NHS: Wound Care

Baroness Watkins of Tavistock Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, in his absence for bringing this important debate to this House, and the noble Baroness, Lady Wheeler, for her excellent introduction to the issue. I draw attention to my registered interests, in particular as a lifelong member of the Royal College of Nursing and the current president of the Florence Nightingale Foundation.

Other noble Lords have addressed the issue of improving the strategy for wound care through the development of generic national specifications classed as clinically acceptably and fit for purpose for at least seven wound care and dressing categories. This is an entirely logical approach which the nursing profession broadly supports and is actively involved in designing. My noble friend Lord Kakkar outlined the macro- economic costs of wound management. It is estimated by Guest et al that 2.2 million wounds were managed in the UK in 2012-13, involving 18.6 million practice nurse visits and 10.9 million community nursing visits. In addition, significant nursing time is spent in hospitals, care homes and nursing homes managing wounds, not only in the NHS but in the independent and social care sectors. Therefore, any strategy for the future needs to consider the total cost of treating wounds, not the unit cost of products. Cost estimates need to focus not only on the price of wound treatments in terms of assessment tools, such as Doppler machines, medicines and dressings but also on the costs of treatment time from a variety of healthcare workers including, for example, medical staff, dieticians and podiatrists, while recognising that wound management, particularly in community settings, is predominantly a nurse-led discipline. The noble Lord, Lord Mackenzie of Culkein, gave an excellent overview of the challenges, the types of wounds and the expertise that clinical nurse specialists in tissue viability use in leading teams.

Innovation is central for the future, but I want to concentrate on four issues—the prevention of wounds, the prevention of infection, treatment expertise and sound models of care—through the lens of patients suffering from leg ulcers. Leg ulcers are painful, debilitating and frequently lead to social isolation. How then can leg ulcers be prevented? Some, of course, cannot, but with education many can be stalled and healed in their very early stages and others can be prevented very effectively by maintaining skin integrity through improved nutrition and exercise in at-risk groups. Keeping even small cuts clean and covered while healing can prevent infection entering a wound. Most patients want to prevent infection and will be happy to concur with a suggested treatment plan.

However, I want to give noble Lords one example from my practice when working as a district nurse more than 20 years ago. I was working with a woman in her mid-70s who was housebound with a severe leg ulcer that was not healing despite what was then regarded as best practice in terms of treatment, which involved a particular form of medically impregnated bandage being put on the affected leg by a relatively skilled nurse, because such bandages must not be put on too tightly. I was not as busy as most district nurses are today, so I returned unexpectedly at about 4 pm to see how she was doing. The answer was that, despite my having asked her not to, she was huddled by a two-bar electric fire, which was in effect setting and hardening the bandage, thus doing far more harm than good. After further assessment, I appreciated that she felt the central heating was too expensive to run and turned it on only when I was due to visit. A referral to a charity resulted in some extra funds towards her heating and over the next two months, with additional ad hoc visits from me, her leg healed. She was able to get out and help her nephew a bit in his shop, while regularly elevating her leg, and I was delighted to be able to discharge her. My point is that we now have just over 4,000 district nurses in England, but when I was working in practice there were in excess of 7,000 and I had the time to take the approach I have described.

Despite the pressure that district nurses are under today, they continue to deliver high-quality care. Investment in continued professional development is vital for healthcare professionals if they are to keep up to date and deliver contemporary evidence-based practice, yet CPD budgets for non-medical staff have been steadily eroded. A fantastic initiative has developed. It originated in Barnstaple in Devon and has already been alluded to by my noble friend Lady Masham. It is the Lindsay Leg Club Foundation. These clubs are usually led by qualified district nurses and have between 50 and 200 active members who have had or have leg ulcers. The clubs are gateways for input from tissue viability specialists, podiatrists and nutritionists. Initial results show quicker healing and improvement of ulcers and reduced prescribing costs through adherence to approved treatments, some of which are expensive but cost-effective. The clubs empower patients as stakeholders to work in partnership with professional staff, volunteers and their peers. Leg clubs are built around the notion of promoting peoples’ independence and well-being. This new social model of care is proving effective not only in the treatment of the physical wound but in promoting people’s independence and mental well-being by reducing loneliness and isolation.

Any wound strategy needs to consider how we prepare health professionals to work with groups, encouraging self-care as far as feasible, and how to integrate evidence-based practice through the dissemination of new evidence. There is little doubt that investment in the nursing workforce, particularly in CPD, is as important as selecting the best treatment product.

An RCT in Queensland, Australia, concluded that nursing time and related costs decreased by 36% using the leg club model, leading to the cost per healed leg ulcer being reduced by 58%. When I was practising, I undertook single home visits. These will always be necessary for some patients, but I delight in acknowledging that today’s leg clinic model is one that I would now wish to adopt. I believe it would have benefited my patients more cost effectively than the intervention I undertook, particularly in terms of productivity in nursing time.

The noble Lord, Lord Carter of Coles, in his report, recommends the adoption of single integrated performance in care pathways centred on customers, workforce and finance. These should apply not only to NHS providers but to independent nursing homes and the wide variety of social care services involved in delivering wound care prevention and treatment.

As the strategy for wound care develops, will due consideration be given to further investment in the workforce, including district nurse training, further development of nursing associates, continuing professional development, and customer education to ensure our workforce—which includes patients—can continue to lead the way in cost-effective care for wound management, based on new research evidence and treatment, thereby reducing individuals’ pain and suffering associated with chronic wounds such as leg ulcers?