NHS: Wound Care

Lord Kakkar Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I too congratulate the noble Lord, Lord Hunt of Kings Heath, on having secured this important debate, and the noble Baroness, Lady Wheeler, on having introduced it in such a thoughtful fashion. I declare my own interests as professor of surgery at University College London, chairman of University College London Partners and director of the Thrombosis Research Institute in London.

As we heard from the noble Baroness, some 2 million individuals suffer wounds every year—one in 20 of the adult population of the United Kingdom. That is a substantial clinical burden in itself, but beyond that we have heard about the pressures that puts on the NHS. Some £5 billion is spent on this every year—a similar financial burden to that involved in NHS management of obesity. There is, rightly, great emphasis on the problem of obesity but very little on understanding how we can avoid and, when they occur, best manage, chronic wounds sustained by health service patients.

Beyond our understanding of the clinical burden and the cost to the NHS, there is a broader economic burden that we do not talk about: lost productivity of individuals who could otherwise be making an important contribution to the economy. Regrettably, our understanding of that is poor when looking at the broader implications of chronic conditions in the National Health Service.

Guest and colleagues, publishing in the British Medical Journal in 2015, provided a detailed analysis of this cost burden on the NHS. Some £320 million was attributable to general practitioner visits; £920 million was associated with nursing visits in the district; £415 million was spent on out-patient visits, and some £1.2 billion was associated with hospital admission. Some £170 million was spent on the use of diagnostic tests associated with wounds, £260 million on the use of medical devices, £740 million on wound care products, and £1.2 billion on prescription drugs. So it really is a substantial burden.

I shall focus my remarks on three areas—chronic venous ulceration, diabetic foot ulceration and pressure ulcers—to try to understand Her Majesty’s Government’s approach to prevention in any national strategy for the management of wounds. It is clear that prevention is always better than having individuals sustain a particular complication; therefore, a prevention strategy should be at the heart of any national strategy on the management of wounds. I should declare a particular interest when I speak about venous ulcers; they are principally associated with a failure to prevent venous thromboembolism, which is one of my major research interests. A strategy directed at preventing venous thrombosis in hospitals would eventually be associated with a substantial reduction in the frequency of the post-thrombotic syndrome, one manifestation of which is chronic venous ulcers. An important element of that strategy is already in place—mandatory risk assessment for thrombosis for patients coming into hospital—but as part of a broader wound strategy, that would clearly be an important area.

An important element of prevention of the chronic wounds resulting from diabetic foot ulceration is screening for diabetes before complications become apparent, as well as the appropriate and fastidious management of diabetics so that they do not go on to develop ulcers. If they do develop ulcers, careful management and assessment are necessary to ensure that the ulcers can be treated and heal quickly or that they are effectively managed to prevent the kinds of complications we see, particularly amputation.

Then there are pressure ulcers in immobile patients confined to bed, not only in hospital but at home. These are very serious problems but careful attention to nutrition and to cardiovascular and non-cardiovascular comorbidities, which can affect the circulation, will provide an important opportunity to prevent, or ensure more effective management of, pressure ulcers.

Pressure ulcers are a particularly interesting problem; we see substantial numbers of them in the NHS. Regulation 12 of the CQC standards when inspecting hospitals for quality assesses in institutions measures to both prevent and manage pressure ulcers. As a result, as part of the NHS safety thermometer, we see regular reporting of the frequency of pressure ulcers in different healthcare institutions. It is striking that in August of this year, the thermometer showed that 4% of patients in institutions had a pressure ulcer; but looking at the most recent thermometer, for October, the figure is between 0.6% of patients in one institution and 7% in another. This variation seems quite remarkable and is clearly unacceptable. There are important lessons to learn across institutions to ensure that best practice is applied across the entire NHS to reduce the frequency of these important complications.

We have to recognise the risk to patients of developing chronic wounds when their care is managed in the community. Those patients are often neglected and not always assessed as part of the overall burden of disease in terms of pressure ulcers. It is anticipated that about 5% of patients being managed in their own home will have pressure ulcers—again, a substantial number of individuals.

There is very good evidence that if best practice and guidelines are properly applied, and if they are integrated into a national strategy and applied more fastidiously, there could be an important impact on reducing the burden of these problems. Initiatives in the Midlands and the east of England with regard to application of Royal College of Nursing and NICE standards on the management and prevention of pressure ulcers resulted in a 50% reduction in their incidence in associated healthcare environments in those regions in the first year after application. Similar impressive results have been seen in care homes in Sutton as part of a community care vanguard in that region.

Clearly, prevention is validated and should play an important role in any national strategy. If they proceed with a national wound management programme, do Her Majesty’s Government believe that prevention should be at its heart and that best practice and prevention should be broadly promoted and adopted at scale and pace through various health economies in hospital and in the community? Secondly, what assessment have they made of the remarkable variation in the frequency of pressure ulcers? I was not able to find data pertaining to other forms of chronic ulceration, such as venous or diabetic ulceration, but I suspect there must be substantial variation. What assessment has been made of such variation in clinical outcomes? Thirdly, I would like to understand how they propose to address that variation. Such variation exists throughout the NHS but this area, with such a large clinical and economic burden, needs to be one of priority. Finally, what advice has the Department of Health given to the National Institute for Health Research in trying to identify opportunities for more research in this area to advance clinical practice?