“Value Doesn’t Run April to April”

Dr Andrew Stradling on the NHS’s new value-based procurement pilots

Dr Andrew Stradling is the Chief Medical Officer for the NHS London Procurement Partnership, which is co-leading the NHS’s value-based procurement pilots across 13 trusts. The MTG sat down with Andrew to discuss the new pilots, advice for SMEs and innovators working with the new framework, and the cultural change needed to embed value based procurement across the system.

The current pilots are largely anchored in clinical metrics – infection rates, readmissions, hospitalisation. But patients often define a successful outcome differently, particularly when it comes to medical devices: returning to independence, maintaining employment. How confident are you that the current methodology can actually capture those outcomes in a procurement decision?

I think this will be an important development of the value-based healthcare agenda over the coming months and years, as all of us, clinicians, patients, regulators, academia, and procurement professionals, iteratively learn how to better measure ‘value’.

We have been used to measuring short-term outcomes and cost, rather than longer-term benefits and value, and the infrastructure, data, and analysis isn’t sufficiently familiar or embedded to enable measuring true value over the life of a product, a pathway, or a patient.

The honest answer is that the current methodology is not yet fully equipped to capture what patients themselves consider a successful outcome — and the gap between clinical metrics and patient-defined value is wider than we sometimes acknowledge. The pilots anchored in infection rates, readmissions, and hospitalisation are measuring things that are genuinely important, but they are also measuring things that are relatively easy to count. The harder question is whether we are measuring the right things.

A useful way to illustrate the problem is the example of the Martini-Klinik in Germany — which specialises in radical prostatectomy for prostate cancer. Its five-year survival rate is broadly comparable to the German national average; the margin of difference is small. If you evaluate it purely on that metric, the additional cost of the Martini-Klinik is difficult to justify. But when you look at other parameters — rates of erectile dysfunction and incontinence following surgery — the difference between the Martini-Klinik and the national average suddenly, the value calculation looks very different.

This matters because it reveals something fundamental about how patients themselves prioritise outcomes. When someone is first diagnosed with cancer, survival is the only thing that matters. But the moment they are told they are cancer-free, their attention shifts immediately to quality of life: the side effects they were not fully prepared for, the functions they have lost, the independence they are trying to recover.

We are not yet building procurement frameworks that are sensitive to that shift. PROMs and PREMs are an important step in the right direction, but their value depends entirely on which parameters we choose to measure — and who decides what those parameters are.

That is where patient demographics become critically important too, and where a one-size-fits-all approach breaks down. A 55-year-old man undergoing a prostate procedure has a very different set of priorities from a 90-year-old man facing the same intervention. If our outcome measures and procurement KPIs fail to account for that heterogeneity, we risk either narrowing our parameters so tightly that they lose relevance, or broadening them so widely that the data becomes meaningless.

The same logic applies across conditions. A patient with a hip replacement, typically a one-off procedure, has a very different relationship to outcome measurement than someone living with a long-term condition like diabetes, who becomes, over time, an expert in their own care. The person managing a chronic condition can tell you in fine-grained detail what works for them and what does not. The person who has just had a joint replacement has, by definition, no prior experience of the procedure against which to benchmark their outcome. Asking both groups the same questions and expecting equally useful answers is not a sound methodology.

I think the direction of travel is clear: we will need to move towards procurement frameworks that are built around specific conditions and patient pathways, rather than applying a universal set of metrics across the board. Each condition brings its own evidence base, its own patient population with its own priorities, and its own definition of a successful outcome. Of course that’s a more complex system to design and administer, but it is the only way to ensure that what we are measuring bears a genuine relationship to what patients actually value.

One potential downside for the shift towards value-based procurement is that SMEs and newer entrants may not have the track record or data to meet the evidence base over larger suppliers. What advice would you offer to those who have this concern?

This is a genuine concern, and one that we have to take seriously if the shift towards value-based procurement is not to inadvertently consolidate the market in favour of large, established suppliers. Innovation, which the NHS desperately needs, is disproportionately driven by SMEs and newer entrants, and those businesses often cannot afford the longitudinal data collection that a mature evidence base requires.

My first piece of advice is pragmatic: any company coming into the UK healthcare market right now needs to be able to articulate its impact clearly in terms of either cost saving or productivity improvement. Those are the two levers that finance directors are pulling hardest on. The NHS is employing more clinical staff than ever, yet gross productivity appears to be declining, and nobody has a straightforward explanation for why. In that environment, there is simply no room for a value proposition that cannot connect, at least in part, to near-term financial or operational gains. That doesn’t mean abandoning a longer-term story — but SMEs need to lead with what saves money or frees up capacity now, and layer the broader value narrative on top.

Secondly, I would encourage SMEs to work collaboratively with clinicians from as early a stage as possible. Clinicians understand patient pathways in granular detail, and they can help a supplier identify exactly where in a pathway their product creates value — not just for the episode of care, but across the wider system. That kind of partnership not only strengthens the evidence base; it also creates clinical champions who can advocate for the product internally and help navigate procurement processes that can otherwise feel opaque.

From a structural standpoint, the Innovator Passport, which aims to prevent suppliers from having to repeat evidence submissions or validation exercises across different trusts, is a genuinely important development and SMEs should be aware of it and use it. The fragmentation of the NHS means that without something like this, a small company can spend its entire commercial budget proving the same thing to twenty different procurement teams. The Innovator Passport should, in theory, allow a validated piece of evidence to travel with the product. The reality is not yet perfect, but the direction of travel is right.

Finally, I think SMEs need to be realistic about timing. The short-term pressure in the NHS is so acute that a product whose value is only realised over three to five years will struggle to get traction right now, regardless of how good the evidence is. The honest advice is to identify the fastest possible demonstration of value within your product’s story, be that a reduction in nursing time, a shorter hospital stay, or a lower readmission rate. Build your initial commercial conversations around that, while simultaneously developing the longer-term data platform that will justify a broader adoption once the funding environment improves.

As part of our Commission on NHS Culture, the MTG is about to launch a report looking at how the system understands value, particularly in relation to medical technology. Could you talk us through what that cultural shift towards value-based procurement looks like in practice, the mechanisms for achieving it, and what you see as the single biggest structural barrier?

When people talk about cultural change in procurement, the conversation often lands on the relationship between clinicians and procurement professionals. Clinicians need to understand what constitutes demonstrable value from a procurement perspective, and procurement professionals need to understand what clinicians actually need for their patients. At the moment, that dialogue is not as fluent as it should be.

But if I am honest, the cultural gap that most needs addressing is between clinicians and finance. Procurement professionals largely do the execution: the heavy lifting and legwork once a decision has been made. The decision itself, about what is best for patient outcomes and what is financially viable for the organisation, typically happens between clinicians and finance directors. And that is a conversation that is often conducted under enormous pressure, within very tight time horizons, with both parties looking at a very different set of incentives.

Clinicians are trained to think about the patient in front of them, and by instinct they advocate for the best available treatment regardless of cost. Finance directors are accountable for keeping the organisation solvent, which in the current environment means prioritising in-year savings. Neither of those positions is wrong — they are both rational responses to the pressures each group faces. The problem is that the structures we work within force a false choice between them. That is what needs to change.

In terms of mechanisms, I think the change has to be locally led. It cannot be mandated from the centre and expected to take root. What it requires is finance directors being given genuine freedom to make multi-year investment decisions — to have conversations with their clinical colleagues about what a three or five year horizon looks like, rather than what the position will be on the 31st of March. If those conversations can happen in a less constrained environment, the relationship between clinical and financial leadership becomes far more productive. Clinicians start to understand the fiscal reality; finance directors start to engage with the clinical logic of longer-term investment. That is the cultural shift we need.

As for the single biggest structural barrier: it is the annual budget cycle. Almost everything else flows from that. The NHS does not run on an April-to-April basis — patients do not, pathways do not, and the value of most investments certainly does not. But our financial architecture forces every organisation to think in those terms. It creates perverse incentives: a trust that invests in a more expensive intervention today, knowing that the saving will be felt in a neighbouring trust or in a community setting three years from now, has no financial mechanism to recoup that investment. So they do not make it.

The logic of value-based procurement is fundamentally incompatible with annual budget silos — and until we address that structural tension more seriously, the cultural change we want will remain partial at best.

Image Credit: Dr Andrew Stradling headshot via www.lpp.nhs.uk

April 2026