The Department of Health together with the NHS Supply Chain are trying to push through Generic Specifications (known as the Carter Report) where the specification criteria can be applied so that products, including dressings, will be able to be used in 80% of circumstances and where the output is “good enough” and “fit for purpose.” In addition, there is the intention to develop a National Formulary that will replace local formularies. We believe these recently announced initiatives to be ill-considered from the outset and that they will neither reduce costs, nor maintain, yet alone improve, the current levels of patient care.
Early in January 2016 the following question was addressed to Lord Carter—a Labour peer who is advising the government on how hospital budgets could be better spent—in an attempt to make our concerns known:
Re: “Medical Equipment: Procurement. HL48002”
“To ask Her Majesty’s Government what assessment they have made of the clinical and ethical justifications for setting the benchmark in the NHS Supply Chain generic project plans for a national formulary for wound care that 80 per cent of patients will be treated using clinically appropriate dressings.”
We have carefully considered the response, posted by Lord Prior, minister for NHS productivity, and make the following comments in respect of the arguments posed.
The stated objective is that the Department of Health is working with the NHS Supply Chain to deliver £300 million of savings by October 2018. Central to this is reducing the number of specifications and variations by category so the NHS can leverage its scale and deliver clinically appropriate solutions that represent “value for money.” Such approaches are common in other countries and help drive savings, improve clinical standards, and protect frontline nursing. In principle we have no objection to this aim provided that certain key elements are not compromised. For example, the quality of patient care is paramount and must be shown to be so throughout this exercise. Clinical judgement aspects must similarly be protected. Finally, our partners in the dressings industry must be able to operate in an atmosphere that supports innovation and thus provide those valuable developments, which have revolutionised wound care over the past 30 years.
The current Drug Tariff part IX includes a large number of wound dressings: it is claimed in Lord Prior’s response that this duplication in products is “…creating more complexity for nurses and clinicians, making their clinical decisions more difficult and potentially leading to over specification and variation in standards of care.” We are not aware of any published evidence that suggests that choice impacts on standards of care in the sense implied above. To claim otherwise is to regard all wounds, and patients, as homogeneous—a reductionist fallacy in clinical care. Standards of care are of concern to us but we would suggest that they, together with substantial cost savings, can be improved through appropriate education. A start in clarifying the variety of dressings available could be made by a change in classification, both in the Drug Tariff and BNF and in product packaging. Dressings should be clearly marked with their designed clinical performance rather than their material composition. Spurious DT classifications, such as “protease modulating matricies,” should be abandoned as of limited scientific or clinical value. The aim of altering the dressing classification system is to try and ensure that dressing selection is made in full consideration of patient need rather than that of commercial interests.
Justification for the scrutiny on dressings, as stated in Lord Prior’s response comes, in part, from a report in the Nursing Times in December 2014 where “74% of respondents saw opportunities to reduce duplication on wound care products.” [1] The factual errors in this response are numerous. Following up this NT reference reveals that in July 2012 (not 2014) a brief summary was published of an earlier study published in the Journal of Clinical Nursing [2] by an Irish research group which presented data from their international Delphi study on research and educational priorities in wound care. In this report only one reference is made to a 74% preference and that was to “infection control in wound care” i.e. not relevant to the current NHS exercise. Indeed, the data for this study were obtained from 350 professionals from 20 countries, the bulk 163 (47%) being from Spain. The UK contingent was England 20 (~6%), Wales 4 (~1%), Scotland 2 (~0.6%), and Northern Ireland 27 (~7.5%). This can hardly be regarded as representative, since most nations involved in this study have very different healthcare systems to the NHS! It is even less a justification for a wholesale review of dressings availability.
It is worth quoting Cowman et al who put this issue into perspective: “A key finding of our study surrounds the issue of wound bed assessment and wound dressings, and to better understand how dressings work and how to select dressings.” [3] This is a complicated yet vital area of patient care that requires the involvement of established experts whose interests lie in maintaining standards of patient care together with rationalising expenditure. We would be enthusiastic to contribute to any DoH/NHS exercise directed at these objectives.
References:
1. Cowman S (2012). Identifying research priorities in wound care. Nurs Times 108(32/33); 16-17.
2. Cowman S, Moore Z et al (2011). An international eDelphi study identifying the research and education priorities in wound management and tissue repair. J Clin Nurs 21(3-4); 344-53.
3. Moore Z, Cowman S (2005). The need for EU standards in wound care: an Irish survey Wounds UK 1: 1. 20-8
Richard J White, Professor of Tissue Viability, University of Worcester and Director, DDRC Wound Care, Plymouth.
Keith F Cutting, Clinical Research Consultant, Hertfordshire.
Steven Jeffery, Professor of Wound Study Birmingham City University and Consultant Burns and Plastic Surgeon, Queen Elizabeth Hospital, Birmingham.
Competing interests:
KC & SJ: None declared.
RW: I have been an employee of ConvaTec, a Bristol-Myers Squibb wound products company. I have received paid membership of speakers panels/bureaus and advisory board for numerous UK and European wound products companies over the period 1999- to date. I have acted as an expert witness in Intellectual Property (wound products) cases in the High Court. I have received travel and accommodation expenses from numerous wound products companies. I perform writing and consulting for a medical education promotional and communications companies associated with wound treatments.