GP and LMC medical secretary Dr John Allingham outlines his tips for running a cost-effective wound management service.
There are a variety of wound care local enhanced services commissioned, many with titles reflecting their exact scope of practice.
Some CCGs commission extensive services that include management of minor lacerations and burns, which overlap somewhat with the Minor Injury schemes that other CCGs commission.
This article focuses on the type of wound management service designed to manage leg ulcers, which are required everywhere at a community level and which in many areas are GP-led.
Here are my tips on how to run this type of service as efficiently as possible.
It is important to follow the contract conditions carefully. Before signing up, check the requirements carefully such as:
This service will need to be led by a wound care specialist. This will normally be a nurse working in an extended role. They will need to have undertaken appropriate training and to attend annual update courses.
In practice, this level of skill may not be deliverable in smaller practices and it may be more effective to run this service across several practices or even at Primary Care Network level. This will require co-ordination and sub-contracting between practices.
The most effective way of using the lead nurse is as a ‘Consultant’ who reviews and prescribes treatment. The dressings can then be applied by suitably trained Healthcare Assistants. This is the time-consuming part of the service and is most cost effective if delivered by less qualified staff working at the top of their licences/scope of practice.
Patients presenting with leg ulcers need to be assessed and treatment started quickly. This is clinically necessary and as many services are commissioned as a total rather than on fee per episode it is financially effective to heal patients as fast as possible. Appointment systems need the flexibility to fit a leg ulcer patient in quickly.
Bear in mind these patients often have mobility issues. Most will want a daytime appointment, but it is worth having the flexibility to offer extended hours for working age patients.
Some patients will be housebound. If this is included in the contract specification it will be expensive to deliver. Be sure this is cost effective at a practice level. Use appropriate staff and ensure they have appropriate insurance for the cars they use.
At initial appointment the assessment will need to include a Doppler ultrasound assessment. Only patients with a score of 0.8-1.3 are suitable for high pressure compression and most service specifications reflect this. Those with a score below 0.8 may need a vascular referral and you will need to set up an administrative system to ensure this happens.
Having dressings changed can be very painful. It is worth considering this and prescribing suitable analgesia to be taken prior to appointments.
Wound should be reviewed as infrequently as is clinically appropriate whilst still complying with contract specifications. This can be as infrequently as weekly. Dressings should not be over-saturated nor so dry that they stick to wounds.
The practice should ensure stocks of dressings to run the service without over-loading the system. If the CCG does not have a system that allows for use of a centralised stock cupboard and requires every item to be prescribed on an FP10 for every patient it is worth engaging with the commissioners or asking the LMC to try to negotiate such a system.
The stock should be simple and not have multiple options. Most CCGs have easy to follow formularies and it is important to stick to these and not to be lured by the latest expensive magic dressing.
The priciest item needed is a hand-held portable Doppler ultrasound machine. These cost £200-300 but are robust and durable.
It is imperative that all staff delivering this service enter the correct SNOMED or READ codes to ensure the activity is paid for in a timely fashion. It is worth setting up a wound care template with the correct codes automatically added.
It is important to audit the number of appointments needed and the staffing costs against payments regularly, to ensure this is cost effective.
Clinical outcomes as measured by healing rates and times may be a key performance indicator in contracts. They are worth recording as a way of demonstrating effectiveness. These data are useful if practices find the service is unviable and LMCs need evidence to persuade commissioners to raise the price.
Some services, in line with clinical guidance, recommend or require follow-up dopplers and prescription of compression hosiery after healing has occurred. This is easily delivered but may require a simple call and recall system.
Done well this is effective clinically, well received by patients and a cost-effective addition to the practice’s range of services.
Dr John Allingham is medical secretary at Kent LMC
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