Have you ever found yourself wondering where the equipment used by the NHS comes from? Maybe, maybe not. If you are in the latter category, then you may find that the answer makes for an uncomfortable truth.

Healthcare is a big business, and navigating through the NHS, its organisations, and supply chains is no easy feat. This industry spends nearly £40 billion per year on the procurement of goods and services, serving more than 63 million people. The supply chains that provide these commodities are global—employing millions of people worldwide, and elevating the NHS to the fifth largest employer in the world. This brings us back to our opening question—as, with such vast sums of money spent and human resources involved, we should question the circumstances under which such goods are produced in.

Evidence shows that many supplies used in the NHS are produced in unhealthy, unsafe, and unfair working conditions. In numerous manufacturing sites—from uniforms, to latex gloves, to disposable surgical instruments—international labour core conventions are persistently disregarded, and the use of child labour is widespread.

Take for example Sialkot, a major exporting hub in northern Pakistan; with around 300 factories preparing products for final export to suppliers in the Western world, this manufacturing site is thought to employ an estimated 50 000 manual labourers. The average labourer will work 12 hours, seven days a week, earning less than US$2 per day. With no secure income or adequate remuneration, labourers are in addition exposed to a wide variety of occupational hazards, including risks from poor electrical wiring and toxic and corrosive chemicals. The full scale of this scandal is difficult to ascertain given the lack of transparency, and so it remains concealed in the complexity of the supply chain landscape.

Upholding the raison d’être of the NHS, which is to improve health outcomes for people in the UK, against the evidence to suggest this is at the detriment of workers’ health in its supply chains creates a distressing paradox.

So what can we do to empower ourselves and break a norm? We are calling for ethical procurement.

This is about the overall sourcing practices of purchasing organisations (such as NHS providers) and the steps they take to ensure that employment conditions and workers’ rights—in the supply chains of the products and services they procure—are maintained in line with internationally recognised conventions and local laws (as a minimum). If buyers and suppliers were to adhere to core standards, production in these countries could be made “clean and ethical.” This includes working with supply companies throughout the supply chain to help their workers access fundamental rights, such as the right to safe and decent working conditions.

Ethical procurement for GPs and clinical commissioning groups

Following the implementation of the Health and Social Care Act 2012, on 1 April 2013, clinical commissioning groups (CCGs) are the pillar of the new health system. Suggested to be responsible for 60% of the total NHS budget (2013-14), CCGs can use their significant purchasing power to foster improvements in the working conditions and health of workers around the world. This can be achieved through contractual levers, and CCGs should consider explicitly specifying ethical standards when awarding contracts. This would make it a requirement of providers to demonstrate the steps that they have taken to address labour standards in their supply chains, and to show a process for the continual improvements of those standards.

BMA guidance, launching on 15 May 2014, provides clear recommendations on how to introduce ethical and sustainable criteria into commissioning and procuring policies. The success of “Ethical Procurement for GPs and CCGs” rests on health professionals insisting that their hospital treat the world fairly, and CCGs working with their providers to embed a culture of ethical sourcing. Let’s reverse the paradox, and clean up the medical instruments sector.

Arthy Santhakumar is a senior research officer in the International Division of the British Medical Association. Her current focus is global health and international development, and she leads on the BMA’s Medical Fair and Ethical Trade campaign.

Competing interests: The author has no competing interests to declare.

This blog is part of a series on ethical procurement in the NHS, with other blogs listed below.

• Tim Ballard: The wider consequences of healthcare delivery
• Tim Rudin: Ethical Sourcing—how organisations can learn from other public sector bodies
• David Maher and David Pencheon: Adding wider social value when commissioning

Read more at www.bma.org.uk/fairmedtrade