There is a challenge in maintaining quality of care within ostomy, whilst also managing the cost constraints. The West Essex Clinical Commissioning Group (CCG) is currently undertaking development of a nurse-led service which incorporates prescribing, with the hope of improving the quality of stoma care.
Background of Service
Within West Essex CCG, pride is taken in a progressive and imaginative approach to improving and enhancing patient care in the community.
Historically, within the area, ostomy patients ordered their prescriptions via their GP surgery. GPs often had little clinical expertise within this area and were unable to support the patients with stoma management issues or review the patient annually to ensure prescribing was clinically appropriate.
The ostomy service at the acute trust was reduced in 2010, and the service could no longer able to support patients within the community. This meant support and advice could only be offered by telephone consultation as there was no patient pathway in place.
In September 2011, the Department of Health and Social Care published a set of recommendations in relation to ostomy care. One recommendation was that patients with an ostomy should receive an appliance use review by a specialist nurse on an annual basis (Department of Health and Social Care, 2011). This recommendation was unachievable without a community service within the area, which led to patients struggling to cope with their ostomy challenges and often using inappropriate/excessive products based on advice from various appliance contractors, literature or social media. This resulted in spiralling prescription costs. The cost of ostomy products within West Essex had increased by 13.3% over three years (NHS Prescription Services, 2018, Data on file).
In summary, the patient's experience was compromised whilst prescription costs were increasing.
Time to Change
Currently, there is a growing trend of increased ostomy prescriptions due to disease detection, survival rates and an ageing population. West Essex CCG recognised this trend and the need to provide a service for all ostomy patients that would allow for better patient outcomes, therefore reducing both complications and costs.
With this recognition for a need to change, in May 2015, West Essex CCG initiated work in partnership with Coloplast to redesign the ostomy service for patients. The aim was to provide a more patient-centred service specialising in ostomy care and helping them to manage their stoma care. This was intended to reduce poor management, and improve care whilst managing costs.
The revised service model for West Essex
As part of the new service, all patients were offered a stoma appliance review in line with NHS recommendations (Department of Health and Social Care, 2011). To facilitate this, clinics were established within the primary care setting at three locations to ensure the service was provided close to the patients' homes. For frail or housebound patients, home visits were offered to ensure all patients received the same level of care and support. The aim was for all patients registered at the stoma clinic service to receive an annual review to ensure their care was well-managed and they were prescribed clinically appropriate products, such as barrier wipes, adhesive remover spray, ostomy power and seals.
Whilst undertaking the reviews, the Coloplast nurse noted that some patients were suspicious of the change in stoma service. It was felt that the changes may be a cost-cutting exercise and that patients would not be allowed supporting products. This challenge was not unexpected, as usage and opinions about supporting products in stoma care vary enormously. A patient can identify supporting products as being necessary for their required physical and psychological wellbeing, though they are often not clinically required (Black, 2013). The nurse overcame initial suspicions by offering clear explanations and discussing with the patient their current care requirements, complications and support required. Reassurance was given to patients that if a product was clinically indicated and appropriate it would be prescribed as part of the review process.
Overall financial savings generated because of the new service
During the first year of the launch of the new stoma service (2015/16), West Essex prescribing costs decreased by 20% in the region of £22 100. The saving was due to improvements in appropriate management of stoma patients, which also led to improved prescription management without compromising patient care. Patients were not changed to alternative products unless clinically appropriate.
In the past 3 years, the cost of a prescription has averaged at £266 per patient. This cost has remained flat, despite annual drug tariff increases, new products to market and an increase in patient numbers. Data from October 2015 to current April 2019 indicates a 9.2% increase in patients to the service with only a 2% increase in prescribing costs (Coloplast, 2019, data on file).
Conclusion
The service redesign within West Essex CCG has provided a patient-focused solution, improving care and allowing for impressive financial savings.
The first year resulted in a 21% reduction of £221 181, based on prescription costs. Over the course of 3 years there has been an increase of 404 new patients yet the average cost per prescription has remained consistent, with improvements in the clinical and quality aspects of the service (NHS Prescription Services, 2018, data on file).
The key to the project success is a nurse-led stoma clinic providing assessment of every patient regularly and transferring the prescribing responsibility to the specialist nurse who understand the clinical needs of ostomy prescribing.
The NHS 10-year long-term plan advocates people taking more control over their own health and the care they receive. This service encourages more collaboration between GPs, their teams and community services, as a ‘primary care network‘. This integrates services with local partners, as ‘Integrated Care Systems‘, to plan and deliver services which meet the needs of their communities.
Working in collaboration with specialist provider companies who can invest the resources required has proved a great success not only in relation to patient care, and reducing demand on other NHS resources, but more importantly the overall wellbeing of ostomy patients within West Essex CCG to ensure they receive the support they require to live life with a stoma.
Benefits for patients
- Patients have access to a clinical nurse specialist
- Patients receive a quick response to ostomy problems, preventing A&E admissions and use of NHS resources
- Services are offered close to patient's homes within primary care as per the NHS Long-Term Plan (NHS England, 2019)
- Housebound patients are supported, providing care in the home as per the NHS Long-Term Plan (NHS England, 2019)
- Prescribing is based on clinical need, the right product, right service and right care (PrescQIPP, 2015)
- Patient pathway together with a call centre assessment ensures patients have fewer challenges with their stoma management.
- Patient satisfaction surveys demonstrate 100% satisfaction based on 210 responses from October 2015 to April 2019 (Coloplast, 2019, data on file)
Quality outcomes
- Patients are aware of how to seek advice/support in relation to their stoma.
- 2% of patients in West Essex would visit a GP for a stoma-related issue compared with 12% nationally (Coloplast, 2019, data on file)
- Savings from avoided NHS activity/resources i.e GP visits, A&E attendance for the CCG were £6995 over a 6 month period (NHS, 2018; Curtis and Burns, 2017; NICE, 2018)
- Coloplast ostomy check reports that 60% of patients in West Essex CCG report no issues, versus 20% nationally reporting no issues
Key Points
- Historically, ostomy patients ordered their prescriptions from their GP service
- The service was reduced in 2010 and therefore unable to provide support for patients
- By working with Coloplast, the service was reworked to provide greater support and minimise costs
- Working with local partners has proven to be a success both in terms of improving care and reducing costs
- This change in services is supported by the NHS Long-Term Plan
CPD reflective questions
- How can services work with local partners to ensure high-quality care and cost effectiveness?
- Can demands on NHS resources be reduced without compromising quality of care?