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Obtaining wound care products for use in the community

Una Adderley
DN RGN MSc BSc BA
Community Tissue Viability Prescribing Nurse
Scarborough, Whitby
and Ryedale PCT

The range of dressings available on prescription has hugely increased. The British National Formulary lists nine broad classes of dressings.(1) Each class is likely to contain many variations in terms of formulations, different makes and different sizes, with or without additional ingredients such as silver. Altogether it is estimated that there are around 600 different dressing products available in the UK. On top of this there are numerous types of bandages, dressing packs, cleansing agents, and so on. Patients are becoming more aware of the differences between dressings and consequently more vocal about what is applied to their wound. Thankfully, the days of expecting a patient to sit quietly and patiently while a piece of dried-on gauze was painfully removed are past. Patients, quite rightfully, expect nurses to choose appropriate dressings that will minimise pain and promote healing and they expect them to have immediate access to those dressings.
In the old days, the district nurse carried a case that bulged with dressings and this was usually supplemented by another box or two in the boot of their car.  Similarly, practice nurses and nursing homes could be relied on to maintain a full dressings' cupboard. The relatively restricted range of available dressings, combined with less attention to who was paying for what (and how long it may have been in the cupboard or car boot), meant that patients could usually receive a dressing that was appropriate by the standards of the time. 
These supplies often consisted of leftover dressings from patients' prescriptions and manufacturers' samples. This somewhat cavalier approach to the provision of dressings is no longer acceptable since the use of a product that has been prescribed for another patient constitutes technical fraud, even if the product has been gifted by the original patient. Similarly, the use of manufacturers' samples is frowned on as there is no traceable supply route in the event of a problem. Therefore clinicians today have a responsibility to ensure that patients have access to wound care products that have been supplied in a legal and responsible manner, are appropriate to the wound, acceptable to the patient, available when needed, and funded in a manner acceptable to both the patient and the NHS.  
Wound care products can be provided either by prescription, from a supply of stock or through the patient purchasing over the counter. They can be prescribed by a doctor, but all the products listed in the "Wound management products and elastic hosiery section" (appendix 8) of the British National Formulary can be prescribed by nurse prescribers. Independent nurse prescribers can prescribe some additional items related to wound care with the exception of maggots, which at present can only be prescribed by a medical practitioner.
The introduction of nurse prescribing has reduced the length of time between the identification of the appropriate product and obtaining that product. If the nurse prescriber is working in a clinic setting in a dispensing GP practice, then supply can be almost immediate, providing the item is held in the dispensary's stock. The use of an agreed formulary to enable the dispensary to stock the products most likely to be prescribed will minimise any delay. However, in other situations, there will inevitably be some delay as the prescription will have to be taken to a chemist for dispensing. Meanwhile the patient's wound requires dressing.

Stock box systems
A stock box system for first dressings will ensure that nurses have access to an appropriate dressing for most situations. This may not be the optimum dressing but should be adequate until the optimum dressing can be obtained. An adequate stock box will contain a range of the most commonly used products in an appropriate range of sizes and quantities (see Box 1 for a suggested list).

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However, the introduction of a stock box system in a GP practice may raise issues about cost. Items prescribed by a GP are reimbursed by the PCT. Items purchased for a GP practice stock box will be funded by the GP practice which may not be acceptable to that GP practice. Similarly, the introduction of a stock box in a nursing home will also be expected to be funded by the nursing home. Again, the owners of a nursing home may not be willing to fund such a project.
In some areas, it may be possible for GP practices or nursing homes to negotiate for the PCT to fund such stock boxes. The success of such negotiations will probably depend on the persuasiveness of the GP practice or nursing home and the financial situation of the PCT.  Involving a key clinician who works across all areas, such as the tissue viability nurse, may enable the relative benefits and costs to be more accurately identified to strengthen any negotiations.
District nurses may find themselves in an easier position. Since most will be prescribing nurses, their primary care trust will already be directly funding their prescribing. It may be relatively simple to persuade the lead pharmacist and head of finance to set up a budget for a stock box. This could be funded by either top slicing from the existing nurse prescribing budget or by monitoring the costs of a stock box and transferring that amount from the nurse prescribing budget on a regular basis. This can be justified by the fact that establishing a stock box system is not incurring additional costs since the stock box is simply speeding up the provision of dressings rather than providing additional dressings. In many areas, district nurses may have had access to a stock box for some years as the advent of nurse prescribing in the mid-90s alerted many teams to the need for an immediate supply of dressings for initial visits.

Financial considerations
Although stock boxes are usually initially implemented as a first dressing initiative until the prescription can be dispensed, there is a strong financial argument for extending the use of a stock box. Items provided by prescription become the property of the patient and cannot legally be used for another patient. It is usual practice to prescribe a box of dressings (usually five or 10 dressings in a box). Therefore if only a few of those dressings are used, either because the dressing does not suit the patient or the wound changes so that the dressing is no longer suitable, then the remaining dressings cannot be used. If, however, the dressing has been obtained from a stock box, wastage is minimal (providing dressings are not stockpiled in patient's home since these cannot be returned to a stock box). A further financial consideration is that while prescribed items are VAT exempt, the cost of items purchased outside the prescribing route are liable to VAT. Consequently, there will need to be considerable savings in quantities in order to offset the increased price per item.
 It has been noted that the use of a stock box may lead to a potential financial loss to the NHS as patients who would usually have to pay for their prescription would receive dressing products free of charge. While this is true, the loss is likely to be minimal. Many patients receiving wound care treatment are entitled to free prescriptions. The small numbers not entitled to free prescriptions are usually encouraged to purchase a prepaid prescription certificate for an appropriate length of time. Therefore, the financial loss to the NHS is likely to be negligible. 
It has also been argued that providing wound care products via a stock box risks deskilling prescribing nurses. While this argument has some validity, many prescribing nurses describe themselves as swamped by the volume of prescribing required in their day-to-day job. A stock box containing only commonly used products (eg, dressing packs) will still allow prescribing nurses to exercise their prescribing skills on those products where a higher level of decision-making is required (eg, antimicrobial dressings). It should be noted that a particular strength of prescribing is its robust data trail.  If a stock box is used, then accurate record keeping of the use of wound care items, is even more vital. 
For organisations wishing to implement a stock box system, help is offered by a variety of organisations.  Several of the dressing companies offer a supporting service to implement a stock box system. This does not necessarily require clinicians to provide a stock box list comprised only of items from that company. Stock may be obtained via the independent pharmacy route, via pharmacy distributors or via the NHS supply chain. The nursing literature also contains several useful articles by nurses who have implemented similar schemes.(2-4)

Conclusion
On balance, although prescribing meets the wound care needs of most patients, prescribing supplemented by a stock box system allows those needs to be met in a more timely fashion with the added benefit of possible cost savings to the NHS. Implementation may take some effort but can be ultimately worthwhile.

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References

  1. British National Formulary. September, 52. London: BMJ Publishing Group; 2006.
  2. Clarkson A. Dressing remedies: a concept for improving access to and use of dressings in nursing homes. J Wound Care 2007;16:11-3.
  3. Hallworth R. Wound management start pack initiative. Prescriber 2003; June:14-20.
  4. Ellis J, Harker J. Innovations in district nursing:  the use of a first dressing starter box. Br J Commun Nurs 2002;7:616-22.