Dressing procurement across the UK is traditionally managed via the prescribing route with additional purchases from NHS Supply Chain within community health services. Patients with wounds are managed across a number of community, primary care and acute services. It is estimated that wound care costs the health service upwards of £5.3Billion, similar to obesity. The facts are unknown but what we do know is that:
Unfortunately the system is fragmented; the real cost to this community system are little understand, data is not collected thus commissioners, providers and Medicine Management teams often do not know where to start to create a system change. There was the opportunity that all services owned the issues and needed to provide a joint solution.
In 2008 Tower Hamlets PCT recognised that we had a number of problems within dressing procurement that could be managed through a centralised budget. The proposal to the Practice Based Commissioning Executive focussed on delivering solutions for the following:
The solution was the development of a bespoke Dressing Optimisation Scheme (DOS) that top sliced 90% of the 2008 dressing spend into the Tissue Viability service who were charged with managing the budget.
The DOS provides an opportunity for the scheme to be the fulcrum of an integrated wound and lymphoedema system of care across a borough, interlinking the understanding and management of patient need and their outcomes. Dressing procurement is directly linked to clinical decision making; thus the impact is that this defined project of a change in procurement has increased its reach into:
The Dressing Optimisation scheme has adapted to the changing population and community workforce needs over the last 10 years.
The key features and strengths over and above other online ordering systems are the controls and analysis provided:
These controls elevate this scheme away from a procurement and adherence task to the development of an integrated system that works with the wound pathway across all services and sites. Patients should only get their dressings by being given them by the nurse caring for them. This does not stop supportive self-management; patients are reviewed monthly and simply given what they require. What this scheme has done is ensure that all patients with wounds are actually known to the system, that they are not within an unmanaged repeat prescription system and that by ensuring all sites utilise the scheme, patient need is understood; their need is directly hooked into the specialist service. Thus at the start of the scheme, we 'found' patients who were self-managing with leg ulcers, Hydradenitis Supprativa and perianal abscesses: after initial concern about the change in system, these patients lives and outcomes improved significantly. This is of particular relevance for the integration of wound and lymphoedema services within the community, primary care and acute system.
Patients remain the primary beneficiary; in meeting their immediate dressing needs they are at the centre of a more holistic approach to system care and a focus on personal quality improvement. Significant issues with either the dressing provision or non-healing is picked identified by the specialist team. Patients also do not pay for prescriptions.
Medicines Management do not have the repetitive task of managing non-adherence to formulary in an area that is not their speciality. They have a flexible system that supports their work with practices and queries that arise.
Commissioners because the release of funds from dressing budgets provide the funding and impetus for transformation thus creating a cost neutral position at the initial stages and negating any requirement for double running.
Community nurses because they are able to access dressings and bandages on site and provide what is required to patients when they need it. Clinical autonomy and decision making within a complex environment is supported with a pragmatism that a strict formulary system cannot provide. Within an urban environment, a greater percentage of nurses do not use their car; this has required the development of a home prescription system for bulkier items.
Primary Care Providers because engagement presents an opportunity to contribute to the reengineering of the primary care contract and incorporating an aspect for practice nurses which real and rewarding in terms of achievement and patient involvement and response
The local health economy benefits from the successful management of the scheme. The success is measured not only from the perspective of savings to the system but also in recognising that the cost of a dressing per head of population. In Tower Hamlets this is estimated to be around £1.52 against a national average of c£3.30.
In addition this approach provides rich information in terms of data which can be analysed to inform change and development. This scheme is now active in City and Hackney via management from Accelerate. Building on this has been the linking of this to education and care planning/management.
Recently added has been a hosiery scheme and a focus on the impact of lower limb management with a drive to early intervention at an initial stage in primary care to actually halt the development of the wound or swelling at that point. This has the potential to create significant cost savings in the longer term once the process has become established. In order to help with self-management Accelerate has also embraced principles of Patient Activation to ensure clarity around patient capability to self manage and at what level.
The original problems that were identified in 2008 were met swiftly by the development of this scheme and we have secured significant cost benefits.
Accelerate now commissioned to manage the scheme for City and Hackney CCG. The DOS delivers:
The controls introduced to manage the Dressing Optimisation Scheme and the understanding that this brings to system delivery reaches into other areas that require transformation such as patient and hosiery management. Effective budget management can release funds to enable investment in improving quality of services and delivery.
This scheme tackles the need to release monies into the system to facilitate transformation of a service; the drive towards reduction of harm for patients living with long term lower limb conditions of wounds, swelling or both; by being aware of issues in primary care, this supports the move towards early intervention and the need to ensure that patients are engaged in understanding their condition and the related state of wellness that can be achieved whilst living with a long term condition. The project recognises the significant role of primary care in grasping the opportunity to engage in ensuring delivery of prevention and early intervention is achievable and thus embraces integration of primary and community delivery as a critical element for success.
Whilst clearly successful the Dressing Optimisation Scheme is not without its challenges; this centres on workforce churn and inadequate capacity within community nursing. This reduces understanding, ownership and the ability to plan ahead providing a risk that both nurses and patients will not have the products they require at the right time. Having a scheme that is directly integrated with the specialist nurses prevents this from being a purely administrative task and it is thus that delivery is underpinned by the values of mutual respect and kindness, finding swift solutions to real problems.
In order to attempt to benchmark the Tower Hamlets service and dressing spend, comparisons have been made with National or STP data. This data remains fragmented because NHS Supply Chain data is not in the public domain. But crude analysis can still tell a story. The key story from Tower Hamlets is:
The National story: The dressing analysis can tell a great deal about the quality of the interventions. This can be powerful when benchmarking against national or STP data. This comparison demonstrates that whilst compression therapy usage is 10th in National categories and creates an acceptance of sub-optimal therapy, for Tower Hamlets compression usage is 2nd ; this reveals a quality intervention that increases healing rates and reduces the use of other products such as absorbent pads.
This scheme has provided national critique of the growing use of sub-optimal compression therapy and its impact on non-healing wounds, patient quality of life and waste of workforce and consumable resources in the system.
There remains a lack of emphasis by CCGs or Providers on understanding their dressing usage within a context of quality improvement. This scheme demonstrates how this can be done alongside delivery of real cost benefits by promoting new models of integrated care.
