Since 2009, one East London borough has turned its wound care services around, developing a new off-prescription route for dressings. This has cut costs, minimised wastage and improved patient care. Alison Hopkins, CEO of Accelerate CIC based in Tower Hamlets, discusses how the plan was implemented and explains how similar schemes might work elsewhere.
In 2009, one inner-London wound management service had challenges on its hands. The clinic, then called the East London Wound Healing Centre, dealt with chronic wounds such as leg ulceration, alongside unmanaged swelling like lymphoedema – long-term conditions that required significant levels of care.
In theory, a nurse or GP would prescribe the dressings necessary, and the patients would be able to manage their conditions adequately from there. In practice, however, the process was often beset with delays.
“There was a delay in getting the dressings through the prescribing route, because at the time there were not enough nurse prescribers and GPs didn’t want to be doing the prescribing without being involved in the clinical care,” says Alison Hopkins, who was then lead nurse for the Wound and Lymphoedema Service in Tower Hamlets PCT. “Also, most dressings are not prescription only products – they were just being prescribed because that was the procurement route.”
As well as slow access to dressings, there was also an issue with wastage, with unused products piling up in nurses’ cars and patients’ homes.
“If you prescribe dressings, then you often prescribe in bulk because it’s easier,” Hopkins explains. “Some dressings come in a box of five, some come in a box of ten, and others come in a box of 50, so as soon as you change a dressing what do you do with the remainder? Because it’s prescribed for the person it’s their property; the nurse can’t take the products back to use elsewhere.”
Hopkins, who had been a community nurse since 1985, had long been involved with wound management: shortly after beginning her career, she set up various services for patients with leg ulcers, eventually joining the East London Wound Healing Centre as a specialist nurse. Over time, the team expanded and its range of services multiplied, with lymphoedema care added to the mix in 2008. Hopkins’ ambition, however, remained consistent: to see improvements in care for patients with wounds of all kinds.
By 2009, maintaining the status quo seemed untenable. Why was such an inefficient system being used, given the widely acknowledged frustrations? Hopkins was tasked with putting together a business case, outlining a new off-prescription route for dressings that would minimise the wastage and delays, as well as standardising infection control. This would be a centralised scheme for community nurses, GP practices and nursing homes.
“We knew there were various parts of this process that could be done better,” she says. “We knew that if we cut out the waste we were seeing we wouldn’t need to go for cheaper products – we could provide a cost saving just through dint of providing products with some brains behind the operation.”
Having looked into similar, albeit non-identical, schemes, Hopkins realised there was no clear-cut reason for dressings to be prescription-only. Other schemes had successfully taken 40-50% of dressings off prescription, and Hopkins wanted to go further still. Her scheme applied to 90% of wound care products, which was the maximum possible figure based on an audit of the prescribing data. The remainder comprised those, like scar dressings, which didn’t technically fall under the ‘wound care’ banner.
Her project team included representatives from the commissioning pharmacy, district nurses, key stakeholder groups and the NHS Supply Chain. Together, they compiled the information they needed, presenting it to Practice Based Commissioning for evaluation. This was signed off in October 2009, giving the team six months to implement their plans.
While the objectives were inarguable – to provide quicker access to dressings and to standardise practice across the area – the change did not prove as straightforward as was hoped. Once the new system was in place, it became apparent that the original figures contained an omission. They did not account for self-caring patients, who had been receiving repeat prescriptions without ever having their care reviewed.
“These patients weren’t in a review loop – nobody knew about them; they were on repeat prescribing, and at that time repeat prescriptions weren’t as controlled as they probably are now,” Hopkins explains. “They may have been embarrassed about their situation, or they may have given up on their local services, thinking it wasn’t worth trying to get an appointment all the time.”
Tooth and nail
In the past, this had led to over-prescription, particularly among patients with leg ulcers, perianal abscesses or hidradenitis suppurativa. Hopkins’ team worked hard to establish solutions for such patients, not only bringing the costs back to budgeted levels, but also ensuring nobody needed to manage their conditions on their own.
“This is why I would fight tooth and nail never to go back to the prescribing system,” says Hopkins. “The GPs now know that they should not be spending their budget on dressings, so they direct the patient to a nurse who then reviews them and gives them what they require. That doesn’t mean we don’t encourage self management; it’s just within the context of review.”
While there were other challenges too – not least low IT literacy among district nurses, and issues associated with delivering products to patients – Hopkins’ team has worked to provide solutions wherever possible, with impressive results overall. Patient care (as assessed by feedback forms) has improved and £600,000 had been saved by the end of the 2013-14 financial year.
“We’ve just had the contract renewed and it’s still the same budget as it was when we began,” says Hopkins. “So the fact we have not increased dressings costs since 2009, considering the current climate and growth in patient population, is really quite unusual. It needs constant tweaking and work, but that’s a good thing to report.”
A year after the scheme was implemented, East London Wound Healing Centre was relaunched as a Community Interest Company (CIC) named Accelerate CIC, with Hopkins at the helm. A not-for-profit social enterprise, the centre sees NHS patients from all across London via GP referral, and places clinical care at its heart.
The new model has reaped impressive benefits so far. With a multidisciplinary team, working right the way from early diagnosis to long-term care, Accelerate provides wound and lymphoedema services, dermatology and podiatry consulting, along with dressing management. Any surplus funds are reinvested into the service: last year, they opened London’s first Centre for Excellence in chronic wounds and lymphoedema care.
Freedom to innovate
“Compared to NHS colleagues in big trusts with massive deficits, we do have a freedom to be more innovative and fleet of foot; to make changes just because it’s the obvious thing to do,” says Hopkins. “We’ve introduced a way of reporting on dressings for instance, which we’ve brought into the work we do with other trusts to help them improve their wound care.”
The team now runs a similar scheme in the neighbouring City & Hackney CCG, where, despite being classed as external providers, they maintain close relationships with all concerned. They have also been contacted by a number of providers seeking advice – although, as Hopkins points out, not all of these providers have the right idea.
“A scheme of this kind requires an internal change; it’s not just a procurement exercise,” she says. “People normally want to save money by using cheaper products, rather than looking at the system itself and asking from A to B, from B to C, where’s the point that costs or waste are incurred? When I’m talking to people and it looks like it’s purely a procurement exercise, I wouldn’t touch it. You cannot bring in a system that makes lives worse for district nurses, because that will definitely impact on the patients.”
Mind over matter
As Hopkins sees it, holistic schemes of this kind could have an important role to play in the future of the NHS. With costs continuing to spiral, and deficits firmly entrenched, there is a clear need for innovation. After all, cutting corners is unlikely to benefit patient care.
With regard to wound care specifically, it’s important to treat patients as early as possible, stopping a small wound from becoming a big wound, or a swelling from becoming cellulitis. The sooner such conditions are managed, the better the likely outcomes.
Similarly, closer attention should be paid to the non-healers – patients suffering from long-term leg ulcers that have not responded to typical management strategies. Hopkins would like to see more creativity in leg ulcer management, particularly through greater use and understanding of compression therapy.
“Unfortunately due to the terrible resource problem with nursing in the UK, wound care has just become a task rather than something that’s more reflective or creative,” she says. “The incredibly restrained use of compression therapy is very destructive and costly, and I think people need to be aware that there’s another way.”
At Accelerate, her team aims to treat each patient on a case-by-case basis, making a genuine difference to their lives rather than simply allocating them a 20-minute outpatient appointment. She cites a recent patient, who came to the clinic with the worst ulceration the dermatologist had ever seen, and later came out ‘a new woman’.
“As a small social enterprise we can bring enthusiasm and a new vision, and then we can show the clinical commissioning groups that change is possible,” she says. “It’s about creating a fantastic model for wound care, which can be easily translated and adapted for use elsewhere. It sounds clichéd, but there are lot of us at Accelerate who say we want to change the world.”
This article appears in the Spring 2016 edition of Practical Patient Care