Agenda Item 7 THE HEALTH SCRUTINY COMMITTEE FOR LINCOLNSHIRE Boston Borough East Lindsey District City of Lincoln Lincolnshire County North Kesteven District South Holland District South Kesteven District West Lindsey District Open Report on behalf of Lincolnshire Community Health Services NHS Trust Report to Date: Subject: Health Scrutiny Committee for Lincolnshire 15 January 2014 Leg Ulcer Care Summary: This report outlines the services provided by Lincolnshire Community Health Services NHS Trust for the treatment of leg ulcer care. In particular, the report focuses on the former Leg Clubs, which used to operate in Mablethorpe and Woodhall Spa, and details the alternative provision available to the patients in those areas since the Leg Clubs closed. Andrea Blakeley, the General Manager of the North East Business Unit of Lincolnshire Community Health Services NHS Trust, is due to attend the meeting to present the item. Action Required: To consider the information presented on Leg Ulcer Care, in particular the service provided by the former Leg Clubs in Mablethorpe and Woodhall Spa and to seek reassurance that patients are satisfied with the alternative provision. 1. Background Role of Lincolnshire Community Health Services During 2009/10 NHS Lincolnshire (Lincolnshire Primary Care Trust) identified Lincolnshire Community Health Services (LCHS) as the provider of choice for the delivery of the lower limb and treatment room in a Local Enhancement Specification [LES] following a process of discussion within Primary Care. However, GPs were also Page 27
given the opportunity to provide this care for themselves and some chose to take this service on with the appropriate funding. LCHS is the provider of choice for all lower limb treatment to patients that are house bound as identified in the community nursing catalogue. Leg Clubs in Mablethorpe and Woodhall Spa In East Lincolnshire there were also two Leg Clubs in Mablethorpe and Woodhall Spa, which were set up in 2006. These were undertaken by the Leg Club Foundation with LCHS Community Nursing. The clubs had been up and running before the agreement in 2009/2010 and continued to operate, until the leg clubs informed LCHS of their closures. Historically, LCHS had provided community nursing staff for all the leg club clinics and in some cases six nurses per clinic to provide this service, when it initially was set up. The Leg Clubs are a registered charity, and nursing care was provided by the Horncastle/Woodhall Spa and Mablethorpe Community Nursing Teams from LCHS. This service was in addition to the Nursing Teams' daily community nursing workloads. The Leg Clubs have only existed in these two parts of Lincolnshire. The remainder of the county followed the local LES agreements. The clinical intervention for the patients who attended the leg club was recorded on Lyndsey Ellis paperwork. This meant that when SystmOne (a clinical software system) was implemented for record keeping and capturing performance, all the leg club activity was not being captured within LCHS. There were no referral criteria for patients to attend leg clubs. Potentially any resident could attend and regularly did, including patients from other areas of the county and country when on holiday, impacting on the community nursing teams staffing capacity to respond to core community activity required by the community nursing teams in both these two areas. LCHS continued to fully support the leg clubs and provide care for each clinic sending 2-3 nurses to the Woodhall Spa clinics each week and 3 nurses to Mablethorpe or as staffing numbers allowed. The criteria for referral to the community nursing service for patients with a lower limb treatment is after 6 weeks for patients with an active leg ulcer, where LCHS holds the LES. The GP practice is funded to deal with patient up to the six weeks and after this if they are contracted to undertake the LES. The patients sent to the leg club were mainly in the well leg category and therefore as in other areas of the county would not have received this care from LCHS. To date the community nursing element of the Leg Club service has not been exclusively commissioned and participation by Lincolnshire Community Health Services NHS Trust (LCHS) has arisen from a historical informal agreement between the community nursing services and the Leg Club Foundation. GPs that signed up to LES were responsible for continued lower wound care, however, in practice GPs send their patients to the leg clubs. Woodhall Spa, Alford and Mablethorpe surgeries sent all their patients requiring Doppler tests to the leg club, further impacting on the community nursing teams, which should have been undertaken by the surgery practice nurses as within the LES agreement. Page 28
A decision was made to treat active leg ulcers in a clinical setting, following moving and handling specialist advice, infection control specialist advice and several back injury claims from staff. LCHS introduced new clinical technology into a clinic setting to ensure that LCHS complies with its duty of care to both patients and staff. This equipment supports patient limbs in an ergonomic and supportive position and also supports staff to deliver clinical care in a safe manner. Closure of the Leg Clubs On 26 June 2013, the Woodhall Spa leg club informed LCHS that they had decided to cease operating due to the fall in their numbers. LCHS have continued to support the clinics and were not part of this decision making. LCHS continued to provide care until the date of closure of 28 August 2013. In Mablethorpe the Community Team leader was invited to a meeting on 27 June 2013 where it was discussed that there was a possibility of this leg club also closing. LCHS asked to be kept fully informed and continued to provide this service until the Mablethorpe Clinical Team Lead was informed by from the Secretary of the Leg Club of the closure of the Leg Club closed on Tuesday 24 September 2013. Caseload There was a caseload of circa 1,117 patients at Mablethorpe and 500 at Woodhall Spa with both active leg ulcers and also well leg advice and treatments. Patients attending also receive advice on general health issues. As well as weekly attendance at the leg club clinics, these patients all require annual Doppler tests and full assessments. Weekly attendance figures were as follows: Woodhall Spa 25 patients approximately seen in a Clinic held on a Wednesday morning. Mablethorpe - 50 patients approximately at each clinic on a Tuesday. However, latterly attendances dropped below 12-15 patients per week at each site. The leg club held at Coronation Hall, Woodhall Spa, was also paid for by LCHS which was a cost pressure to the community nursing budget that was not funded. Action Taken Since Leg Club Closures All the patients who were actively attending the Leg Clubs have now been placed in the most appropriate service for their needs. These serviced are provided in clinics or in patients' homes, if they are unable to attend a clinic. LCHS have taken great care to organise and seek alternative arrangement for those people with social needs such a leg washing and applying stockings and have even taken two patients into the clinic setting, where alternative arrangements could not be found. Page 29
All patients who are mobile and able, will attend their GP practice for the first six weeks to have their lower limb treatment. Then at six weeks, if the leg ulcer has not healed and where LCHS holds the LES agreement, the patient's care is transferred to LCHS community nursing team. Where GPs opted not to deliver their treatment room care then this first six weeks treatment is carried out by the community nursing team from the point the initial treatment was identified. In Mablethorpe, LCHS has the LES agreement for both treatment room care and therefore are contracted to see patient before the six weeks and after the six weeks with an active leg ulcer. In Woodhall Spa LCHS is not contracted to have the Local Enhanced Service [LES] agreement and is therefore not funded to undertake any of this work except for patients from The New Surgery GP Practice and the patients do receive their care for the first six weeks at the GP practice. However, Horncastle, Tasbourgh Lodge, Tetford and Coningsby patients did attend the leg club. Consultation and Engagement by LCHS The Matron for Integrated Care along with the Patient and Public Lead completed a Duty to Involve exercise to ensure that intelligence gathering had taken place with key stakeholders in relation to leg ulcer treatment services in Mablethorpe and Woodhall Spa. The engagement period was from the 1 April 2012 to 20 February 2013 and involved communication with internal and external stakeholders through formal meetings, reports and letters. The consultation included an equality assessment which did not identify any negative impact on the inclusivity if the service was changed from its current location to a clinic environment 2. Consultation This is not a direct consultation item for the Health Scrutiny Committee. However, LCHS has involved and engaged with patients during the course of the process. 3. Conclusion The Leg Club and its partners have served the communities of Mablethorpe and Woodhall Spa and surrounding areas for seven years and should be commended for their work. It is disappointing that despite the offer from LCHS to the leg club to run the service from LCHS clinic locations this offer was declined. With the active leg ulcer being treated in proper clinical environments, this left limited numbers attending the leg club, which in turn led to the volunteers giving notice to continue with the service in its current form. Patients living in Lincolnshire now receive the treatment as described in the LES agreement and community nursing catalogue. Where clinically appropriate the patients with active leg ulcers that attended the two leg clubs were being asked to attend the GP surgery to be seen by the community nurses for their treatments due to infection control and manual handling health and safety precautions and therefore the majority of patients being seen were well legs Page 30
who have made alternative arrangements around well legs in line with other patients in Lincolnshire. Evidence around patient experience has been carried out in an area of service where patients were receiving their care in a clinical environment of which has been positive. Also, individual feedback from the patients has been received following treatment being transferred to a clinical environment for patients receiving active lower limb treatment that attended the leg club as captured in the letter below. 4. Background Papers Available on request The following background papers were used in the preparation of this report: i. Letter from patient regarding clinical setting ii. Leg Ulcer Survey Protocol 1 iii. Duty to Involve Assessment of service change (Section 242 of the NHS Act 2006) iv. Equality analysis to assess the environment change This report was written by Maria Storti, Matron for Integrated Care, Lincolnshire Community Health Services. Page 31
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