Nurses in community and acute settings are very aware these days that ignoring swelling (oedema) of the ankles, or indeed any part of the body, it is not good health care. Oedema is a sign that something is out of balance and may be corrected pharmaceutically if the cause can be found. However, there are occasions when disease or the ageing process mean that compression garments need to become the mainstay of long-term care.
The British Lymphology Society (BLS) regularly receives enquiries on how best to access medical compression garments — a question often asked when a clinician is exasperated with delays or incorrect provision of garments. Unfortunately, there is no straightforward answer. A factor that can influence access is location and funding arrangements, and routes of access change as funding sources alter.
Part of the complexity is that health costs and supply are devolved to each of the four nations; then there are local purchasing routes through local efforts to reduce costs by services. Then there are efforts by the companies who supply/distribute the goods to find easier ways for nursing and therapy services (and their patients) to access garments. Even when you think you have sorted out the issue, the politics and pathways can change again.
Lymphoedema garments first became available on community prescription (FP10/GP10) in April 2007, and it was thought that this would make things easier for everyone, but of course, no system is perfect, especially at the beginning (Hopkins, 2007). Several BLS members have written about this challenge over the years. For example, 5 years ago Woods (2018) described a 3-year audit, based at the Royal Marsden Hospital in London, into whether patients received the correct requested garment via a GP prescription route. Despite responding to audit cycles with improvements in process, the audit standard was not met in any of their audits. It was concluded that compression garments were difficult to find on NHS electronic prescribing systems, leading to a delay in patients receiving their prescriptions and a risk of error due to the wide range of options available. Around the same period, Board and Anderson (2018) (also based in England) identified waste, harm and variation in garments being prescribed via NHS prescription forms. By working with commissioners to enable negotiations with manufacturers for direct purchase the percentage of patients experiencing issues with the drug formulary route dropped from 83% to 10%. In addition, the deal negotiated with the manufacturers led to a saving for the NHS.
Economic evaluation leads to a standard process in Wales
More recently, Lymphoedema Wales Clinical Network published an economic evaluation in collaboration with medicine management personnel of the local health board pharmacy department (Thomas et al, 2021). It aimed to compare the impact and costs of the community prescription process to a new direct procurement route. Data were collected over a 12-month period by lymphoedema therapists regarding each compression garment issued to patients attending two different lymphoedema services in NHS Wales.
The data collected included information on the garment ordered, costs (prescribed compared to procured), the timing between the garment ordered and received plus a comparison of the processes. A total of 5392 completed patient data forms were included. Analysis found that using a prescription route was overwhelmingly more costly than procuring directly. Overall costs suggested the potential for substantial savings to NHS Wales (£71.10 per patient) which were statistically significant (P <0.001). The potential for improved patient outcomes was also observed as garments were provided directly on the day of the appointment rather than the significant delays previously experienced. However, the findings of this evaluation are context-based and, outside of Wales, you would need to make your own evaluation. The process of ordering garments in Wales is now standardised so that there is little variation across the 7 health boards, and this allows more purchasing and negotiating power with the manufacturers when arranging annual contracts to supply.
Beyond what has been formally published from Wales, anecdotal reports around the UK show that many lymphoedema, vascular and community leg care services are finding ways to meet this challenge, what follows are some of the solutions BLS members described.
Scotland’s varied routes of access from historic development
In Scotland, there is no nationwide agreement on how compression garments for lymphoedema/chronic oedema patients are supplied and it will vary depending on the health board. For example:
- Lymphoedema service holds an NHS budget for compression garments and supplies all garments for their patients (new garments and repeats) on NHS Hospital contract (PECOS). Historically this was the case for most services before specific lymphoedema (eg, RAL standard) compression garments became available on prescription.
- Lymphoedema service has no budget, and all compression garments are supplied by GP prescriptions
- Lymphoedema service holds a limited budget and supplies first garments with any subsequent garments supplied by prescription
- Service has a prescribing lymphoedema specialist with a budget who prescribes on FP10
- Hospice-based lymphoedema services ordering directly from manufacturers using hospice budgets. Some clinics may have a small stock and will fit a patient on their first visit.
In Ayrshire, Specialist Physiotherapist, Connie Le Maitre described how they had a ‘hospital budget’ for lymphoedema garments that was not increased when the clinic appointed additional staff, which led to an increase in patient referrals. They only had a budget to supply first garments and so changed their practice to request subsequent garments on prescription. This process was supported with a community compression garment formulary and an agreement with the practice pharmacist to generate the prescriptions. This has been working well. The downside is that community prescribing does not benefit from the hospital contract savings (which for some items can be considerable), so the procurement department is keen to revisit central purchasing). The hospital contract is renewed every few years by tendering process and the concern would be that the ‘preferred/first supplier’ might change so then repeat prescriptions could become tricky if patients don’t accept that the ‘like for like alternative’ is not suiting them.
In Forth Valley, Specialist Nurse Margaret Anne Garner says they can order direct from the manufacturers via PECOS and this is then paid for within the NHS Forth Valley budget. The keyworkers (who are community nurses) normally order the first garments via PECOS, which comes out of a community budget and the subsequent ones are obtained through GP prescription. Since 2008, she says they have had a good service ordering through PECOS direct from manufacturers and would be concerned about pharmacists changing the product without consultation with the specialist. Recently, the problem has been delivery delays due to customs issues.
Four key processes in England and a key innovation
In England the standard prescription service currently has four processes.
- Clinician performs a patient assessment that includes a full vascular and holistic assessment. They identify an appropriate compression therapy treatment plan, measure for the selected garment from this and then request this from the patient’s GP or prescribe themselves if qualified prescribers
- Prescription process is initiated by a form or letter to the patient’s GP. The administrator in the GP practice receives this request and collates it. The GP then signs the script and the prescription is then ready for collection or sent to a chosen pharmacy
- Ordering of garments varies depending on the average time to get an off-the-shelf or made-to-measure garment to the pharmacy. An off-the-shelf garment averages 5-10 working days and a made-to-measure one averages 10-14 working days. However, it is important to appreciate that is currently taking longer following COVID-19 and Brexit. Pharmacy orders the products from a wholesaler, who then delivers the product to the pharmacy, where the prescription is then dispensed
- Collection of garments is done by the patient or family member who picks up the prescription or when the pharmacy delivers the product to the patient’s home.
A delay in any one of these processes, for whatever reason, can result in the patient’s symptoms deteriorating, so a swift understanding of each of the processes is imperative to patient care.
One of the English services that has taken a critical look at the issue of compression garments is social enterprise, Accelerate, in East London. They have done direct garment provision in one borough since 2018. This was following a proposal to the clinical commissioning group (CCG) based on the premise of:
- Saving GP time (6 weeks whole-time equivalent was the conservative estimated full-time saving on the initial proposal)
- Avoiding delays to the patient regarding therapeutic treatment
- Efficiencies in the system in that the right person was requesting the right garment and that a convoluted process was avoided thus reducing errors in the system.
This scheme is called ‘garments made easy’. The process is simple. The clinician raises the order directly within the patient management system, emailing the suppliers directly with a purchase order. There are built-in forms and automated purchase orders and automated emails to suppliers. The garment is then delivered to the patient’s home or, if required, directly to the treatment centre if this is the preferred pick-up point.
‘Part of the complexity is that health costs and supply are devolved to each of the four nations; then there are local purchasing routes through local efforts to reduce costs by services’
Specialist Nurse Caitriona O’Neill of Accelerate said that as a process this is invaluable in avoiding any delays to patient treatment, with most orders being completed and with the supplier on the day of the appointment. There is no restriction on company, the choice of garments is patientled but based on the therapeutic clinical requirement. This was an important factor for the team, allowing for a focus on the clinical intervention, not necessarily being driven by a restrictive formulary based on cost alone. However, this system has been developed further and integrated, meaning it is now linked to an automated reporting function allowing for visibility on ‘in month spend’ and by ‘category of garment’. As a clinical team we are considerate of the cost of the garment, routine monitoring and checks are in place, in addition, review of the categories of garments are routinely monitored by percentage spend.
Where there is a therapeutic intervention within an area and good provision for lymphoedema you will note a year-on-year spend on lymphoedema garments may increase gradually — this is what should be anticipated if therapeutic intervention is being used. In contrast, compression bandage spends or ‘subtherapeutic spend’ on a large absorbent dressing and light supportive bandages reduces.
The scheme has been successful to the point that the local GP and commissioning group requested that patients are not discharged on repeat prescription but are kept on the ‘garments made easy’ scheme. This is included in the commissioning price ie the fee relates to the administration, which is largely linked to the complex financial backing data required for cost reconciliation. Within the service, the team has developed an enhanced patient-initiated follow-up programme, which allows for screening every 6 months prior to providing repeat garments. This also allows for patients to be reassessed should there be a clinical concern.
Having this built-in system also allowed the team to be responsive during the COVID-19 restrictions. As part of the COVID response in the wider system, all other CCGs that they delivered wound and lymphoedema supplies to were provided with direct orders in this period, thus releasing valuable GP time.
Northern Ireland reviewing processes
From Northern Ireland, Specialist Physiotherapists Jane Rankin and Jill Lorimer described how they currently use prescription access for the vast majority of their needs. Particularly the off-the-shelf products and for review patients, which seems to work quite well, they say. The first made-to-measure garment will usually come from the trust’s budget, but once the fit and suitability are checked the second will be ordered on FP10. They keep a small stock in each team setting, particularly for those items that are not on FP10, such as midline garments. They have a few non-medical prescribers, so this is shortening the prescribing process. They also request garments through internal trust processes for some consultant-linked made-to-measure products. They are currently reviewing their processes with the regional pharmacy team to look at all options.
Lymphoedema Network Northern Ireland (LNNI) has considered the formulary process in the past, but felt it limited patient/clinician choice. LNNI is, however, currently investigating a new regional supported procurement model regarding financial efficiency, and recognise the associated requirements for a new funded stock management and administration system plus staffing.
Top tips from around the UK
Having gone around the UK we finish with some general points from an experienced clinician who has worked for the NHS, third sector, and for a garment manufacturer:
- Dealing directly with the companies can mean potential cost savings, quick turnaround, and the correct garment being delivered, resulting in good patient care
- Always speak to a few companies, none are perfect for everything
- Dealing through pharmacies: some pharmacies must order via a wholesaler, and the wholesaler can add on costs not related to the company, making a £22 armsleeve cost over £40. Others may hold on to a prescription for days/weeks because they don’t know what to do with it. Others will tell the patients that ‘the company no longer provides this’ which is not always the case and may be tied up with the pharmacy not knowing where to go for it. Some companies hold a 6-8 week stock of products and with drug tariffs can supply on demand — ask them!
- Prescribing clinician: if you are a prescriber you can deal directly with the company and most offer a ‘prescription by post’ service, linking with the dispensing appliance contractor (DAC) who can legally deal with the prescription. This is a better way because the garment can be delivered to the clinic or patient (the clinician just stipulates the delivery address in the envelope), and the product is delivered once the order is placed by the DAC
- Electronic prescribing systems (EPS): the NHS is trying to get prescribers to use EPS, which sends the prescription directly to the NHS Spine, the prescriber can direct where the prescription goes and the order is received by the DAC within a very short period of time. This makes the order turnaround fast and efficient
- Non-prescriber: the easiest way, if it is possible, is to order direct with the company. Most companies have a 30-day pay period, and the clinician may be able to discuss a discount (which cannot happen with drug tariff/prescription goods as there is no flexibility there, by law). The clinician may be able to have a stock of the product (consignment stock) so that they re-order once the garment size has been issued. The company can keep an eye on the shelf life and swap out sizes that are not moving for sizes that are. Ask them!
- Made-to-measure options — look at whether the company has an online shop. Look for whether you can have your own login, and whether it’s an easy programme, with direct ordering, so that you can expect faster turnaround and direct help with made-to-measure queries
- Empower patients to ensure that their individual prescription is forwarded by giving them a copy to take to a pharmacy as back up, where there have been problems in the past
- If you are having delays in supplies, speak to the main distributor, it may be that the information they received is incomplete and they have been trying to get hold of you. It may be that your finance department have not yet paid previous invoices. Essentially: just ask!
Finally, there is more information in the BLS Tariff Guide on garment provision and sourcing: https://tinyurl.com/mr2j26h8. It is free to become a Friend of the BLS and we welcome enquiries from nurses on all matters related to chronic oedema and lymphoedema, visit https://www.thebls.com for help.