Expert opinion: Access to topical negative pressure therapy

TNP is considered effective, but its cost has made it difficult to provide in primary care. By Maureen Benbow

ABSTRACT

Topical negative pressure (TNP) therapy has been shown to accelerate healing in a variety of wounds, but access to it has been difficult to provide in primary care. In one survey, the main reason identified for not using TNP in the community was lack of funding. Clear variations were found in access, funding, continuity and responsibility for the therapy across the country.

Key words
Diabetic foot, ethics, equality, primary care, cost-effectiveness

The increase in diabetes mellitus brings with it the possibility of more chronic wounds to be managed in future. Fast, effective wound healing is an important factor in the reduction of morbidity and mortality in these patients, as well as reducing financial and staffing costs in hospital and community.1

The prevention and management of complicated diabetic foot problems constitute a large proportion of the workload for many doctors, nurses, podiatrists, orthotists and others.

Topical negative pressure therapy
In recent years, there has been better understanding of how chronic wounds heal and how healing may be facilitated, leading to a number of advances. Examples of newer methods include TNP therapy, larval therapy and debridement using high velocity excision and aspiration of devitalised tissue.

These therapies have been widely used in hospital settings for managing chronic wounds, but access has been limited in the community, where most such wounds are encountered, owing to their cost. In practice, there may be initial increased costs associated with new therapies, which have to be absorbed by existing healthcare budgets. The longer-term benefits to the patient and the NHS outweigh these initial costs in terms of improved healing rates and reduced numbers of amputations.

TNP has been shown to be effective in accelerating healing in various types of wound.2 In particular, it is a recognised technique in managing challenging, contaminated, difficult, acute and chronic wounds.3,4

So why is TNP not freely available to patients in primary and secondary care settings when clinical need is indicated? This article explores the underlying ethical issues in relation to the practical barriers, as identified in one study,5 to the adoption of new technologies in practice.

Equality, equity and ethics
The White Paper Our health, our care, our say: a new direction for community services includes a commitment to promoting equality in terms of age, disability, gender, race, religion and sexual orientation.6 It sets out four aims - better prevention services and earlier intervention, more choice, combatting inequalities and improving access to community services, and more support for people with long-term needs. Patient choice must be reflected in the change from a provider-driven to a commissioner-driven service, in terms of a more diverse range of high quality services.

Equity refers to fairness in the distribution of the costs and benefits of available care among all who use the NHS. There is a view that until the 1980s, the NHS had a good record of putting its principles into practice,7 but the gradual introduction of business values and the market-based reforms of the 1990s triggered a move away from the ethos of equity. Today, choice and patients' rights are dominant values, but are constrained by finite (and scarce) resources, resulting in some inevitably difficult choices. Studies of equity in healthcare seek to identify whether particular social groups receive systematically different levels of care to others.

Ethically, we would expect those choices to be based on fair and consistent principles. To the utilitarian, the ethically correct action is the one that results in maximum overall benefit, taking account of the various competing options for the patient and how many stand to benefit.

In this scenario, resources may be allocated to less expensive treatments to provide greatest benefit to a small number of patients, or smaller benefit to a larger number of patients. A major criticism of this approach is that it does not consider differences in individual need, but relies on cost-effectiveness and thus does not provide an equitable way of distributing resources. It might be argued that those in greatest need will not necessarily benefit.

The deontological view (that is, of duty and obligation) would hold that resources should be allocated according to individual need and ability to benefit. However, this approach would be incongruent and unworkable within the boundaries set by scarce healthcare resources.

The responsibility for fair allocation of these resources is complicated and viewed by many as unfair in terms of the availability of treatments in different healthcare sectors. In considering patient autonomy, questions emerge about whether they should be allowed to make choices, particularly where that preference is for an expensive treatment. Here, individual autonomy conflicts with other values, such as equity, by potentially disadvantaging other members of a community.

A balance must be achieved between fair distribution of resources, respect for individual autonomy and benefits to the population as a whole.

The TNP therapy project
TNP therapy has been used in secondary care in the UK for more than 10 years and has proved cost-effective for a range of chronic and acute wounds.8 There is no reason why it should not be available to all; the postcode lottery should be eradicated.

The TNP therapy project group had expressed concerns about the patchy access to TNP in primary care and believed that this inequity should be investigated. In 2005, a national survey was conducted, with the objective being to illustrate the use of TNP across primary and secondary care settings. In completing the questionnaire, tissue viability practitioners were asked to reflect on their use of TNP (see box 1).

BOX 1: CRITERIA FOR THE USE OF TNP

Criteria to identify the use of TNP included:

  • Availability and access to TNP therapy
  • Responsibility for initiating, reviewing and discontinuing TNP
  • Types of wounds treated by TNP in hospital and community
  • Number of patients having access to TNP when required
  • Availability of protocols or guidelines for TNP therapy
  • Delayed discharge from hospital due to unavailability of TNP
  • Responsibility for community funding
Source: Newton H, Benbow M, Hampton S et al. TNP therapy in the community: findings of a national survey.

The response rate was 28 per cent (104 out of 371), comprising 24 community practitioners, 63 hospital practitioners and 17 practitioners with joint responsibility.5 The survey confirmed that the highest use of TNP was in secondary care (67 per cent), followed by joint nursing responsibility for primary and secondary care (18 per cent) and primary care (15 per cent). This is surprising, because most patients with chronic wounds are managed in primary care.

Lack of funding by the PCT was cited as the greatest barrier to accessing TNP, with lack of education and competence among nursing staff identified as a key issue in relation to patient access to the therapy.

Education and protocols
Appropriate education and guidance are vital to ensure safe, cost-effective use of TNP. Protocols were reported to be in place for 68 per cent of hospitals, 8.3 per cent of PCTs and 41 per cent of those with joint responsibility. Of those who responded, 79 per cent said that clinical guidelines for TNP were in place.

Patients starting TNP therapy in hospital should be able to continue it in the community, thus vacating beds for others. However, there was lack of agreement between respondents about whether the length of patient stay in hospital was reduced when TNP was still indicated, but discontinued.

It was reported that TNP was discontinued in 30 patients to facilitate their discharge, although it was still indicated. The reasons were not given, but the decision presumably links with lack of funding and/or competence, providing an indication that patients are being disadvantaged in different settings.

TNP is clinically indicated for leg ulcers, as well as a range of other wounds, but it was found that these patients were rarely treated with TNP, in primary or secondary care.

Delayed discharge from hospital
Lack of availability of TNP was cited as the reason for delayed discharge by 16 hospital respondents and, on average, the discharge of 15 patients per month was delayed for this reason. PCT respondents (n = 2) identified two delayed patient discharges per month and among those with joint responsibilities (n = 2), there was an average of four delayed patient discharges.

Studies have demonstrated a reduction in the length of hospital stay when using TNP therapy for patients with diabetic foot ulcers and open abdomens.9,10 Despite this, there appeared to be a reluctance on the part of secondary care trusts to fund TNP therapy for patients who were being discharged.

However, according to the survey, opinion varied among clinicians, with some stating that length of hospital stay was not affected by lack of funding and others saying that it was. Discharging patients early does not save money, but if more patients can be treated, long-term costs are reduced and government targets can be more easily met.

The main reason given for not using TNP therapy in the community was that the PCT (64) or the hospital (24) would not fund it. In five PCTs, the lack of a framework for obtaining TNP therapy was a major barrier to access. Tissue viability nurse (TVN) specialists are primarily responsible for the management of complicated wounds in primary and secondary care. In some cases, however, concerns were raised regarding responsibility for follow-up and review, particularly when patients were discharged from hospital. In many cases, the TVN was the key link between care settings. A major barrier for the TVN is ease of access to TNP therapy.

Conclusion
All healthcare professionals have legal, ethical and professional responsibilities for ensuring that patients' needs are met. Patients who need a particular type of care that has been proven to be both effective and cost-effective should be given equal opportunities to receive that care.

The survey identified clear variations in access, funding, continuity and responsibility for TNP across the country, and between primary and secondary care. The main issue regarding availability in primary care appeared to be related to funding, with education and training also noted as important factors.

- Maureen Benbow is a senior lecturer at the School of Health and Social Care, University of Chester.

Competing interests: Ms Benbow was a member of the project team for the study, which was funded by KCI Medical (UK)

References
1. Ballard K, Baxter H. Developments in wound care for difficult to manage wounds. Br J Nurs 2000; 9(7): 405-12.
2. Venturi ML, Attinger CE, Mesbahi AN et al. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) device: a review. Am J Clin Dermatol 2005; 6(3): 185-94.
3. Argenta LC, Morykwas MJ. Vacuum assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38(6): 563-76.
4. Moues CM, Vos MC, van den Bemd GJ et al. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Rep Regen 2004; 12(1): 11-17.
5. Newton H, Benbow M, Hampton S et al. TNP therapy in the community: findings of a national survey.  (accessed July 2008).
6. DoH. Our health, our care, our say: a new direction for community services. Cm 6737. DoH, London, 2006.
7. Whitehead M. Equity issues in the NHS: Who cares about equity in the NHS? BMJ 1994; 308: 1284-7.
8. Wild T, Wetzel-Roth W, Zoch G et al. Consensus of the German and Austrian societies for wound healing and wound management on vacuum closure and the VAC treatment unit. MMW Fortschr Med 2003; 9(145) suppl 3: 97-101.
9. Armstrong DG, Kunze K, Martin BR et al. Plantar pressure changes using a novel negative pressure wound therapy technique. J Am Podiatr Med Assoc 2004; 94(5): 456-60.
10. Kaplan M. Managing the open abdomen. Ostomy Wound Manage 2004; 50(1A suppl): C2 1-8.

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