An audit trail to PPE management (#DoingOurBit)

by Steve Brown

06 August 2020

In mid-March, with contracting on hold as part of the NHS response to Covid-19, Alice Forkgen, assistant director of contracting and transformation at North West Boroughs Healthcare NHS Foundation Trust, offered to help out with some stock takes for the six boroughs the trust operates across. However, it turned out to be a much bigger job than she’d anticipated, meaning four months away from her normal finance role.

‘When our silver command group asked for some finance support to do some stocktakes to support all our boroughs, I offered to help, with my auditing background making me an obvious choice,’ she says, adding that colleagues would describe her as task driven and meticulous. ‘But when I went to one of the boroughs I found out they didn’t actually have any stock or any system in place to manage it.’Doing our bit_Alice Forkgen portrait

This was a problem given the growing realisation across the NHS that it was going to need unprecedented levels of personal protective equipment (PPE) across all points of delivery. While the mental health and community services that the trust delivers are historically minor users of PPE, the Covid pandemic has altered infection control measures for all parts of the service.

‘PPE was nobody’s role at this point,’ says Ms Forkgen. ‘In the past, we used some aprons and gloves, but services and teams would just order what they needed on a day-to-day basis through the normal procurement route.’

This all changed with the creation of a PPE push system by NHS Supply Chain. Normal procurement channels were no longer working and, in any case, the trust needed PPE on a massively expanded scale.

It was a steep learning for someone unfamiliar with PPE and unable at that point to tell the difference between the different models of FFP3 (filtering facepiece) masks. But Ms Forkgen did know her way around a stock take and promptly created a stock management system. ‘We set up a central stock hub  so we could get all our deliveries from the push system in one place, from which we could then distribute PPE to all our boroughs, and we had a stock hub in each borough and two in the bigger boroughs,’ she says.

The trust had nobody trained in stock management, so Ms Forkgen set up the system using Excel spreadsheets to record stock received, where it had been issued to, and what was left. Initially – as has been widely reported – push deliveries varied from day to day. One day the trust might receive 3,000 gloves, the next day it might be 20,000 – supplies weren’t necessarily matched to specific needs and the trust itself wasn’t sure what volumes it required.

‘When we initially asked the assistant directors of operations in the boroughs what PPE they would need, they couldn’t come up with any figures because they just had no experience in this area,’ she says. ‘It was very much a guesstimate. However, after about three weeks, we were able to calculate daily usage levels from the stock management system that I had put in place.’

Working with the estates team, Ms Forkgen helped set-up a central stores and, while waiting for the initial push stock to come through, the trust sorted some PPE from local suppliers including gloves, face visors and alcohol hand-cleaning gel.

PPE stock was distributed from the central store by porters, who were already visiting boroughs to distribute mail and laundry. And each borough used one of the offices vacated by staff homeworking as a local store.

‘There was a lot of learning about the type of PPE that we used and that our staff needed,’ she says. ‘And we also had to understand when it was appropriate to use various types of PPE in different circumstances.

‘Understandably, staff were asking for PPE, but an FFP3 mask should only be used by staff undertaking an aerosol generating procedure. So, we had to work with the stock controllers in each borough to ensure they understood how to use FFP3 and who it should be issued to. And we worked closely with infection prevention and control and the communications team to make everyone aware of what to use and when.’

This process was supported by the trust’s clinical ethical reference group (CERG), which could clarify any grey areas. For example, according to national guidance, the trust’s swabbing team needed fluid resistant IIR masks, aprons and gloves. But they felt they needed more protection going into care homes to perform infection tests. CERG were asked to make a decision on this and the trust approved the use of FFP3 masks and gowns as it felt the risk was higher.

Trusts across the country were encouraged to support each other by balancing out excess stock items and shortages across systems. Across Cheshire and Mersey, the procurement group created Stockwatch to collect every trust’s daily stock balance and requirements. ‘We used this for mutual aid,’ says Ms Forkgen.

‘If a trust didn’t have enough FFP3 masks, you could see who did have some stock and, based on their burn rate, how many days’ worth they had. Quite often one of our neighbouring acute trusts would request stock from us. We’d all share push stock where it was needed.’

One difficult thing the trust encountered was dealing with safety alerts and stock recall. ‘We don’t have a materials management system like an acute trust would have,’ she says. ‘And if there was an alert about an item, it was very difficult to work out who had used it or who had got it.’ She says that is something the trust will be working on as it moves forward.

Her work has clearly been appreciated across the trust as she was nominated for the trust’s July Star of the Month award, recognising the important lead role she has taken in the distribution of PPE since the start of the pandemic.

Ms Forkgen’s more than four months in charge of PPE came to an end at the end of July, with the role moving across to the procurement team. However, she says PPE is here to stay – a new fact of life for the medium term for all providers including community and mental health.