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Plan (NHS England 2019). Clinicians should equip patients with a
toolbox of information and advice in order for them to manage their
conditions independently– in the case of management of well legs,
this would be exercise, hosiery application and maintenance, skin
care regimen, diet and lifestyle education and advice on when and
where to seek a healthcare professional’s help between appointments. The wound care agenda was highlighted across the United
Kingdom by the
earlier in the chapter).
Coleman etal. (2017) discovered that there was no national minimum data set for generic wound assessments or leg ulcer assessments which was leading to variations in practice and outcomes for
patients. After a literature review and a structured consensus, a set of
criteria was set out to improve and standardised wound assessments
in clinical practice, which was adapted and adopted by the National
Wound Care Strategy to form the lower limb recommendations
(2020). The aim was to standardise care for patients.
The NWCSP was commissioned by NHS England and began in
2018 to improve the prevention and management of pressure ulcers,
lower limb ulcers and surgical wounds. The goal of the project was to
implement a high standard of care for all patients receiving care
across England. The lower limb recommendations from the NWCSP
(2023) put a greater focus on the importance of patients receiving
compression therapy in a timely manor and early endovenous intervention for all suitable, and to achieved by greater public awareness.
This would be achieved by reducing variations in practice, improving
safety and increasing patient experiences and outcomes.
Commissioning for Quality and Innovation (CQUIN) and NHS
England in 2018 set about improving outcomes and quality for
patients with leg ulceration managed by community services. CQUIN
targets, introduced in 2020–2021, are aimed to reduce unwanted variation in practice across the country for the management of lower
limb wounds. The purpose of the CQUIN is to ensure appropriate
assessment, diagnosis and treatment for 50% of patients with lower
limb wounds, a gure that trusts must achieve in order to benet
from income fromCQUIN targets. This will in turn encourage the
development and redesign of services and therefore better outcomes
for patients and the health economy as a whole.
There also needs to be an increase in patient and public awareness if the general population are to start recognising early signs
of venous disease progression and seek early help to slow the
publication of the Guest etal. data in 2015 (discussed
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progression down. An increase in public campaigns to highlight the
importance of leg care would be needed, such as the Legs Matter
campaign, Leg Club Model and Lively Legs Model.
The Queen’s Nursing institute (QNI) (2019) has described how
stang levels are reducing across community nursing services
nationally and this, coupled with the increasing demands on district
nursing services, is reducing the capacity for essential training opportunities. The QNI estimated that 46% of the overall highly skilled and
experienced workforce is expected to leave or retire in the next
ve
years, which will leave an unskilled workforce in these essential
clinical skills, with very few mentors to facilitate learning opportunities in lower limb management and essential skills such as performing Ankle brachical pressure index readings (ABPI) skills. Sta must
have training and investment in time must be made in order to be
procient in the skills and support need to deliver the CQUIN targets
across community services. The challenge to practitioners is how this
is achieved with a reducing workforce, reduction in skill mix and
greater demands on services.
A study into the comparison of compression therapy uses by
Hopkins and Samuriwo (2022) identied that there was a greater
number of patients with lower limb wounds than those that had been
recognised, recorded and classied as having leg ulcers within community settings. They also showed substantial variation in access to
diagnostics and compression therapy practice between the sites of
data collection, and by locations within those local areas. They identied that lack of use of compression increased nursing time by 37% and
that where there is a lack of access to therapeutic intervention, the
resultant patient harm is not being recognised, reported or documented.
Wound care services had to adapt and change during the
Covid- 19 pandemic and had to utilise other ways of connecting with
patients and healthcare professionals, such as telemedicine or video
calls. But with this came a reduction in patient contacts and in the
community workforce in the early 2020s, which may well have a
longer- term impact on service delivery and patient outcomes.
Evaluation ofService
NHS services are under increasing pressure to prove the value of the
service provided to patients to secure ongoing funding and resources–
and wound care services are not excluded from this. Evidence is
needed to justify and prove the worth of the existence of services and
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the rationale for the intervention and pathways that support local
system change; the provision of system data enhances an anecdotal
or case study focus to delivery. The Health Foundation (Jones
etal.2021) dened a quality service as care that is eective, safe and
provides as positive an experience as possible for the users by being
caring, responsive and person centred. The denition also states that
care should be well led,sustainable and equitable, achieved through
providers and
with, and for, local people and communities.
In order to prove the worth of a service a combination of elements
need to be used: evidence- based practice, following local policy and
this should be updated in line with national guidelines, combined
withpatient satisfaction surveys alongside wound care audits. These
need to be used to provide an improvement plan for service change
and development and the cycle then starts again. Auditing should be
a continuous cycle.
Over the last 10 years the introduction of CQUINs for wound
care, rst for pressure ulcers and then leg ulcer services, has driven
the audit process through community nursing teams, community leg
ulcer services and community tissue viability teams. It concentrates
on the evaluations of healing rates although there are many variable
with this and waiting times from referral to full holistic assessment.
The other important elements of a service audit should not be forgotten, such as quality- of- life audits, patient experience surveys and the
link to resource management and consumable (dressing/bandage)
usage and cost data. Triangulating this data and information is often
insightful into how services are performing.
commissioners working together and in partnership
Plan–Do–Study–Act Cycle
Implementing change in the NHS is not easy (NHS England2018).
For the change to be sustainable and eective, a recognised framework and change model should be used. The Plan–Do–Study–Act
(PDSA) cycle (Figure 9.3) is simple to implement for healthcare
teams on the ground to use and assists the clinician in testing potential quality improvement on a small scale, which can than allow for
any adjustments and changes to be made to a project prior to its wider
roll out and implementation. The cycle runs as follows:
Plan– plan the change to be made.
Do– carry out the test or change.
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ACT PLAN
• Plan for the next cycle
• Can the change be
implemented?
• Does anything need to be
changed or improved? Make
recommendations
• Collect post-implementation
data
• Analysis – did the project
achieve the change?
• What has been learnt – the
positives and the negatives?
• Identify an opportunity and plan
a change
• Who needs to be involved/consulted?
• What – what needs to happen?
Does anyone need training on
the change? How will this
happen?
• When – set a timescale
• Where – which team/unit will be
involved?
• What are the aims of the
change?
• What are the strengths and
weakness of the change/project?
• What are the barriers to the
change and what can be
implemented to avoid them?
DOSTUDY
• Implement the change on a
small scale
• Agree a timescale for the
implementation phase
• Observe and document the
change
FIGURE 9.3 Plan–Do–Study–Act (PDSA) cycle.
Source: Adapted from NHS England (2018).
Study– based on measurable outcomes, collect data before and
after the change and reect on the impact of the change and
what was learned.
Act– plan how the change will be fully implemented.
Using a change model that has been validated gives a structured
way of organising ideas and identifying potential changes to services
and also helps to pinpoint any barriers (NHS England2018). Using
the cycle can also encourage educational opportunities that will help
to highlight which ideas will work and which ideas may be less
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successful going forward. NHS England maintains that using the
PDSA cycle can be less disruptive to patients and sta than larger
change models, as it allows repeated cycles through the model and
changes to smaller pilot studies.
NHS Improvement (2020) suggests answering three sets of ques-
tions before testing a change idea:
What are you trying to accomplish? What is the overall aim?
How will you know if the change is an improvement? How will
you measure success?
What changes can you make that will result in improvement?
This process and the identied outcomes can support the development of business cases that aims to improve the outcomes of people with leg ulcers.
Some areas that have been suggested for change (Mahoney and
Simmonds2020) within community nursing in relation to leg ulcer
management are:
Poor compliance on the part of the professional with guidance
within teams, which can lead to delays in implementing appropriate care.
Time from referral to rst full holistic assessment including ABPI.
Time to heal.
Poor holistic assessments, which could result in delay referring
patients to the most appropriate healthcare professional for care
delays in getting appropriate compression therapy.
Increased costs of resources through inappropriate and ineec-
tivetreatments prolonging the length of stay of a patient on the
caseload.
Costly dressings that were inappropriate.
Underuse of strong compression bandaging.
Poor quality of care, patient satisfaction and quality- of- life
outcomes.
Audit Process
Audit should be a continually component of all leg ulcer services
delivered to patients. It is important for service development and
monitoring the of quality of the service, and it gives the healthcare
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professional outcome measures to see if the service is providing quality, safe, eective care to patients. Prevalence and incidence audits
are necessary tools in planning workforce and resource management
(Vowden and Vowden2010; Hopkins and Worboys2014). Audit can
also be used to show what impact changes have had on the service
and outcomes for patients, and can be implemented to continually
monitor care and measure outcomes. Audit tools need to be standardised across the service/organisation, so that the audit should be
able to be repeated at any point within the service or organisation
and by any clinician.
If you have not conducted an audit before, starting small this will
give you the opportunity to see if your data collection tool works
before embarking on a larger audit of patients. Using the PDSA cycle
discussed previously in the chapter.
For an audit to be successful you rst need to do the following:
Gather your working group. If you are working within a team,
decide on the roles that each of you will undertake.
Identify your stakeholders. This could be people who have an
interest in your service, the district nursing team, GP, intermediate care team, Care Commissioning Group, secondary care.
Set a timetable for when the dierent elements of the audit will
take place and allocate them to members of the audit team.
Check to see if your organisation/trust has an audit policy. Who
do you need to tell that you are planning an audit? Do you need
approval from ethics and governance? There might be certain
data that all audits have to collect; there might be an organisational data collection tool or a report format for writing the data
up; there might also be a clinical audit team within the organisation that you need to register your audit with. Do you need
patient approval for the data you are collecting? Do you need ethics approval for your audit?
What do you want to nd out? The process of audit can be applied
to many things, from type of treatment used to healing, patient
experiences of pain, patient experiences and opinions of the service, sta knowledge, experience and competencies, or costs
spent on treatment for patients. You need to develop your audit
questions. For example: How long was the wait from referral to
rst assessment including Doppler assessment? What was the
mean time to healing for a venous leg ulceration with the
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service? The answers to both questions can be measured against
national data. Wider questions for an organisational audit might
include nding out about sta training alongside the audit. There
might be a correlation between this and patient assessments if
there are not enough sta available with the skills to carry out
full holistic assessments for patients.
Inclusion criteria for the audit. Inclusion and exclusion criteria
both need to be specic, or you will nd that your audit has too
big a scope and the data collected will be hard to analyse and
report on. For example, if the inclusion criteria are patients with
an ABPI between 0.8 and 1.3 and receiving full compression UK
standard compression therapy in line with NICE guidance
(40 mmHg), they might have had their assessment within a set
period, and you might also want to look at the type of compression they are receiving, such as two- layer bandaging, four- layer
bandaging or compression hosiery kits.
Exclusion criteria for the audit. This is all the patients you do not
want to include. For example, if you are looking at patients with
a venous leg ulcer you may want to exclude patients who have an
ABPI less than 0.8 or greater than 1.3, patients with a diabetic
foot wound or patients who have had a pressure ulcer. Be specic, as this will help to narrow down your patient group and
give a more reproducible audit tool for the future.
Limitations of the audit. Document any limitations such as time
frames, workforce to conduct the audit or any IT system issues
that may aect the data collection process.
When is the audit going to take place and what is its scope? For
instance, is it going to capture a moment in time (this is called a
point prevalence audit, e.g. patients seen on a particular day) or
will it examine the caseload as a whole?
Resources needed to carry out the audit. This could be funding
for sta to collect data, printing, expertise for data entry
and so on.
How many patients you are going to include and how they will be
selected. For example, if the whole caseload is to be included you
could number them from 1 to 100, then pick 10 random numbers,
which would mean the audit is covering 10% of the caseload. If
patients are taken from a sample seen on a certain day, this would
be a point prevalence audit looking at a moment in time.
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After those aspects have been decided on and documented, move
on to the following steps:
Development of the audit tool. There are some audit tools online
or you may nd that your organisation has a set pro forma for
standard audit collection, to which you can add your servicespecic questions. What is the minimum data set that needs to be
collected? What questions do you need to include on your audit
tool? Are you going to use a spreadsheet or a paper tool to collect the data?
Data collection. Set aside time to conduct the audit to ensure all
data is collected as required. If allocating collection to other
members of the team, ensure everyone knows who is collecting
what data and when. For example, person A collects data for
patients 1–10, person B collects data for patients 11–20, person C
collects data for persons 21–30 and so on. This will stop miscollection of data. Also decide prior to data collection how the data
will be collected, for example if using a spreadsheet and your
question is what type of compression the patient received, you
might want to allocate letters to the answers, e.g. A=hosiery kit,
B=two- layer compression, C=four- layer compression.
Data analysis. How will this happen? Will an Excel spreadsheet
be used, who will complete it and how long do you plan for this
part to take?
Decide who you will present the data to. Which members of
your organisation need to have the data? Do the audit results
need tobe presented to others such as the local integrated care
system group?
Identify recommendations for change and write an improvement
plan based on the audit. Identify good practice and areas for
improvement. How can this improvement be achieved? It could be
introduction of a care pathway, a new piece of documentation, or
training and education for sta in a particular subject. Think about
how these could be implemented with the use of the PDSA cycle.
Set a date for the next audit. For example, re- audit in quarter four.
Write up the data in a structured format:
Outline the scope of the audit.
Described the method for data collection– inclusion and exclu-
sion criteria, data collection tool.
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Write up the ndings from the audit. Did the data you collected
answer your audit questions? Did you experience any limitations
on the audit? Identify any pockets of positive or negative practice.
Recommendations for change.
Identify anything you would change if you were to conduct the
audit again.
Include who the audit results will be presented to and when.
Add in the improvement plan.
Write a conclusion.
Specify the date for implementing the improvement plan.
Specify the date for the re- audit.
PATIENT SATISFACTION ANDQUALITY OFLIFE
All NHS organisations now regularly conduct friends and family
testing to see how patients experience the organisation, services provided and how they feel about living with a condition (NHS2023).
This helps the NHS to make improvements to services.
Patient quality of life is dened by WHO (2012) as an ‘individual’s perception of their position in life in the context of the culture
and value systems in which they live and in relation to their goals,
expectations, standards, and concerns’. Quality- of- life surveys should
look at four domains: social, psychological, health and function.
Such surveys should be given to patients at certain points of their
care: at the beginning of care (rst contact) to assess how they feel
about their leg ulcer, then monthly throughout the treatment plan,
and then once they are healed (Mullings and Merlin- Manton2018).
Conducting surveys regularly through the treatment phase checks if
the patient’s views or thoughts have changed and if any of the
patient’s concerns have be addressed.
LEG ULCER PATHWAYS
Leg ulcer pathways came to the forefront of clinicians’ minds with
NHS England’s RightCare scenario featuring Betty’s story (2017),
which put a national focus on the optimal pathway for patients. NICE
implemented the Venous Leg Ulcer scenario (2021), which outlined
nationally recognised leg ulcer guidance and focused on best practice.
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Pathways have a structured approach, which can provide personcentred benets to the clinician, patient and the health economy. They
enable patients to receive the right evidencetime and ensure equitable care for all (correct assessment, primary
dressing, compression regimen and reassessment or onward referral).
Pathways also need to be auditable and audited to establish if best
practice is actually being delivered, with a reduction in recurrence and
occurrence demonstrating system- wide improvement or the reverse.
Implementing a clinical pathway for leg ulcer management and
care is essential to ensure that there is a standard of care across an
organisation and that patients are receiving evidence- based care that
considers both physical and psychological impacts of living with a
lower limb wound. The pathway should also include the impact on
patient quality of life. It needs to be bespoke to support holistic
patient care that is specic to local communities while meeting
explicit care needs (Mullings and Merlin- Manton2018). The pathway needs to be broken down into sections for leg ulcer assessment,
management and reassessment. Its primary aims should be to reduce
time to heal and provide standardised, equitable care to all patients.
Mullings and Merlin- Manton (2018) found that by introducing a
standardised approach to leg ulcer care that: time to heal has been
reduced, waiting lists have decreased and the patient journey has
become more streamlined, therefore providing the best chance to
achieve healing quickly.
Atkin etal. (2021) stated that it is essential that health services
move towards the elimination of unwanted variations in leg ulcer
management. The introduction of leg ulcer pathways (assessment
and treatment) reduces the variation in wating times, treatments and
outcomes for patients and provides an equitable research- based
service to patients across whole organisations.
based care at the right
CONCLUSION
One element is clear: the patient should be at the centre of the process
of preventing recurrence of leg ulceration. They need to have the
tools and the knowledge to empower them to manage and maintain
their well legs independently in the community. Healthcare professionals need have the skills and the knowledge to carry out full
holistic regular assessments, including ABPI assessment, for a patient
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