There is a large number of highly skilled clinicians working within the ‘discipline’ of wound care and a clear need for the development of a national wound care strategy. Such a strategy should go a long way towards resolving the wide variation in UK wound care services, confronting the lack of differential diagnoses and improving wound care product selection, resulting in improvement in outcomes and a reduction in costs. A confounding element pertinent to efficient and effective wound management is a clear understanding of the role that wound dressings have to play.
Different initiatives, to rationalise the availability of ‘suitable’ and ‘appropriate’ wound dressing products, have commenced in recent years. The backdrop to these schemes is the understandable need to contain costs bearing in mind that the NHS does not have recourse to unlimited finances. There is also a need to alert Government and the NHS to the reality of wounds as a burden on the population, health professionals and on budgets. Legally, wound dressings and bandages etc are classified as Medical Devices and bear the CE mark, signifying ‘they meet the essential requirements’ of the directives. This has resulted is a vast array of products listed in part IX of the Drug Tariff. As far as we are aware the first concerted attempt to rationalise—a euphemism for reduce—wound dressings started in 2015 with the creation of the NHS Supply Chain Generic Specification Project. Within this project, a national formulary was mooted that would contain a limited list of dressings that would be ‘clinically acceptable to 80% of patients'. This arbitrary identification of potential non-responders (20%) threatened to introduce a new selective principle into the NHS. Additionally, the ‘clinical acceptability’ or otherwise has not been defined, nor established by empirical research.
The current initiative to ‘rationalise’ wound care education and dressing availability now lies with the National Wound Care Strategy Programme (NWCSP) commissioned by NHS England with the aim of improving the quality and consistency of wound care (http://bit.ly/NWCSP). This NWCSP has the remit to consult widely among clinicians, academia, manufacturing industry, purchasers and patients.
The Supply and Distribution Workstream is managing dressing product categories, recording wound product current spend and volume. The aim here is to develop an improved supply and distribution model. These objectives are admirable insofar as the proposed end result is to make available a range of high-quality products that meet clinical needs and are appropriately regulated. However, a different reality seems to be occurring. Despite the dismal failure of the Generic Specification Project the NHS Supply Chain has embarked upon a series of e-tenders or auctions involving different groups of dressing classes. The aim is to reduce costs seemingly without regard for other relevant factors. For example, the recent exercises involving foam dressings and superabsorbent polymers were conducted using inconsistent criteria. Non-silicone foam candidates for tender were measured by 50% quality + 50% economic value (ie price) whereas for the super absorbents, the criterion was 100% economic value (ie price). In these contexts, the price component was unit price, not a carefully measured and calculated costutility. Upon what validated basis of evidence was this exercise conducted?
‘Is this an attempt at cost saving for purely financial reasons, without regard for clinical outcomes?’
There is clearly a lack of communication, let alone joined-up thinking, between the NWCSP and the NHS Supply Chain. Who is in charge here? Remember, it is patients' care that we must be most concerned about. What is required for credibility, truth and as a matter of urgency is clarity. What criteria is the NHS Supply Chain exerting and on what basis of science or logic? Specifically, who is involved in the national strategy? What of health economics applied to wound care thus ensuring best value for the money spent? What is the level of interaction, if any, between the leaders of the strategy and the NHS Supply Chain, and what will be put in place to monitor the success, or otherwise, of these initiatives? How much did the Generic Specification Project cost after delivering nothing of use? Is this an attempt at cost saving for purely financial reasons, without regard for clinical outcomes? We need answers to all of these questions.
We indicated 3 years ago that savings could be made without risk to patient care or an increase in long-term costs (Cutting, 2016):
If the NWCSP and NHS Supply Chain are serious about wanting to improve the supply and use of dressings then they would do well to consider the value of including material engineers in the decision-making process.