Leading change

The Lead Nurse for the Wound and Lymphedema service at the East London Wound Healing Centre and the team undertook a project focused on a patient-centred procurement system for wound care. The team, which is part of Accelerate CIC, a Community Interest Company working with the NHS to provide specialist care for patients living with chronic wounds and lymphoedema in Tower Hamlets developed and implemented new ways of working which reduced unwarranted variation whilst delivering better use of resources, experience and patient outcomes.

Where to look

The nursing team identified significant unwarranted variation in the supply and use of wound care products across their service, with variation in a standardised approach to dressing choice and in some instances the most optimal dressing was not being utilised.

What to change

Wound care products in primary care were being administered to patients using routine prescribing routes via the FP10 prescribing route however in other areas it was identified they had successfully implemented a centralised procurement model with good success and positive outcomes. The nurse identified under their current way of working there was unwarranted variation in:

• the prescribing process experienced a number of delays due to disjointed diagnosis and prescribing approaches as well as low numbers of nurse prescribers able to prescribe dressings
• delays in accessing wound care dressings related to tradition prescribing processes
• high wound dressing waste volume as a result of individual prescribing processes
• variation in treatments prescribed, inappropriate dressings used and variance in infection control practices due to a lack of standardised clinical approach.

How to change

The nurses introduced a centralised procurement system, drawing 90% of the allocated wound care budget into a central funding resource. Once the funding was centralised the nurse reviewed the key stakeholders and suppliers within the NHS Supply Chain. The nurse and her team identified one central provider with access to an online ordering system, enabling focused provision of wound care products. Community-based service providers were set up and users were trained how to use the ordering system.

A wound care formulary was developed in collaboration with the medicines management and community nursing teams. Whilst some flexibility needed to remain, the intention was to provide consistent patient treatment and improve outcomes. The formulary was set up as a “favourite list”, making it easy for users to order products.

The procurement was reviewed by an administrator to support compliance to the new formulary and approach, and with the collation of data for review. New routine reports were developed from the system to inform planning and clinical decision-making, with purchase analysis and comparison made possible by team/individual, by product type and by cost. The nurse was therefore able to monitor the impact via this data and other sources in order to evidence the progress made and improvements in the unwarranted variation.

Adding value

Better outcomes – Enabling clinicians to directly order on a patient needs-based approach has improved care and outcomes, helping to identify patients with complex needs and triggering specialist interventions. Standardising wound care based upon best practice will also improve outcomes for patients.

Better experience – The supply system has reduced delays in treatment for patients and keeping track of ordering trends has highlighted training needs and targeted support to some teams and providers. The new system has resulted in effective and efficient access to dressings for patients and improved patient care.

Better use of resources – The scheme has operated within the original budget despite an 18% increase in population. Savings of £45,000 have also been reinvested in services. Total wound care spend per patient in Tower Hamlets is significantly below the national average without compromise on quality of service provision. The procurement system has done this by reducing over-ordering and the associated risk of dressings going unused. The scheme has generated cash savings of £82k that has been reinvested back into services such a wound care projects or interventions.

Challenges and lessons learnt for implementation

• The team has highlighted that transporting dressings can be difficult in urban areas and needs consideration if looking to roll similar models out.
• The reactive nature of community nursing does bring with it additional challenges regarding planning and stock management, this needs careful consideration and engagement with teams.
• Annual reviews of the scheme in the context of local need will be essential to delivering ongoing benefits.
• The scheme is built on equity of access to wound care dressings, meaning that those who would normally pay for prescriptions no longer need to. An increase in out-of-area patients could cause unexpected cost pressures.

For more information contact:

• Alison Hopkins , Chief Executive Accelerate CIC, alison.hopkins2@nhs.net