What are your thoughts on some of the statements that have been made around the role of the tissue viability nurse (TVNs), such as, ‘we should be fiercely protecting the role’, ‘the role is dying’, ‘the new strategy may re-ignite interest in the role of the TVN’ and ‘we should be taking the role of the TVN seriously’?

AS: One of the main issues within tissue viability is there is no structure within the service or the specialism, unlike other services, such as infection control, vascular services or podiatry, which seem more cohesive by comparison. Sometimes tissue viability seems under resourced, with some jobs being de-banded. There is also no recognised qualification for tissue viability. TVNs are excited to see the impact that the NWCSP will have on these deficiencies.

UA: TVNs will be the clinical leaders in how we move forward. TVNs tend to hold senior roles and are paid accordingly but not every patient needs to see a senior TVN. We need services that are led by a senior TVN working in partnership with other specialities. Education is key and the NWCSP will be pushing for specialists and TVNs working at a senior level to be educated at Masters level or working towards this. The role of the TVN must be seen as part of the solution — not the only solution — and the role is well represented throughout the NWCSP.

RC:  In order to generate a service that improves clinical outcomes and patient experience, industry sees the TVN as the focal point. The TVN is the director or coordinator of a standardised approach.

JG: From my experience as a commissioner, and from what I have observed in other services, what is needed is a service specification which will ensure focus is maintained on outcomes rather than the number of people required to deliver them. I see the NWCSP key in informing this.

JFG: The original burden of wounds study (Guest et al, 2015) showed that less than 5% of patients with a wound actually saw a TVN but the majority were seen in the community by a district nurse or healthcare support worker. These are the people who need to know how to manage wounds and education should be improved for them.

How are developments for the workstreams of the NWCSP going to be implemented across England, Scotland, Wales and Northern Ireland?  

UA: The work of the NWCSP is only for England but there has been conversation with other countries as it is important to work together and learn from each other. It is relatively easy to write a set of guidelines but it’s much harder to implement and we recognise that this will not happen overnight. It we are going to get the attention of the commissioners, it needs to be a robust, financial case with the benefits and risks outlined, which we are currently looking at. The key is to combine the ground swell of passionate, interested people with a top-down approach at a national level and we are in conversations with the policy department of NHS England.

JG: Priorities vary between different commissioning groups depending on local needs. The key to getting the message across will be how it contributes to some of the other priorities and co-morbidities.

CO: I understand high priority areas include coronary heart disease, diabetes and obesity and the burden of wounds study concluded that wounds are comparable to obesity in 2012/2013.

RC: Part of the problem is that because no importance has been placed on wounds over the years the data that is needed doesn’t exist, so a typical CCG doesn’t know how many patients with wounds they have, where they are being treated or the costs involved. As a consequence, how can the CCG know what they are commissioning?

CO and UA both agreed that robust national evidence existed demonstrating that most wounds were on the lower limb and that 70–80% of a district nurse’s workload involved wound care but that local level, precise data was also needed to bring clarity.

Product quality and efficiency is paramount to healthcare staff on the front line and to patients. Are we honestly going to see these values reflected in procurement or is obtaining the cheapest product the main concern for NHSSC?

JG: Since the launch in 2018 of the new operating model, products are required to be value for money, fit for purpose, safe and represent user needs. The assurance framework, which looks at quality and value for money for the NHS, is applied to every product that comes through the supply chain. Quality is the first point and we are working with the NWCSP so that any recommendations proposed are directly implemented through future procurement.  
 
UA:  the NWCSP does not have a remit around procurement but we will provide clinical advice about what we are seeking, for example, a system for absorbency that indicates quickly and simply whether a dressing absorbs a low, moderate or high volume of exudate.

RC: Industry believe that quality assurance is the remit of medical device directives, medical device regulations and CE marking. All of the wound care products sold in the UK have gone through this rigor in order to be sold. We worry that the focus is on the unit cost of the dressing, but as JFG found in the burden of wounds study, this represents only 10–13% of the cost of wound care. We would like the focus to be more around the whole pathway of care with regard to value and improved outcomes.   
   
AS and UA both agreed that it was more about people choosing the correct type of dressing or treatment to address a particular situation and using the product to the best of its ability and ensuring all patients have equality in wound care provision. For example, the under use of compression and the overuse of absorbent dressing in venous leg ulcer management is common, whereas appropriate use of compression will see an automatic reduction in the number of absorbent dressings used.

CO: Are we actually talking about limiting the number of products available for use by specialist nurses and district nurses?

UA: It is not within the remit of the NWCSP and it has no intention of having a national formulary or limiting products.

 
MG: The NHSSC works closely with the clinical engagement team and examine previous documentation to determine perceived quality of products and look for areas that have potential for standardisation and rationalisation. Within wound care there are only five areas that have completed a nationally contracted product (NCP) and there has been very positive feedback from those areas, not just on cost savings. It has forced commissioners to examine alternative products and has overcome existing loyalties to some products. The products selected and now used are working well. If there is a genuine belief that a different product is needed, this can be addressed using a Clinical and Product Assurance (CaPA) process.

AS: We use some advanced products with very specific roles for some chronic and complex wounds. We currently use a formulary system, but we are fearful that we will only have access to simple products that are not always suitable.

UA: There is a supply and distribution workstream within the NWCSP and we are evaluating all of the different ways of obtaining products, looking at the advantages and disadvantages of each system within each different setting and then making that accessible to those who make the decisions on how wound care products come in to their organisation.

JFG:  If the clinician isn’t able to select the right product for the right patient at the right time, that has the potential to increase the time to healing or lead to non-healing which results in increased risk of complications, increased recourses required to manage the wound and ultimately increased costs.   

RC: We need more evidence to see if restricting choice and saving money on dressings actually saves nursing time and reduces the overall cost of the whole wound healing process or just the procurement cost of the dressing.

 
MG: We always give more than one choice of supplier in each product area. The minimum is two and on average it is 3–5 suppliers.

AS: There will always be the risk that individual organisations will take things literally beyond the intention of the NHSSC.

JG: We are trying to find a solution for the whole NHS and products were only a part of this process. It was important to focus on product and unwarranted variation in practice, and approach it systematically.

RC:  Industry fully endorses the drive for better clinical outcomes, better patient experience and to reduce costs to the NHS. However, it is too easy to look at the wound dressing first as it is tangible. Focus should be upon the delivery of care as this will have a much bigger impact to the NHS.

UA:  The wound dressing is important, but not as important as the delivery of care.


If industry is limited on the products they are able to sell, what would happen to the innovation and education they provide?

UA: We are very grateful to industry for providing wound care education, but should it be the responsibility of industry? We also welcome innovation, but the only innovation the NHS can afford is effective innovation that delivers meaningful outcomes.

AS: There is currently a huge problem with staff in all clinical areas being released for classroom-based education. Often, they undertake educational activities in their own time and, without industry support, conferences like Wound Care Today wouldn’t happen. Facebook Live education is an ideal and popular way to learn and is also supported by industry. As a sole TVN in an organisation I am unable to deliver education on my own and value the partnership approach with industry, especially when delivering formulary-based product education.

RC: Wound care in the UK is considered ‘gold standard’ globally, but if there is a continued race to the bottom of wound dressing price, the margin is eroded, and this is what we use to invest in innovation and education.


Do primary care networks (PCNs) provide an opportunity for General Practice Nurses (GPNs) to engage with wound care?

UA: The real opportunity for PCNs is to adopt an integrated way of working across the boundaries in order to make wound care better. We do not expect GPs or GPNs to become TVNs but what we would expect is that if they saw a patient with a wound on the lower limb they don’t just apply dressings and prescribe a course of antibiotics, but they organise themselves to work collaboratively with their tissue viability service to deliver the care or they refer the patient on to a service that can deliver the care, as some are doing already.

AS: The delivery of wound care by GPNs is something that needs to be tackled, as we have seen in the example from NHS England – Right Care (https://www.england.nhs.uk/rightcare/products/ltc/). In my experience, even when you have a specialist leg ulcer service, patients are still not accessing it. CO stated that she felt it was a real opportunity and UA commented that it should not be their sole responsibility, but they should be encouraged to be part of the conversation and engage with others.


Where does prevention and self-care fit in to the conversation so far?

AS: This is a really important topic which will help reduce workloads and associated costs. We know that the older population is growing, bringing an increase in wounds and leg ulcers. We should be proactively handing some of the care over to patients who are willing and able to self-care, and using the solutions that are available.

UA: There have been some good initiatives to raise public awareness of self care, for example the Legs Matter campaign. We should also make better use of the systems that are already available, such as NHS Choices. The information could be updated, and the system could be used to sign post people to places where they can get more information.

JG: An example of a successful campaign was the use of anti-emboli stockings when you are travelling on a plane.


Is there anything we can learn from parallel specialities, for example infection control surveillance? What would be the outcomes you would look for in wound care?

UA: The outcomes would depend on the area of wound care:

• Pressure ulcers – outcomes may be prevention, but this is very difficult to measure, and pressure ulcer healing rates
• Lower limb – healing rates and the prevention of recurrence
• Surgical site infection (SSI) – the number of open surgical wounds, the prevention of SSI, the diagnosis of SSI, this is also not straight forward and often undertaken by junior medical staff. The data does not often capture rates outside hospital, and because of early discharge if a surgical wound breaks down it will be at home and not in hospital.  

Are the roles and aims of NHSSC and the category tower clear?

UA: the NWCSP had no jurisdiction over the NHSSC as they are a body in their own right. The NWCSP aims to improve patient care while the NHSSC puts quality first, and where there is unwarranted variation, aims to reduce costs for the NHS while also wanting the best outcome for the patient.

NWCSP is a stakeholder that complements the NHSSC, and offers collaboration and support.

MG: The category tower is finalising the strategy for the wound care renewal contact and it is important to understand how TVNs could get involved going forward. The clinical engagement network comprises of current TVNs in practice ,but as there are 240 acute Trusts it is impossible to engage with every TVN from each of the Trusts. However, there had been significant engagement nationally, with a good geographical spread that includes a community perspective.

JFG: If the 2012/13 burden of wounds study costs are compared with the new analysis for 2017 (both excluding wound care product costs), you would see a huge increase over the five years which reflects the increased number of wounds and resources needed. The cost of the wound care product used is irrelevant. In order to re-think wound care and implement change, we need to think of it as a human resource driven discipline.

CO: To summarise and conclude, If cost savings focus solely on product, it will not improve diminishing NHS resources. The only way we can do that is by combining how we approach products with changing working practices.

There are a number of clinicians who are costing the NHS a great deal of money, not in product use, but by delivering poor care and, in some cases, causing harm though outdated ways of working. The challenge is, how do we solve this together?