A bold statement for the future of the health service has been made in The NHS 2010-2015: From Good to Great. Preventative, People-centred, Productive, which states quality of services should be improved while accommodating financial constraints.
The need to improve standards of care was highlighted in former health minister Lord Darzi’s review of the NHS. To help address this need, the first three national nursing indicators have recently been agreed by chief nursing officer for England Dame Christine Beasley. These will measure performance on pressure ulcers, falls and urinary tract infections (news, page 1, 6 April).
This standard approach demonstrates the demand for objective evidence to demonstrate quality and value for money.
Tissue viability must now adapt to these requirements and demonstrate its value. This requirement should come as no surprise as service commissioners have clearly stated that tissue viability nurses must demonstrate what they do, at what cost, and with what outcomes.
‘It is useful to consider the amalgamation of tissue viability with related therapeutic areas for economy of scale, cost efficiency and improved delivery of care’
With a few notable exceptions, tissue viability and wound care services are generally failing to provide evidence to justify their existence. Services within the NHS have been too parochial, focusing on local issues rather than regional or national ones. Management is not entirely without blame in this, often failing to provide the support required for a quality service.
However, the outlook is not totally bleak. Most TVNs are now well educated post registration, practise evidence based care, work from carefully prepared formularies, and openly acknowledge the need for prevention within their practice.
The quality outcome indicators for tissue viability include pressure ulcer incidence and prevalence, wound healing (where appropriate), wound related pain control, patient feedback (that is patient reported outcome measures or PROMS), and staff effectiveness and competency.
The figurehead of tissue viability is the consultant nurse, who must function at several levels and engage in strategic planning as well as the operational delivery of care. The core aspects of the role include clinical practice, education, governance, finance, business management, formulary development, and communication. Many of the 800 TVNs will also claim an involvement in these activities.
The discipline is widely perceived to be under threat in the UK. How can this be with such a clear clinical workload, high treatment costs, patient morbidity, and the growing older population? The solution may lie in the need to demonstrate the role of tissue viability, and its functions and outcomes.
This has already been achieved, to a degree. High impact actions for nursing and midwifery and the From Good to Great document, both clearly identify pressure ulceration as a major cost to the NHS in terms of morbidity, mortality and finance. Furthermore, with category three and four pressure ulcers being assigned “zero tolerance” status, and being eminently avoidable in NHS settings, the essential role of the TVN is established in this context.
The financial burden of wounds on the health service is between £1.8bn and £3.1bn or, 2-4 per cent of the annual NHS expenditure. Realistically, this figure could be as high as £4bn, with total chronic wound care costs being substantially more. These figures identify the significance of tissue viability to patients, the Department of Health, the NHS and stakeholders. Compounding this burden is the added load of an increasing older population with a huge predicted increase in those aged over 60.
It is important to consider a future structure and responsibility. The ongoing quality initiatives in the NHS have given tissue viability the chance to demonstrate the existing quality service provided, a history of innovation, and an important preventive function as well as a significant future role as outlined in the From Good to Great vision.
The quality indicators set for nursing practice in From Good to Great include three of direct relevance: pressure area care, pain management and infection prevention and control. Each falls within the domain of tissue viability and impacts on morbidity, mortality and expenditure in primary and acute care.
Given the estimated total spend on pressure ulceration, added to the cost of leg ulcers and other chronic wounds, due consideration for preventive measures and optimal standards of care in tissue viability could enable substantial savings on the estimated total costs of £4bn in 2010-15.
It is also useful to consider the amalgamation of tissue viability with related therapeutic areas for economy of scale, cost efficiency, and improved delivery of care. In this respect, the discipline should be enlarged to include acute traumatic wound care, paediatric wound care and tissue viability, lymphoedema, fungating wound care and continence, as well as aspects of skin care related to stomas, end of life and dermatology. Only by doing this can the recognition that will secure funding and jobs be obtained - thereby providing a quality of care suited to the needs of the population in the coming decade.
Richard White is professor of tissue viability, Institute of Health, University of Worcester