Stoma Appliance Service in the Community: Stoma Care Quality and Cost Effectiveness Review 2015

1. Executive Summary

QUALITY AND COST EFFECTIVENESS REVIEW

The main focus of the stoma care quality and cost effectiveness review is the stoma appliance service provided to patients in the community across Scotland.

The Specification of Requirements for Dispensing and Supply of Stoma Appliances to Patients in the Community for NHSScotland provides the national framework for the stoma appliance service in the community. It determines the service standards to be met by all dispensing appliance contractors (DACs) and community pharmacy contractors for the purposes of being placed on a list of approved suppliers authorised to dispense and supply stoma appliances to patients in the community. It also sets out the ongoing standards to be met for the purposes of remaining on that approved supplier list. The specifications for the service were first introduced in 2007 and updated in July 2011.

This report details the findings and recommendations following a multi-layered national audit involving patients, NHS Board staff, DACs, community pharmacies and manufacturers designed and conducted during 2014-15. The purpose of the national audit was to gauge whether the arrangements for the provision of stoma appliance services in the community remain fit for purpose and cost effective. It would also help to inform whether and what changes may now be appropriate.

Background

1.1 The provision of stoma appliance services and its associated care to post-operative patients in the community is an important and sensitive service for the patients concerned, many of whom continue to need this service for many years after their original surgery. The optimum choice of stoma appliance, and ready access to these appliances, significantly enhances the quality of life for stoma patients and supports them to live as near normal life as possible.

1.2 In 2014-15, over 361,600 stoma appliance items were dispensed to patients in the community with reimbursement to appliance contractors for the supply of these items of just over £21m. Between 2004-05 and 2014-15, the number of items dispensed and reimbursement to contractors has increased by 69% and 58% respectively. In 2014-15 remuneration (dispensing, customisation and delivery fees) for the service was over £3.6m.

1.3 Following a comprehensive review in 2006-09^[1] of the Stoma Appliance Service within NHSScotland, one of the conclusions of the National Review Group was that national audit arrangements of contractors' performance against service standards (including patient satisfaction) would be developed in partnership with the key stakeholders. This would be augmented by supplementary checks by NHS Boards as they thought necessary to address specific local issues including patient complaints about stoma appliance service provision.

1.4 Subsequently, new specifications for the supply of appliances were introduced in July 2011 (The Specification of Requirements for Dispensing and Supply of Stoma Appliances to Patients in the Community for NHSScotland^[2]). During 2014-15, a multi-layered national audit involving patients, NHS Board staff, DACs, community pharmacies and manufacturers was designed and undertaken in order to assess whether the arrangements for the provision of stoma appliance services in the community remain fit for purpose and cost effective in meeting the needs of patients. It would also help to inform whether and what changes may now be appropriate.

1.5 The national audit was designed to assess both the quality and the cost effectiveness of the new arrangements and to determine the level of contractor compliance with the modified Specification of Requirements in meeting the needs of patients.

Overview of respondents

1.6 Patients (or carers) were invited to complete a survey questionnaire to assess the level of satisfaction with the stoma appliance service and related care. NHS Board staff, DACs, community pharmacies and manufacturers were invited to complete audit pro forma in relation to their specific role in the provision of stoma care in the community.

1.7 Over 960 responses were submitted as a result of the audit which was coordinated across all 14 territorial NHS Boards in Scotland. The spread of responses across patients, NHS Board staff, DACs, community pharmacies and manufacturers is set out in section 4 (Respondents). The main findings from the audit exercise are summarised in following sections.

Views of Patients/Carers

1.8 Responses were received from 784 individuals. The majority of patients that took part in the survey audit reported that they routinely received their stoma appliances from a DAC (59%), with 39% reporting that they routinely received the service from a community pharmacy. Four patients indicated they routinely use both suppliers to suit their personal preference and convenience at the time.

1.9 A high level of satisfaction with the appliance service and related care was generally reported by patients/carers. This included:

• The majority of patients/carers were satisfied with the standard of stoma care service provided, whether it involved NHS staff, a DAC or community pharmacy;
• 94% were satisfied with range of products available, and 88% reporting free supplies of disposal bags and wipes when required;
• 94% were satisfied with the timeframe for supplying stoma items, with 95% satisfied that products were provided in discreet packaging;
• The vast majority (91%) were satisfied that they could contact their pharmacy or DAC for advice or help when needed;
• Similarly most patients/carers (89%) were able to contact an NHS healthcare professional when needed, with 87% reporting that they were always treated with dignity and respect.

Views of NHS Staff Teams

1.10 A total of 20 audit returns were completed by staff working in stoma care teams, including 9 of the largest NHS Boards reflecting the distribution of specialist centres across Scotland. Of the 20 staff audit returns submitted the following key points emerged from specific comments received:

• 18 reported that a Stoma Care Forum was established within their Health Board. 15 of these said Forum membership was inclusive and representative, with meetings held on a regular basis.
• 9 reported that planning of the service was incorporated into the Board's Strategic Plan, however more needed to be done to raise awareness and understanding of the service.

• A similar picture was reported in 12 of the returns regarding succession planning to support of continuity of service.
• 16 indicated satisfaction with current arrangements for provision of stoma care, with processes in place to gather intelligence to improve quality and effectiveness of service.
• 8 reported awareness of efforts to promote the service and inform patients, but it was clear from all 20 returns that more could be done to publicise information about local services across NHS Boards.
• Although specialist teams were invited to report on the numbers of stoma nurse specialists not all made a full contribution to this aspect of the audit. However, there was a perception that numbers were insufficient.

Views of Dispensing Appliance Contractors and Community Pharmacies

1.11 A total of 150 responses were received from stoma appliance contractors. This constituted returns from 21 dispensing appliance contractors (DACs) and 129 community pharmacies (CPs). Of the CPs and DACs who responded:

• 42% confirmed they had appropriate support materials informing patients of arrangements in place to obtain stoma services in Scotland.
• 82% confirmed that staff dealing directly with patients had a basic understanding of ostomy requirements, with DAC providers reporting a higher level of compliance.
• 92% provide disposal bags and wipes free of charge, with DACs appearing to have a more established pattern of supply.
• The majority (91%) confirmed compliance with specifications in only ordering products for patients where a valid prescription is in place.
• 62% indicated compliance with the requirement of basic Disclosure Scotland clearance for personnel having direct unsupervised contact with patients.
• Only 50% reported compliance with the requirement to provide National Procurement with patient numbers every 6 months.

1.12 It should be noted that some DACs, although based within a particular location, supply products to patients throughout Scotland and may therefore have submitted a collective return covering all the NHS Board areas in which they operate. This may explain why fewer returns appear to have been received from DACs compared to community pharmacies where individual submissions were received. Conversely, some DACs may have responded to more than one NHS Board.

Views of Manufacturers

1.13 8 manufacturers responded to the audit. They were generally less positive than patients, NHS staff or stoma appliance contractors about the arrangements for supply of stoma products.

1.14 When asked whether the process of adding products to the stoma appliance list in the community is efficient and fair, 6 agreed while 2 disagreed.

1.15 With regard to the introduction of the application of the 'limited list' of products in hospital settings, manufacturers who responded were of the view that it had not resulted in any cost savings to the NHS in Scotland. They believe that it limited patient choice and restricted opportunity to consider new and innovative products that may be more suitable and better value for money.

Cost Effectiveness

1.16 This strand of the review focused on the existing commercial arrangements and what, if any, changes may be appropriate. The evaluation of responses to the quality audit and engagement with interested parties helped to inform the outcome of the work in this area.

1.17 The group looked at 3 main Areas: the current arrangements for stoma fees; the current level of spend and recent trends; and areas for potential further review including guidelines and a greater involvement of Stoma teams in reviewing prescribing.

1.18 On fees, the current (2015/16) £3.8m Global Sum was considered together with increasing volumes and the fixed remuneration global sum for appliance contractor fees.

1.19 In the review of spend there was evidence of a steady increase in expenditure reflecting increasing use of stoma products from a widening of the patient base.

The community service, unlike the hospital service, has a wide range of available products and new products have been introduced over time but the principal growth factor is additional patients both for long and shorter term treatments. The spend patterns were consistent across the health boards. Stoma / Ostomy bags remain the major component of spend. Recently growth has been greater in the non-bag accessories.

1.20 There is potential to review and make efficiencies on the level of spend and maximise patient care at the most efficient cost. From the review of current spend it was established that the range of community products is far wider than those provided on hospital discharge. It is recognised that any future arrangements should focus on person-centred choice for patients and clinicians.

1.21 The principles of effective prescribing show it is important to minimise variation and review prescribing. The potential to adopt national guidelines and the protocols similar to those used in England were considered. Review of prescribing by appropriate clinical stoma teams is recommended. These teams are the wider resources over and above the Stoma Clinical Nurse Specialists. A detailed review of one health board showed there are potential outliers and scope for further review around the quantities prescribed and also the appropriateness of items prescribed.

Recommendations

1.22 Crucially, the findings of the multi-layered national audit demonstrated that the 784 patients and carers that took part have a high regard for all aspects of the service they receive.

1.23 The findings from this exercise in the main identify a number of improvements that may be required to fine tune the service offered and enhance the patient's experience. All responses to the audit surveys have been taken into account in drawing up the findings and the specific areas of recommendation detailed in this report.

1.24 In total there are 26 recommendations covering a range of areas associated with stoma care provision. These include, for example, the stoma appliance supply arrangements to patients; advice, help and contact with appliance contractors and health care professionals; patient/carer satisfaction with stoma care services; NHS Boards planning arrangements; information for patients.

1.25 All 26 recommendations are detailed in section 8 of this report.