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

3. Methodology

The Quality Audit

3.1 During 2014, four levels of the quality audit were developed, in conjunction with the Scottish Stoma Forum, tailored to facilitate responses from each of the targeted audiences:

• Patients/carers;
• NHS personnel;
• Community Pharmacy and Dispensing Appliance Contractors (DACs); and
• Manufacturers

3.2 Patients (or their 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.

3.3 The Scottish Government and NHSScotland wrote to Chief Executives of the 14 territorial NHS Boards in October 2014 providing details of the Quality and Cost Effectiveness Review and seeking nominated lead contacts to co-ordinate the process locally.

3.4 In December 2014, the suite of documentation was sent to each named lead that would be expected to manage the audit process within their respective NHS Board and collate responses for subsequent submission to NHS Greater Glasgow & Clyde (GGC) who were co-ordinating the exercise of behalf of NHSScotland and the Scottish Government.

3.5 The nominated NHS Board leads were requested to prepare sufficient copies of each version so that each community pharmacy and dispensing appliance contractor (DAC) would receive 5 copies of the patient/carer survey questionnaire, plus 1 copy of the service audit pro forma relevant to the nature of the appliance contractor. Sufficient quantities of pre-paid addressed envelopes were also to be provided to facilitate responses from patients (or carers).

3.6 It is not possible to state the patient/carers sample size with accuracy as it is not known exactly how many survey questionnaires were handed out to patients as it was possible for contractors to photocopy additional copies if they wished.

3.7 The audit pro forma for NHS personnel working in stoma care services was issued within NHS Boards to the lead nurse within the stoma service.

3.8 The audit pro forma for manufacturers was distributed by the relevant NHS Boards to manufacturers of stoma products providing supplies to contractors and patients within that NHS Board's area.

3.9 Copies of all documentation were scheduled for distribution to all participants during December 2014 with an expectation that the actual audit would commence on 5 January 2015 and continue for a 4 week period. For a variety of reasons, this timescale could not be accommodated and in an effort to encourage participation, and be as inclusive as possible, timescales were extended as necessary on a Board by Board basis to suit local circumstances.

Cost Effectiveness

3.10 A team including National Procurement and NHS Board representatives was established under the leadership of Mark Hunter of NHS Lothian to consider what updates to existing commercial arrangements may be appropriate. Engagement involved other interested parties such as the British Healthcare Trades Association (BHTA) and NHS Board FHS Finance Leads.

3.11 The cost effectiveness strand of the review has taken into account the information in the Quality Audit and the views of interest parties such as dispensers and manufacturers through the BHTA.

3.12 The arrangements for Stomas fees (dispensing, customisation and delivery) were considered. Most dispensing is covered within the community pharmacy remuneration and reimbursement arrangements and in the main specific dispensing fees no longer exist. However, the retention of fees was considered to be appropriate for the supply of stoma appliances given its specialist nature. The service is not provided by all pharmacists and the majority is through DAC's (Dispensing Appliance Contractors).

3.13 Detailed analysis of expenditure on stoma appliances was carried out by NHS Board, product and manufacturer. This suggested a high degree of consistency of behaviour across all health boards.

3.14 The main source of information was PRISMS (the Prescribing Information System for Scotland) with the focus on cost and quantity. In addition, there was analysis by NSS Information Services Division to determine patient levels through unique patient identifiers (e.g. patients' Community Health Index (CHI) number). This helped to distinguish patients receiving longer term stoma supplies and those receiving products for shorter periods.

3.15 Prescribing information data was used to further enhance the PRISMS summaries and develop some anonymised patient level statistics. This allowed NSS National Procurement to match the 2014-15 prescribing against quantity and product protocols adopted in England, highlighting the areas for further review.

3.16 There was considerable interest from industry members of the Scottish Stoma Forum in this aspect of the review. Manufacturers were keen to explore ways in which they could assist in future arrangements, including the introduction of new cost effective products which would be more beneficial to patients.