How wound care can be a priority for the NHS

The NHS has many Cinderella services, but wound care must be the one that has some of the greatest impacts on patients’ quality of life. It costs the NHS so much to care for, both in and out of hospital.

The cost of wounds to the public purse has been calculated at more than £8bn a year, forming a major component of community nurses’ workload. But there is also a human cost – more than two in five wound care patients have had their wound for more than three months and one in six have been admitted to hospital due to it.

Those sorts of figures would suggest wound care ought to be top of the agenda for NHS organisations with a concerted attempt to quantify and address the challenge. But that does not always seem to be the case.

An HSJ roundtable, in association with Smith+Nephew, looked at how wound care can be made a priority for the NHS and what can be done to improve services.

Full screen in popup

• Previous
• Next

Denise Everett, assistant director, integrated nursing and conditions services Hull and East Riding, City Health Care Partnership

Joanne Greengrass, essential standards of care quality improvement lead, Frimley Health and Care ICS

Alison Hopkins, chief executive, Accelerate

Jacqui Hughes, senior health outcomes manager, Smith+Nephew

Joanna Swan, senior lecturer in tissue viability at Birmingham City University and tissue viability nurse

Simon Wootton, managing director, Irwell Valley Consulting and former national wound care strategy lead

Alison Moore, HSJ – chair

1/7

show caption

Wound care patients are marginalised with little recognition from NHS boards that they are suffering avoidable harm and that there are patient safety risks around poor care. Their care takes up a great deal of community nursing time but does not always meet best practice standards, leaving many patients with chronic wounds which persist for years.

That is the bleak picture put forward by Alison Hopkins, chief executive of Accelerate, a social enterprise which specialises in chronic wound and lymphoedema care.

“Wound care is not a priority because it has not been a priority,” she said. “There is not actually the acknowledgement of harm for these patients – no one actually believes this is a patient safety issue and that it is unnecessary or avoidable harm. Unless the board believes that, they are not looking for the data, they are not analysing the data they could have.”

But even when harms occur, they are often not reported through Datix or other systems. And, rather than being seen as an issue for multiple board members, wound care tends to be viewed as a nursing issue with assumptions made that it is being managed, she added.

Simon Wootton, who worked for the national wound care strategy team for five years and is now an independent consultant, said the data was not there to back up the problem that health professionals knew existed – and there was no incentive to develop it, although bits were collected in different datasets.

“Fifty to 80 per cent of community nursing time is spent on wound care,” he said but some of that time could be released if wound care was improved. During his time with the national team, he attempted to push the issue further up the agenda, through various committee meetings at NHS England. Although it was in the planning guidance, he suggested NHSE’s community and nursing teams “did not know what to do with it”. And NHSE was now likely to see it as an integrated care board responsibility, he said, adding there was no national lead for wound care as there was for other conditions.

And Ms Hopkins questioned whether the time nurses spend on wound care was always productive. If they were not using evidence-based care but were instead doing daily dressings, then this was time-consuming but might not deliver the improvement the patient would want. Many patients had no idea what level of healing to expect within what time when they developed a wound, she said.

But some areas are tackling this. Frimley Integrated Care System is a pilot area where progress is being made on putting wound care further up the agenda, said Joanne Greengrass, essential standards of care quality improvement lead, Frimley Health and Care ICS.

“I have been able to get wound care into the ICS strategy,” she said. “That begins to up the agenda of wound care.” However, there have been challenges in showing the impact of changes in the available data. Consistency of coding was an issue which also made it hard to track a patient’s journey and show the impact of what has happened.

Denise Everett, assistant director, integrated nursing and conditions services Hull and East Riding, City Health Care Partnership, had seen a mixed picture in her areas. The team had managed to improve some services and address some procurement issues but there were still differences in how some of the consumables were supplied and paid for.

However, it had been hard to get agreement to continue some elements of the service when the two areas moved to being commissioned jointly and they had lost funding for some services or were unable to start others, such as a “well leg” clinic. “We are probably going to have to go back an enormous number of steps,” she said. “We have just been told to deliver more for less. Our key issue is the funding.”

And she warned the situation could return to the most expensive person in the health service – the GP – having to write prescriptions for wound care products.

Jacqui Hughes, senior health outcomes manager, at Smith+Nephew, said: “It’s really difficult to get this cohort of patients on the agenda.”

She was in no doubt wound care would be a growing issue for the NHS as the population aged and became more prone to non-healing wounds. The data Smith+Nephew had collected covered approximately 15,000 patients and showed 88 per cent had one or more co-morbidities, she said. And Ms Hopkins also pointed to the impact of obesity which would drive more cases.

“We do a lot of service redesign with organisations but it’s making it last – you can show all the health economic benefits, the health outcomes benefits, the patient benefits but sometimes that does not go anywhere further,” she said. Adoption at scale across systems remained a challenge, she added.

Senior lecturer in tissue viability Joanna Swan pointed out good treatment benefits for patients – such as a reduction in ongoing care – generally accrued to community providers. This could mean acute trusts treating these patients for a short time might not see any benefit from investing in improved wound care during their stay.

So, what could drive change? One aspect would be the workforce. Wound care eats up significant amounts of NHS staff time, especially among community nurses. In principle, better wound care – where wounds healed more quickly and did not reoccur – would deliver big benefits to community trusts in time released for other tasks.

But there was sometimes a misconception that compression care, which could help many suffering from chronic wounds, took more time for nurses to administer – especially around assessment – whereas actually, it could be time releasing, said Ms Hopkins.

Another issue is having the staff trained to provide good evidence-based care for those with wounds. Here, acute trusts can pose a particular issue – in part because of the focus on pressure ulcers, often the only wounds mentioned in board papers.

Ms Swan said the expertise of specialist tissue viability nurses in acute trusts was taken up by pressure ulcers – often very low-grade ones which ward staff should be able to care for.

On the other hand, many nurses would struggle with the more complex cases including leg ulcers and lymphoedema and more training was needed – but boards often assumed they were able to provide evidence-based care. She called for more focus on wound care in the undergraduate nursing curricula so that all nurses were equipped to provide some care for those with wounds.

However, there is also a question of whether nurses are delivering evidence-based care and whether patients were persuaded of its benefits – as well as whether ICBs were prepared for the upfront costs (but longer-term benefits) of improved care. Ms Everett said spending on compression bandages increased in her area after staff were given more training in better wound care.

She advocated working with both staff and patients to move them towards evidence-based care and overcome any reservations patients had, such as around compression treatment.

Getting consistency across an ICB area can also be challenging, but there can be different ways of arriving at the same end of improved care rather than a “one size fits all” approach. Ms Greengrass said her area had two models of care delivery with practices providing lower limb care in the south of her patch and wanting to continue doing so. A locally commissioned service had been introduced to incentivise the delivery of best practices there and she planned to work with the primary care networks to aid further improvement such as practices working together.

“We are looking at being cost-effective and how we can do things better together,” she said. “We have to work together to make things better for patients.” But transformational leadership was needed within the system – a point taken up by Ms Hopkins, who stressed the importance of commissioning organisations leading on this to help join the dots. 

“What is the thing that we need at the ICB level to drive this forward? Is it passionate people? Is it key opinion leaders in commissioning? Is it sets of data?” she asked.

The panellists thought data had a role to play in driving improvements – but it had to be the right data. “We have data on people with diabetes with foot ulcers… how do we get something similar on people with leg ulcers? Then we start having the information we need to drive things forward and I think that is very important… it will then drive this up the agenda,” said Ms Greengrass.

And when the data started to show things like fewer amputations, then people would start to listen, she said.

Ms Hopkins suggested healing rate targets could be useful in areas like venous leg wounds where it was known compression improved healing. “It’s very complicated to get it – because the recurrence rate is really high – but there must be something we can do.”

A recent evaluation from sites implementing lower leg care changes indicates investment is worthwhile with pilot sites showing massive returns on investment – a 27.6 benefit-cost ratio – lower recurrence rates and good overall healing rates, said Mr Wootton.

Lower leg ulcer healing rates could be an area where a target could work – expecting 80 per cent of them to heal within six months, for example. However, some aspects of care would be hard to meaningfully quantify – whether compression therapy was used, for example, could be counted but might not capture the compression’s quality.

Ms Hopkins pointed to how stroke services had been transformed because people had looked at data and seen the differences between trusts.

But national figures needed to resonate locally, she added: “I hope it makes people go ‘do we know our numbers.’ But people want to know where to focus… they need a couple of big numbers.”

Disseminating good practice remains an issue. While there are great examples across the country, there are many disparities and good care does not always get replicated. Ms Hughes said: “You can have one example of good practice but it is then difficult to scale.”

Systems should also aim for continuous improvement, she added: “People need to see the [benefit] of continuous improvement [and understand that it has to be embedded through adoption] at every level of the organisation.

“This has to be the way forward for wound care. It’s almost like a cultural change needs to happen within a system not just someone at the top saying [so]… and not just a one-off event.”

And, finally, there are opportunities for prevention or for very early treatment to heal wounds which could become non-healing. Ms Hopkins suggested change could start at the primary care level with intervention in small traumas which could lead to leg ulcers – even with pharmacists providing appropriate hosiery in the early stages, and GPs and PCNs “owning” their patients before they got worse.