Cost cutting in wound management is not cost effectiveness

Financial constraints in healthcare are necessary if the NHS is to provide a service but it is vital for the successful management of any service that both managers and clinicians work in partnership, says Pauline Beldon, chair of the Tissue Viability Nurses Association

Our population is growing older. We are currently seeing a steep increase in the number of people over the age of 65 , as the baby boomers born following World War II retire. The number of individuals aged 85 years and older grew by 64 ,000 in 2005 and is set to continue to increase. Together with the ageing population, we are seeing an increase in obesity and diseases such as diabetes. By the end of this decade, it is estimated that the number of individuals with diabetes could increase to three million , most of whom will have type 2 diabetes directly attributable to ageing and obesity. 5% of the NHS budget is spent on treating diabetes and its complications. In the UK, the rate of amputation is 15 times higher in diabetics than non-diabetic patients. Prior to amputation, it is common for the patient to have had one or more diabetic foot ulcers. 5% or approximately 90 ,000 patients will develop a diabetic foot ulcer in a year.

The ageing population is at particularly high risk of developing pressure ulcers and it is unfortunate that neither the Department of Health nor local strategic health authorities are sufficiently interested in the development of pressure ulcers to demand that incidence and prevalence rates are recorded and compared nationally. If consideration and appropriate provision is not made to reduce the risk to these vulnerable people, the incidence is likely to rise with population growth , developing into an expensive ‘epidemic’. The cost of treating a severe pressure ulcer has been estimated at £10 ,551 with the total cost of pressure ulcers to the NHS as high as £1.4 – 2.1 billion annually or 4% of the total NHS budget. Yet many TVNs struggle to obtain the necessary funds from their trust to obtain pressure-relieving equipment as managers fail to see the financial danger in lost bed days , blocked beds and complaints made by families who are becoming increasingly litigious in attitude.

A rise in the number of people living with chronic wounds such as diabetic foot ulcers , leg ulcers and pressure ulcers is unsurprising and is likely to increase. While acute wounds may excite the media and layperson and undoubtedly cause distress to the individual , the cost of dealing with the volume of chronic wounds in the UK remains unknown. All trusts have-or should have!-a wound management formulary with associated guidelines. In a perfect world such a formulary should be compiled by a group of experts such as a tissue viability nurse, pharmacist , pharmacy buyer and logistics buyer. By doing so a balance is achieved. When pharmacists or logistics personnel alone decide a formulary, they cannot take into consideration how the products are likely to be used or indeed whether the products they may have selected are ‘fit for purpose’. The vast majority of TVNs are cynical and ruthless when selecting dressings for a formulary. There are hundreds of wound management dressings in the market , many of which are not cost effective, although initially they may appear so , since piece for piece they are cheaper than a competitor. For example , a hydrocolloid dressing which is designed to remain on a wound for 3-5 days but is such poor quality that it falls off and needs replacing every day is clearly neither clinically or cost effective. It must remain the TVNs responsibility to critically evaluate such products since neither pharmacists , logistics buyers nor indeed surgeons have the necessary clinical skills or opportunity to do so. There exist quality products which are ostensibly expensive when examined per piece but whose cost effectiveness is clearly demonstrated if they remain in place on a wound for 7 or even 10 days.. All wound management companies are good at marketing but whether or not their marketing practice is ethical is another question.

While many companies belong to the Surgical Dressings Material Association, a self regulatory body with a strict code of practice, not all do and there have been instances of trusts excluding TVNs from discussions in an attempt to drive through the use of cheaper dressing products. This is poor practice and must not be encouraged , particularly when those involved do not have sufficient skills to judge the merit of a product. Financial constraints in healthcare are necessary if the NHS is to provide a service but it is vital for the successful management of any service that both managers and clinicians work in partnership. Clinicians need to be included within the budget setting process so that they understand their responsibilities regarding a trust’s financial position and without clinical expertise there is no healthcare provision. Inclusion within the budget setting process will enable the clinician to bring to the attention of managers possible alternative solutions , some of which may bring a cost effective solution to wound management provision in the long term , rather than a short term vision. It is too easy to be reactive. It takes more vision to be proactive.

If trusts are to avoid the accusation of penny pinching , then the wider picture needs to be embraced when considering wound care management. Wound care products are sometimes expensive but there are often hidden extras within the price , such as the training offered by companies to accompany their products to ensure appropriate use. Value for money does not always mean using the cheapest option. Wound care products require careful evaluation and it is possible that a more expensive product might offer several advantages. A reduced frequency of dressing change due to better exudate management is advantageous both in reduced cost and time saved and if the patient has less discomfort and uses less analgesia, that is a hidden cost benefit.

Recently, some NHS trusts have reduced or even cut a tissue viability service. This is short sighted because, unlike most other nursing specialisms, there is no medical equivalent of a TVN. To lose such a service is likely to leave a trust without the capability to manage pressure relieving equipment appropriately , an increase in the incidence of pressure ulceration with resultant increase in length of stay due to lack of training and without the expertise to select quality and cost effective wound management products. NHS trusts need a TVN and in return should demand performance criteria in audit to demonstrate the worth of the TVN in reducing the incidence of pressure ulceration and managing a wound formulary. A partnership with equal expectations between clinician and managers must be the way forward for success.

“a partnership with equal expectations between clinician and managers must be the way forward for success”

“recently, some NHS trusts have reduced or even cut a tissue viability service. This is short sighted because, unlike most other nursing specialisms, there is no medical equivalent of a TVN”