Tim Minshall, Dr John C Taylor Professor of Innovation & Head of the University of Cambridge Institute for Manufacturing, discusses the challenges of matching the offers of support from the manufacturing community to respond to the COVID-19 crisis with the dynamic and uncertain needs of the healthcare system.
Connecting healthcare and manufacturing: The challenges of COVID-19
Two examples of activities of the UK manufacturing community’s response between mid-March to mid-April 2020 in supporting the NHS with its response to COVID-19 are revealing.
The start: Deluge of offers of support
In early- to mid-March, as the scale of the likely impact of COVID-19 became clearer, there was an almost overwhelming wave of offers of support from the manufacturing community to address the needs of the UK healthcare system.
Aside from existing healthcare firms, offers of support came in from firms of all sizes across all sectors, offering to repurpose their manufacturing operations to address COVID-19 related needs, there were also multiple offers of support from local makespaces, schools and university departments offering access to their equipment to make whatever was needed, as well as individuals with technical experience asking what they could do to help.
In addition, numerous ideas were proposed and circulated for new or modified products that could address specific COVID-related issues.
Capturing data on what support was being offered
While the scale, range and enthusiasm of support on offer was extremely reassuring for the government, it wasn’t immediately clear how this support could best be utilised.
To ensure that offers of help from the manufacturing community were connected to the rapidly changing needs of the NHS, at a national level, UK government websites were used to capture information from businesses who might be able to assist with COVID-related challenges. These ranged from sites set up to capture the broadest range of offers of support through to sites capturing data on offers of support that addressed clear and immediate NHS Supply Chain requirements, as well as websites focused on specific challenge areas, such as those set up to mobilise efforts relating to ventilators (which, the minister for business and industry reported, attracted interest from over 3,000 companies).
In parallel, numerous unofficial, volunteer-run websites were set up for those who wanted offer specific capabilities, such as access to 3D printing that could address various COVID-related needs. For those who were proposing new or adapted product ideas, many were posted on social media to highlight their potential utility; or shared on one of the numerous semi-public project groups (using platforms such as Slack) that sprung up online; or emailed to anyone who was perceived as ‘someone who might be able to help take this forward’ within various government agencies or universities.
Useful data thus sat in many – often unconnected or overlapping – databases, networks, or rested with key individuals. For those who submitted data to various government databases, it wasn’t clear how this data was being used nor whether it was going to be given serious consideration.
The problem become one of matching the actual or potential – and rapidly changing – needs of the healthcare system with the most appropriate sources of support drawn from a fast growing and largely unstructured pool of data.
Matching offers of support to NHS needs
The matching of the offers of manufacturing capabilities and new product ideas to NHS needs in the midst of a rapidly evolving crisis was a complicated process as:
- At a national level, there were huge margins of error on the predictions of the scale and timing of the surge in hospital admissions resulting from COVID-19, hence substantial differences in the estimates of what products would be needed, where and when.
- At the regional level, the differences in the potential scale of impact of the surge across different parts of the UK meant that the individual hospitals had not only to develop plans in the face of high levels of local uncertainty but also to add often substantial contingencies in case other regions were overloaded and needed to transfer patients between healthcare trusts.
- The UK healthcare system is complex and multi-layered with over 200 trusts, dealing with specific aspects of hospital and primary care (e.g. GPs, community pharmacy, dental, and optometry services, et al.) plus the extended networks of healthcare providers such as care homes. As the such, attempting to comprehensively map the needs and sources of supply for equipment required for patient pathways through the whole COVID-19 cycle (from admission through to return to the community) was extremely difficult.
- To support this complex network, the NHS has a centralised model for the distribution of supplies. While this system is normally well-stocked, and reserves are kept to deal with major crises, the speed, scale and impact of spread of COVID-19 meant that the actual or anticipated demand for supplies of certain products could not always be met. The scale and complexity of the system resulted in multi-layered lines of communication between front-line clinicians and suppliers, which sometimes hindered rapid responses to fast changing conditions on the ground.
Given these issues, the balancing of supply and demand of equipment throughout the UK healthcare system as the COVID-19 pandemic has unfolded has been particularly diffcult. In the following section, two examples are described of how the capabilities offered by the wider manufacturing community have been used to address emerging gaps in supply in the midst of this crisis.
Evolving gaps: From ventilators to PPE
Early on, there were well-publicised concerns at the anticipated shortfall in the supply of ventilators required in response to COVID-19. With around 8,000 being available but an anticipated need for 30,000, multiple parallel approaches to address this were deployed:
- Buy more from existing ventilator manufacturers, whether in the UK or overseas. Given the pandemic nature of COVID-19, global demand for ventilators has increased substantially and, as such, the UK has to compete with many other nations also seeking to build up their supplies of ventilators. Increasing the output of existing UK ventilator manufacturers is also difficult as the supply of key components from global suppliers is now also constrained due to the rapid growth in demand.
- Get more manufacturers to make ventilators. This could either be done by modifying existing designs or creating new designs to be accelerated through the approvals process and manufactured at scale in the UK. The UK government set the specification for minimal functionality required for such ventilators, and multiple partnerships and consortia were formed to deliver prototypes that met these requirements. From the responses submitted and filtered, the government then commissioned orders, subject to successful fast-track approval being granted, which was very likely given that the preferred options are either based upon existing designs or are based on clinically proven components. In doing so, the typical multi-year development cycle was reduced to 5-6 weeks.
- Reduce need for ventilators in ICUs: Increasing the supply of equipment that supported patients’ breathing without the intubation required for full invasive ventilation in Intensive Care Units (ICUs) could reduce the number of ventilators required. Continuous Positive Airway Pressure (CPAP) machines are one example of such equipment. One high profile project that sought to address this need was the collaboration between UCL and Mercedes/McLaren F1 to develop a rapidly manufacturable CPAP device, the design details of which were made available for any manufacturer to download.
- Prepare for ‘worst-worst case’: Some projects also sought to develop technologies that could be utilised in extreme cases, e.g. splitters to allow single ventilators to be used by more than one patient, or enhancing the performance of simple ‘bag valve mask’ or ‘ambu-bag’ devices by automating the bag squeezing. Some drew upon the significant number of open source designs for ventilator technologies, while others sought to develop new or partially new solutions. Some open source designs had already been proven in use in specific contexts but the use of these in the UK healthcare system would still require testing and approval (albeit fast-tracked, with certain exemptions permitted). Some projects chose instead to focus on developing and deploying solutions overseas in regions ‘that have traditionally been unable to get high-end medical equipment’; one such example is the Open Ventilator System Initiative.
Whether these approaches in combination will ensure that the UK healthcare system does have access to sufficient ventilators to meet demand has yet to be seen as we head towards the peak of the spread of COVID-19 in the UK, but the speed, creativity and levels of collaboration shown by the UK manufacturing community has been extremely impressive.
In early April, reported shortfall in the supplies of Personal Protective Equipment (PPE) available to frontline staff began to receive substantial media attention. Many of the problems arose from the rapid scaling the NHS’s centrally managed PPE supply chain designed for the ‘normal’, more predictable and stable operations of the healthcare system, coupled with extension of requirements for PPE across the primary and secondary healthcare contexts.
Though the UK government revised its planning and operations for the delivery of PPE on 10 April, during the period when the needs of some primary and secondary providers were clearly not being addressed in certain locations, the manufacturing community responded very rapidly, and in a ‘bottom-up’ manner.
Two modes of operation were noted: the re-purposing of production capabilities within manufacturing firms, and the emergence of what some labelled as ‘citizen supply chains’.
An illustration of this can be seen in the need for face shields. When stories emerged of a shortage of face shields in some hospitals, coupled with the Public Health England requirements for such equipment to be used in many primary care contexts, the response from the wider manufacturing community was rapid. The availability of open source designs, coupled with the publication of detailed production notes, enabled manufacturing firms, makespaces, otherwise unused university and school workshops and even individuals to start making face shields.
Many were not responding to specific calls, but rather started making the shields and delivering them to whoever asked, or in anticipation of possible needs within, for example, GPs surgeries and care homes. The design and production process requirements of face shields make them particularly well-suited to this distributed model of manufacturing.
Whether such approaches could also be used for making a broader range of PPE at scale is now being tested, with multiple examples of firms attempting to do this. To support firms in different sectors convert their high volume manufacturing operations to the production of a broad range of PPE, the UK government has recently published detailed guidance notes. However, the situation reported in many hospitals in recent days show that there are still issues with PPE supplies.
The experience so far
These examples show how two large, geographically dispersed, complicated systems (healthcare and manufacturing) were attempting to find mutual points of connection to respond to rapidly changing and uncertain needs. One system is largely hierarchical (the NHS), the other self-organising (the broadly defined ‘manufacturing community’) but both are operating in a highly dynamic context. As such, effective collaborations between organisations within each system are always going to be difficult to manage. It has therefore been particularly impressive to see the multiple collaborations that have enabled both immediate and longer-term support to the delivered to the UK healthcare system by the manufacturing community to help address some of the numerous challenges of COVID-19.
These two examples also illustrate a broader issue of how the use of local manufacturing capabilities can act as a balancing mechanism to address short-term needs to give time to the national NHS supply chain to adjust at scale to changes in demand. We could be seeing the emergence of a ‘new normal’: What might now feel like an ‘all hands to the pumps’, short-term crisis response mode could be the basis of a more flexible, resilient, distributed UK manufacturing infrastructure.
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