Journal of Community Nursing

5 / 20

BURDEN OF WOUND CARE
JCN supplement 2018,Vol 32, No 2 5
the numbers of patients with pressure
ulceration (153,000) were substantially
lower than those with lower limb
ulceration (730,000) (Guest et al,
2015) — 34% of all wounds were on
the lower leg and this figure excluded
diabetic foot ulceration.
Furthermore, Guest et al (2015)
also reported that only 16% of patients
with a lower limb wound had their
ankle brachial pressure index (ABPI)
measured. The requirement for
ABPI assessment and calculation is
embedded within national leg ulcer
guidance (Scottish Intercollegiate
Guidelines Network [SIGN], 2010;
Wounds UK, 2016), with this arterial
assessment being linked to whether
patients are treated with evidence-
based compression therapy. Without
such assessment, there is a substantial
chance that proven treatments will
not be utilised or that the patient will
receive sub-optimal therapy (Harding,
2016). Thus, it is of no real surprise,
that only 47% of venous ulcers healed
within the one-year study period. This
is a great deal lower than previous
research studies, where above 70% of
venous ulceration healed at 24 weeks
(Moffatt et al, 2003; Franks et al, 2004;
Ashby et al, 2014).
Therefore, in the author’s clinical
experience, it is important that
patients are managed according to
proven protocols to ensure that:
 Healing rates are optimised
 Unwanted variations in practice
are eliminated
 The impact on patients’ quality of
life is minimised
 Vital resources are not wasted.
COST TO THE NHS
As said, the total annual cost to the
NHS for the care of patients with
wounds and associated comorbidities
was reported to be £5.3 billion, which
equates to 4% of the total expenditure
within the UK on public health (Guest
et al, 2015). Of this, £1.94 billion was
attributed to resources required to
manage patients with leg ulceration.
Following on from the original
research paper, further analysis
was undertaken relating to the cost
imposed to the NHS by different
wound types (Guest et al, 2017).
After removal of costs associated with
comorbidities, the isolated costs to
the NHS for managing wounds was
estimated to be between £4.5 and £5.1
billion, with two-thirds of this cost
occurring within primary care services.
Guest et al (2017) also highlighted
that 39% of all wounds did not heal
within the one-year study period,
and the costs of managing the
unhealed wounds was substantially
greater (£3.2 billion) than the cost
of managing healed wounds (£2.1
billion). The per-patient costs varied
greatly, ranging from £698 to £3,998
per healed patient, and £1,719 to
£5,976 for those who remained
unhealed. This equates to the mean
cost of the latter being around 2.5
times more than those who have
healed. The legacy of only healing
61% of all wounds in the one-year
period and only 41% of leg ulcers in
the same time period, means that
year-on-year, patient numbers will
be nearly doubling. This questions
the long-term sustainability of the
current provision for wound care.
IMPACT ON PATIENTS
The impact to the individual patient
of having a leg ulcer can be severe,
and many studies have shown that
leg ulceration affects many aspects
of quality of life including activities
of daily living, pain, mobility, anxiety
and depression (Franks et al, 2003;
Charles, 2004; Persoon et al, 2004;
Jones et al, 2006; Green et al, 2014).
Healthcare professionals and many
of the clinical guidelines/pathways
(e.g. SIGN, 2010; Wounds UK,
2016) recognise the need to focus
on reducing the impact of pain and
other quality of life issues, while
also optimising healing. However,
Meaume et al (2017) highlighted
that health-related quality of life
issues seem to receive inadequate
attention during assessment and
management planning.
The true impact of living with
a leg ulcer was recently powerfully
articulated by a patient, who
published her own story, and
provided clinicians with an insightful,
emotional and at times distressing
understanding of what living with
a wound is truly like (Goodwin
and Atkin, 2018). There are many
published papers relating to the
impact of ulceration on patients’
self-esteem and quality of life, but
reading how it personally affects
an individual’s self-worth, ability
to work, married life, career, and to
read a patient’s own words —‘I cry a
lot: tears of frustration that the ulcer
won’t heal, tears of self-pity when
people are sympathetic and, most of
all, tears of sadness for the things that
have been taken away from me’ —
provides a different level of insight
and, in the author’s clinical opinion,
should prompt reflection for many
healthcare professionals.
BARRIERS TO HIGH
QUALITY CARE
The main barriers to high quality care
can be described in three essential
components:
 Workforce
 Budgets
 Training (White et al, 2017).
Workforce
The number of district nurses who
are skilled in providing complex care
to patients in their own homes is
reducing
and-events/news/qni-responds-
to-bbc-report/). Furthermore, there
are issues around continuity of
clinicians, with wound care commonly
being provided by GPNs who have
limitations in terms of time allocation
and availability of equipment, such as
ABPI machines (NHS England, 2017).
Demands on primary care services are
also increasing year-on-year, due to an
ageing population with more complex
needs, but these issues have not been
reflected in the size of the nursing
workforce (King’s Fund, 2016a).
Budgets
When referring to the cost of wound
care, both providers and payers
focus on the cost of the actual
dressing, but this has been found
to be only 14% of the overall cost
to the NHS (Guest et al, 2015). The
majority of the costs actually come
from healthcare professional visits,
hospital admissions, out-patient
appointments and drug prescriptions.
When considering costs, it is
important that decision-makers take
into account the larger issues, as the
cost burden associated with caring for