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

2. Background

2.1 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.

2.2 The existing arrangements for the provision of stoma appliance services in the community were first introduced in 2007 and updated in 2011. In 2014-15, over 361,600 stoma appliance items were dispensed to patients in the community with the cost of reimbursement to appliance contractors for the supply of these items of just over £21m. This compares to some 341,100 items in 2013-14 at a reimbursement cost of just under £20m (increases of 6% and 5% respectively).

2.3 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.

2.4 As part of this review, information on the numbers of the different groups involved in the Stoma Appliance Service in Scotland has been gathered and provides a baseline for the future development of the service. The figures are as follows:-

2.5 In relation to staffing it should be noted that a range of nurses with mixed responsibilities can support patients who have stomas. This is a core skill set and there are many nurses within differing units and specialties within Boards, including in the community, who are able to support stoma patients who do not have the Clinical Nurse Specialist title. It is therefore difficult to quantify exactly how many nurses within NHS Scotland are providing stoma care.

2.6 Following a comprehensive review in 2006-09^[6] of the stoma appliances service to patients in the community within NHS Scotland, new specifications for the service were introduced in July 2011 replacing the arrangements that had been in place since 2007.

2.7 The Specification of Requirements for Dispensing and Supply of Stoma Appliances to Patients in the Community for NHSScotland^[7] provides the national framework for the service. This 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 and associated services 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.

2.8 Upon the introduction of the new specifications in 2011, an undertaking was given that the service would be subject to a subsequent audit to determine the level of compliance with these modified specifications and how well these met the needs of patients. This followed a key conclusion of the National Review Group (2006-09) that national audit arrangements of contractors' performance against service standards (including patient satisfaction) would be developed in partnership with the key stakeholders. These 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.

2.9 To fulfil this commitment, a national Quality and Cost Effectiveness review was established to gauge whether the arrangements for the provision of stoma appliance services in the community, introduced in 2011, remain fit for purpose and cost effective. The review would also provide an opportunity to establish whether and what changes may now be appropriate.

2.10 In Summer 2013, the Scottish Government invited David Thomson, Lead Pharmacist, Community Pharmacy Development & Governance, and the Pharmacy Team at NHS Greater Glasgow and Clyde, who had been involved in previous Scottish Government work in this area, to undertake a quality and cost effectiveness review of the arrangements in place since July 2011. The review focussed on 2 strands: (1) the Quality of the service provided to patients as a result of the Specification of Requirements; and (2) the Cost Effectiveness of these arrangements.

2.11 After engagement with interested parties, the proposed way forward with respect to the Quality strand of the review involved a two part audit to be conducted commencing winter period 2014/15 involving:

(a) Patients receiving stoma appliances on prescription during a set month were invited to contribute to the audit to be conducted across all Boards.

(b) In parallel, other interested parties, Health Boards, professionals such as stoma nurses, and commercially interested parties including stoma appliance manufacturers, dispensing appliance contractors and community pharmacies and their representative bodies were invited to provide responses to structured audit pro forma.

2.12 The Cost Effectiveness strand of the review ran in parallel and would also be informed by the outputs from the quality audit. A team including National Procurement and NHS Board representatives was established under the leadership of Mark Hunter, Head of PCCO Finance, NHS Lothian to consider what updates to existing commercial arrangements may be appropriate drawing on the evaluation of responses to the quality audit and other relevant engagement with interested parties.

2.13 The objectives of the review were to ensure that:

• on-going commercial arrangements are updated to be contractually robust and to allow all interested parties to plan ahead;
• the range of stoma appliance products which are available continues to be subject to determination by prescribing clinicians;
• clinical discretion as to what appliances are appropriate for an individual patient is maintained and as part of that the views of the patient concerned remain central to product selection;
• individual patients are offered a reasonable choice at the point of dispensing;
• supply chain partners have an opportunity to participate in the development of updated arrangements;
• future arrangements are defensible on the grounds of cost-effectiveness for NHSScotland.

2.14 While the objectives of the review were to consider the quality and cost-effectiveness of the stoma appliance service, with the valuable input from the Scottish Stoma Forum, the opportunity was taken to seek feedback from staff working in NHS Board stoma care services and to gauge views on wider aspects of the quality and effectiveness of stoma care services in the community. This included for example the planning of stoma care services, succession planning and continuity of care, and service improvement activity.