The National Prescribing Centre was asked to lead a project on behalf of the Department of Health to produce a handbook of guiding principles to support the effective prescribing of dressings. During February 2012, the SDMA was invited to comment on a draft entitled ‘Prescribing of dressings – Guiding principles: optimising the quality and productivity of wound management services’.
The SDMA feel there is much in the draft guiding principles document that merits strong support, and would especially highlight the following in that respect:
- they promote the need for improved education and training of staff
- they advocate the development of treatment pathways and care plans
- they aim to implement guidelines and audit.
- they encourage the use of better screening tools and the broader use of risk assessment to help reduce the burden of chronic wound care on the NHS
- In particular, the recommendation for controlled investment to save can only be supported.
Limitation of waste and achieving economies
Point 2 of the guiding principles rightly emphasises the need to minimise waste and there are several published works that identify how waste in prescribing can occur. Interestingly, there is only limited data to support the assertion that wound care products are being over-prescribed or wasted in the community. A recent report, produced at the behest of the Department of Health, concluded that wound care products represented less than 1% of all the prescription items returned to pharmacies. In addition, returned wound dressings were generally of modest cost when compared to pharmaceutical items 1.
1 Evaluation of the Scale, Causes and Costs of Waste Medicines – Final Report, November 2010, York Health Economics Consortium and The School of Pharmacy.
2 The resource costs of Wound Care in Bradford and Airedale Primary Care Trusts in the UK, by K R Vowden and P Vowden, J Wound Care 2009 18(3) 93-102; and The cost of Wound Care for a local population in England, by P Drew et al., Int Wound J 2007 4(2) 149-155.
For wound dressings, we would argue that the efficiency and appropriateness of their use is likely to have a much greater cost impact than prescribing wastage. A good illustration of this is provided by NHS audits in Bradford and Hull. These showed that dressing/material costs accounted for 10-15% of the total cost of treating wounds – with 85-90% related to the provision of care. Using lower cost dressings might reduce the 10-15% element, but at the expense of increasing the 85-90% element. We would argue that appropriate use and training for dressings is more likely to provide savings overall, along with relevant measures and KPIs targeting the total cost of treatment rather than just lower product costs 2.
The term ‘wound care product’ covers a very broad spectrum of prescription items – including traditional gauze pads, foams, alginates, hydrocolloids, protease modulating dressings and other high technology items. Taking a simple average cost per dressing approach may incentivise the use of the lowest cost dressing, rather than the most cost effective dressing. A consequence might be less efficient healing, leading to increased costs overall. Clearly, there are ways to avoid this, including the development of treatment pathways and care plans, and the implementation of guidelines and audit. Further options include the use of the lowest cost dressings based on evidence, or the limitation of the highest cost dressings to specialists.
The evidence required to support the use of wound care products
The draft guidelines refer to an MeReC Bulletin published in June 2010 3. It suggested that the evidence base supporting the choice of dressings may be less established and of poorer quality than in other areas of prescribing. We have to question whether principles appropriate to pharmaceutical products are being applied to the rather different circumstances of medical devices. As a consequence, the SDMA is currently undertaking a wide survey amongst its members to determine what quantity of evidence is available to support wound care products and of what strength.
3 Evidence-based prescribing of advanced wound dressings for chronic wounds in primary care, June 2010.
4 Professor of Tissue Viability, University of Worcester.
5 Medtech Business, June 2010.
The survey is very much a work in progress. However, we can offer an indication based on a sample of 55 wound care products of the type in question. For these products the following mean levels of support have been reported:
Randomised trials 93 1.7 per product
Cohort studies 52 0.95 per product
Observational studies 104 1.9 per product
Case series 141 2.6 per product
Case studies 499 9.1 per product
In vitro testing 205 3.7 per product
These preliminary results appear to indicate that there is an established evidence base. Clearly we would be more than happy to share the final results when they are available.
Specific reference was made to the efficacy of silver and other antimicrobial dressings. Currently this is a matter of wide debate, with many publications providing strong support for the appropriate use of these dressings. The views of acknowledged experts such as Professor Richard White 4 should certainly be taken into account:
“To withdraw silver without adequate justification and/or without clinical advice on alternatives will compromise care, increasing morbidity and mortality. The latter has been established through audits showing that the arbitrary withdrawal of silver has led to increased incidence of septicaemia and death (Newton 2010)” 5.
We have to specifically challenge the statement concerning resistance and toxicity in relation to silver dressings. We are not aware of evidence to support this claim when silver dressings are used as recommended by manufacturers. Statements along these lines may lead, for example, to restrictions on the use of silver dressing that would not be supported by evidence, and with the consequences described above by Professor White. If used when clinically indicated, antibacterial dressings clearly have a place in wound management. A recent best practice statement made the following observations:
“ Wound infection is without doubt the most troubling of all wound complications (Cutting, 1998). Whether present in a closed surgical wound or in a large open pressure ulcer, the impact on the patient is such that they may experience relatively minor symptoms such as pain, swelling and discharge, but also may be at risk of a potentially life-threatening sepsis (Collier, 2004).” 6
6 Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. Wounds UK, Aberdeen, 2010
7 Race for Learning Programme, Peer Review: NHS Bristol, 2010.
“Similarly, the wound dressings industry now realises that it, too, has a responsibility to provide clear, evidence-based instructions for use, and to educate customers in the best practice for use of their products.” 6
This best practice statement allowed industry a role in assisting the development of guidelines in the wound care arena. The SDMA and its members would welcome opportunities to assist or help coordinate industry input into the development of other best practice guidelines.
Local procurement and formularies
Point 3 in the guiding principles emphasises a need for local health economies to understand their local procurement and prescribing arrangements for dressings across all sectors. Clearly, too much procurement activity or fragmentation of procurement can lead to inefficiencies. Best practice exercises and reviews of procurement have been developed locally inside the NHS, a good example being supplied by NHS Shared Intelligence 7.
The increasing use of local wound care tenders and formularies may well be limiting the ability of the procurement system to evaluate and introduce new and improved products for patient care. Such limitations need to be avoided – and guidance is required to ensure that new products with a benefit to patients and the QIPP agenda are more rapidly integrated into practice. We fully support the statement in point 2 that there should be a policy for the review of formularies, including how new products should be considered for inclusion. The process used should be published and transparent.
Also under point 2 is an estimate that 80% of patients could be treated using existing products on local formularies. This implies that targets set for prescribing compliance will need to recognise and make allowance for a need to prescribe outside of the formulary for the remaining 20% of patients. In addition, measures of prescribing compliance for wound care could not mirror the generic prescribing of pharmaceuticals, since the shapes, formulations and overall design of dressings listed within the same category can vary greatly and are generally not interchangeable.
The provision of wound care services is fragmented – being provided by hospitals, nursing homes, prisons, community nurses, and so on. The approach in each of these individual sectors is tactical. An overall strategic approach by NICE and the NPC that challenges this fragmentation could offer benefits, and would certainly address any misalignment between wound management in acute and community settings. Such a focused strategy could allow wider and more efficient use of the specialist nursing resource that already exists in some sectors (for example Tissue Viability Nurses).
Involvement of Industry
Over the years, there has been a considerable amount of innovation by industry, which has led much of the move from gauze to advanced wound care products. SDMA members
continue their innovation process and would clearly welcome greater involvement from users and prescribers that might help direct that process.
In point 8 of the guiding principles the key role that industry currently plays in the wound care education of front line staff is not recognised – nor are the cost implications to the NHS if it had to take over this role.
Silver products are mentioned above, and actually represent an area where industry has played a role in promoting more appropriate use of wound dressings. Over the last two years, the use of silver dressings has reduced significantly by around £5M/annum 8. Part of this was due to manufacturers educating users that indiscriminate use was inappropriate – instead defining a ‘2 weeks message’, with wound healing being reviewed after that period with a view to changing the care plan and prescribing.
The greatest benefit for patients, clinicians and the NHS would come from a broader understanding of the prevalence of wounds and the best practice to prevent, manage and heal those wounds. It is here that guiding principles most clearly have a place – and increasing their breadth could only be helpful. Industry would certainly support such a move, and maybe should develop its own guiding principles on the use of its products. We already have guiding principles for the sale and promotion of wound care products in the form of a well-known Code of Practice 9 to which member companies are held to account.