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How we developed a community leg clinic

Anne Kelly
BSc HVCert RN
Director of Clinical Services - Nursing
Eastleigh and Test Valley South PCT
E:anne.kelly@etvs-pct.nhs.uk

The impetus to develop community clinics to treat leg ulcers started with the passion, vision and commitment of a district nurse, Lisa Rice, 2 years ago. She had previous experience in running leg ulcer clinics in other organisations, the success of which provided the driver to initiate clinics in Eastleigh and Test Valley South (ETVS) PCT. Lisa gained an ENB qualification in leg ulcer management in January 2002 and therefore had the expertise and knowledge to lead this service development. Her energy and enthusiasm to initiate this project, knowing that this type of service offers the best quality care and outcomes for patients, resulted in agreement from the PCT Board and Professional Executive Committee (PEC) to develop four "leg clinics" in each of the PCT localities. Lisa is now the PCT Leg Ulcer Nurse Specialist.
This article outlines the development processes that occurred to implement the first leg clinic, the rationale for taking the clinic concept forward, the audit and results, basic costing information, the challenges encountered, and the way forward.
The overarching aims of the leg clinics were:

  • To provide accessible, appropriate, high-quality, ­evidence-based care for all PCT patients with leg ulceration.
  • To improve effectiveness and efficiency.
  • To increase the skill level of all district nurses and practice nurses in the treatment and ­management of leg ulceration.

In the beginning - getting started
Commitment, energy and enthusiasm are the first requirements to getting a project of this type off the ground! To take the concept of "leg clinics" forward it was absolutely imperative to win interest and support from all colleagues. They needed to understand both the clinical and cost benefits of leg ulcer clinic treatment.
Lisa conducted some public relations exercises with her colleagues - a time-consuming task. Once she gained support locally she led a series of three audits: two within her own GP practice and one across the PCT. To get the ball rolling Lisa initially canvassed the support of her GPs - no mean feat but well worth the effort. Having seen the promising results from the first audit, their support facilitated the second audit within their own practice, and latterly the third audit across the PCT.
Their reinforcement of the benefits has also been invaluable to the continuation of the project, helping to gain the support of PEC members. It is also worth mentioning that, at this stage, Lisa undertook the bulk of the work in her own time as she was already ­managing a busy district nursing caseload and team.

The audits
The first audit took place over 2 weeks in a GP practice with 14,500 patients. Both district nursing and practice nursing patients were included.
The second took place over 3 months within the same patient population. The third audit was conducted across the PCT - with a patient population of 160,000. At each stage, good clinical audit results facilitated the next audit cycle. In addition, at each stage Lisa had to present the findings to colleagues, both nurses and doctors, to gain support in order to proceed, which was quite a lengthy and time-consuming process but an integral part to sustaining interest and support.

Audit content
In summary, the audits requested:

  • Numbers of patients with active ulceration.
  • Male/female prevalence.
  • Age.
  • Aetiology.
  • Evidence of Doppler ultrasound assessment.
  • Duration.
  • Recurrence.
  • Face-to-face contacts.
  • Treatments in use.

Discussion
The audit findings are presented in Table 1. Clinical effectiveness for patients treated in the clinic, in terms of healing rates and appropriate use of dressings, was favourable compared with traditional district nursing and practice nursing practice.

[[NIP15_table1_70]]

Time was spent with the accountants to work out the estimated costs of running four clinics and the savings that could be made. Details of this can be requested from Lisa. In summary, offering the service in the traditional manner costs £16.88 per patient per week approximately, while in the clinic it costs just £12 per week, thus providing a saving of £4.88 per patient per week (see Table 2).

[[NIP15_table2_72]]

In addition, more appropriate and evidence-based care in the clinic means that the number of patient contacts should be reduced by as many as 4,660 across the PCT in the first year, and further reductions are expected as all the clinics become operational. Estimated savings of £80,542 gross in the first year are possible with one clinic operational, and obviously this number should increase in line with the increase in the number of clinics. Clearly, assumptions have been made about the numbers of patients being treated in the clinics and only time will tell whether these assumptions are correct.
Certain costs from the estimated savings must be found, and these include:

  • The salary of the specialist nurse.
  • Some administrative and clerical time to support her.
  • Nurse travel.
  • Voluntary transport for patients.

Ensuring that patient transport is available is fundamental to the success of any community clinic. A surprising outcome from the "clinic patient questionnaire" was the value that leg ulcer patients, who are often housebound, placed on getting out of the house to visit the clinic! The social interaction at the clinic and on the bus was rated very highly and contributed significantly to patient satisfaction with the whole episode of care.

Next steps
These are both professional and material and range from finding suitable accommodation, without which clinics cannot be provided, to engaging healthcare professionals. This engagement is not a foregone conclusion as offering treatment in a specific leg clinic is a change from traditional practice and takes the care and treatment away from individual practitioners - Lisa is finding this aspect one of the most challenging.

The following next steps will need to be taken:

  • Phased roll-out of all clinics by April 2004.
  • Close working with the pharmacy team to develop ­an evidence-based formulary and to facilitate bulk ordering to ­promote quality of care and cost-­effectiveness.
  • Development of an education programme to ­support delivery of high-quality treatment of leg ­ulceration.
  • Support to leg ulcer specialist nurse from all nurse colleagues.
  • Development of leg ulcer link nurse group.
  • Development of consensus policy and standards for ­treatment across PCT(s) and acute providers (ETVS PCT works with two acute providers).
  • Development of "well-leg clinic" to reduce ­recurrence, support self-learning and ­independence, and offer generic health ­promotion.
  • Maintenance of the high profile of the leg clinic by active PR and robust relationships with the ­communications manager, practice managers, ­voluntary sector, and so on.

Conclusion
These issues will keep us busy for some time to come. The initiative has been very well received to date, especially by patients, which is most rewarding. In terms of the policy context nationally, nurses are being encouraged to take the lead and develop nurse-led services.2-4 Locally, the PCT nursing strategy and the local health delivery plan also support such initiatives.
Progress to date has been somewhat slower than envisaged as Lisa has been on maternity leave. However, an experienced senior staff nurse with an interest in leg ulcer management has most ably kept up the momentum. She has established a second clinic that is well attended with excellent healing rates and unsolicited thanks and praise from patients. Upon Lisa's return, another audit of clinical and cost benefits will be undertaken, and the implementation of two further clinics should be accomplished by the end of this financial year.
Lisa would be pleased to hear from other nurses working in the field for information exchange, networking and dissemination of good practice. Lisa can be contacted at lisa.rice@etvs-pct.nhs.uk

References

  1. Moffatt C, Franks PJ, Oldroyd M, et al. Community clinics for leg ulcers and impact on healing. BMJ 1992;305:1389-92.
  2. Department of Health. Making a difference. London: The Stationery Office; 2001.
  3. Department of Health. First class service. London: HMSO; 1999.
  4. Department of Health. Shifting the balance of power. London: The Stationery Office; 2002.