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Time to tackle the burden of wound care

Public Policy Projects’ (PPP) ‘Going further for wound healing’ series examines the impact of chronic wounds on patients, professionals and systems in the health and social care services. Through this series, PPP aims to explore the unmet needs in wound care, break down silos between the frontline and leadership, and help to transform the delivery of wound care.

Wound care is rarely considered a strategic objective within health and care, and is sometimes entirely forgotten. So, it’s not surprising to hear the prevalence of wound care and costs are increasing in the UK. In some instances, wound care is overtaken in importance by more ‘interesting’ conditions, is regarded too complex, or is missing leadership from outside the nursing profession.

Wound care leaders and those that understand the scale of the problem demonstrate an abundance of passion and direction, but many barriers exist to improving wound care, such as professional silos between leadership and the front line, and a culture of acceptance of poor care and outcomes. Added to the mix is a lack of prioritisation, understanding, documentation, national guidelines, workforce shortages, skill and leadership.

Yet, there is considerable evidence demonstrating the scale of the problem; patient voices and best practice pathways, tirelessly created by wound care champions, are constantly trying to translate this to their peers.

The scale of the wound care burden

Wound care represents the third highest expense for the NHS, after cancer and diabetes, and cost the NHS £8.3 billion in 2017/18.1 It’s believed this cost is now closer to £10 billion a year.2 Despite this, wound care is not included on any integrated care board strategic objectives or Quality and Outcomes Framework points.

Given that 67 per cent of the cost of wound care – £5.6 billion in 2017/18 – was spent on managing unhealed wounds, there is much to be gained from early intervention programmes. Optimal care pathways have been shown to heal wounds or make them less problematic and this would make a significant impact on the cost and resources associated with wound care.

It’s crucial, now more than ever, to translate wound care to the professions that don’t usually champion it; GPs, commissioners and policymakers. Evidence needs to be heard on how better wound care outcomes positively impact the workforce, expenditure, and the lives of the people and the carers living with wounds.

There is often a focus on reducing costs by focusing on product spend, yet products account for only 6 per cent of wound care costs and over 70 per cent of costs are spent on doctor, nurse and healthcare assistant visits. Thus, proper management of wounds not only benefits budgets, it frees valuable workforce time and reduces primary care and community nurse visits, that can then be used to bring down waiting times.

Given that there was a 30 per cent decline in the number of district nurses employed between 2012 and 2017, the increase in wound care patients is squeezing this resource and raises questions around how the system is managing more patients with fewer workforce resources.2

It is therefore not surprising that the provision of wound care services accounts for a substantial amount of NHS resources. In 2017/18, the NHS treated 3.8 million patients with a wound, equivalent to 7 per cent of the adult population. This was 71 per cent higher than in 2012/13, while the real-term patient management cost increased by 48 per cent in the same period.1 This massive increase in cost and prevalence signifies a system that is broken and not fit for purpose; it is a leaking tap that is being ignored. A deep look at local services and commissioning needs to happen to see if they are still fit for purpose. Considering that the fastest growing prevalence is in the wounds that are the least expensive to treat, the return on investment could be substantial.

One of the challenges seems to lie in the lack of documentation, standardisation and continuity of care. Hence, it’s not surprising that 25 per cent of wounds go unrecorded or undiagnosed. It is fair to argue that it is difficult to monitor or assess interventions for effectiveness if there is no proper documentation.

One in 50 people in the UK lives with a chronic wound that reduces their quality of life, causing pain, loss of mobility and restrictions that can be debilitating and 46 per cent of these people experience depression.4 Many patients with wounds have comorbidities that put them at higher risk of developing a chronic wound, while 57 per cent of all wound patients also have diabetes.2 Yet, there is a lack of services for non-diabetic wounds as they fall through the gap.

Leg ulcers impact approximately 1.5 per cent of the adult population. In 2019, the estimated cost of leg ulcers to England’s healthcare system was £3.1 billion per year, with healing rates of 47 per cent at 12 months.

Best practice pathways, such as NHS RightCare’s Betty’s Story, however, suggest leg ulcers can be healed in eight-to-12 weeks. But in Betty’s case, it took two years after she fell and grazed her leg for her wound to heal as she wasn’t offered optimal care. Unless action is taken, leg ulcer prevalence is predicted to grow by four per cent per year. Given that non-elective lower limb admissions for an average ICS result in 19,886 hospital admissions, 6,928 patients, 123,261 bed days and £20,931,221 cost over three years, more needs to be done.

Badly managed lower limb wounds can also result in unnecessary amputations. In 2021/22 Greater Manchester had approximately 4,500 people with lower limb wounds, costing approximately £200 million a year for treatment and amputations. The Manchester Amputation Reduction Strategy (MARS) records approximately 600 lower limb amputations across Greater Manchester every year, half of which are preventable.

Between 2015/16 and 2021/22 they achieved a reduction in amputations by 21 per cent across Greater Manchester, through a whole system approach, 25 new pathways, leveling up to diabetes and lower limb guidelines, developing community vascular assessment teams, integrating leisure facilities into clinical pathways. However, evidence shows the Covid-19 pandemic has resulted in increased risk of amputation for venous leg ulcer patients.3

A troubling aspect is that the latest data on the burden of wounds predates the pandemic, and 90 per cent of the 251 nurses who responded to a survey reported they were concerned about the backlog of patients needing care post-covid.2 With such a high prevalence and impact on peoples’ lives, it is surprising that wound care services are not higher up on the agenda.

Why:

The National Wound Care Strategy Programme has devised tools, pathways and workstreams, that demonstrate patients can heal faster than they currently tend to, yet suboptimal care is sometimes the standard. There are many system-wide efficiency gains to be made; for every £1 invested, a return of £9.8 in net financial benefit can be realised. Despite this, there are unwarranted variations in practice and outcome.

What is needed:

Wound care is too big a problem to ignore. Investment has been disproportionate to the scale of the problem and this needs to be reversed. Upstream prevention is needed in order to deal with the backlog of patients needing care, workforce shortages and growing demand on services. There are many successful examples of wound care to draw on, yet translating it to key stakeholders in primary care, as well as to commissioners and politicians, has been difficult. It is evident that silos need to be broken down to make wound care better understood across the system.

More partnership working between patients and those delivering care services are needed to allow more self-care where it is appropriate. Patients need the right care the first time and services that recognises patients’ needs.

There is evidence that social network analysis can improve effectiveness and efficiency of workforces and may be useful for ICSs wanting to optimise communication channels and workforce collaboration, when breaking down silos.4

New focus needs to be placed on patterns of patient need, the delivery of services and documentation to classify and measure outcomes, to provide more effective care and make better use of resources. Otherwise, it is highly likely that costs to the NHS and Social Care for providing services will continue to rise and at the heart of it, people will suffer. By doing nothing, this situation will only get worse.

Through four roundtables taking place from April to June 2023, PPP is convening experts from around the country to discuss the challenges and opportunities to improve outcomes in wound care. The recommendations from the series will then be brought together in a policy report and discussed through three panel debates at a delivery conference on 19th October 2023.

References:

1. Guest, J.F., Fuller, G.W., Vowden, P. 2020. Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open 2020;10:e045253. doi:10.1136/ bmjopen-2020-045253. Available at: https://bmjopen.bmj.com/content/10/12/e045253

2. Mölnlycke. 2022. Making wound care work: Rebuilding services for the 3.8 million people living with a wound in the UK. Available at: https://www.molnlycke.co.uk/campaigns/making-wound-care-work/

3. Guest, J.F., Fuller, G.W. 2023. Cohort study assessing the impact of COVID-19 on venous leg ulcer management and associated clinical outcomes in clinical practice in the UK. BMJ Open 2023;13:e068845. doi:10.1136/bmjopen-2022-068845. Available at: https://bmjopen.bmj.com/content/13/2/e068845.info

4. Saatchi AG, Pallotti F, Sullivan P. 2023. Network approaches and interventions in healthcare settings: A systematic scoping review. Plos one.  23;18(2):e0282050. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0282050

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