Hard-to-heal wounds create a significant burden on individuals and on the financial resources of healthcare organisations (Phillips et al, 2016). The management of hard-to-heal wounds, including pressure ulcers (PUs), is associated with annual costs of over £5 billion to the NHS, and mismanagement of these wounds has been an ongoing challenge (Greener, 2019). Confounding the economics of hard-to-heal wound care, significant public health reform in 2013 led to a real-terms reduction in spending power of 28.6% between 2010 and 2017 in the newly devolved healthcare budgets (Buck, 2020). The NHS Long Term Plan mentions the reversal of this funding deficit with a focus on increasing funding in areas including multi-morbidity and diabetes, as well as specific wound-related targets including the National Wound Care Strategy Programme and the development of a Commissioning for Quality and Innovation (CQUIN) for wound care, to help monitor the quality of care (NHS England and NHS Improvement, 2019). In addition to these responses to the growing demands of hard-to-heal wounds, the NHS Long Term Plan aims to reduce unjustifiable variation in care (NHS England and NHS Improvement, 2019). This issue is likely to impact the delivery of care and the experience of patients with chronic wounds, which is associated with significant variation in clinical practice (Adderley et al, 2017).
Patient-centred care represents the accepted paradigm for modern healthcare (Richards et al, 2015). However, clinicians often believe their care is patient-centered despite this not being reflected in patient surveys, indicating the importance of managing patient expectations in the delivery of healthcare (Eaton et al, 2015). This is particularly relevant in the prevention of PUs, which have been associated with a 43% increase in litigation costs between 2014 and 2018, suggesting an increased public awareness of PUs and the expectation that they should be prevented (Stephenson, 2019).
This article will debate the issues of healthcare demands, and patient expectations and perceptions of healthcare services in relation to PU prevention in the NHS, in addition to potential barriers to the implementation of effective PU prevention according to the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP) and Pan Pacific Pressure Injury Alliance (PPPIA) guidance (EPUAP et al, 2019).
Healthcare policy and government priorities
Contemporary Government priorities in healthcare are published in the NHS Five Year Forward View (NHS England, 2014). PU care is not referenced explicitly within the document; however, a planned shift in the focus of healthcare towards primary and secondary prevention is a common theme (NHS England, 2014). In addition to the promotion of preventive care, which has clear implications for PU prevention, the plan also includes workforce development and improving the efficiency of services (NHS England, 2014).
Workforce issues have also been identified in the context of PU prevention within studies related to community nursing in the NHS (Cross et al, 2017; Clarkson et al, 2019). Specifically, these studies identified poor interprofessional collaboration and limited education as potential barriers to effective PU prevention. Nonetheless, since these studies relied on small samples of staff from a single trust, extrapolation of thee findings to all NHS settings is not appropriate. However, the findings of Cross et al's (2017) study, which focused on community care workers, may be more representative of care delivered by non-registered nursing staff throughout the NHS due to the lack of consistent training these staff receive (Cunningham et al, 2019). The issue of inconsistent training and its impact on nursing care was identified in the 2013 Francis inquiry and led to a recommendation that healthcare support workers (HSWs) become registered (recommendation 1.194) and subject to a consistent training programme throughout the NHS (Francis, 2013). Despite this, regulation of HSWs has not been adopted into national policy and remains a controversial issue potentially contributing to an avoidable variation in care, inefficiencies and the risk of care being delivered by staff without adequate training (Webb, 2011). This represents a potential conflict of healthcare priorities, with the NHS Long Term Plan aiming for a reduction in unwarranted variation, while continuing to operate non-standardised training and the NHS employing unregulated healthcare workers (NHS England and NHS Improvement, 2019).
Education standards for registered nurses in the UK were updated in 2018 and now include specific PU prevention-related competencies, including the assessment of skin and the use of pressure-relieving techniques (Nursing and Midwifery Council, 2018). Although this is in keeping with the Five Year Forward View (NHS England, 2014) and the Government's emphasis on preventive care, the impact of this reform is unlikely to be seen yet, with the first nurses trained to the post-2018 standards not due to qualify until 2021. It is evident that more training and education is needed, particularly for nurses trained prior to changes to the nursing curriculum in 2018.
Pressure injuries are recognised as a high-priority area for quality improvement by NHS England, which is reflected in funding for NHS England-commissioned campaigns (Public Health England, 2015). Ongoing campaigns include the development of the National Wound Care Strategy (NWCS) Programme (Webb, 2018), the React to Red campaign (Nottingham Healthcare NHS Foundation Trust, 2014) and the development of National Institute for Health and Care Excellence (NICE) guidance (2014). The NWCS Programme was inspired by a review of the economic burden of wound care on the NHS by Guest et al (2015). The NWCS Programme is broadly split into three workstreams and three missions (Webb, 2018). One of the missions is the assessment and prevention of PU with workstreams, including the generation of a national data set and standardisation of education and training. The programme, therefore, represents a clear manifestation of Government priorities led by experts in wound care (Adderley, 2019). However, work on establishing data baselines related to PU care is ongoing, and the impact of the NWCS programme on PU prevention is yet to be determined (Adderley, 2019).
The ‘Stop the Pressure’ campaign, initially launched by NHS England Midlands and East and then developed as part of the NWCS, aimed to improve risk assessment and data collection (NHS Improvement, 2019). It has seen an increase in awareness of PUs, with some trusts producing case study posters showcasing their work related to the campaign (NHS Improvement, 2019). Examples include a poster produced by Waller (2016), which included an audit of documentation, followed by procurement of new equipment and training. Waller (2016) concluded that the incidence of PUs had reduced due to this intervention; however, no data was presented to support this, and no observational audit methodology was described to indicate that data were collected on PU occurrence. Farman et al (2017) described the development of a framework to reduce PUs based on the acronym aSSKINg. However, no data were presented to indicate the impact this approach had on PU prevention. Overall, there is little robust data to indicate the clinical impact of the Stop the Pressure campaign (NHS Improvement, 2019). However, it may contribute to an increased awareness of PUs and, consequently, patients' expectations of PU preventive care via access, dissemination and sharing of campaign materials. Data may yet emerge on the value of this campaign on the Government's preventive care priority and the NWCS Programme's mission to reduce PU occurrence. Specifically, case studies and service reviews describing the impacts of the campaign are needed to help elucidate its impact clinically, in addition to any barriers to its implementation. These should be produced by clinicians and healthcare leaders responsible for the provision of preventive PU care.
The healthcare demands of pressure ulcer prevention
Economic evaluations of the cost of PU prevention have been conducted in a variety of healthcare settings; however, they are limited in guiding priorities due to methodological challenges undermining the value of results (Ocampo et al, 2017). Specifically, evaluations of preventive interventions and the associated costs are often evaluated in combination, making the relative cost-effectiveness of individual interventions challenging to measure (Ocampo et al, 2017).
Recent studies have sought to better evaluate the cost-effectiveness of PU-prevention methods. For example, Whitty et al (2017) conducted a large-scale randomised controlled trial (RCT) including eight tertiary hospitals. The authors concluded that multi-component PU prevention may not be cost-effective, despite improving overall nursing practice. However, they acknowledged that the sample size was insufficient to provide statistically meaningful data, indicating the costs associated with determining the cost-effectiveness of PU prevention. In addition, patients who developed a PU during the trial were excluded from the final analysis. This may limit cost-effectiveness outcome data due to the absence of data indicating the cost savings yielded by prevention of PU deterioration; more severe PUs often cost more to manage than superficial ulcers due to a myriad of factors (Brem et al, 2010).
A more recent study by Padula et al (2019) investigated quality of life years (QALY) as a secondary outcome alongside cost-effectiveness. The authors concluded that PU prevention is cost-effective and improved QALY in patients. The results, however, were limited by assumptions that the inter-rater reliability of PU risk assessment was consistent using the Braden tool, as well as patient compliance with PU prevention. PU risk assessment tools are associated with no change in the incidence or severity of PU incidence, which may indicate a lack of clinimetric value in PU risk assessment tools or the methodology used to demonstrate their efficacy (Moore and Patton, 2019). Notably, studies have indicated the poor inter-rater reliability of the Braden PU risk assessment tool (Kottner and Dassen; 2010, Wang et al, 2015; Riccioni et al, 2019). This suggests that trials evaluating the cost-effectiveness of PU prevention may include patients with an inaccurately calculated risk for PU, leading to the inefficient use of resources and the limitation of conclusions drawn from data associated with them. In addition, the assumption is often made that patient compliance with PU prevention measures is likely to be high. However, a recent study by Ledger et al (2020) reported that patients in the community demonstrated poor compliance with preventive interventions. This may undermine studies investigating preventive interventions where consistent compliance among study participants is assumed. Future studies should include regular audits of interventions under investigation throughout trials to mitigate this. More studies are also needed to establish the clinimetric properties of available PU risk assessment tools and how these can be optimised in order to mitigate biases introduced by the reliability of the tools.
In addition to the clinimetric flaws of the risk assessments used to recruit patients into trials and inconsistent patient compliance, the ‘event frequency’ associated with PU development has been identified as a limiting factor in the interpretation of economic data on PUprevention (Nixon et al, 2019). The incidence of PUs may vary between healthcare facilities due to variations in risk and PU-prevention practices, which ultimately undermines statistical power calculations (Nixon et al, 2019). This may have impacted a recent study by Beeckman et al (2019), in which alternating pressure mattresses (APMs) were reported to significantly reduce PUs in a nursing home population and was, therefore, cost-effective (P=0.04). However, the power calculation guiding the sample size used was based on incidence data from a tertiary care setting (Demarré et al, 2013). Patients in a tertiary care setting are likely to be at higher risk and, therefore, more PUs may develop in this population (Koivunen et al, 2018), leading to a potential overestimation of efficacy when APMs were used in a nursing home population. However, prevalence data on PU in different care settings are inconsistent, which may be due to differences in reporting, PU prevention care and the inherent risks in the specific patient population (Courvoisier et al, 2018; Moore et al, 2019). This ultimately indicates the need for contemporaneous prevalence data in power calculations for the study of specific patient populations when evaluating the economics of PU prevention, although this does present pragmatic challenges to researchers. Studies should seek to determine sample sizes based on contemporary local epidemiological data where possible, for example, from incident reports.
Patient expectations in relation to pressure ulcer prevention
Public perceptions of PUs have changed over the past decade, with growing awareness of the impact and potential avoidability of pressure damage; this is reflected in increased litigation against the NHS associated with PUs (Stephenson, 2019). Increases in litigation have been observed despite root cause analyses of PUs, indicating that the avoidability of PUs had previously been overestimated and that potentially only 50% of PUs can be avoided (Downie et al, 2013). The growing expectation of the British public that PUs can be avoided may be due to the mainstream media raising awareness of the impact of PUs on individuals or documenting pay-outs received by those who have made claims (Wighton, 2012; Gregory, 2013).
Government campaigns to increase awareness may have also contributed to the changing expectations of patients. Integration of modern patient-centred and evidence-based care paradigms in PU prevention in campaigns such as Stop the Pressure requires professionals to share care decisions with patients (Guy et al, 2013). Patients expect to receive effective counselling on the options available to them and to receive care based on robust clinical evidence (Greenhalgh et al, 2014). This is complicated, however, in cases where the care is complex in nature and outcomes are dependent on a multitude of factors (Greenhalgh et al, 2014). Effective PU prevention is reliant on various factors, including the initial assessment of risk in combination with one or more preventive interventions that, independently, have poor evidence bases (Gillespie et al, 2014; McInnes et al, 2018; Moore and Patton, 2019). A poor evidence base may contribute to the unwarranted variations in clinical practice, which have been identified as an issue requiring action in the NHS Long Term Plan (NHS England and NHS Improvement, 2019). It is possible that with more investment in research on the efficacy of preventive interventions for PUs, variation in practice may be reduced.
Variation in practice and advice may also negatively impact patients' health literacy, which was demonstrated to be poor in a recent mixed-methods study on NHS patients in community settings (Durrant et al, 2019). According to the authors, information leaflets had a poor impact on the functional health literacy of patients; instead, effective patient–professional relationships are key to improved literacy. It is unclear whether the results from this study can be extrapolated to inpatient settings where patient–professional interactions are more frequent, creating more opportunities for patients to develop greater health literacy regarding PU prevention. However, this was not indicated in a review by Ledger et al (2020), which reported that patient compliance with PU prevention was low in both community and inpatient settings. The authors recommended further research to indicate factors affecting patient engagement in preventive strategies. This suggests that patients have limited expectations that recommended preventive strategies will be effective, regardless of the availability of health professionals or access to advice and information. This may indicate a failure of clinicians to effectively balance the interplay between medical factors, treatment environment and personal factors, which have been established to influence patients' locus of control and subsequent motivation to comply with recommended management plans (Papadopoulos and Jukes, 1999). Ledger et al (2020) proposed that patients' lifestyle considerations, in combination with shared-decision making, may impact patient adherence to preventive strategies.
Conclusion
Preventive care has been identified as a Government priority in addition to workforce development (NHS England, 2014). This is likely to impact PU preventive care in the NHS. The NWCS Programme has been created, which includes workstreams addressing PU prevention (Webb, 2018). However, there remains little robust data indicating the impact of the programme due to its infancy. Government priorities relating to PU prevention are conflicting in certain areas; specifically, the target for a reduction in unwarranted variation in clinical practice is not reflected in the decision not to regulate all healthcare staff made following the Francis (2013) report, which indicated that a lack of regulation of staff contributed to inconsistent and poor care.
Economic analyses of PU-prevention interventions are undermined by factors including the multifaceted approach taken towards prevention (Ocampo et al, 2017) and poor inter-rater reliability of PU risk assessment tools undermining recruitment into trials investigating PU prevention (Moore and Patton, 2019). Statistical analysis of results yielded by economic analyses are limited by the inconsistent frequency rate of PU development among patient populations. These are sometimes recycled between trials despite significant variations observed between care settings (Courvoisier et al, 2018; Moore et al, 2019). This may influence the observed efficacy of preventive strategies and influence economic evaluations.
Overall, the healthcare demands on the NHS created by PU prevention remain unclear although the burden is clearly high with costs associated with litigation rising continually (Stephenson, 2019). The implications of the poorly understood economics of PU prevention may include variation in practice contrary to the NHS Long Term Plan (NHS England and NHS Improvement, 2019). Sub-optimal allocation of resources may be a problem, due to the lack of robust data indicating the efficacy of preventive strategies, as well as the cost-effectiveness of specific interventions, such as APMs (Beeckman et al, 2019) or multicomponent care bundles (Whitty et al, 2017). Crucially, PU prevalence may be higher than it would be with more effective resource allocation (Moore et al, 2019).
Patient expectations of PU prevention may be influenced by mainstream media (Wighton, 2012; Gregory, 2013), awareness campaigns created by health professionals (Guy et al, 2013) and the varied information, advice and intervention offered by healthcare staff (Durrant et al, 2019). Patient expectations, a lack of robust evidence guiding health professionals and a low level of functional health literacy among community patients may create confusion and unrealistic expectations (Durrant et al, 2019). This is reflected in low compliance among patients, with contemporary authors suggesting that more research needs to be conducted to identify what contributes to patients' adherence to advice and understanding of PU prevention (Ledger et al, 2020).