Introduction

ALISON HOPKINS AND JOSEPH MONTGOMERY

In order to understand the placement of and need for this textbook, it is critical that practitioners understand the resources being used in the management of the lower limb. In order to improve outcomes for patients, we need to critically appraise the resources being used, the waste in the health system and where to focus our attention. Resource management is also part of excellent system management. Unfortunately the collection and analysis of system and patient data concerning those with wounds are not routinely accessible and providers often have to rely on the data of others or studies to make conclusions about their local provision. This has created much paralysis in our commissioning landscape. However, there is some local data that can be accessed and this introduction sets the scene and clarifies the role the insights can play in improving care delivery. Dressing spend will reduce when best practice is utilised and wound chronicity avoided. Thus clinical improvements as a result of increasing readers' knowledge and skills in leg ulcer management will create a profound and positive impact on the health economy.

THE WOUND CARE BURDEN

During 2017 and 2018 it was estimated that more than one million people in the United Kingdom had an active ulcer on the lower limb (Guest et al. 2020). This equates to 2% of the population and is a 37% increase from the prevalence data recorded in 2012 (Guest et al. 2020). More than 50% of these patients were recorded as having venous leg ulceration and approximately 36% of all lower limb wounds did not have a documented diagnosis. This lack of accurate diagnosis indicates that a significant proportion of the population is likely to experience delayed wound healing associated with the absence of effective treatment. The cost of lower limb ulceration cannot be underestimated, as experiencing a leg ulcer is known to be associated with a negative effect on the biopsychological, spiritual and socioeconomic aspects of patients' health, well-being and quality of life.

Treatment and management of leg ulcers are expensive, and the financial costs of wounds overall are well documented. Approximately £8.3 billion per year are spent on wound management, of which £2.7 billion is associated with managing healed wounds and £5.6 billion is associated with managing unhealed wounds (Guest et al. 2020). In terms of practitioner time, this equates to 54.4 million district or community nurse visits per year, 28.1 million practice nurse appointments and 53.6 million healthcare support worker visits (Guest et al. 2020). It is estimated that 50% of community nursing caseloads is attributed to lower limb wounds (Hopkins and Samuriwo 2022). Missing from the picture is health economics data about the amount of money and time spent by patients, their families and support networks in managing their wounds.

For practitioners this so-called 'big data' can feel disconnected from day-to-day practice, but effective resource management is an area that practitioners can influence, through learning about local needs and patterns, choosing the right management plan, analysing and understanding available data and working effectively to be aware of sustainability. Front-line healthcare practitioners are well positioned to make a difference in resource management and environmental sustainability (Ritchie 2019) for the benefit of the local health economy.

Effective management of resources, whether that is clinical consumables, human time or a commitment to environmental sustainability, has the potential to underpin effective leg ulcer management. When managing resources for the population of citizens who have wounds, it is necessary to be cognisant of the resources being used, those that are obvious and measurable, as well as where we are data poor. This is an important area for practitioners to appreciate and lead on, whatever level of change they are attempting to create, from developing a basic business case to those who wish to promote system-level change. Table I.1 highlights areas of data that could support a strategy to improve resource management.

TABLE I.1 Data for insight into the use of healthcare resources.

• Understanding the burden on the local workforce such as frequency of dressing and nursing activity per week.
• The dressing spend per resident for the borough and comparing to others.
• Identifying unwarranted variation such as use of compression therapy or antimicrobials across teams.
• Identifying the types of wounds on the caseload and proportion of bilateral leg ulcers.
• Obtaining data on urgent admissions for cellulitis and the impact of unmanaged oedema.

THE COST OF SUB-OPTIMAL WOUND CARE

Dressing prescription costs are a known resource within community services alongside the awareness that waste is prevalent and there is a chronic lack of adherence to formularies. This brings an opportunity for cost control and reduction often led by medicines management teams. Less known or understood is the extent of time spent on delivering wound care; this has been reviewed in some studies (Guest et al. 2020; Hopkins and Samuriwo 2022) but it is rare for an area to know accurately how many hours of practitioner time are spent on care delivery. This prevents the development of a comprehensive workforce strategy that will utilise an effective skill mix for the successful management of patient need.

The successful management of lower leg wounds and lymphoedema is very dependent on the skillful use of dressings, compression bandages and compression garments. When evidence based care is utilised for people with leg ulcers, this has a positive effect on spend and patient outcomes, as well as practitioner time. Hopkins and Samuwiro (2022) found that more nursing time was spent on lower limb management when compression was not used; non-use of compression increased nursing activity by 37%. Analysis of the usage and costs of dressings, compression bandages and compression garments bring insights to direct care delivery at the front line, as well as improving the system-wide population health management. Yet the insightful management of dressings and bandages as a critical resource remains a rarity in resource management.

Collecting local data on practitioner time, dressing and bandage usage and unplanned admissions remains a difficult task but can provide profound insights into the evidence of sub-optimal care and unwarranted variation. Persuading commissioners of the worth of investment remains problematic and hence the need for the National Wound Care Strategy to provide a framework for evidence production and business cases. While data may be lacking, enthusiastic local leaders can help commissioners or nursing leaders make system-changing decisions. Table I.2 offers some tips for how practitioners can develop good resource management practices.

TABLE I.2 Tips on how practitioners can develop good resource management practices.

• Identify a person with sub-optimal management of leg ulcers; explore the resources used in time and dressings, the number and costs of infections and admission. Describe an alternative journey for this person and identify the impact on cost reduction.
• Use the insights developed through dressing analysis with terminology that targets the commissioners' understanding and focuses on population health, such as 'unwarranted variation', 'inequity', 'sub-optimal care', 'unplanned admission'.
• Highlight the need for budget holders to invest in robust, high-quality education, rejecting a 'see one, do one' approach to lower limb management that perpetuates the cycle of sub-optimal care and ineffective resource management.
• Look at your caseload of all those with lower leg wounds of all types. Establish how many are using compression therapy and whether this is optimal.

CLASSIFICATION OF DRESSING PRODUCTS

Dressings are classified according to their primary purpose, with the exception of some antimicrobial products. Categorising products, as in Table I.3, is beneficial when reviewing the use of dressings and spending attributed to them. This method provides a quick overview of the most-used or highest-spending products and brings insight at a glance, while highlighting where further analysis is needed.

TABLE I.3 Product classification.