Patient pathways - Consortia must foster innovation

Why designing a money-saving leg ulcer care pathway failed.

Mr Dodds (left) examined leg ulcer wounds using the LUTM system to great overall success (Photograph: Author image)

The White Paper states clearly that in the new world of GP commissioning we will need to improve quality of care and reduce costs.

It also suggests that some GP income will be paid to consortia and then redistributed to practices but only if quality and financial expectations are met.

We believe quality improvement at lower cost is possible and to illustrate how, we are sharing our story of community wound care in north Birmingham. Our experience highlights the hurdles within the current PCT/practice-based commissioning world and shows that it may be better for clinicians to commission new pathways for local services.

Key learning points
  • Care pathways for chronic conditions cross many organisational boundaries.
  • Small changes in the design of a pathway can have large benefits to everyone on the pathway.
  • Experience shows that technology alone does not deliver benefits - technology can only support process redesign.
  • Care pathway design skills will be a valuable asset for future GP consortia to acquire.

Community wound care
Wound care is a significant issue for primary care given that 0.5 per cent of the population suffers from leg ulcers and 78 per cent of ulcers take longer than 12 weeks to heal.

Each year, 200,000 people develop leg ulcers and 1 per cent of the NHS budget is spent on community wound care. Treating leg ulcers consumes 60 per cent of district nurses' time and the average cost of healing a leg ulcer is £5,000.

In 2002, we started a pilot study with the local community nursing sites in north Birmingham. The pilot compared a new leg ulcer telemedicine (LUTM) system of sending wound images to the consultant vascular surgeon (Mr Dodds) with the conventional letter/fax/phone methods of communication.

Patients were randomised between the pathways and there were no other changes to treatment. The results showed an increase from 35 to 69 per cent in the number of wounds healed at 12 weeks. Many factors seemed to account for this dramatic improvement including:

  • Earlier referral and assessment.
  • Objective measurement of progress.
  • Easy access to specialist advice.
  • Improved patient and staff motivation.

Most importantly, community nurses and patients loved the system, so when the pilot ended and the LUTM service was discontinued there was uproar.

The community nurses wanted it back, so after securing ongoing funding the service was recommenced. In 2004, the project received the NHS Innovation Award for Service Improvement and we later came to appreciate that the success of this project was not merely due to the use of information technology.

So what about the potential benefits if the service was rolled out nationwide? The UK spends about £1 billion annually on community wound care so if our experience were replicated we calculate it could release £300 million.

Other early adopters have piloted the approach in several other sites, including north Hampshire and Wiltshire.

Process redesign
What they learnt is that just adding technology on top of the existing processes does not sustain or deliver the improvement in quality and costs. The process redesign is a critical factor for success.

Despite demonstrating significant advances in quality and cost of care, the LUTM initiative stalled. As we appeared unable to influence take-up from within the NHS, we formed a company called Wound Care Logistics and went back to our PCT.

The PCT enthusiastically supported a further pilot in a new locality. The aim was to link primary, community and secondary providers with one shared electronic record, to redesign the current pathway and to illustrate the improvements.

Introducing the LUTM system into practices and community nurse teams was easy but we never managed to get the providers to work together to redesign their processes. We found it difficult to convince community and PCT managers that the benefits they sought would only follow if the underlying processes were redesigned - and that technology alone would not be enough.

We have learned that changing NHS pathways from within is very difficult. Hopefully GP consortia will allow healthier innovation to flourish.

Dr Ingham: NHS was reluctant (Photograph: Author images)

An outside provider of wound care services would be free to design their processes from scratch and this may be an easier path to the holy grail of improved quality at lower cost. To that end, we have started to work with an independent healthcare provider.

Transmitting ulcer images
  • Consultant Simon Dodds developed the leg ulcer telemedicine (LUTM) system to improve communication between hospital and community wound care teams.
  • LUTM is designed to provide secure access to a common electronic wound care record.
  • Wounds are photographed regularly; LUTM calculates the area of the wound from the image and then plots the results on a graph.
  • Both clinicians and patients can see if the wound is healing as expected and if further intervention is necessary.
  • The shared record allows a community nurse to electronically ask for remote specialist advice and for the specialist to provide it.

Redesigned wound care services could offer demonstrable quality benefits to your patients at lower cost; and at a time when GP commissioners will have the responsibility for the cost and quality of provision, wound care service redesign might be a good place to start.

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