The need for efficiency and cost savings in order to sustain, and allow improvements to, the National Health Service has long been recognised (NHS England, 2014). In English acute hospitals, an independent review was carried out by Lord Carter of Coles in order to identify ways in which these goals could be met (Carter, 2016). The resulting report highlighted the need to improve productivity, quality and efficiency in order to realise the necessary cost savings, without compromising service delivery (Carter, 2016). Key to achieving this was the need to eliminate unwarranted variation across all resource areas, including in procurement, where a wide variety in the number of products and suppliers used across and within trusts was identified (Carter, 2016). The report also recognised that the provision of high quality care and resource management go hand in hand, leading to the recommendation that trusts should use their resources more effectively, including staff (Carter, 2016). 

Implementing positive change and forming partnerships was recommended in Leading Change, Adding Value (NHS England, 2018) as a way in which all nurses regardless of work setting could put healthcare services on a financially sustainable footing. To achieve this, NHS England (2018) pointed to the ‘Triple Aim’ set out in the Five Year Forward View (NHS, 2014) of obtaining better outcomes, better experiences for people and better use of resources to deliver high quality care (NHS England, 2018). Similarly, the Royal College of Physicians (RCP) (2018) recommended that health professionals must become resource advocates, procuring, using and disposing of all resources in the most efficient way to reduce waste and ensure sustainability of the NHS. 

As part of a commitment to providing high quality, sustainable healthcare, Chesterfield Royal Hospital NHS Foundation Trust is always looking at ways in which services can be run more efficiently while maintaining or improving on quality. The ‘Proud to CARE’ values of the trust have six strategic objectives, which include managing budgets wisely, fostering innovation and becoming more efficient through improving quality of care (NHS Chesterfield Royal Hospital NHS Foundation Trust, 2020). 

This article reports on a review of the tissue viability service, and changes that were implemented in order to improve dressing procurement, availability and usage and reduce dressing spend throughout the trust, while adhering to the Proud to CARE values. Key to this was a formulary review, the use of an online non-prescription ordering service (ONPOS) and partnership working with Coloplast (Table 1). 
 

Table 1. Online non-prescription Ordering Service (ONPOS) and Coloplast partnership

 

ONPOS	Coloplast partnership
ONPOS is an online non-prescription ordering service for wound management dressings.	As part of their commitment to partnership working, Coloplast provides ONPOS software installation and training support.
It has been available from Coloplast for more than a decade and is currently used by over 40 trusts in the UK, processing over 300 orders per day.	Coloplast also provides ongoing support in the form of monthly real-time data reports on dressing usage and spend.
Using ONPOS means that dressings can be ordered  directly from an agreed formulary.

Identifying the need for change to improve procurement efficiency

Chesterfield Royal Hospital NHS Foundation Trust is a district general hospital with 24 wards and 500 beds. The tissue viability service for the Trust consists of two tissue viability nurses, a clinical nurse specialist and a nurse practitioner. The service has approximately 1900 patient contacts annually.  

Historically, the tissue viability service had been under-resourced and mainly focused on reducing pressure ulceration across the trust. Expansion of the service to its current size, however, provided the opportunity to identify areas in which improvements could be made, including a formulary review, and increasing efficiency in the supply and availability of wound dressings on the wards.

Variation existed in the type and availability of dressings on different wards, as there was no minimum stock requirement for the dressing stores. As a consequence, the tissue viability service often found that recommended, preferred dressings were not available at the point of care. This led to a culture of the wards taking dressings from each other’s stock, or having to use an inferior dressing until the preferred dressing was available. 

In addition, dressing procurement was via several routes, including materials management and pharmacy, leading to confusion among ward staff in some instances in how best to obtain the desired dressings. Multiple procurement routes also enabled off-formulary purchasing and created difficulties in tracking stock and dressing spend and usage for the individual wards and departments. On a practical level, dressing storage was chaotic on the wards and uncertainty existed around where dressings were stored, and what was available. Physically finding the dressings on the wards could also be a time consuming challenge, with no standardised organisation of dressing stock across the trust.

In order to increase efficiency in all aspects of how dressings were accessed and procured, a need to overhaul both the dressing formulary and supply routes was identified. 
 

Developing a new formulary

A wound dressing formulary is required to help healthcare professionals select appropriate products to treat their patients and is therefore an integral part of wound management practice (Beldon, 2008; Milne et al, 2019). Regular formulary audit is a clinical necessity to ensure it meets the needs of patients and their wounds, and to monitor appropriate dressing use (Beldon, 2008). 

A formulary review was undertaken by the tissue viability service, with the aim of reducing the number of dressings and suppliers listed. This took several months in order to consider the dressings available on the market, and to compile a shortlist of products that fulfilled the department’s criteria of clinical and cost efficacy. The existing formulary was reduced from 41 to 14 products, greatly simplifying the number and types of dressings available, without compromising access to a suitable dressing for all the wound types encountered within the trust. It is recognised that selecting from a large range of dressings can be overwhelming and time-consuming (Milne et al, 2019) so it was hoped that by reducing the number of dressings available within a category, e.g. foams, the selection process would be less confusing and more streamlined for ward staff. Dressing suppliers were reduced to just three or four who cumulatively could provide a complete range of dressings for the wards. 

As part of this process, prospective company suppliers who were identified as having dressings of interest, where invited to visit the department for a dressing performance review and presentation of value-added services. The Coloplast range of dressings and clinical evidence were reviewed as part of this process, and potential cost savings were identified as a result of including the Coloplast dressings on the formulary. ONPOS, in addition to staff training and ongoing support with its use, was highlighted as a possible solution to the problems identified with stock procurement and supply. Access to educational materials such as Coloplast’s Healthcare Excellence through Access and Learning (HEAL) educational initiative (Table 2) via ONPOS, also represented additional educational value for ward staff. 
 

Table 2. Healthcare Excellence through Access and Learning (HEAL).

 

The HEAL educational initiative enables staff to access educational materials, including local policies and guidelines as well as national guidelines and a library of wound literature through ONPOS via ‘non-ordering access’.

The availability of a platform for staff to access educational  and training materials means that best practice recommendations underpins practice.

In addition, Coloplast produce an award-winning range of wound care products that can be used as part of wound care delivery.

Following discussion with procurement, it was agreed that the use of ONPOS could provide the infrastructure to support the tissue viability service and lead to transparency around dressing spend and use, so it was agreed to pilot the system within two surgical wards. 

Pilot of ONPOS

A switch to ONPOS was made in order to streamline and track wound dressing procurement in an attempt to reduce dressing waste and costs, improve efficiency, and allow analysis of spending and use of dressings in the pilot wards. 

Initially, two surgical wards were used to pilot the use of ONPOS over a 5-month period from July to November 2018. The wards were selected for their physical proximity (they were next door to each other) and willingness of the ward matrons to implement the change. The wards also shared their dressing budget, enabling them to share one ONPOS account.

The ONPOS software was quickly and easily installed by a Coloplast representative and training given to the two designated ward housekeepers in how to use it. The whole process took only a couple of hours. The ONPOS system was then managed by the designated housekeeper on each ward. Initially the housekeepers were wary of taking on additional tasks but following training they embraced the change, and manage the system efficiently, with any issues and/or queries raised with the Clinical Nurse Specialist. 

The housekeepers and Coloplast also reorganised how stock was stored on both wards, and introduced a standardised colour coding system that helped staff to rapidly identify product categories in the store at a glance. Shelves were colour-coded, and a colour-coded laminated list of formulary products made, so that by identifying the product category colour on the list the product was easily located in the colour-coded store.

 This was a relatively simple system but one which had not been previously implemented. Set-up took half a day and resulted in a more efficient system than previously used, making dressing access very quick and leaving more time to care. A baseline level of stock was determined, ordered and stocked on the wards and levels maintained so that dressings were always available.

The implementation of the new formulary and ONPOS on the surgical wards met with no resistance from staff, since the new system streamlined the process for accessing dressings and gave confidence that there was a ready supply of the items on the formulary in the stock cupboard. Furthermore, the staff maintained autonomy over dressing choice but from a reduced number of products making the selection process simpler and less time-consuming and confusing (Milne et al, 2019). 

Roll-out across the trust

Very quickly during the pilot, it became obvious that the use of ONPOS in conjunction with the revised formulary improved organisation and efficiency on the wards by making the right product accessible at the right time. The success of the pilot spread by word of mouth and soon other wards were asking if they could use ONPOS, including areas not previously considered, such as outpatients. At the time of writing, ONPOS is used in 21 locations throughout the trust. 

The benefits of using ONPOS 

NHS England (2018) stated the importance of measuring outcomes, as this enables improvement to be demonstrated. Similarly, the Carter report (2016) highlighted the need for data analysis to identify both good and bad variations in practice. The monthly reports generated by ONPOS using real-time data enabled the Trust to have a very clear view of dressing spend and patterns of use by location, and address any arising issues with incorrect use by providing education and training. 

For example, the use of ONPOS during the pilot quickly highlighted a large spend on alginate dressings on the surgical wards and further investigation revealed the dressings were being used as a cavity filler that was not needed in some wounds, incurring unnecessary cost.  Coloplast provided education and trust-wide training on the use of Biatain Silicone with 3DFit Technology, eliminating the need for a filler in some wounds, resulting in a decrease in the inappropriate use of alginate dressings. 

It also became apparent that some wards were using Biatain Silicone as a first-line foam when Biatain Silicone Lite was appropriate for superficial wounds. Coloplast supported education on the wards, again leading to a reduction in costs through appropriate dressing use.  Access to real-time data therefore helped to direct education and training of frontline staff and aid the decision-making of team members responsible for the formulary, both of which resulted in improved care and cost savings.

Formulary compliance 

The use of ONPOS put a stop to the purchase of dressings not available on formulary as staff are only able to order the formulary products listed on ONPOS. As this is strictly controlled, there is no alternative procurement route and there is 100% compliance with formulary as a result. However, there is still flexibility should an off-formulary product be needed under special circumstances and access is possible via the clinical nurse specialist on a case by case basis.

As the trust has several different wards and departments with varying dressing requirements, the facility to list six different formularies on ONPOS is beneficial. For example, head and neck outpatients have their own formulary listed but it can be only accessed by that department, as each ONPOS administrator has a user name and password for the location, thus preventing inappropriate access and purchasing by other departments.

ONPOS is definitely very useful and Coloplast helped us to add the specific products for our department [Head and Neck] to the system so that we always have stock available.

Caroline Bowdler, Macmillan Head & Neck Clinical Nurse Specialist

However, the decision to include items on the formulary and on ONPOS is still clinician-led, and can be implemented quickly, as it is important that a formulary is fluid and adaptable (Beldon, 2008). During the recent COVID-19 outbreak, with the need for staff to wear PPE, skin protection products were needed. The tissue viability service quickly generated guidelines for the trust on how to prevent PPE-related skin damage, the dressing products needed were identified and procurement agreed to listing on ONPOS. Coloplast were informed of the decision and the ordering facility was added to ONPOS overnight, enabling quick access to the products throughout the trust.

Reduction in the number of dressing brands available

Following the formulary review by the tissue viability service, a reduced number of brands were available;  in 2018/19, 41 dressings were available, whereas when ONPOS was implemented in 2019/20 this was reduced to 14 brands. Staff reported finding dressing selection easier and less confusing. 

Reduction in the number of individual dressings used 

In 2018/19, before ONPOS was installed, a total of 92,283 individual dressings were used decreasing to 86,251 in 2019/20 following the implementation of ONPOS. This was a total reduction in 6032 dressings used. 

The reduction in the number of dressings used was a result of the changes to the formulary. Unfortunately,  ‘cost effectiveness’ is often mistaken as only applying to the unit cost of a dressing, at the expense of poorer patient outcomes (Beldon, 2008; Browning, 2017). Cheaper dressings listed on the formulary needing frequent changes were replaced with more expensive dressings that had a longer wear time. Similarly, more expensive silicone foam was used to prevent skin stripping on removal, which had occurred with a cheaper foam, demonstrating that dressings with a higher unit cost can result in cost savings.

Improved efficiency on the wards 

Before the implementation of ONPOS, one ward would take stock from another ward when they ran out or did not stock a specific dressing type. This no longer happens as Housekeepers can increase their stock levels as and when needed.  For example, a recent patient needed twice daily dressings so the housekeeper upped the stock level of that product, but noted on ONPOS to reduce it again when the patient was discharged.  The system has helped to ensure the patient gets the right dressing at the right time.

Time spent by staff physically looking for dressings was reduced as they can see at a glance where stock is kept. In addition to improving every day efficiency on the ward, the system has proved helpful during the COVID-19 outbreak as a streamlined and clear system was in place to access and procure dressings in a time of high staff turnover and redeployment. Agency nurses unfamiliar with the ward, for example, were able to quickly and easily understand the dressing store. 

Cost savings 

In total, the use of ONPOS generated savings of £29,586 ( 2018/19 dressing spend =£117,081 versus 2019/20 dressing spend = £87,495). These savings were a result of improved formulary adherence, the monitoring of dressings and a reduction of waste.

From a Materials Management point of view ONPOS works well. We very rarely get a phone call that an area has run out of a particular dressing, and when we moved over to ONPOS we saw a saving straight away. I believe this was due to the end user actually seeing what they were ordering and how much it was costing.

Cem Cahit, Logistics and Supply Chain Manager

Patient benefits

As stated, ONPOS monthly reports highlighted areas of concern in dressing use and spend, and informed decisions to make product changes to the formulary, or to deliver education to staff in correct dressing use. These changes ultimately improved patient outcomes and experience in line with the Trust’s Proud to Care values.

Discussion

As hoped, the use of ONPOS resulted in a more efficient ordering system, better stock management and cost savings for the Trust. After identifying the need to improve efficiency of the tissue viability service within the trust, steps were taken to reduce the size of the dressing formulary by streamlining the number of suppliers and wound dressings available, while ensuring there was a suitable range of clinical and cost-effective dressings to meet the needs of the service. Following evaluation by the tissue viability service, the Coloplast dressing range was introduced to the formulary, due to the potential for cost savings and improved clinical effectiveness. As previously stated, cost efficacy does not always translate to the cheapest dressing (Beldon, 2008; Browning, 2017). 

The use of ONPOS was a value added service provided by Coloplast which proved to be invaluable. In particular, the access to real-time data enabled the identification of areas of unwarranted variation, was of benefit to the trust, and had previously been reported in community settings (Grothier, 2013; Griffin, 2015; Markey and Barrett, 2017; Dowley and Tomes, 2018). Other benefits of using ONPOS are in line with those reported in community settings, including a reduction in avoidable product wastage (Grothier, 2011; Griffin, 2015; Markey and Barrett, 2017; Milne, 2018; Dowley and Tomes, 2018; Jones, 2020) and increased formulary compliance ranging from >85% to 100% (Grothier, 2013; Griffin, 2015; Markey and Barrett, 2017; Dowley and Tomes, 2018; Jones, 2020). Similarly, an improved patient experience by ensuring the patient has the right product at the right time is a benefit of using ONPOS regardless of care setting (Griffin, 2015; Markey and Barrett, 2017;  Dowley and Tomes, 2018). 

Real-time monitoring and reporting was described as a feature of best performing hospital systems by Carter (2016) since it allowed daily/weekly/monthly/decisions to be made that improved both quality and efficiency. The RCP (2018) stated that careful procurement and stock management could prevent over purchasing and expiration of products, leading to savings in procurement costs, while regular review can prevent the routine ordering of products that are unnecessary, and prevent goods reaching expiration before use. The use of ONPOS throughout the trust has found these actions have indeed resulted in efficiency and cost savings. 

Conclusion 

Improving outcomes requires reflection on practice and implementation of change. This is not always easy, support is often needed, and measurement of change is needed to demonstrate improvement (NHS England, 2018). The implementation of ONPOS and partnership working with Coloplast led to demonstrable improvements in the procurement  and use of wound dressings throughout the acute trust.