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Delivering leg ulcer care in the community

Caring for patients with leg ulcers is challenging and time-consuming.  Solutions are needed that provide the highest possible quality of care delivered in the most cost-effective manner, such as community specialist leg ulcer clinics

Karen Walker
RGN BA(Hons)
Practising District Nurse and Team Leader
North Yorkshire and York PCT

Una Adderley
DN RGN MSc BSc BA
Community Tissue
Viability Prescribing
Nurse
North Yorkshire and York PCT

The changing needs of society, advances in technology and increased knowledge of the public regarding health have highlighted the need to re-evaluate the traditional delivery of leg ulcer management by practice nurses in GP practices and district nurses in patients' homes. This is supported by the NHS Improvement Plan, which promotes healthcare in the community although the government has not yet recognised leg ulcer management as a key priority.(1)
Cost-effective practice within the NHS requires evidence-based interventions with healthcare practitioners providing measurable and positive patient outcomes. In the UK it has been estimated that between 80,000 and 100,000 patients have a leg ulcer at any one time, with many ulcers remaining unhealed for more than 10 years; when healed, 69% of venous leg ulcers reoccur within one year.(2) The management of leg ulcers places a significant drain on health resources with district nursing spending 25-50% of time treating patients with leg ulcers.(3,4) Within the next two decades the elderly population is expected to increase, and the prevalence of leg ulceration impacting on the district nursing service and healthcare system will have a significant effect.(5)
Historically, venous ulceration has been a Cinderella service. The results from the 1999 Audit Commission report showed wide variations in the quality of assessment for patients with leg ulcers.(6) Robust evidence shows that multilayer compression bandaging systems are the most effective treatment for healing venous leg ulcers: the recent availability of graduated compression hosiery for healing also looks promising.(7)
Achieving healing usually depends on the willingness of the patient to accept clinically effective care and this is closely related to the nurse's ability to transfer their knowledge and confidence to their patient.(8) However, previous research has shown that community nurses' knowledge of leg ulcer management is often inadequate.(9,10) Evidence shows that delivering leg ulcer care through community leg ulcer clinics improves healing rates and offers additional support and empathy to the patient.(11,12,13)

Leg ulcer clinics
Leg ulcer clinics offer the opportunity to provide holistic specialist care for patients with leg ulcers while reducing the volume of practice nurse appointments and district nurse caseloads. They may also lead to improved healing rates.
Unfortunately much of the research evidence regarding the effectiveness of caring for patients with a leg ulcer in a clinic setting is flawed through poor design and cannot be regarded as reliable. However, Morrell et al and Edwards et al used randomised controlled trials to measure healing rates, pain, nursing time, cost consumables and quality of life of patients receiving care in a clinic compared with those receiving care at home.(14,15)
Morrell et al found that patients who received care in a community leg clinic tended to heal earlier and remain ulcer-free for longer with fewer recurrences than patients receiving care at home.(14) Edwards et al also found significantly improved healing rates for patients receiving clinic care compared with patients receiving individual home visits.(15)
Although both studies show an improvement in healing rates for patients attending a leg ulcer clinic, the costs of transport were not addressed. This may have significant financial implications for patients and healthcare providers in rural areas where access to clinics can be problematic. Quality of life was also not evaluated. Leg ulcers have a major impact on quality of life which may result in issues that are more significant to the patient than healing alone, such as restricted mobility, sleep deprivation, depression and reduced social activities. Other studies suggest that leg ulcer clinics may reduce pain, improve social functioning and psychiatric morbidity.(16,17)

Clinic "package"
It is unclear as to what the improvements in healing in community clinics can be attributed. It is possible that leg ulcer clinic clinicians have a higher level of skills and knowledge than practice nurses and district nurses. Possibly, patients who attend clinics may be more motivated towards obtaining best treatment to heal their ulcers. Alternatively, patients who attend a clinic may be healthier and more mobile than those receiving home treatment, although since these were randomised controlled trials, this last explanation is unlikely. The most probable explanation is that the specialist clinic "package" has combined intrinsic benefits over and above the home visit or GP surgery visit "package" of care.
Initially, community leg ulcer clinics were based on a strong medical model concerned with rationalisation and cost-effectiveness, but this approach did not necessarily lead to improvements in the quality of life for those suffering from leg ulcers. The evidence suggests that organising leg ulcer care in a community clinic setting may have benefits beyond simply improving healing rates. Innovative developments have tried to capture these benefits.

Leg Club®
The development of the Leg Club® concept brought a new approach to the idea of leg ulcer clinics. Ellie Lindsay, a district nurse providing leg ulcer management in a rural community, realised that compression therapy would only ever be effective if a patient complied with the treatment. Therefore she developed Leg Clubs to provide holistic care in "an environment of patient empowerment, destigmatisation and peer support".(18)
Leg Clubs are based on the Health Belief Model, which looks at the patient's influences and thoughts behind why they have sought professional clinical help at that particular point in their life. Leg Clubs have developed in partnership with community nurses, patients and the local community. They aim to provide leg ulcer management in a nonmedical setting with an emphasis on social interaction, participation, empathy and peer support.(18) The four key features are:

  • Community-based clubs in a nonmedical setting.
  • Patients are treated collectively.
  • A drop-in basis - no appointments necessary.
  • A fully integrated well-leg regime.

The Leg Club literature suggests that they may reduce health costs, promote evidence-based practice and achieve higher healing rates while improving quality of life for patients with leg ulceration.

Our experience
Current government policy appears to be introducing fundamental changes to the way in which the NHS services are organised and commissioned. Practice-based commissioning aims to determine and shape local services, and community nurses need to demonstrate that their services are efficient and cost-effective. The delivery of leg ulcer care may be better provided through the establishment of community leg clinics than through existing individualised arrangements. Obviously there will be some patients who are too frail to attend a clinic and require home visits from the district nursing team. However, a surprising proportion of patients are able to attend a clinic, particularly if it is close to their locality and transport is available. We undertook an audit in our rural area and were surprised to find that 50% of patients with leg ulcers, currently receiving care from their district nursing team, would be able to attend a clinic if transport was available. Transport appears to be a key issue. 
On a personal level, we set up a pilot leg ulcer clinic in Scarborough, which is staffed by nurses from our local district nursing teams, and currently only accepts referrals for patients who would otherwise receive home visits from the district nursing team. Transport is provided. To date we are seeing similar improvements in healing rates and quality of life to that suggested by the literature.(13,15,16) Although a full audit has not yet been undertaken, patients have been given questionnaires to evaluate their experiences within the clinic. The results all report positive findings, and some patients have explicitly remarked on the positive social interaction they achieve from attending the clinic. Our next challenge is to persuade our commissioners to allow us to expand this service.
Community clinics appear to offer an effective means of providing high-quality care to patients with venous leg ulcers. Community nurses working in a community leg ulcer clinic will see enough patients to enable them to become specialist practitioners in this clinical field, thus acting as a resource to their community colleagues. Working alongside fellow experts, nurses increase the opportunities to learn from each other and develop expert teamwork. Patients obviously benefit from receiving high-quality evidence-based care. However, equally importantly, patients have the opportunity to participate in supportive networks with other patients with a similar condition. Patients have more opportunity to become "expert" patients and thus develop skills and access support for managing this chronic condition.
 
Conclusion
Delivering leg ulcer care in a clinic setting to as many patients as are able and willing to attend appears to offer big advantages to patients, community nurses and healthcare providers. Patients get access to an expert service, close to home, and benefit from developing support networks with fellow patients. Nurses can develop their skills to become experts while healthcare providers can utilise nursing time more effectively.

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References

  1. Department of Health. The NHS Improvement Plan. Putting people at the heart of public services. London: DH; 2004.
  2. Moffatt CJ, Dorman MC. Recurrence of leg ulcers within a community ulcer service. J Wound Care 1995;4:57-61.
  3. Simon DA, Freak L, Kinsella A, et al. Community leg ulcer clinics: a comparative study in two health authorities. BMJ 1996;312:1648-51.
  4. Casey G. Leg ulcers. Primary Health Care. 1999;9:31-6.
  5. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers. In: Cochrane Review. The Cochrane Library. Chichester: John Wiley and Sons; 2004.
  6. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: Audit Commission; 1999.
  7. Royal College of Nursing. Clinical practice guidelines. The nursing management of patients with venous leg ulcers. London: RCN; 2006.
  8. Jull AB, Mitchell N, Arroll J, et al. Factors influencing concordance with compression stockings after venous leg ulcer healing. J Wound Care. 2004;13:90-2.
  9. Luker KA, Nurse B, Kenrick M. Towards knowledge-based practice; an evaluation of a method of dissemination. Int J Nurs Stud 1995;32:59-67.
  10. Dealey C. The importance of education in affecting change in leg ulcer management. 7th European conference on advances in wound management. London; EMAP Healthcare Ltd: 1998.
  11. Moffatt CJ, Franks PJ, Oldroyd M, et al. Community clinics for leg ulcers and impact on healing. BMJ 1992;305:1389-92.
  12. Simon DA, Freak L, Kinsella A, et al. Community leg ulcer clinics: a comparative study in two health authorities. BMJ 1996;312:1648-51.
  13. Chaloner D, Noirit J. Treatments and healing rates in a community leg ulcer clinic. Br J Nurs 1997;6:246-52.
  14. Morrell CJ, Walters SJ, Dixon S, et al. Cost effectiveness of community leg ulcer clinics: randomised controlled trial. BMJ 1998;316:1487-91.
  15. Edwards H, Courtney M, Finlayson K, Lindsay E. Chronic venous leg ulcers: effect of a community nursing intervention on pain and healing. Nurs Stand 2005;19:47-54.
  16. Franks PJ, Moffatt CJ, Connolly M, Bosanquet N, Oldroyd M, Greenhalgh RM, et al. Community leg ulcer clinics effect on quality of life. Phlebology 1994;9:83-6.
  17. O'Hare L. Implementing district-wide nurse led leg ulcer clinics: a quality approach. J Wound Care 1994;3:389-92.
  18. Lindsay E. The Lindsay Leg Club Model: a model for evidence-based leg ulcer management. Wound Care 2004;June:515-20.

Resources
The Leg Ulcer Forum
W: www.legulcerforum.org
The Leg Ulcer Forum provides a forum for nurses involved in leg ulcer care

Leg Club
W: www.legclub.org
The website of the Leg Club provides information on many aspects of leg ulceration and specific information about the Leg Club

RCN Clinical Practice Guidelines
W: www.rcn.org.uk/publications/pdf/guidelines/venous_leg_ulcers.pdf
The 2006 RCN Clinical Guideline for Managing Venous Leg Ulceration gives an up-to-date account of current research in this area and suggests gold standards of care