Question for Short Debate
My Lords, in my noble friend’s unavoidable absence, I shall ask the Question standing in his name on the Order Paper. Wound care is a massive challenge to the NHS, but it currently lacks priority, investment and direction. This debate is designed to press the Government to recognise the need for urgent action and for the development of a strategy across care providers for improving the standards of wound care.
I am delighted that so many noble Lords with expertise on this highly important matter have put their names down to speak. It will ensure that we can cover a wide range of issues across medical, nursing and patient care and the quality of medical supplies. It will also give the Minister the stepping stone for developing the national strategy that I hope he will recognise is sorely needed.
A staggering 2 million patients are treated for wounds every year at a cost of more than £5 billion. The overwhelming majority of this figure goes towards paying for nursing care costs rather than products such as bandages. In other words, the cost is more than, for example, we spend on tackling obesity, which is the centre of major national campaigns. Treatment costs include more than 700,000 leg ulcers and 80,000 burns. Pressure sores also feature highly, with estimates of an 11% increase overall each year.
While 60% of all wounds heal within a year, a huge resource has to be committed to managing unhealed wounds. The NHS response is very variable. Healing takes far too long; diagnosis is not good enough; and inadequate commissioning of services by clinical commissioning groups compounds the problem, with undertrained staff and a lack of suitable dressings and bandages. There has also been a very worrying drop in the number of district nurses, whose role in ensuring safe and effective wound care in the community is crucial.
Ideally, 70% of venous leg ulceration should heal within 12 to 16 weeks and 98% in 24 weeks. In reality, however, research shows that healing rates at six months have been reported as low as 9%, with infection rates as high as 58%. Patients suffer and the cost of non-healing wounds is substantially greater to the NHS. The failure to treat wounds swiftly and effectively can lead to more serious health problems, such as sepsis, which is often the result of an infected injury; we also know that foot ulcers on diabetics can lead to amputations if they are not dealt with properly.
The situation will only be turned around with a nationally agreed strategy to reduce variation, prevent wounds getting worse and improve outcomes. Wound care therapy strategies are needed and national care pathways for wounds must be established to cover the complexity and variety of wounds, using evidence-based health economic data and academic and clinical expertise. The Bradford study and survey that is summarised in the Lords’ Library brief for this debate—a good brief but sadly received only yesterday—underlines the point about the importance of evidence-based care, with nearly one-third of patients interviewed in the study failing to receive an accurate diagnosis for their wound. As the study puts it:
“Wound care should be seen as a specialist segment of healthcare that requires clinicians with specialist training to diagnose and manage. … There is no doubt that better diagnosis and treatment and effective prevention of wound complications would help minimise treatment costs”.
Dedicated wound clinics in the community are also needed, alongside a co-ordinated treatment plan to achieve best outcomes for patients. A focus on the prevention of wounds, as well as treatment and healing of wounds, is also very important. The NHS must also invest in high-quality bandages and dressings, in contrast to the current skimping that takes place in many areas. We know, however, that with the NHS as financially hard pressed as it is, there is huge pressure to reduce the costs of medical equipment and clinical supplies such as dressings. The result is that in the procurement of dressings and other forms of treatment, there is not enough emphasis on the cost of patient care and too much focus on the unit cost of products. Not only does this lead to poorer and more costly outcomes for patients but there are a number of unwelcome side-effects. Products will be less innovative and effective; a reduced amount of educational support will have a detrimental effect on patients; there will be fewer appropriate treatments available; and all this will lead to job losses if there is less sourcing from high-quality British suppliers and manufacturers.
With cost as the primary driver, suppliers to the NHS will have a race to the bottom, compromising quality. Poor-quality dressings simply cannot withstand the rigour required to produce effective healing. It is massively counterproductive. Reduction in the availability of clinically appropriate dressings, which comprise only 10% of costs, will result in patients suffering as wounds take longer to heal. An increased burden on the NHS will follow and the result is longer hospital stays, particularly for the elderly, more readmissions, compromised quality of life and repeated visits to GPs and community services.
Of course, we fully support improvements in the way that medical equipment and other supplies are procured. I am not sure whether, in his absence, I have to declare my noble friend Lord Hunt’s interest and commitment to these matters as president of the Health Care Supply Association but I am sure he will value it being mentioned. We also support the work of my noble friend Lord Carter and his 2015 review on how the NHS can avoid unwanted and unnecessary variations in the cost of supplies. The overall aim of his review was to see how the NHS could reduce spending by £5 billion by the 2020-21 financial year. It proposed £600 million in savings for supplies, half of this to be saved before October 2018; limiting the NHS to 40,000 products instead of 300,000, with an overwhelming majority of this—80%—going towards a newly revised supply chain process; as well as replacing local formularies with a national formulary.
Although we welcome the report’s efforts at saving the NHS money, we need to ensure that any shift in focus to the short term will not lead to the knock-on effect of costs rising in other clinical areas. There is also strong concern that the short-term focus could lead to a scarcity of supplies in the future. I would be grateful to hear reassurances from the Minister on the steps being taken to guard against these two unwanted outcomes. Evidence clearly shows that the current problems can only worsen. The average number of adult wounds that every CCG will have to manage is expected to rise from 11,200 in 2012-13 to 23,000 in 2019-20.
The Government urgently need to get a grip, with a nationally driven strategy. Without it, patients will receive worse care for their injuries and the financial burden on other parts of the NHS will continue to increase because patients will develop chronic wounds or catch an infection that could lead to potentially life-threatening illnesses. I look forward to the contributions of noble Lords to this very important debate and to the Minister’s response.
My Lords, I congratulate the noble Baroness, Lady Wheeler, on her explanation of the follow-up questions asked by the noble Lord, Lord Hunt, on the development of a strategy for standards of wound care in the NHS. If noble Lords will permit, I shall establish the context in which wound care sits within the pressures faced by health services. I do not have any financial interests to declare.
It is no exaggeration to say that improving wound care in the NHS is a crucial part of tackling one of the greatest health and economic challenges of our age: antimicrobial resistance. AMR is causing a rise in drug-resistant infections, killing some 700,000 people worldwide. In the UK alone, it results in 3,000 deaths a year, with an estimated cost to the NHS in excess of £180 million a year. Without global action, according to the 2016 report of my noble friend Lord O’Neill on this issue, AMR will kill another 10 million people annually by 2050. According to my noble friend’s findings, the increase in death and illnesses is set to wipe approximately $8 trillion off the world’s annual output by 2050. Discussing how we can improve wound care is vital to addressing the challenge of AMR.
Some of the most challenging wounds are skin and soft-tissue infections. These include infections of skin, tissue, fascia and muscle. SSTIs are the second most common infection in hospitals. They often involve the invasion of deeper tissues and typically require significant surgical intervention. Between 7% and 10% of hospitalised patients are affected by SSTIs and such infections are very common in the emergency care setting. For complicated SSTIs, the response to therapy is often complicated by underlying disease states, such as infected burn wounds and deep-space wound infections. These infections are often limb or life-threatening.
A significant body of research on SSTIs has been conducted by Dr Matthew Dryden, clinical director of infection at Hampshire Hospitals NHS Foundation Trust and at Public Health England. Dr Dryden has highlighted that SSTIs are some of the most common infections, suffered by everyone at some point in their lives and encountered by all doctors. However, it is clear that if we are to improve the way the NHS addresses wound infections and halt the rise of antimicrobial resistance, new treatments are needed. Thankfully, along with colleagues at the Universities of Manchester, Birmingham and Southampton, Dr Dryden has been working to develop an extremely promising new treatment based on reactive oxygen technology.
At this point I have a personal interest to declare, as my younger brother suffered wounds infected with MRSA, C. difficile and pseudomonas. Despite hospitalisation and intravenous antibiotic treatment over three years, the bacteria were antibiotic-resistant and, after he eventually developed sepsis, to save his life his leg was amputated. Following this, a further wound developed, showing pseudomonas. Having read about the success experienced with reactive oxygen and the work carried out by Claire Stephens and her charity Woundcare4Heroes, I was able to introduce them to my brother’s clinical team. His wound has since been successfully treated with reactive oxygen and I am pleased to say that the bacteria have cleared and the wound is now fully healed—although he is still minus one leg.
The research and development of reactive oxygen is being led by a British biotechnology SME, Matoke Holdings, which is committed to meeting the challenge of antimicrobial resistance. In my career as a dentist, I was aware of some of the important work being done using oxygen in oral healthcare, about which I have spoken in previous debates. I am excited that oxygen is now at the forefront of work to address wound care and AMR, with the development of reactive oxygen.
Reactive oxygen is a British-led innovation that represents a new generation in antimicrobials and offers a breakthrough in medical research. In both laboratory and clinical tests, reactive oxygen has been proven an effective treatment of Gram-positive, Gram-negative, multi-resistant and pan-resistant bacteria. Indeed, research has demonstrated that it can kill many of the priority superbugs highlighted by the World Health Organization.
The first product based on this technology, a medical device, is already approved by the EU regulatory body and being prescribed through the NHS. Such technology has huge potential to save lives and deliver significant savings to the NHS by providing an effective new treatment for chronic wounds. This can reduce the number of amputations and days spent in hospital with nursing care. Scientific research suggests that the technology has a far wider potential, including as a stimulant of tissue regeneration and in the treatment of urinary tract infections and respiratory infections.
I am aware that Matoke is going through the pharmaceutical regulatory approval process, involving clinical trials, to address infected human soft tissue. Such innovative British technology, which represents a new generation in antibiotics, needs to be brought to the forefront of the policy discussion about wound care, both within the UK and globally. However, the cost and timescales involved in research and development are a hindrance to bringing new treatments into the NHS. Given the scale of the AMR threat, public bodies need to do more to identify the most promising potential solutions and help push these forward.
I welcome the announcement of the new accelerated access pathway, chaired by Sir Andrew Witty, which I hope will accelerate the development of reactive oxygen and bring transformative treatments to patients in the NHS as a priority. I hope that Sir Andrew will consider reactive oxygen as a candidate for the pathway. If the Government are to deliver on their bold commitment to meet the global AMR threat, they also need to include specific support for SMEs involved in the development of new antimicrobials in their response to Sir Hugh Taylor’s life sciences strategy.
Britain is a world leader in scientific research. Improving the standard of wound care in the NHS will require us to improve how we translate this research into new wound care treatments in the NHS. I believe that reactive oxygen offers one of the most exciting prospects for achieving this. I would be grateful if the Minister would meet Matoke Holdings so that he can hear first-hand the challenges faced by SMEs working on the front line to make new wound care treatments available to the NHS.
My Lords, I am delighted that my noble friend Lord Hunt of Kings Heath was able to secure this important short debate, which was so ably introduced by my noble friend Lady Wheeler. As a former nurse, I find this subject of obvious interest. As someone who was at the receiving end of suboptimal wound care some nine years ago, and has residual problems to remind me every day, I find that interest reinforced.
Wound care is no longer part of what many years ago used to be called basic nursing practice. Obviously, I expect that all registered nurses will know a lot about wound care—but nowadays it is much more than that. Before treatment there have to be proper diagnosis and proper identification—or perhaps I should say classification—of the wounds. There are many types of wounds: surgical incisions; abrasions; granulating or overgranulating wounds; and diabetic foot ulcers and ischaemic leg ulcer wounds, about which we have already heard quite a bit in the debate.
One of the least excusable wounds to me, as a nurse, is the hospital-acquired or care home-acquired pressure sore. It should never be forgotten that sloppy, incorrect care of a tiny wound, as in a jugular vein cannulation site, can lead to sepsis, with all the horrors that follow, such as acute kidney injury. I know because it happened to a relative of mine very recently.
There is no doubt that the care of wounds is staff-intensive, extremely costly to the National Health Service and, not least, costly to the patient in terms of pain, infection and immobility. Wounds not healed within, say, six weeks can be defined as chronic. There are many factors which delay and impair wound healing, including: underlying disease; reduced blood supply; infection; malnutrition; poor patient compliance; and, indeed, smoking and alcohol. There are more, but I am not going to list them—except to say that one of the most important is inappropriate or poor wound management.
It is here that I will speak about the role of the tissue viability nurse. That nurse specialist comes into their own in cases of wound management. They have an important role in clinical practice. Their skills are important so that there is correct diagnosis and classification, which in turn will lead, one hopes, to the correct treatment—there are huge variations in the types of tissue damage in different wounds. Is the wound clean? Is there debris? Is there infection? Is there pus, a lot of exudate or a lot of necrotic tissue? All these issues have to be identified before treatment.
The tissue viability nurse also has an important role in prevention; in education; in research; in working with other National Health Service teams, including pharmacists, and, ideally, outside the hospital with, for example, community staff, care homes and hospices. It is, or should be, part of the tissue viability nurse’s role to educate senior finance and procurement staff about what really works in wound care. Tissue viability nurses, individually or in teams, have the capacity to reduce trauma for patients and mitigate the huge costs to the health service, but there are too few of them, too few specialist doctors and far too many protocols. As my noble friend Lady Wheeler said, there is a vital need for a nationally agreed and properly resourced strategy to improve prevention and, where prevention fails, to improve the quality of wound care and thus reduce costs.
I turn to dressings. There appears to be increasing pressure to redefine what we used to call “cost-effective treatment” in relation to wound dressings to mean the cheapest—or, in the jargon currently used in procurement, those said to be “clinically acceptable”. That is not necessarily the best way to reduce costs. Dressings classified as “acceptable” cannot always be those that are clinically indicated and appropriate. If healing is compromised and delayed, that which might be acceptable to accountants becomes, in fact, the antithesis of what is really cost effective. Doctors, tissue viability nurses and other nursing staff need to be able to access the treatment which is essential to promote the best outcome —for the sake of the patient and of the service.
I have no problem with cheaper generics when it comes to paracetamol or the many other drugs which have exactly the same formula as the more expensive branded versions. This is not so in the highly specialised field of wound dressings and treatment. Cost must not be the primary driver.
My daughter, who is involved in clinical teaching, tells me that programmes that have been developed to carry forward professional development in her trust are now severely curtailed by the massive reduction in the funding for continuing professional development. That includes development of courses on issues such as wound care.
We are seeing reductions in opportunities for training, the drive for the cheapest possible procurement, the huge workload pressures on nursing staff in hospitals and, even worse, in the community, as evidenced by the massive reduction in the numbers of district nurses. All those factors together must militate against the good developments in wound care. There cannot be any argument against the need for a coherent national strategy if we are to reduce poor outcomes for patients and reduce the costs involved.
I hope that this short debate will reinforce the seriousness of this matter to the Government and give the Minister the opportunity to tell the House what plans there are to increase, for example, the number of tissue viability nurses so that there can be more support, not just for staff in hospitals but for hard-pressed community staff and for nursing and care homes. Will the Minister say how the important matter of wound care is to be taken forward? Will there be a new coherent national strategy? I very much look forward to his response.
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?
My Lords, it is a great pleasure to follow my noble friend Lord Kakkar, if I may call him that. He always speaks with great knowledge on medical matters and I will not be able to follow him down the same path, as I unfortunately have no medical qualifications. I join other noble Lords in thanking the noble Lord, Lord Hunt, for enabling us to have this important debate. I am sorry that he is not able to be here with us, as I know he is keenly interested in the subject. I, like other noble Lords, was looking forward to hearing what the noble Lord would have to say but the noble Baroness, Lady Wheeler, covered his unavoidable absence well and set the scene for tonight’s debate.
I say straightaway that I have no medical background nor any interest to declare in this matter, other than as a somewhat accident-prone individual who has had more than his fair share of injuries and operations where wound care has been an issue. We are told in the briefing papers from the House of Lords Library that the NHS treats an estimated 2.2 million wounds each year, at an estimated cost of £5 billion. Several noble Lords have already mentioned this, but having done the maths I have worked out that it comes out at an average cost per individual wound of £2,300. Quite obviously, this is an extremely costly problem, which we must address. It is imperative that less expensive and more effective ways are found of dealing with these injuries as a matter of urgency; I am sure that we could all agree on that. We are running out of options as far as antibiotics are concerned, and I believe that we need to turn to Mother Nature for help.
I was introduced to the amazing healing properties of one product in nature’s armoury some 25 years ago, while taking on the somewhat ambitious project of building a house on a remote hillside 1,500 feet up on the Greek island of Samos. I was being helped by four or five locals from the nearby village and work was progressing well, until I stumbled and cut my hand quite badly. One of the men dashed off into the forest nearby and came back, moments later, with several pine tree branches. He proceeded to milk them of their sap, which he then used to completely cover the wound. It was then bandaged with an old shirt—I hope noble Lords are keeping up. I never had to go to hospital or have any other intervention. After three more applications of pine sap over the course of a week, the wound had completely healed and there was no scar tissue. I have since looked up the healing properties of pine sap on the internet and discovered that it is not only antiseptic but an anti-inflammatory.
Since then, another even more extraordinary product of Mother Nature has come to my attention, and that is honey. My noble friend Lord Colwyn spoke persuasively and movingly about this when he mentioned reactive oxygen, but in fact the main component of the product I will talk about is honey. I said a little earlier that I am somewhat prone to accidents, and honey has now supplanted pine sap as my wonder potion. My noble friend Lady Harding, who sadly is not in her place tonight, first told me about it as she had had astonishingly successful results from applying manuka honey to the badly injured leg of one of her horses. I thought that I had better try it myself and I subsequently used manuka honey to good effect on burns and cuts.
More recently, I have been using Surgihoney reactive oxygen. This can be bought on the internet and rapidly destroys the bacteria that cause wound infection, including MRSA. It can be used for all stages of healing on a wide range of acute and chronic wound types including leg ulcers, pressure injuries, burns and surgical wounds. The Surgihoney website has a 20-minute video on it, which I venture to recommend to anyone with an interest in this subject. It shows the near-miracle healing properties of this product.
My question to my noble friend the Minister arises from an Answer that the then Minister, my noble friend Lord Prior, gave to a Written Question from the noble Lord, Lord Hunt. It was answered on 10 March 2016 when my noble friend Lord Prior said:
“In order to progress this work, from April 2016 a new NHS Clinical Evaluation Team will be put in place. The Clinical Evaluation Team will assess wound care products through a comprehensive evaluation process, which will have extensive engagement with NHS clinical staff”.
Can my noble friend the Minister assure me that that NHS clinical evaluation team will include, or is including, Surgihoney reactive oxygen as one of the products in its wound care assessment? I will quite understand if he is unable to answer this evening, but a letter in due course would be much appreciated.
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for selecting this very important subject and the noble Baroness, Lady Wheeler, for leading the debate.
I must declare an interest. I have been a paraplegic, paralysed from the chest down with no feeling, since breaking my back in 1958. I know only too well how important it is to have a high standard of wound care in the NHS. I also have to confess that I have a pressure sore, which needs constant care. It developed after one of my helpers inserted a slide board with too much gusto when I was getting out of my car. This broke the skin in a very difficult to heal place. My skin can be problematical and some wound dressings can give allergic reactions. There should be a good choice of dressings, as different wounds need a variety of dressings and patients like me can react and heal in different ways.
Wound care should be raised up the agenda. We need an upgrade, but some interested parties fear that wound care might be downgraded. Billions of pounds are involved and this is a very serious matter. I ask the Minister: does that figure include the millions lost to the National Health Service because of litigation from bad care?
I also declare an interest as a patron of the Lindsay Leg Club Foundation, which is a charity concerned with the leg ulcers that affect about 700,000 people in the UK. The cost of leg ulcer treatment and management is around £1.94 billion. The ulcers are painful and debilitating, they consume a vast amount of district nurses’ time and they often lead to social isolation. The Lindsay Leg Club Foundation helps promote a social model of care which improves healing rates, decreases social isolation and enables healed legs to be maintained with a “well leg” regime of care.
Does the Minister agree that a key aspect of improving wound care and reducing infections within hospitals rests with good hand hygiene? The first step in improving hand hygiene to reduce hospital infections is to acknowledge that the current method of direct observation is inaccurate. The availability of modern technology means that NHS trusts can today seek more accurate methods to monitor and drive improvements in hand hygiene and hence to reduce the risk of infections.
The Surgical Dressings Manufacturers Association is concerned that likely changes to NHS procurement in wound care could compromise patient safety and increase NHS costs. A possible reduction in the availability of clinically appropriate dressings will cause suffering to patients, as wounds will take longer to heal and place an increased burden on the NHS. If hospitals and care homes do not use the most appropriate dressings, patients with pressure ulcers will have to stay in hospital longer and will have a poor patient experience and outcome. The same applies to patients living in the community, but there is the added problem of the shortage of district nurses.
I hope the Minister will give the House some assurances tonight that wound care will not be downgraded and that there will be a strategy that will include the NHS and public health and that the private sector can learn from it too. We need people to work in this field who understand the importance of good wound care and who have the necessary skills and dressings to look after civilian men, women and children, the Armed Forces and people in prison in the best way possible.
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, in his absence for bringing this important debate to this House, and the noble Baroness, Lady Wheeler, for her excellent introduction to the issue. I draw attention to my registered interests, in particular as a lifelong member of the Royal College of Nursing and the current president of the Florence Nightingale Foundation.
Other noble Lords have addressed the issue of improving the strategy for wound care through the development of generic national specifications classed as clinically acceptably and fit for purpose for at least seven wound care and dressing categories. This is an entirely logical approach which the nursing profession broadly supports and is actively involved in designing. My noble friend Lord Kakkar outlined the macro- economic costs of wound management. It is estimated by Guest et al that 2.2 million wounds were managed in the UK in 2012-13, involving 18.6 million practice nurse visits and 10.9 million community nursing visits. In addition, significant nursing time is spent in hospitals, care homes and nursing homes managing wounds, not only in the NHS but in the independent and social care sectors. Therefore, any strategy for the future needs to consider the total cost of treating wounds, not the unit cost of products. Cost estimates need to focus not only on the price of wound treatments in terms of assessment tools, such as Doppler machines, medicines and dressings but also on the costs of treatment time from a variety of healthcare workers including, for example, medical staff, dieticians and podiatrists, while recognising that wound management, particularly in community settings, is predominantly a nurse-led discipline. The noble Lord, Lord Mackenzie of Culkein, gave an excellent overview of the challenges, the types of wounds and the expertise that clinical nurse specialists in tissue viability use in leading teams.
Innovation is central for the future, but I want to concentrate on four issues—the prevention of wounds, the prevention of infection, treatment expertise and sound models of care—through the lens of patients suffering from leg ulcers. Leg ulcers are painful, debilitating and frequently lead to social isolation. How then can leg ulcers be prevented? Some, of course, cannot, but with education many can be stalled and healed in their very early stages and others can be prevented very effectively by maintaining skin integrity through improved nutrition and exercise in at-risk groups. Keeping even small cuts clean and covered while healing can prevent infection entering a wound. Most patients want to prevent infection and will be happy to concur with a suggested treatment plan.
However, I want to give noble Lords one example from my practice when working as a district nurse more than 20 years ago. I was working with a woman in her mid-70s who was housebound with a severe leg ulcer that was not healing despite what was then regarded as best practice in terms of treatment, which involved a particular form of medically impregnated bandage being put on the affected leg by a relatively skilled nurse, because such bandages must not be put on too tightly. I was not as busy as most district nurses are today, so I returned unexpectedly at about 4 pm to see how she was doing. The answer was that, despite my having asked her not to, she was huddled by a two-bar electric fire, which was in effect setting and hardening the bandage, thus doing far more harm than good. After further assessment, I appreciated that she felt the central heating was too expensive to run and turned it on only when I was due to visit. A referral to a charity resulted in some extra funds towards her heating and over the next two months, with additional ad hoc visits from me, her leg healed. She was able to get out and help her nephew a bit in his shop, while regularly elevating her leg, and I was delighted to be able to discharge her. My point is that we now have just over 4,000 district nurses in England, but when I was working in practice there were in excess of 7,000 and I had the time to take the approach I have described.
Despite the pressure that district nurses are under today, they continue to deliver high-quality care. Investment in continued professional development is vital for healthcare professionals if they are to keep up to date and deliver contemporary evidence-based practice, yet CPD budgets for non-medical staff have been steadily eroded. A fantastic initiative has developed. It originated in Barnstaple in Devon and has already been alluded to by my noble friend Lady Masham. It is the Lindsay Leg Club Foundation. These clubs are usually led by qualified district nurses and have between 50 and 200 active members who have had or have leg ulcers. The clubs are gateways for input from tissue viability specialists, podiatrists and nutritionists. Initial results show quicker healing and improvement of ulcers and reduced prescribing costs through adherence to approved treatments, some of which are expensive but cost-effective. The clubs empower patients as stakeholders to work in partnership with professional staff, volunteers and their peers. Leg clubs are built around the notion of promoting peoples’ independence and well-being. This new social model of care is proving effective not only in the treatment of the physical wound but in promoting people’s independence and mental well-being by reducing loneliness and isolation.
Any wound strategy needs to consider how we prepare health professionals to work with groups, encouraging self-care as far as feasible, and how to integrate evidence-based practice through the dissemination of new evidence. There is little doubt that investment in the nursing workforce, particularly in CPD, is as important as selecting the best treatment product.
An RCT in Queensland, Australia, concluded that nursing time and related costs decreased by 36% using the leg club model, leading to the cost per healed leg ulcer being reduced by 58%. When I was practising, I undertook single home visits. These will always be necessary for some patients, but I delight in acknowledging that today’s leg clinic model is one that I would now wish to adopt. I believe it would have benefited my patients more cost effectively than the intervention I undertook, particularly in terms of productivity in nursing time.
The noble Lord, Lord Carter of Coles, in his report, recommends the adoption of single integrated performance in care pathways centred on customers, workforce and finance. These should apply not only to NHS providers but to independent nursing homes and the wide variety of social care services involved in delivering wound care prevention and treatment.
As the strategy for wound care develops, will due consideration be given to further investment in the workforce, including district nurse training, further development of nursing associates, continuing professional development, and customer education to ensure our workforce—which includes patients—can continue to lead the way in cost-effective care for wound management, based on new research evidence and treatment, thereby reducing individuals’ pain and suffering associated with chronic wounds such as leg ulcers?
My Lords, I join other noble Lords in thanking the noble Lord, Lord Hunt of Kings Heath, for calling this debate and the noble Baroness, Lady Wheeler, for being such an excellent substitute. It has been a fascinating debate, with much clinical and personal experience. There are many voices and players in this discussion: the clinicians, the commissioners, industry, those who are trying to improve performance and save money by rationalising systems and processes, and of course the patients, too.
I confess that I came to this subject completely cold and ill-informed. The debate covers: innovation and the management of wounds as a result of great British dressings with amazing technology, but, according to NICE, the need for a stronger evidence base; the escalating crisis in our nursing workforce; the need to share good practice in the NHS; decisions made by clinical commissioning groups; and, as ever, the money.
The cost of wound care—as others have said, around £5 billion each year—is the same as the nation’s bill for managing obesity. This came as quite a surprise to me. We have heard some really interesting numbers from both the noble Baroness, Lady Watkins, and the noble Lord, Lord Kakkar, and I have a few more. In 2012-13, there were 2.2 million wounds to be dressed and healed, 7.7 million GP visits and 3.4 million out-patient visits. The numbers suddenly become not surprising when it is patient-professional interactions and professional treatment that are increasing the costs, and not the dressings.
Much of the debate about wound care is about dressings and their cost. The Carter report talks about procurement but not the cost of treatment. If he had looked at total treatment costs, the story would have been very different. As a proportion of total cost, even some of the most advanced dressings are not hugely significant. What is required in this care—and I am sure that in most instances it is given—is a patient-centred decision, and I am sure the Minister would agree with that. I would like commissioners of such services to be mindful of this.
The area of innovation is quite a good British success story. We have interesting and new techniques that are used in dressings. Several noble Lords have spoken about AMR, and we need to be mindful of that. There are also smart dressings that will talk to your iPhone, or any other mobile phone of your choice. Also, the dressings are completely unlike those that I remember seeing my mother-in-law having to wear on her legs 10 or 15 years ago. The change in technology is huge. Hand-held technology can also be really important. All clinicians should have access to patient data from all NHS settings. Could the Minister tell us when this might really happen? How imminent is it? I think 2020 is the date we look for, and I would just like some clarification that this is still on track.
The noble Lord, Lord Kakkar, spoke about sharing good practice, which should reduce the variation in outcomes. There are clusters of really good practice, and one of the upsides of battlefield medicine is some of the treatments that have come from it for treating wounds. The noble Lord, Lord Colwyn, emphasised that. The use of communications technology assists with this, but we acknowledge that this will never replace the clinician-patient practice relationship.
Nurses are pivotal in delivering good care, and in the briefings that we have received there is considerable anxiety around the nursing workforce. Some 60% of NHS costs are in community settings—in our own homes or care homes—and we need to attract to the profession many more young men and women who are willing to take on this role. Careers advice and perceptions of careers in schools are not always absolutely as they might be—or indeed probably as they were 10 years ago. We need to examine the financial support given to nurses as undergraduates. We all know that nurses will not always be well paid—certainly not in the first instance—but bursaries should be part of the package. Professional development is also key to good practice, to retention and to making nurses feel valued and part of a team. What time is protected within clinical settings for nurse training and CPD?
Overseas nurses have always had a key role in the NHS—historically from the West Indies, south Asia and the Philippines, and more recently from EU states. Could the Minister confirm whether, to replace these nurses, there are any plans to recruit from third-world countries? I remember being at an NHS conference 19 years ago where the Health Minister of one of the southern African countries spoke very movingly about how much they invest in training their nurses, and we come along and offer better packages. We have sometimes to weigh up issues around third-world development and our own failure to train enough nurses here. The pay cap is hugely detrimental to nursing retention and the feeling of being valued. We have this perfect storm around the workforce, which gives us the loss of expertise of retiring nurses and the loss of EU nurses.
Finally, as noble Lords will know, I forgot that this debate was today—I thought it was tomorrow—so I was not as well prepared as I would like to have been. However, the House has really covered this issue well and at length. We have seen that there are huge advances in technology and in dressings, and that these are all moving faster than the regulators can deal with. From all that we have heard today and that I have read in the briefings, I endorse the call within the title of this debate for a strategy for dealing with wound care standards.
My Lords, I join noble Lords in thanking in absentia the noble Lord, Lord Hunt of Kings Heath, for having tabled this debate. I thank the noble Baroness, Lady Wheeler, for introducing it so expertly, and I thank all noble Lords for, as ever, their wise and insightful contributions, which have raised the salience and the importance of this issue. As the noble Baroness, Lady Jolly, said, this has been covered both well and at length.
As all noble Lords have said tonight, wound care matters because it has such a big impact on people’s quality of life. In fact it matters more than ever because people are living longer, with greater comorbidities and health complexities, so the role of good wound care will only grow. The noble Baroness, Lady Masham, and the noble Lord, Lord Kakkar, pointed out that getting this wrong and not having the necessary standards of care will have not only health impacts but social impacts too, and the Government are very aware of that. It is a picture that we recognise and that we believe the wider public sector, and the health sector, recognises too.
A number of important areas of work are already making a difference. I should point out that both MRSA and C. difficile rates are down 50% in the last seven years. As we have discussed before in this House, a second sepsis plan was published in September this year to try to make some progress on sepsis. The noble Baroness, Lady Masham, pointed out the importance of hand hygiene, and I believe that the changing attitudes to hand hygiene have played a role in the reduction of hospital-acquired infections.
All noble Lords have asked whether there is a national strategy. I reassure them that from a health perspective NHS England is leading an overarching programme of work on wound care. The major landmark was the publication in 2015 of the burden of wound care study, which highlighted the need for improvement of the assessment and treatment of patients, their outcomes and the cost incurred in the care pathway. I reassure noble Lords that this is a priority for the NHS.
As a result of the study, a national programme of work on wound care was launched by Professor Jane Cummings, the Chief Nursing Officer for England, under the aegis of Leading Change, Adding Value, which is NHS England’s framework for nursing, midwifery and care staff. Within this national wound care programme there are a number of initiatives. These include a national education and competency framework for all clinicians regarding good wound care, while a new national pathway has been developed for people with lower leg wounds, which represents 41% of all wounds. As several noble Lords have pointed out, variation is one of the great curses here, and these programmes are specifically aimed at reducing variability.
A national financial quality incentive has been introduced to improve wound assessments in the community, using a recommended minimum wound assessment tool. Wound care makes up 40% of community nurses’ workload, and they are supported in those efforts by both GP nurses and specialist tissue viability nurses, whose important role the noble Lord, Lord MacKenzie, and the noble Baroness, Lady Watkins, pointed to.
I would like to dwell on nursing numbers because they have been the subject of debate tonight. We know from looking at the figures that there has been a reduction in both community nurses and district nurses. I assure noble Lords—particularly the noble Baroness, Lady Watkins, because I know it is a great passion of hers—that Health Education England is reviewing the role and training of community and district nurses. She was right to highlight the important role in improving nursing numbers that nursing apprentices and nursing associates can play; indeed, properly trained, they can play an important role in supporting good care, particularly in the community.
The noble Baroness, Lady Jolly, when asking about nursing numbers, asked where we might recruit extra nurses from. The intention is to grow more of our own, as it were. There is a plan to increase by 25% the number of nurse training places so that we do not engage in the kinds of activities that she is talking about, where nurses who are very much needed in developing countries find their way to the UK, so that instead they can focus on improving healthcare in their own countries. We will grow our own.
The pay cap was also mentioned. I hope noble Lords will have noted in the Budget, as we had an opportunity to discuss earlier, the support from the Chancellor for funding an Agenda for Change pay deal, which will be focused largely on nurses.
I mentioned the new quality incentive that we have introduced. It will help nurses to improve the quality of care through a more standardised assessment, enabling appropriate treatment and improvements in both outcomes and value for money. In order to raise the profile of good wound care among commissioners, a point that has also been raised by noble Lords, a story about “Betty” within the Right Care programme demonstrates the benefits of appropriate care and pathways to support improved commissioning. Central to the Right Care programme, as the noble Baroness, Lady Jolly, said, is the question of “patient-centred” and patient choice within care.
I should also mention the Getting It Right First Time programme. It is not specific to wound care but it is led by front-line clinicians to improve the quality of care within the NHS and reduce variations. It initially focused on orthopaedics but is now moving to over 30 specialities, with clinical leads appointed.
Pressure ulcers have been the focus of a number of noble Lords’ comments, including those of the noble Lord, Lord Kakkar, and the noble Baroness, Lady Watkins. I join them in stressing the importance of prevention. I reassure noble Lords that the NHS has set out its specific ambition to reduce pressure ulcers. The noble Lord, Lord Kakkar, mentioned the Stop the Pressure campaign, a national campaign that began in 2012 as a regional programme within the Midlands and the east and drove improvements across those regions, including a 50% reduction in the number of new ulcers within 12 months. That campaign was rolled out nationally last November and includes acute, community and mental health settings. The aims of the campaign are to eliminate avoidable pressure sores by creating a significant culture shift with regard to avoidable harm, harnessing the collective energy of the nursing workforce and providing focus and support to front-line staff. Another example of local-level work being rolled out nationally is a framework called React to Red, an education and competency framework initially designed specifically for staff working in care homes but now being used across all sectors with the aim of reducing the incidence of pressure ulcers.
The acute sector of course has an important contribution to make to the establishment of good wound care across the NHS. Several noble Lords have mentioned the important work of the noble Lord, Lord Carter, for NHS Improvement. There is now a national Carter team that is working with an expert advisory group to understand what good practice looks like in relation to wound care and to support better ways of providing care in acute settings.
In addition to ensuring that we have the best trained and indeed the right number of staff, the Government are also working to simplify and improve product supply and distribution. Good wound care is not simply about medical skill and care; it is also about the availability and management of the most effective products. To support these efforts, a clinical evaluation team, currently based within the department, has been created. Its aim is to reduce unwarranted variation and to ensure that medical staff have access to high-quality products. It will achieve this by procuring fewer product lines and getting better value. I stress that this is happening under the guidance of clinical expertise. It is not simply, as the noble Baroness, Lady Watkins, pointed out, about reducing numbers and not simply a financially or accountant-driven programme; it is driven by a search for quality and ensuring that the NHS can procure at scale the clinically endorsed products that will help patients. This work is part of the overall reforms of the NHS supply chain known as the future operating model, and it is guided by NICE’s evidence base on wound care products that was published in January this year.
Speaking on the subject of wound care products, the noble Earl, Lord Liverpool, mentioned—as did my noble friend Lord Colwyn, rather elliptically—Surgihoney. I can tell them that it is in the British National Formulary. The clinical evaluation team has considered reviewing it but apparently it has a complex mode of action and more research is needed—there is a researcher’s answer—and the team wants to see the outcomes of clinical trials to understand its effectiveness better. I was particularly impressed by my noble friend Lord Liverpool’s exposition of how to treat a wound using sap and an old shirt; I think Bear Grylls would be incredibly impressed by those efforts.
Supporting good wound care and providing the best and most effective products in the health system are both essential parts of the strategy, but it is just as important to be able to track patients’ outcomes in order to inform best practice. That is why we asked NHS Digital to roll out the first nationally mandated community services dataset. It is currently being launched, with the first publication of data planned for February next year.
The dataset will provide national, comparable, standardised data about children, young people and adults in contact with community services in England. It is aimed to equip providers with the information they need to understand and compare the quality of care they are providing. In time, it will help build a much clearer picture nationally of the quality and impact of wound care, as well as other medical services. Further work will be undertaken over the next two or three years to refine the dataset to ensure that it is measuring patient outcomes and that it is as useful as possible for providers and patients in the provision of wound care.
I now touch on a few of the other issues that noble Lords raised. My noble friend Lord Colwyn talked about antimicrobial resistance. It is of course an incredibly important topic on which my noble friend Lord O’Neill has led the charge, and will continue to. We have an ambition to reduce gram-negative bloodstream infections acquired in the health setting by 50% by 2021. Of course, we will be fascinated to see whether reactive oxygen and other products have a contribution to make to that. I stress that the accelerated access review is now actively looking for transformative products that could fit its categories and be sped up into the NHS. There is specific support for SMEs to apply for that process, and I encourage the organisation that my noble friend mentioned to do so.
On the specific issue of research that the noble Lord, Lord Kakkar, mentioned, the NIHR is funding some research. I will write to him with more details, but I believe that a four-year award for a healthcare technology co-operative on wound care has just been made, and there may be other examples.
Finally, the noble Baroness, Lady Jolly, asked about patient data. She is absolutely right that having access to good quality data at patient and more aggregated level is critical to good wound care. Patients will begin to have universal access to their summary care record next year. That was a pledge that my right honourable friend the Secretary of State set out at NHS Expo this year, with the intention of having integrated local health records—which is where the joined-upness of all the detail and data on a patient comes—by 2020.
To conclude, I hope that I have gone some way to set out the work that is being undertaken in the NHS to improve wound care. Patient engagement is of course a large factor in wound management. Dressings are only one aspect of wound healing, because the patient has a critical role, as the noble Baroness, Lady Masham, pointed out, in supporting the healing process, and health professionals have a key role in providing the optimal environment, expertise and support to encourage healing. This requires a combination of access to products, clinical knowledge, measurement tools and patient education.
I end by saying how impressed I have been by the briefing received from the Lindsay Leg Club, which the noble Baroness, Lady Watkins, talked about and of which I know that the noble Baroness, Lady Masham, is patron. If noble Lords have not read it, I encourage them to do so. It provides just the kind of activity and intervention that we want to see. It is not just about good care; it is also about individual psychosocial needs and health beliefs. It is about getting good patients, as well as having good care and good products. I thoroughly commend the work that it is doing, and I would like to see more of it.
I hope that I have been able to reassure noble Lords that the NHS and the wider health system is engaged in a broad strategy to achieve better wound care, and that, as the issue becomes more pressing, we can expect to see significant improvements as a result of the actions being taken.
House adjourned at 8.23 pm.