NHS: Wound Care

Lord MacKenzie of Culkein Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord MacKenzie of Culkein (Lab)]

My Lords, I am delighted that my noble friend Lord Hunt of Kings Heath was able to secure this important short debate, which was so ably introduced by my noble friend Lady Wheeler. As a former nurse, I find this subject of obvious interest. As someone who was at the receiving end of suboptimal wound care some nine years ago, and has residual problems to remind me every day, I find that interest reinforced.

Wound care is no longer part of what many years ago used to be called basic nursing practice. Obviously, I expect that all registered nurses will know a lot about wound care—but nowadays it is much more than that. Before treatment there have to be proper diagnosis and proper identification—or perhaps I should say classification—of the wounds. There are many types of wounds: surgical incisions; abrasions; granulating or overgranulating wounds; and diabetic foot ulcers and ischaemic leg ulcer wounds, about which we have already heard quite a bit in the debate.

One of the least excusable wounds to me, as a nurse, is the hospital-acquired or care home-acquired pressure sore. It should never be forgotten that sloppy, incorrect care of a tiny wound, as in a jugular vein cannulation site, can lead to sepsis, with all the horrors that follow, such as acute kidney injury. I know because it happened to a relative of mine very recently.

There is no doubt that the care of wounds is staff-intensive, extremely costly to the National Health Service and, not least, costly to the patient in terms of pain, infection and immobility. Wounds not healed within, say, six weeks can be defined as chronic. There are many factors which delay and impair wound healing, including: underlying disease; reduced blood supply; infection; malnutrition; poor patient compliance; and, indeed, smoking and alcohol. There are more, but I am not going to list them—except to say that one of the most important is inappropriate or poor wound management.

It is here that I will speak about the role of the tissue viability nurse. That nurse specialist comes into their own in cases of wound management. They have an important role in clinical practice. Their skills are important so that there is correct diagnosis and classification, which in turn will lead, one hopes, to the correct treatment—there are huge variations in the types of tissue damage in different wounds. Is the wound clean? Is there debris? Is there infection? Is there pus, a lot of exudate or a lot of necrotic tissue? All these issues have to be identified before treatment.

The tissue viability nurse also has an important role in prevention; in education; in research; in working with other National Health Service teams, including pharmacists, and, ideally, outside the hospital with, for example, community staff, care homes and hospices. It is, or should be, part of the tissue viability nurse’s role to educate senior finance and procurement staff about what really works in wound care. Tissue viability nurses, individually or in teams, have the capacity to reduce trauma for patients and mitigate the huge costs to the health service, but there are too few of them, too few specialist doctors and far too many protocols. As my noble friend Lady Wheeler said, there is a vital need for a nationally agreed and properly resourced strategy to improve prevention and, where prevention fails, to improve the quality of wound care and thus reduce costs.

I turn to dressings. There appears to be increasing pressure to redefine what we used to call “cost-effective treatment” in relation to wound dressings to mean the cheapest—or, in the jargon currently used in procurement, those said to be “clinically acceptable”. That is not necessarily the best way to reduce costs. Dressings classified as “acceptable” cannot always be those that are clinically indicated and appropriate. If healing is compromised and delayed, that which might be acceptable to accountants becomes, in fact, the antithesis of what is really cost effective. Doctors, tissue viability nurses and other nursing staff need to be able to access the treatment which is essential to promote the best outcome —for the sake of the patient and of the service.

I have no problem with cheaper generics when it comes to paracetamol or the many other drugs which have exactly the same formula as the more expensive branded versions. This is not so in the highly specialised field of wound dressings and treatment. Cost must not be the primary driver.

My daughter, who is involved in clinical teaching, tells me that programmes that have been developed to carry forward professional development in her trust are now severely curtailed by the massive reduction in the funding for continuing professional development. That includes development of courses on issues such as wound care.

We are seeing reductions in opportunities for training, the drive for the cheapest possible procurement, the huge workload pressures on nursing staff in hospitals and, even worse, in the community, as evidenced by the massive reduction in the numbers of district nurses. All those factors together must militate against the good developments in wound care. There cannot be any argument against the need for a coherent national strategy if we are to reduce poor outcomes for patients and reduce the costs involved.

I hope that this short debate will reinforce the seriousness of this matter to the Government and give the Minister the opportunity to tell the House what plans there are to increase, for example, the number of tissue viability nurses so that there can be more support, not just for staff in hospitals but for hard-pressed community staff and for nursing and care homes. Will the Minister say how the important matter of wound care is to be taken forward? Will there be a new coherent national strategy? I very much look forward to his response.