such as technical engineering team members who would be familiar with the products from a maintenance perspective and understand the battery standards, may have been the most appropriate source for engagement.

Although this finding concerns one example, it suggests that further research around some non-clinical consumables might be warranted to see if this issue is more widely experienced. If so, how products are categorised would need to be reviewed to determine whether clinical engagement is needed.

Factors that achieve value, savings and standardisation

This section explores factors that influence achieving positive outcomes, savings and standardisation. An additional comparisons analysis was carried out on the experiences of two further cohorts of participants: cohort WO (procurement without clinical engagement); and cohort W (procurement with clinical engagement). Table 2 shows the comparison of procurement activity with and without clinical engagement.

The higher responses from cohort W (77%) than cohort WO (23%) could reflect current practice and a shift in the involvement of clinical stakeholders in the procurement process. Data associated with the reasons for undertaking or omitting clinical engagement show that in cohort WO, clinical engagement was omitted because it was not seen as a required for a project (67%). The primary reasons for clinical engagement (cohort W) was to understand product use, identify suitable options (75%) and define the product specification (72%). Responses from both cohorts suggest there is a sense of urgency in cohort WO to deliver an outcome quickly, intimating that clinical engagement would slow this down, whereas cohort W's responses reflect preparatory work undertaken to lay the foundations for procurement outcomes, to define the need for a project (to understand the rationale for conducting a project to obtain specific products) and ensuring the outcome is fit for purpose.

Successful outcomes and financial savings have been associated with clinical engagement (Jones, 2020), which is also reflected in this study. For cohort WO, successful outcomes were achieved in only 25% of cases and financial savings achieved in only 33%, whereas for cohort W, 78% achieved successful outcomes and there were financial savings in 82% of cases. This finding is pertinent as the main driver for procurement activity in cohort WO was the achievement of savings. This also correlates with the preparatory work undertaken in cohort W, which suggests that engagement starting in the preparation process can lead to successful outcomes and financial savings.

Table 3 provides an overview of the impact of product change and implementation with and without clinical engagement. One of the most significant differences found between the two cohorts relates to the longevity of product adoption. In cohort WO, 36% of new products were in use 12 months after implementation, whereas for cohort W, this was 57%. It can also be seen that in cohort WO, 64% reverted back to an old or previous product, whereas for cohort W this happened in only 13% of cases. The difference in longevity following implementation and reversion rate represents huge savings in time and effort as well as substantial value in the procurement process.

Considering the extent to which standardisation is achieved with and without clinical engagement, the data show that, overall, clinical engagement has a positive impact on product standardisation. Cohort W achieved 78% product standardisation compared with cohort WO, who achieved 58%. Factors influencing low levels of product standardisation at micro and meso levels are considered in the interview analysis.

Thematic analysis of interviews

Analysis of interview data revealed three key themes, which help to explain some of the trends observed in the survey:

• Process for clinical engagement
• Clinical stakeholders and CPPs as experts
• Perceptions of product standardisation.

Process for clinical engagement

It was evident that existing procurement processes for clinical engagement affect not only the success of the outcomes but also the level of value, savings and standardisation achieved. NHS trusts with robust clinical engagement processes resulted in savings and overall value through procurement.

Interviewees identified a number of factors that appeared key to clinical engagement, including using regular, cross-service clinical product reviews or evaluation groups to define specifications and product acceptance and/or dedicated procurement leads to focus on specific directorates:

‘We have a clinical product review group which meets on a bi-monthly basis… made up of individuals from various clinical services who would use the product… procurement officers who are aligned to different care groups… [The procurement officers] propose a specific project or workstream product that they would like to review, because they have identified it as a savings opportunity, perhaps.’

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In other trusts, there has been a focus on having a specific approach to selecting certain product types. Several examples were given:

‘Everyday healthcare consumables… clinically sensitive items… clinical preference items.’

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There were varying levels of engagement regarding the everyday healthcare items being procured via the procurement team and consultation with relevant stakeholders.

Trusts also used dedicated review groups to assess products and projects and, for the clinician preference items (where practitioners prefer a specific brand or model of product and alternatives are unavailable or rarely accepted), a dedicated group:

‘We would form specialist task and finish groups, where we would bring representation from the consultant body…, finance, the divisional management teams… [and] work through a process where we would develop key clinical criteria for the project to enable us to come to a decision.’

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These two examples relate to procurement activity from both a clinical and procurement perspective in the acute hospital setting, whereas the next quote refers to procurement in the community, where the engagement with procurement was seen as transactional, reflecting how procurement processes vary between settings.

Participants' experiences suggest that certain products were simple to obtain but, in other cases, engagement with the procurement buying team was ‘tricky’. Concerns were raised regarding price, and practitioners felt frustrated about knowing what patients needed and yet still having to going through a challenging process to procure products:

‘For day-to-day stuff, that was straightforward… they would just sort it out and send it to you… You might know what you want, but you would always have to go through the procurement team, the buying team… there would be objections and things coming back, going, “we can't afford that”. Well, I'm sorry but the patient needs that. So it's always a little tricky doing that.’

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Clinicians also perceived that procurement was part of an elite hierarchy, situated at a distance from clinical practice:

‘[It] sits in, er, its ivory tower.’

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There was also evidence of the procurement team and the clinical stakeholders vying for control of procurement decisions, which could put a strain on relationships:

‘The final decision is up to the clinical end users in [the] trust.’

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This perception of relinquishing control of decision-making was predominantly felt by procurement professionals in a ‘generalist’ role, deferring to a clinician to make the decision on product suitability:

‘If you're the generalist managing the entirety of the end-to-end process, you have to deal with it with a level of pragmatism and common sense. So, actually, when you need to make an assessment of the product – is it fit for purpose? Does it have the right attributes? – you are making those on a sensible and unbiased basis. However, when you're working with an expert, you need to defer to the expert who is then going to make that assessment on behalf of the team in delivery. And, actually, it's a really difficult thing to do when you've worked as a generalist making all of the decisions, suddenly having to say, “well… I've got to respect your view because you know better than I do.”’

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There was a clear sense that procurement personnel were responsible for the research around procuring products but that their role was only to recommend and the decision-making authority lay with the clinical teams using them. However, if their recommendations were not agreed by clinicians, procurement teams could escalate decision-making to a higher, managerial level:

‘We will draft a report and make a recommendation, but we're really clear that that's a recommendation… On the odd occasion, where we've made a recommendation and it's not accepted by the service, if there's no clear clinical rationale as to why that is, then we do escalate that within the appropriate clinical area.’

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Clinical teams working on behalf of national centralised procurement prioritised product opportunities based on their clinical experience and knowledge, acting as gatekeepers to sharing potential opportunities. The clinical teams' involvement highlighted the tension between procurement as a financially driven function to achieve savings as opposed to the provision of a clinical product that meets the end user's needs:

‘They are a barometer of “actually, that is a really good idea” or “it's simpler” or “it's effective”. They can cascade that out and, because they are clinicians, they can talk the clinical language. It definitely helps to open doors, more so than if they were just to talk numbers, because the people who instigate and influence these changes are not finance directors in the hospitals – they are the clinicians doing the work.’

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Clinical stakeholders and clinical procurement professionals as experts

The interviews highlighted the importance of engaging with clinical stakeholders in procurement for their expertise, as well as getting them to accept and sign off the procurement result.

There was a distinct difference in the perception and value of expertise between clinical and non-clinical participants who were part of the procurement function. For non-clinical procurement personnel, the value of engaging clinical stakeholders to achieve value, savings and standardisation was always seen as part of the process:

‘Without that clinical engagement, it wouldn't happen.’

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The negative financial impact of omitting clinical engagement in procurement can be seen in this example of surgical gloves:

‘The outcome was that the recommendation in our report was accepted to change the surgical gloves. However… the limited clinical engagement on that project had a huge impact on the savings achieved because they weren't in line with… the analysis that we produced. There was a lot of, erm, slippage in terms of scope creep coming back in with the old provider et cetera.’

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The correlation between the principle of procurement activity being driven by the need and the role of clinicians as experts was discussed in terms of the expert's complementary role to support procurement and, when this worked well, how congruent savings and efficiencies could be achieved:

‘Clinical expertise in how a product is used and clinical expertise in what differentiates one product from another means that the procurement individual is more informed as they co-ordinate that decision-making process to select the product that doesn't just make the NHS cheaper but also makes it more efficient and better.’

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From a CPP perspective, their role in the procurement team meant they were able to draw on both their clinical and procurement experiences of products to apply to decision-making. This hybrid role enabled both procurement and clinical teams to get on with their jobs:

‘I believe I don't need to engage all of my clinicians in every decision I make… I'm a clinician and I'm employed to make those decisions on behalf of the organisation so, arguably, my organisation has seen that clinical engagement in procurement is very important.’

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Using expertise beyond the procurement team was essential in achieving value. Involving clinical specialists and clinical leads was helpful, and engaging the practitioners who would be using the items was also central to achieving significant value in terms of finances and sustainability for some products:

‘The savings for them [procurement of remanufactured medical devices] are colossal but, for the trust, what's mainly important is the sustainability element of it… the work that they've done to gain clinical engagement is massive… if he'd not got the clinicians on side, it would never have happened. That's a really good example of where values have been brought and that's including clinical engagement.’

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When interviewees were asked what value – as in VBP – meant to them, there was a consensus that it was about not just making financial savings but also considering the long-term impact of products being purchased, and that the items were the right product in terms of specification and were suitable for the environment as well as clinical staff and patients. Terms such as patient safety, patient outcomes, clinical outcomes and experience featured heavily.

Although, a move towards VBP as opposed to a focus on price paid (Meehan et al, 2017) was not evident, clinicians working within procurement centrally reported a ‘theoretical’ shift towards value. The concept of value was seen as problematic, as it could have multiple meanings depending on product category, so interviewees said it should not be applied centrally as a one-size-fits-all macro solution. Instead, it was argued that value should be defined at project level, centred around need fulfilment:

‘Value can mean different things in different categories because value really is about and understanding how you fulfil the need… and has to be recognised and measured, based on what is important… So value to me is an all-encompassing definition between capacity, productivity, unitary cost, sustainability, the whole range of what's important, but it should be defined at a project level under a sourcing strategy, not just at a macro level in the organisation.’

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Perceptions of product standardisation

Participants were asked to define what standardisation meant to them. Definitions from non-clinical and clinical procurement professionals involved reducing the number of suppliers, using the same products in practice and not focusing on a specific brand:

‘[It's about] defining products and characteristics.’

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‘Standardisation means where we can use, erm, less suppliers and less products and achieve the same outcome. But it's really got to be driven by clinical outcomes and clinical safety.’

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Significant benefits in relation to clinical practice and patient safety were also associated with standardisation:

‘Standardisation on the ward would basically mean that… you would reduce time for selection [of products]… Training is absolutely easier… if there's only one variant within a ward setting for that particular procedure.’

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The benefits of clinician-to-clinician engagement in the process of standardisation was highlighted as positive because it allowed for a frank conversation regarding the realities of product use, to identify the rationale for its use and to develop a solution that was also financially acceptable. This was associated with an understanding of the value of clinicians in the standardisation process and through collaborative engagement and how this could lead to positive standardisation that promoted resilience rather than dictating product choice:

‘The person that is actually going to put their hands on this thing, to get their acceptance of the opportunity to simplify the supply chain and provide a more resilient, lower cost, better patient outcome solution. That's how you drive standardisation in a positive way into the system rather than a negative way just by providing an array of products and telling clinicians they've go to do it in one way. Which doesn't tend to work.’

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A secondary theme of standardisation that emerged was the complex relationship between the various people involved in procurement activity and their ability to reach agreement between multiple departments within a hospital and throughout a trust, notwithstanding national expectations. Cross-departmental, hospital-wide and trust-wide procurement was also heavily supported through clinical engagement, both to facilitate the process of standardising products and to manage the differing perspectives between departments and sites. When factors were aligned across service, departmental or site boundaries, standardisation could be achieved:

‘It's just, again, lots of different opinion and no one wanting to agree but, when you've got two main trusts who are completely aligned, then actually you can drive it through.’

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Timing of this research has proven to be significant in terms of standardisation. The majority of participants were aware of the drive to standardise following publication of the Carter review (DH, 2016) but this has now been superseded by the impact on the procurement landscape of Brexit, increased freight costs and the war in Ukraine, all of which affect supply. This has led to a procurement environment focusing on resilience and sustainability not just maximising value through standardisation:

‘Especially during the current climate. I guess if I go back a number of years… when we were procuring from a clinical perspective – looked at savings, looked at standardisation. However, that's most definitely evolved and developed over the past couple of years. Looking at the actual market itself, looking at whether standardisation and single sourcing is appropriate, or whether dual sourcing is more appropriate. Looking at resilience, availability in the market, looking at supporting the wider economy, so looking at where we can build more resilience within the UK.’

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Discussion

The aim of this empirical research study was to examine and understand whether clinical engagement in the procurement of healthcare products in the NHS was necessary to achieve value, savings and standardisation, addressing a gap in the literature.

Three factors that positively influence the achievement of value, savings and standardisation in the procurement of healthcare products were identified.

First, processes for clinical engagement are set out predominantly at a micro level. They incorporate the clinical voice in the procurement process and preparatory work to understand the need at the centre of the procurement activity, defining the product specification and preparing for different outcomes. Within this influencing factor, there is evidence of a power dynamic and gatekeeping function between those involved in the procurement process. These centred around the final decision to accept or reject recommended products, as well as potential workarounds.

Second, it was identified that clinical stakeholders and CPPs are experts at the centre of procurement activity, but there are some differences between the perspectives of clinical and non-clinical participants. CPPs used their clinical expertise as well as their product and procurement experience when making decisions, which enabled the procurement team and clinicians in the service to get on with their jobs. Clinical employees outside a procurement function also felt there was a sense of letting procurement get on with their jobs and having trust in that relationship. From a non-clinical procurement perspective, clinical stakeholders were seen as the expert central to the procurement activity, but that the role of expert could be from having the greatest expertise in the product, not just having a clinical background.

Third, valuing clinical engagement in standardisation that delivers positive outcomes was also an important influencing factor. However, standardisation has been significantly impacted by the current procurement landscape because of pressures on resilience following Brexit, increased freight costs and the war in Ukraine, which have affected supply.

Analysis of the survey responses showed that results were sometimes inconclusive regarding the impact of healthcare product procurement with and without clinical engagement. Most product groups appeared to be both successfully and unsuccessfully procured with clinical engagement, with only IV therapy consumables reported as being unsuccessful without clinical engagement. An additional interview question to elicit more information proved difficult to answer. However, one example of categorisation of a product as ‘non-clinical’ (and therefore clinical engagement was assumed as not necessary) negatively impacted patients and healthcare delivery, suggesting that categorisation of products should always consider product use to determine whether clinical engagement would be beneficial. It was also suggested that products that were already in use in the clinical area would not require additional engagement.

Clinical engagement has made a difference to levels of value, savings and standardisation achieved. It has realised higher levels of successful procurement and financial savings than procurement activities without clinical engagement. Also, investment in undertaking clinical engagement as part of the procurement process resulted in greater acceptance of product change, fewer clinical incidents or patient safety concerns, greater standardisation and longevity in product adoption. The difference in longevity following implementation and reversion rate (higher without clinical engagement) represents huge value savings in time and effort and substantial value in the procurement process. Clinical engagement was also seen as adding value in terms of financial and sustainability benefits.

Nonetheless, the shift towards VBP is still in its infancy and results suggest only a theoretical shift has been made, and that procurement strategies are still predominantly based on making savings on price paid. This is an area for further research as the landscape grows and develops.

Decision-making: power and influence in role

Tensions and power dynamics in procurement roles were evident in the procurement decision-making process. Procurement personnel were clear their role was to only recommend products and they recognised that they had to ‘defer’ to clinical ‘experts’ who ‘knew better’. However, there was evidence of an inherent tension around recognised expertise when it came to decision-making. This was particularly so for generalist procurement personnel, who were used to managing the whole procurement process and making decisions on their own. They found deferring to a specialist to make the decision ‘really difficult’, and defined the role of expert as having the ‘greatest expertise in the product’ not just a clinician.

Smeltzer and Goel (1995) considered the organisational influence of purchasing managers, suggesting that they too are experts, and it is this expertise that influences power. When this is considered in the context of this research and the dynamics in the relationship between clinicians and procurement personnel, it could be argued that both are experts in their own right and that ‘bounded rationality’ (Simon, 2000) is at play; procurement staff have their inherent objectives to make savings and efficiency, whereas clinicians focus on patient safety and outcomes. This tension is also discussed by Montgomery and Schneller (2007), who highlighted the dichotomy as the physician as an expert who has their own product preference, which is at odds with the organisational agenda for optimisation and savings.

Tensions between financial and clinical objectives in national centralised procurement clinical teams were evident in this study. CPPs, in the national role, acted as gatekeepers around procurement opportunities and decisions, and were able to draw on both their clinical and procurement experience to creatively manage the inherent tensions between financially motivated and clinically driven decision-making requirements.

In addition, Donohoe's (2019) findings highlight the way in which value is apportioned between stakeholders, specifically that value is placed on doctors' views but not on the opinions of nurses. One participant suggested that when a product directly relates to the practice of doctors, the decision is made by doctors based on their specialist area, skills and preference, whereas general products used by nurses were procured based on cost. Applying Ronchetto et al's (1989) findings to Donohoe's (2019) example, it can be seen that all doctors are central to the workflow in clinical services, and this would definitely provide positional influence in the right place to assert a product preference. However, frontline doctors do not all fulfil the other criteria asserted by Ronchetto et al (1989), which are closeness to organisational boundaries, ‘active in communication across departments’ and ‘linked directly to senior managers’, which would suggest other influencing factors are at play.

A model for clinical engagement

Now that the benefits of clinical engagement in the achievement of value, savings and standardisation are understood, a potential approach to clinician and stakeholder engagement to address uncertainty around the products for which clinical engagement should take place has been developed.

The power/interest matrix by Mendelow (1991) features heavily in the stakeholder management literature. The matrix aims to classify stakeholders into groups based on the power and interest they have in supporting or rejecting an organisational strategy (Johnson et al, 2008).

Although Mendelow's matrix offers a solution to stakeholder mapping, in isolation this does not address the problem faced by research participants in identifying when clinical engagement is required and which products this would relate to. Therefore, a hybrid model has been developed (Figure 3), which incorporates the key attributes of Mendelow's matrix with the addition of clinical/expert impact on the Y axis and clinical/expert preference on the X axis. Here, the terms clinical and expert can be used interchangeably to reflect non-clinical stakeholders who hold the expertise in a specific product area.

Considering procurement activity, the term clinical/expert impact is defined as the extent to which a product being procured is used within an organisation, ranging from a single ward or department to the whole trust or the wider integrated care system. The term clinical/expert preference is defined as the degree of preference associated with the type of products being procured, based on brand preference, product attributes or familiarity. The main consideration is that changing from a product deemed high preference could lead to clinicians/experts not accepting the outcome if clinical engagement is inadequate, as discussed above.

The use of this model has not been tested as part of this research, but the author recommends it should be examined in future studies. If its application proves effective, it can be a resource to make the most of finite resources both from clinical and procurement perspectives and also engage a wider body of experts in product areas as opposed to having a singular focus on clinicians as the expert.

Limitations

Although participants in the semi-structured interviews represented the target participant groups, corroboration of results was not seen in the clinical response group as it was in the procurement professional group. This was because those in the clinical group worked in four very different roles. Nevertheless, results are deemed valid as saturation was identified in the penultimate interview and the breadth of feedback was captured during the survey.

Overall, the size of the survey fell short of the expected response rate (100 participants), and there was not an equal spread across all groups. However, using the principles of purposive sampling helped mitigate this through the selection of participants who were representative of the research population.

Future research

As this is the first research of its kind, there are several considerations for practice and future research.

The uncertainty around when clinicians or experts should be engaged in procurement activity potentially has been addressed with a model for future practice; however, further research is required to understand and test the efficacy of this model as it was beyond the scope of this study. Research is also required to understand whether clinical engagement in the procurement of non-clinical consumables is warranted.

The results of the survey and interviews support the benefit of clinical engagement, especially through the means of specific forums for engagement at a trust level. This method of engagement should be included in practice going forward from a trust collaborative procurement perspective.

Differences were identified between experiences at a national centralised procurement level and activities being undertaken at trust level. Research is required in this area, especially to understand the impact of the new Target Operating Model (NHSSC, 2022) and developments in VBP, to ascertain the role of clinical engagement beyond the NHS trust, at a macro level.

Conclusion

The intention of this multi-method study was to address a gap in the literature, specifically to provide more contemporary research findings on clinical engagement in the procurement process. Three factors that influence the achievement of value savings and standardisation as a result of clinical engagement were identified: micro-level processes for clinical engagement; clinical stakeholders and CPPs as experts at the centre of procurement activity; and clinical value in standardisation.

There has been a shift away from a focus on product standardisation, which was emphasised in Carter's review (DH, 2016), to one of resilience as a result of current market supply difficulties.

Furthermore, this research offers two new contributions to knowledge in the field of clinical engagement in procurement. First, it brings new, empirically derived findings to address gaps in the evidence on clinical engagement in the procurement of healthcare products in the NHS. Second, it adapts Mendelow's (1991) power interest matrix to incorporate clinical/expert impact and preference, and offers a wide range of procurement experts a potential resource to maximise finite resources.

KEY POINTS

• As healthcare expenditure is increasing, pressure is mounting on procurement departments to make savings
• Clinical procurement professionals (CPPs) are pivotal to realising value in healthcare procurement through effective clinical engagement
• Clinical stakeholders and CPPs are seen as experts central to procurement activity to identify product needs for their services in the NHS
• A complex arrangement of people are involved in procurement, and tension and power dynamics are evident in the decision-making process
• There has been a noted shift in NHS public sector procurement focus from standardisation to resilience

CPD reflective questions

• If you work in a clinical procurement role, how do the findings of this study resonate with you and your organisation?
• If you are not employed directly within clinical procurement, who is the lead for clinical procurement in your organisation? What is your involvement in deciding which products would provide the best outcomes for your patients and which should be bought?
• How can you optimise your involvement in clinical procurement decisions to create value opportunities for your organisation?
• How can nurses share their impact on clinical involvement in procurement decisions to improve patient care?