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cost-effectiveness

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Article 2 of a 3 part series on the NHS

Original illustration for Healthcare-Arena by Fran Orford

As anyone with any experience in repairing things will tell you “you can’t fix it until you know which bit is broken”.

But is the NHS broken? Maybe the more important question is whether we view the NHS a problem or an asset? Does it need fixing because it’s broken or does it need improving so that it can be better still?

The NHS is the most cost-effective health system in the world according to the Commonwealth Fund report “Mirror, mirror on the wall”(1). But we don’t have any way of measuring whether our hospitals are as efficient as our overseas counterparts in day-to-day delivery of healthcare (2).

However, three cost and efficiency issues for the NHS are critical right now:

  • Workforce: the cost of agency nursing
  • Junior doctors: new pay and conditions contract
  • Procurement: the new procurement processes being implemented and the relationships with suppliers

Workforce and agency staffing

The NHS employs 1.3 million staff, and had a pay bill of £45.3bn in 2013/14. Of that total, the bill for nurses was £19bn. A focus on safer staffing levels and an increase in the rate of nurses leaving the profession of 29% in the last two years has led to the doubling of agency nurses (3).

The unprecedented rise in the amount that the NHS spends on agency nursing staff is set to be at least £980 million. According to the Royal College of Nursing (RCN) there are an estimated 20,000 nursing vacancies in the UK but filling them is difficult as a result of workforce cuts, reductions in nurse training places, years of pay restraint and attacks on terms and conditions. This has caused many nurses to leave and also encouraged many others into agency work (4). The RCN is calling for serious workforce investment and sensible, long-term workforce planning. The money currently being paid to nursing agencies would, the RCN estimates, pay for 28,155 permanent nursing staff with the right balance of skills and experience.

Training qualified staff to fill those vacancies is currently the responsibility of Health Education England (HEE) who try to balance the requirements for future medical and non-medical workforce, training the existing staff and balancing local and national needs as well as prioritising workforce decisions in the context of wider systems and strategic goals. And all within an annual budget of £5bn of taxpayers’ money. The current HEE ‘Investing in people’ document (5) recognises the gaps but claims: “this does not automatically mean increased training is a necessary parallel response”, and adds “if we always respond … by increasing training, then we risk condemning ourselves to a system in which we use all our resources on the future workforce rather than the current”.

The HEE lays much of the blame for the need for new training places at management’s door. Apparently it is the result of a “leaky bucket effect” where “employers are failing to retain and develop their skilled staff”. Perhaps the authors of the report should have paid a little more attention to what the RCN says about how nurses feel they are being treated: the word ‘morale’ does not appear in the HEE report. The Royal College of Nursing’s 2014 pay consultation survey revealed that 96% of nursing staff felt undervalued and underappreciated (6); even the NHS’s own survey found 59% of staff feeling that the NHS does not value their work!

This challenging juggling act for the HEE is all set to change with the very new proposals to completely scrap nursing bursaries announced on 25th November. This proposal is allegedly to increase the number of student training places from 20,000 to 30,000 within the next four years in line with increased demand for nurses. According to George Osborne, nurses should fund their education through loans like the rest of the student population, except nurses – training on the job, working unpaid for almost 50% of the time ­– are not like other University students. The reason that it is even possible is because the HEE can be removed from the NHS budget ring fence, as yet another cut to non-frontline areas of NHS activity and funding.

Junior Doctors pay and conditions contract

As part of a plan to build an affordable seven-day-week NHS – where non-emergency health services are also available outside office hours and during the weekend – the Health Secretary proposed new pay and conditions for junior doctors. The new proposal, which many view as both a reduction overall earnings and unsafe working hours, has been a source of intense debate and resulted in overwhelming support for industrial action (76% of junior doctors). This was called off at the last minute but negotiations are still on-going. Safety concerns due to tiredness have been raised regarding the working conditions of frontline medical staff. The proposals set out pay and conditions including a 11% pay-rise, but simultaneously reveals longer working hours and unclear direction post-2019, highlighting both political incompetence and mismanagement of the NHS for many individuals. Politicians have the audacity to claim the doctors concern is that they will lose money.

Industrial action is not taken lightly; in fact this is the first time in NHS history that junior doctors were prepared to provide no care whatsoever as part of strike action. The cost-neutral offer of November 2015 is the basis for further negotiation. The BMA, NHS Employers (acting on behalf of the employers of junior doctors) and DH will work collaboratively to develop and oversee new contractual terms and conditions of service for junior doctors. Allowing negotiations to progress, NHS Employers have agreed to extend the timeframe for the BMA to commence any industrial action by four weeks (to 13 January 2016); the BMA agrees to temporarily suspend its proposed strike action; and the Department of Health agrees similarly to temporarily suspend implementation of a contract without agreement. The saga continues…

Procurement

The good news is that an e-procurement system is being put in place that will, for the first time, provide the NHS with a catalogue-type system for purchasing. The system will depend on the implementation of global GS1 coding and PEPPOL messaging standards throughout the NHS. Once in place, these systems will enable the NHS to control its non-pay spending much more accurately. There will also be spinoffs in patient safety as the GS1 barcodes will be accessible at any point in the supply chain (7). The role of the e-procurement strategy meshes well with the Carter recommendations which estimate that the introduction of the standards will allow every NHS hospital in England to save up to £3m each year while improving patient care (2).

Superficially, at least, this all seems very positive, but in advance of the full implementation of the new systems, significant savings are still to be delivered over the next four years and NHS purchasing departments are quite open about their desire to pass the problems of achieving these savings on to their suppliers. Healthcare Arena has seen letters from NHS Purchasing consortia explaining that although they recognise that “the private sector has its own pressures and the zero-inflation policy will potentially have an impact on your business” they are happy to rely on the suppliers’ “continued goodwill in helping us to move forward”! That degree of buck passing would probably lead to disciplinary action if it were directed at an internal department, but in this case it is directed towards external suppliers.

The most recent interim guidance from the Carter review is quite clear: the primary savings that can be made in the area of procurement will come from internal NHS organisational improvements (2). Carter reviewed procurement data from 22 hospitals and noted in the interim report that

“we collected all accounts payable and purchase order data … for the last two years and only 18% could be matched” (2).

The report also noted the variation in inventory management practices and concluded that:

“…there are greater savings to be had by managing the demand for products through better inventory management rather than price reductions.” (2).

Nevertheless, the purchasing consortium offers suppliers a number of ways they can help to reduce their prices, including: extending current contracts with improved prices, waiving carriage charges and retrospective rebates. Ironically, the consortium also suggests that suppliers might like to offer a discount for early payment … and therein lies a further issue: quite a few NHS Trusts have surreptitiously moved to 60-day, and in some cases, 90-day payment terms.

This is in direct conflict with the government’s position on large customers working with small business suppliers, which has been clearly stated: small businesses should be paid within 30 days of providing an invoice. However, some of the NHS Trusts have stated that their new 60-day terms apply for all suppliers, effective immediately. This is not a defensible position for taxpayer-funded organisation and is, in fact, in breach of NHS terms and conditions which state:

9.6       The Authority shall pay each undisputed invoice received in accordance with Clause 9.3 of this Schedule 2 within thirty (30) days of receipt of such invoice at the latest. However, the Authority shall use its reasonable endeavours to pay such undisputed invoices sooner in accordance with any applicable government prompt payment targets.

If the proposed Enterprise Bill is enacted then we can expect that the new Small Business Commissioner will be looking into the NHS’s procurement performance, especially in areas that have already been identified as causing dispute between small suppliers and large customers, which includes extended payment terms and discounts for prompt payment (8).

It is now time-critical that the Government and NHS pay urgent attention to:

  • “Joined up” workforce planning for both the long-term, and the interim period, while new medical staff with a scheduled reduction in the use of agency staff
  • Safe and fair treatment for NHS staff, delivering professional high-standard care should be rewarded with a reasonable wage and both safe and fair working hours
  • Proper rationalisation of procurement processes and implementation of e-procurement systems with enforcement of terms and conditions that meet the Government’s guidelines

So, if the NHS is already the most cost-effective healthcare system in the world in terms of value for money for the taxpayer, the only real way to have a significant additional impact is for the taxpayer to be prepared to pay more for healthcare. In its final section, Healthcare Arena looks at the challenges facing the NHS today. If the NHS is to continue delivering a first class service, increased funding, improved education and transparency are key to its future success.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References:

  1. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally [Internet]. [cited 2015 Sep 23]. Available from: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
  2. Carter. Productivity in NHS hospitals – Publications – GOV.UK [Internet]. [cited 2015 Sep 23]. Available from: https://www.gov.uk/government/publications/productivity-in-nhs-hospitals
  3. The cost of short-term planning – £1bn on agency nurses in 2014/15 – Frontline First [Internet]. [cited 2015 Sep 23]. Available from: http://frontlinefirst.rcn.org.uk/sites/frontlinefirst/index.php/blog/entry/nhs-runaway-agency-spending-report/
  4. RCN. The cost of short-term planning – £1bn on agency nurses in 2014/15 [Internet]. 2015 [cited 2015 Sep 18]. Available from: http://www.rcn.org.uk/newsevents/news/article/uk/the-cost-of-short-term-planning-1bn-on-agency-nurses
  5. Health Education England » Workforce plan for England 2015/16 [Internet]. [cited 2015 Sep 23]. Available from: https://hee.nhs.uk/2015/02/05/workforce-plan-for-england-201516/
  6. RCN responds to Health Minister’s comments on pay and morale [Internet]. 2015 [cited 2015 Sep 22]. Available from: http://www.rcn.org.uk/newsevents/news/article/uk/rcn-responds-to-health-ministers-comments-on-pay-and-morale
  7. NHS e-procurement strategy – Publications – GOV.UK [Internet]. [cited 2015 Sep 23]. Available from: https://www.gov.uk/government/publications/nhs-e-procurement-strategy

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Image: ©Rocter/iStock #10848284

Physicians and healers have been sucking poisons and toxins (for example, snake bite venom) from wounds for about 2,500 years [1]. Cupping, a procedure thought to stimulate blood flow, has also been used for many centuries. In effect therefore, negative pressure wound therapy (NPWT), also known as topical negative pressure (TNP) and vacuum assisted closure (VAC), is not new. The first mention of a ‘vacuum’ wound treatment appeared in the Russian literature in the 1980’s [1]. Further developments finally led to the Vacuum Assisted Closure (VAC™) [2], the forerunner of most modern systems.

The mode of action in open wounds
A closed drainage system applies controlled suction (negative pressure) to the wound bed. The wound bed is covered firstly with a wound contact layer (WCL), then a wound filler. As the pre-determined negative pressure is applied, the filler compresses into the surface of the wound, reducing microvascular blood flow at the wound bed and contraction at the wound margins (macro-deformation). Negative pressure is often applied at -125mmHg, although pressure may be tailored to the patient’s risk of ischaemia and pain tolerance [3].

Fillers include open-pore polyurethane foam or saline-moistened gauze – the choice depends upon the wound, the system used, and patient preference. Gauze is more conformable (good for large and/or irregular wounds) [4], is thought to minimise scarring [4]. and produces thinner, dense granulation tissue [5]. Foam filler produces thick, hypertrophic granulation tissue (Borgquist et al, 2009), and if used without a WCL, can facilitate in-growth of granulation tissue, causing pain and/or bleeding upon removal, disruption of the wound bed tissue, and potentially acting as a focus for infection [5].

Effectiveness of NPWT
There is a plethora of studies indicating the clinical effectiveness and financial/patient benefits of NPWT in both dehisced wounds (abdomen, sternum) and chronic wounds such as pressure ulcers and leg ulcers. These include meta-analyses [6], systematic reviews [7], literature critiques [8] and evidence based recommendations [9].

Benefits include:

  • Rapid wound healing [10], through exudate management, reduction of oedema [11], and direct stimulation of granulation tissue [12]
  • Fewer dressing changes, therefore less clinician time required [13], leading to reduced wound management costs and length of stay [14]
  • Improvement in patient quality of life (QoL) [15]

Incisional NPWT (iNPWT)
Single-use products for reducing closed incision complications in high risk patients have been developed over the past decade. This has been in response to the increasing incidence and cost of treating incisional complications (SSCs) such as surgical site infection (SSI) and dehiscence, which increase length of stay and costs, may require repeat surgeries, and poor patient outcomes, particularly as infection can present several days post-discharge and can affect long-term survival [16]. Tanner et al’s study [17] identified a higher SSI percentage that that reported in the literature (27% incidence, vs. 19.4%), most of which manifested post-discharge. SCC’s present a large financial burden and may devastate (or even kill) the patient, so along with assessing risk factors, prevention strategies must be considered.

Incisional NPWT is emerging as a possible prophylactic measure against SSCs. Studies both published and currently being undertaken demonstrate decreased SSI, wound dehiscence and better scar quality in:

  • Breast surgery [18]
  • Cardiothoracic surgery [19]
  • Trauma [20,21]
  • Orthopaedic surgery [22]
  • Abdominal surgery [7, 23]
  • Diabetic foot wounds [24]

On-going iNPWT studies have also been presented at a recent expert meeting [25].

The cost-effectiveness of iNPWT has been demonstrated [8]. In an earlier study, Stannard et al [26] estimated that the application of INPWT costs less than $500 for the mean 2.5 days of therapy, making it a cost-effective intervention due to shortened hospital stay and prevention of postoperative surgical site infection.

To date, many of the studies have centred on patients with high risk factors for SSC – those who are obese, use steroids, have had previous radiation exposure (or awaiting radiotherapy), or who smoke. Other risk factors include the actual procedure and use of implants. Further studies are needed to explore any clinical and/or cost benefits in low-risk patients undergoing high-risk procedures.

iNPWT mode of action
How exactly iNPWT works is not entirely clear; Stannard et al [21] suggests that the reduction in haematoma and seroma, accelerated wound healing, increased removal of oedema and splinting of the incisional area, appear contribute to its effectiveness, but further studies are required to ascertain the exact mechanisms of action.

Conclusion

While further studies are required to determine iNPWTs exact mechanism of action, early indications are that it is a useful prophylactic tool for the prevention of surgical site complications.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Kubek EW, Badeau A, Materazzi S, et al. Negative-pressure wound therapy and the emerging role of incisional negative pressure wound therapy as prophylaxis against surgical site infections. In: Microbial pathogens and strategies for combating them; science, technology and education. 2013. (Mendez-Villas A, (Ed.). Formatex Research Center. Available at: http://www.formatex.info/microbiology4/vol3/1833-1846.pdf Accessed July 2015
  2. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Annals of Plastic Surgery. 1997. 38:563-576
  3. Malmsjö M, Borgquist O. NPWT Settings and Dressing Choices Made Easy. Wounds International. 2010. 1; 3. Available at: http://www.woundsinternational.com/other-resources/view/npwt-settings-and-dressing-choices-made-easy Accessed July 2015
  4. Jeffrey S. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty. 2009. 9:e28. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714221/ Accessed July 2015
  5. Borgquist O, Gustafsson L, Ingemansson R, et al. Tissue ingrowth into foam but not into gauze during negative pressure wound therapy. Wounds. 2009. 21; 11:302-9. http://www.woundsresearch.com/images/Borgquist_NEW-Nov09.pdf (to access pdf) Accessed July 2015
  6. Zhang J, Hu ZC, Chen D, et al.) Effectiveness and safety of negative-pressure wound therapy for diabetic foot ulcers: a meta-analysis. Plast Reconstr Surg. 2014. 134; 1:141-51. Available at: http://www.ncbi.nlm.nih.gov/m/pubmed/24622569/ Accessed July 2015
  7. Bruhin A, Ferreira F, Charika M et al. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen Int J Surg. 2014. 12; 10:1105-14. Available at: http://www.journal-surgery.net/article/S1743-9191%2814%2900881-4/abstract Accessed July 2015
  8. Stannard JP, Gabriel A, Lehner B. Use of negative pressure wound therapy over clean, closed surgical incisions. Int Wound J. 2012b 9(Suppl. 1): 32–39 Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2012.01017.x/pdf Accessed July 2015
  9. National Institute for Health and Care Excellence (NICE) Negative pressure wound therapy for the open abdomen. NICE Interventional Procedure Guidance [IPG467]. 2014. Available at: www.nice.org.uk/guidance/ipg467 Accessed July 2015
  10. Armstrong DG, Lavery LA. Diabetic foot study consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. The Lancet. 2005. 366; 9498: 1704–1710. Available at:
  11. Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multi-centre randomized controlled trial. http://www.researchgate.net/publication/7477570_Diabetic_Foot_Study_Consortium.Negative_pressure_wound_therapy_after_partial_diabetic_foot_amputation_a_multicntre_randomized_controlled_trial Accessed July 2015
  12. Webb LX New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002. 10:303-311
  13. Mouës CM, van den Bemd GJ, Meerding WJ, et al. An economic evaluation of the use of TNP on full-thickness wounds. J Wound Care. 2005. 14; 5:224–227
  14. Searle R, Milne J Tools to compare the cost of NPWT with advanced wound care: an aid to clinical decision-making. Wounds UK. 2010. 6; 1:106–109
  15. Ousey KJ, Milne J, Cook L, et al A pilot study exploring quality of life experienced by patients undergoing negative-pressure wound therapy as part of their wound care treatment compared to patients receiving standard wound care. Int Wound J. 2014. 11; 4:357-6. Available at: http://eprints.hud.ac.uk/15024/1/IWJ_QoL_NPWT_repository%5B1%5D.pdf Accessed July 2015
  16. Artinyan A, Orcutt ST, Anaya DA, Richardson P, et al. Infectious post-operative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer. Ann Surg. 2015. 261; 3:497-505
  17. Tanner J, Padley W, Kiernan M, Leaper D, et al., A benchmark too far: findings from a national survey of surgical site infection surveillance. Journal of Hospital Infection 2013. 83; (2): 87-01.
  18. Holt R, Murphy JA. PICO™ incision closure in oncoplastic breast surgery: a case series. Jour Hosp Med. 2015. 76; 4:217-23
  19. Grauhan O, Navasardyan A, Tutkun B, Hennig F, et al. Effect of surgical incision management on wound infections in a poststernotomy patient population. International Wound Journal. 2014. 11: 6–9. To access pdf go to: http://www.researchgate.net/publication/262609088_Effect_of_surgical_incision_management_on_wound_infections_in_a_poststernotomy_patient_population Accessed July 2015
  20. Krug E, Berg L, Lee C, Hudson D, et al..,Evidence-based recommendations for negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011 42; s1 – s12.
  21. Stannard J, Volgas DA, McGwin G 3rd, Stewart RL et al., Incisional NPWT After High Risk Lower Extremity Fractures; J Orthop Trauma. 2012a. 26: 37-42 13
  22. Karlakki S, Brem M, Giannini S, Khanduja V, et al., (2013). Negative pressure wound therapy for management of the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication. Bone & Joint Research. 2; 12:276–84. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3884878/ Accessed July 2015
  23. Fry DE. The Prevention of Surgical Site Infection in Elective Colon Surgery. Review Article. Scientifica. 2013. Available at: http://dx.doi.org/10.1155/2013/896297. Accessed July 2015
  24. Faroqui L, Mills JL, Rogers LC, et al. Use of an Incision-Line Negative Pressure Wound Therapy Technique to Protect High-Risk Diabetic Foot Wounds, Postoperatively. The Journal of Diabetic Foot Complications. 2013. Issue 5, 2; 3:44-47. Available at: http://jdfc.org/2013/volume-5-issue-2/use-of-an-incision-line-negative-pressure-wound-therapy-technique-to-protect-high-risk-diabetic-foot-wounds-postoperatively/ Accessed July 2015
  25. Smith & Nephew. 6th International NPWT Expert Meeting. Highlights. Berlin, 2015. Available at: http://www.smith-nephew.com/documents/education%20and%20evidence/videos/2015/npwt%20experts%202015/npwt%20expert%20panel%202015%20-%20highlights%20booklet.pdf. Accessed July 2015
  26. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. 2006. 60; 6:1301–6

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