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

6. Survey Results

Patient/carers

6.1 Overview

6.1.1 A total of 784 patients/carers participated in the patient survey questionnaire. Most respondents provided an answer to each question. A high level of patient satisfaction was reported across each of the 11 areas covered in the survey.

6.1.2 The survey asked patients/carers to feedback their experiences of using the stoma appliance service in terms of the supply arrangements for receiving stoma products and whether they were generally satisfied with the service they receive. It also asked if respondents knew who to contact for help or advice and asked for feedback on the quality of the support provided; and whether they had made any complaints and, if so, how well they were handled.

6.2 Choice of supplier

"I use both, my own chemist if I'm short."

"Prefer to use [DAC] contractor as it is more anonymous and discreet."

"My pharmacist has looked after my needs for over 20 years and there are no complaints from me. His service is really outstanding."

"I have tried a DAC but the best service I get is from my pharmacy."

"I found using the pharmacist proved to be quite difficult - items were not always available."

6.2.1 The survey began by asking respondents if their stoma requirements were routinely provided by a community pharmacy or a dispensing appliance contractor. Patients would usually use one or the other as their main supplier for stoma items. Of the 788^[8] who responded to this question:

• 39% used a community pharmacy contractor;
• 59% used a dispensing appliance contractor (DAC); and
• 2% responded 'Other' or were not sure.

6.2.2 At 59%, the majority of respondents said they receive their service from DAC suppliers. Respondents report similar experiences from both types of providers with no strong preference expressed at the expense of the other.

6.2.3 A number of patient comments indicate a strong loyalty to their stoma appliance provider, with many remaining with the same contractor for several years.

6.2.4 It was apparent that a small proportion may be confused with the terms used to describe the contractor with 2% selecting other or not sure as their stoma appliance supplier.

6.2.5 One respondent provided an additional comment on the importance of maintaining and respecting the patient's choice of service supplier.

6.3 Supply arrangements

"Items are dispatched quickly but have had a few problems with delivery."

"Although delivered within 2 weeks supplier used to deliver next day or day after but now need to wait on prescription."

"I do keep a month's stock in hand."

"I was advised to allow 14 days for delivery and work on this basis."

"Used to be next day delivery but now its 10 days."

6.3.1 Patients were asked if stoma items were supplied within an acceptable timeframe once their provider had received their prescription. Of the 691 respondents who answered this question:

• 94% answered Yes/Always;
• 5% answered Sometimes; and
• 1% answered No/Never.

6.3.2 Although 94% of respondents to this question indicate they are satisfied with the time taken to deliver an order, 86% reported difficulty in obtaining supplies within the specified time frame of 48 hours with around 92% believing a 2 week period to be the normal timeframe.

6.3.3 Around 23% of patient/carer respondents also reported difficulties with deliveries and missing items on occasions. Some reported ordering more stock than they need to ensure they have a sufficient supply at home in case of any future delays.

6.3.4 Patient/carers appear critical of GP involvement in the ordering process and suggest this is the cause of the extended timescales. Supplies rightly cannot be provided through the NHS until the supplier is in receipt of a valid prescription. However, it is apparent that a longer timeframe is necessary as GPs are not always able to provide prescriptions in time to allow for supplies to be made within 48 hours. This was an area covered in patients' comments suggesting that the delivery timescales may need to be reconsidered.

(1) NHS National Services Scotland National Procurement (NP) should work with NHS Boards and appliance contractors to determine a more realistic timeframe for delivery of products to patients, recognising the time pressures in GP practices in issuing prescriptions. A time period of up to 5 working days for delivery following the patients request should be considered as the potential new standard.

6.3.5 Patients were asked if they were provided with free supplies of disposal bags and wipes when these are required. Of the 774 respondents who answered this question:

• 88% answered Yes/Always;
• 7% answered Sometimes; and
• 5% answered No/Never.

6.3.6 From the responses it can be concluded that the majority of respondents are receiving free supplies of disposal bags and wipes when required. Those using DAC suppliers report obtaining bags and wipes routinely, however, 18% of respondents who use community pharmacy providers reported difficulties in obtaining sufficient quantities.

6.3.7 10 patients reported receiving wipes but not disposal bags while 15 reported the opposite experience. 5 respondents were unhappy that certain types of accessories are not available on the NHS e.g. deodorant sprays. One respondent suggested that bags and wipes should be provided without patients having to request them.

6.3.8 It is noted that patients have different regimes so some require more bags than others, or prefer different types of wipes.

(2) NHS National Services Scotland NP should work with NHS Boards and all appliance contractors to ensure compliance with the specification requirement that sufficient quantities of bags and wipes are supplied with each prescription.

6.4 Advice/ help

"Supplier has a good telephone advice line."

"DAC better at advice."

"Very fortunate to have a local pharmacy who are always happy to make sure I have everything I need on time." "service

"Never fail to be surprised at continued level of support and pleasant response."

6.4.1 Patients were asked if they were able to contact the pharmacy or DAC for advice or help. Of the 726 respondents who answered this question:

• 91% answered Yes/Always;
• 5% answered Sometimes; and
• 4% answered No/Never.

6.4.2 The vast majority of respondents report being able to contact their provider for help and advice when necessary. A small proportion (4%), indicate they are unable to contact their provider for this type of support while some respondents appear to be unaware that they could. Some patients (5%) acknowledge the help and support they receive from the third sector which could be more formally recognised.

6.4.3 There were also suggestions that there should be a named member of staff at the service supplier as the patient's key contact; a helpline or website for patients; and advance notice of public holidays or other events which may impact on delivery times.

(3) All appliance contractors should provide a mechanism which allows this patient group to access appropriate help and advice when required. The expectation would be that this should be available from trained personnel during opening hours, and a website or help line during 'out of hours'. The website should also provide links to third sector support organisations and patient groups.

6.5 Contact with health care professionals

"A very busy [stoma] nurse. Can't always get an answer the same day. Also can't get to see her except on certain days."

"I have an excellent stoma nurse with whom I can easily get in touch with."

"Only my GP. Have great problems getting advice and help."

"I do not have a stoma nurse."

"Would like a stoma nurse to be more available."

6.5.1 Patients were asked if they were able to contact an appropriate healthcare professional when necessary. Of the 654 respondents who answered this question:

• 89% answered Yes/Always;
• 7% answered Sometimes; and
• 4% answered No/Never.

6.5.2 The majority of respondents indicate they have access to a healthcare professional when needed and mentioned the support available from stoma nurses, GPs, pharmacists and NHS24. References were made to the general perception of stoma nurses being very busy and resources appearing to be stretched.

6.5.3 A number of patients did not answer this question denoting that the question was either n/a (not applicable) suggesting they are satisfied with the current level of provision across most Boards, or that they had not had cause to contact someone for advice.

6.5.4 Some patients commented that they did not know who or how to contact a healthcare professional or stated that they did not have a stoma nurse.

(4) NHS Boards should prepare a directory of services relevant to stoma care provision in their area. This should include details of who and how to contact the appropriate healthcare professional, and under which circumstances, to ensure effective resolution of the support or advice required.

6.6 Packaging

"Packaging carries suppliers' name."

"Have had problems with my packaging been open and people could see what it was."

6.6.1 Patients were asked if products were supplied in discreet packaging. Of the 754 respondents who answered this question:

• 95% answered Yes/Always;
• 3% answered Sometimes; and
• 2% answered No/Never.

6.6.2 95% of respondents confirm products are received in discreet packaging. Around 12 commented on the need for greater discretion when goods are delivered. Concern was also expressed that the use of orange bags for disposing of waste is inappropriate.

(5) NHS National Services Scotland NP and NHS Boards should work with appliance contractors to ensure the specification requirement of discrete packaging is adhered to at all times, and the need for discretion and sensitivity of staff when working in this area is emphasised. Manufacturers and appliance contractors should review the types of packaging in use and improve as necessary.

6.7 Satisfaction with service

"Sometimes have to wait too long before we receive our order."

"From my experience and speaking to one other stoma patient there is little help available."

"Feel GPs don't have enough training on matters relating to stoma. Quite a few in my surgery looked a bit panicked when I refer to my stoma and don't really know me."

"Never had any dealings with NHS staff regarding stoma care for years."

6.7.1 Patients were asked if they were satisfied with the standard of stoma care service provided. This question was broken down into the service provided by community pharmacists, DAC suppliers, and healthcare professionals.

6.7.2 Of the 300 respondents who commented on their level of satisfaction with the service provided by community pharmacists:

• 83% answered Yes/Always;
• 11% answered Sometimes; and
• 6% answered No/Never.

6.7.3 481 respondents commented on their level of satisfaction with the service provided by DAC Suppliers:

• 90% answered Yes/Always;
• 7% answered Sometimes; and
• 3% answered No/Never.

6.7.4 With regard to the service provided by NHS Board healthcare professionals, of the 556 who commented on their level of satisfaction with the service:

• 83% answered Yes/Always;
• 13% answered Sometimes; and
• 4% answered No/Never.

6.7.5 There was a high level of satisfaction with the standard of service reported across all three levels of service provision, with the highest level of satisfaction amongst those who use a DAC (patients can opt to change supplier if they are unhappy with service received). The majority are also satisfied with the standard of service provided by healthcare professionals.

6.7.6 The responses indicate that patients are not fully informed of the services available to them and what they can expect from their stoma care provider. Some respondents felt their GP did not have sufficient knowledge to provide support.

(6) NHS Boards should work with NHS Education for Scotland (NES), healthcare practitioners and appliance contractors to:

• Ensure all practitioners are competent and confident to advise and support patients, with mechanisms in place to refer to specialist advice should this be necessary;
• Improve the content of patient advice materials available, including website and information leaflets;
• Develop a template detailing core stoma services to ensure consistency across Scotland irrespective of provider, with a facility for Boards to tailor to local provision. This is directly linked to recommendation (4) regarding the NHS Board directory of services relevant to stoma care.

6.8 Range of products

"I feel the range of products available is able to meet the needs of any stoma patient."

"I am able to contact my provider and get samples."

"The only thing I don't like is when 'a company' send you letters saying you can claim free samples then when you phone them they tell you, you can't get them because you do not get your supplies from them."

"Supplier active in advising any changes or improvements in what's available."

"Unaware of all products available. Not sure if there maybe something more suitable for me."

"Better to stick to product always used. Any change just causes huge problems."

6.8.1 Patients were asked if they were satisfied with the range of products available. Of the 646 respondents who answered this question:

• 94% answered Yes/Always;
• 6% answered Sometimes; and
• 1% answered No/Never.

6.8.2 The vast majority of patients responding (94%) are satisfied with the range of products available to them. Although many would appear reluctant to change the products they use, patients indicated they are unaware of new products and no formal procedure appears to be in place to manage this process.

6.8.3 There was a general desire for more information on the range of products available as well as new products.

(7) NHS National Services Scotland NP and NHS Boards should work with appliance contractors to develop and apply good governance principles in the product selection process that respects patient choice and the impartiality of clinician involvement.

6.8.4 A small number of patients indicated a personal preference for specific products they like to use, some of which are available on prescription and some that they purchase.

(8) NHS National Services Scotland NP and NHS Boards should work with appliance contractors to ensure that product choice is person-centered and cost-effective. This is intrinsically linked to the recommendations relating to the cost effectiveness strand of the review.

6.9 Complaints

"Have had a few times that there was damage to my products."

"Problem only seems to be when using local chemist. Again any problem usually time taken for script to get to suppliers."

"Often supplier blaming GP and vice versa on delay from prescription being returned."

"Letter to supplier re leaking bags not acknowledged or responded to."

6.9.1 Patients were asked if they had ever had cause to complain about the standard of service provided. Of the 664 respondents who answered this question:

• 2% answered Always;
• 6% answered Usually;
• 2% answered Sometimes;
• 16% answered Rarely; and
• 74% answered Never.

6.9.2 They were also asked, if they had complained, were they satisfied with the outcome of their complaint. Of the 237 respondents who answered this question:

• 40% answered Always;
• 29% answered Usually;
• 14% answered Sometimes;
• 6% answered Rarely; and
• 11% answered Never.

6.9.3 The majority of respondents have had no cause to complain (74%), although around a quarter of patients on occasion have had reason to raise an issue.

6.9.4 Comments on complaints appear to apply to a cross section of the service in general rather than highlight a specific aspect. The complaints referred to in responses were across a range of issues including damaged products, delays in receiving prescription, GPs not providing complete prescriptions, perceived confidentiality issues within a community pharmacy, difficulty accessing support/ advice, and obtaining supplies out of hours.

6.9.5 Overall, responses received regarding satisfaction with the outcome of complaints are less positive suggesting that contractors could improve upon their handling of complaints. One respondent called for more robust complaint procedures.

(9) NHS National Services Scotland NP, NHS Boards and appliance contractors should work in partnership to:

• Promote the NHS complaints procedure as a mechanism to obtain patient feedback and to improve the overall quality of the stoma appliance service in the community;
• Extend the NHS complaints procedure to include DAC suppliers;
• Reinforce principles of handling complaints and promote a more positive culture regarding receipt and response of stoma appliance complaints within an acceptable timely period.

6.10 Respect and dignity

"My experience with NHS staff has always been first class - always respectful and dignified."

"Very grateful for the care and understanding shown to me at a difficult time."

"Locum pharmacist, whilst on the phone, shouted out my name and stoma bag query."

"Found Stoma Care Staff very supportive."

"I am very happy with the service I get."

6.10.1 Patients were asked if they felt NHS staff treated them with respect and dignity. Of the 661 respondents who answered this question:

• 87% answered Always;
• 11% answered Usually;
• 2% answered Sometimes;
• 1% answered Rarely; and
• 0% answered Never.

6.10.2 The majority of respondents agreed they were always or usually treated with respect and dignity. Very few were dissatisfied with their experience of NHS staff. One respondent suggested the service could be improved through additional training for staff to ensure patients are treated with respect and dignity.

NHS Staff

6.11 Summary

6.11.1 A total of 20 completed staff audit surveys were received from NHS staff working in health board provided stoma care services. This responses were from staff employed in 9 out of the 14 territorial NHS Boards and representing most of the largest NHS Boards across Scotland.

6.11.2 The audit survey was distributed to the lead nurse within the managed stoma service and was aimed at all NHS personnel involved in the stoma care service. The survey sought feedback from staff on a range of aspects concerning stoma care provision within their Board, and provided an opportunity to suggest modifications they would wish to be considered for the service.

6.12 Health board structures and resources

"We have stoma nurse specialist meetings 2-3 times a year."

"Not aware of the Stoma Care Forum."

"Have an annual meeting."

6.12.1 Respondents were asked to confirm whether their NHS Board has appropriate structures in place to support local Stoma Care Fora. Of the 20 completed NHS staff audit surveys received, 18 reported that a Stoma Care Forum was established within their NHS Board, with 15 who thought the membership to be inclusive and representative and with meetings being held on regular basis. 15 felt that action points from Forum meetings were progressed by the health board, whilst 5 suggested this was not the case. Staff/teams felt there should be better recognition of stoma care services and there was also a suggestion to have a stoma care champion in each NHS Board.

6.12.2 Although not covered in the audit survey, at a national level the Scottish Government should continue to engage with established groups, in particular the Scottish Stoma Forum (SSF) on service and policy issues. The Scottish Government and SSF should consider how the membership of the SSF could be developed so that it is fully representative.

(10) NHS Boards should review and update local stoma fora arrangements to ensure they are relevant, add value and are fit for purpose. At a national level the Scottish Government should continue to work with the Scottish Stoma Forum (SSF) as a reference group on policy and service provision.

6.12.3 Not all NHS Board staff teams completed the audit pro forma, especially in the smaller board areas where structures, resources and patient populations do not lend themselves to specially designed arrangements for stoma care services. For example, NHS Borders and the island Boards do not have stoma fora, but regularly liaise with consultants, hospital management, GP practices and pharmacies with regular patient satisfaction surveys to inform service improvement.

6.13 Staffing

"All nurses are providing a professional high level of care to stoma patient due to their competencies and experience. However satisfaction could be increased with greater numbers of CNS's."

"This is delivered from stoma nurses. I feel we provide a good service to stoma patients. I still feel there is a gap in community follow up since home visits from stoma nurses were stopped. It can be difficult managing a busy service at times."

"Yes - due to the geographical area covered, the team rationalise patient care providing equity of care."

6.13.1 Respondents were asked to specify the ratio on WTE of Stoma Nurse Specialists to stoma patients within their NHS Board. Although specialist teams within NHS Boards were invited to participate, not all made full contributions to this section. However, there was a perception among NHS personnel that insufficient numbers of specialist staff are deployed within the service. Changes in working practices and devolvement of responsibilities from secondary to primary care were considered to have had an impact on workload.

6.13.2 This aspect requires fuller consideration within NHS Boards at a national level in context of known numbers of specialist nurses in the field of stoma care, the use of nurses in other specialisms, and nurses in the community who are able to support stoma patients. There is also a clear link to future and succession planning and how the wider skill mix of the nursing workforce can be developed to meet the ongoing needs of stoma patients, drawing on the skills of specialist stoma nurses to support this and develop capacity.

(11) The Scottish Government should work with NHSScotland to identify a stoma care service within a specific NHS Board that could be designated as a 'demonstrator' that others could learn from and benchmark against in terms of planning, skill mix and service delivery.

6.13.3 Staff comments included the suggestion that roles and responsibilities of stoma care nurses and district nurses should be redefined.

6.14 Future and succession planning

"No - I have discussed the future of the service with my line manager."

"No succession planning is in place."

"From within the stoma department and colorectal unit rather than being planned by the Board."

"I discuss the service with the ward managers but there is no formal tool."

"An audit was done a few years ago but has to [be] repeated."

"Questionnaire sent out but not sure how often."

6.14.1 Respondents were asked to state if future planning of stoma services features in the Board's Strategic Plan. Of the 15 who responded to this aspect of the audit, 9 indicated that the future planning of stoma services had been incorporated into the Board's Strategic Plan, whilst 6 indicated no awareness.

6.14.2 Responses suggest a low level of awareness and understanding of the service with a perception amongst staff of no visible leadership in evidence.

(12) NHS Boards should review their arrangements for the planning of Stoma Care Services and give proper recognition of these services within their Strategic Plans. An appropriate person within the established team should be designated as the lead or champion for Stoma Care Services.

6.14.3 Respondents were also asked to state if a succession plan was in place to maintain continuity of the service. 12 of the 16 responding to this aspect of the audit reported that a succession plan was in place, whilst 4 indicated they were unaware of any such plan. In most instances, it appeared that planning had been initiated at a local level in isolation from other areas of the service.

(13) NHS Boards should adopt a more formal approach to assess capacity and manage projected demand for stoma care services to inform local succession planning processes and continuity of service. The role of the designated lead or champion for Stoma Care Services will be important in this process.

6.14.4 As highlighted at 6.12.3, not all NHS Board staff teams completed the audit proforma, especially in the smaller board areas where arrangements are scaled and proportionate to local circumstances. However, service planning and development is reported to be carried out on an ongoing basis with all that this entails for the stoma service involving multidisciplinary team members and management in both primary and secondary care.

6.14.5 The particular circumstances pertaining to smaller NHS Boards should be recognised in taking forward the findings and recommendations from the review.

6.15 Staff input

6.15.1 Respondents were asked if a process was in place for staff to comment and feedback on service provision.

6.15.2 Of the 17 who responded to this aspect of the audit, 16 acknowledged that a system was in place to comment on service provision, while 1 respondent indicated no awareness. Whilst the majority of respondents indicated that a system did exist, it was unclear as to how structured and effective the process is.

6.15.3 In addition, respondents were asked if their NHS Board maintained a process for gathering intelligence on what aspects of the service could be improved upon in terms of quality, effectiveness and efficiency. Of the 18 who responded to this aspect of the audit, 15 reported an awareness of a process in place to improve services although this may not be specific to Stoma Care services. 3 reported no awareness.

6.15.4 Respondents expressed pride in the service they provide but have concerns over some aspects.

(14) NHS Boards should have a formal, structured mechanism to facilitate staff feedback, comments and concerns on Stoma Care services, with systems in place to respond accordingly to points raised where there is potential opportunity to improve the quality, safety, effectiveness and efficiency of service provision.

6.16 Information

"Have not seen anything regarding the stoma service."

"Our contact numbers are on the Board's website and we are completing a service booklet at present."

"Colorectal/stoma community Nurse Specialists have written and given out informative handbooks."

6.16.1 Respondents were asked if their NHS Board publishes information on the stoma service e.g. website, leaflets. 18 Responses were received, with 8 reporting an awareness of efforts to promote the service and inform patients. On the other hand, 10 indicated no awareness. 4 of the 10 confirmed they have produced information leaflets within the department to supplement this need.

6.16.2 Respondents were asked if they were satisfied with the current arrangements for provision of stoma care to their patients. Of the 20 responses received, 16 reported satisfaction with current arrangements whilst 4 did not answer this question. There was a suggestion to have standardised information detailing local stoma care service arrangements in place for each Health Board.

See recommendations 3, 4 and 6.

6.16.3 From the range of feedback received through the completed staff returns, it is recognised that there would be benefit in ongoing audit of stoma services within NHS Boards, building on the tools developed for this national exercise. Regular audits would serve to benchmark service improvement and development as a result of audit activity.

(15) Building on the tools developed for the national quality and cost effectiveness review, NHS Boards should introduce quality monitoring of Stoma Care services to assess the quality, effectiveness and efficiency of existing services to support continuous quality improvement.

Stoma Appliance Contractors: DACs and Community Pharmacies

6.17 Summary

6.17.1 A total of 150 stoma appliance contractors responded to the audit survey. 21 were received from dispensing appliance contractors and 129 from community pharmacies.

6.17.2 The audit survey asked stoma appliance contractors to submit a response on the level of compliance with the specifications for the service. It also provided an opportunity to record any additional comments about the service.

6.18 Profile

6.18.1 Stoma appliance contractors were asked if their publicity material or website, which advises patients across the UK on dispensing arrangements for stoma appliances provided by the contractor, has a specific section detailing the arrangements for patients in Scotland. Of the 126 contractors who responded to this section of the audit:

• 42% answered Yes;
• 9% answered No; and
• 48% answered Not applicable.

6.18.2 The importance and availability of appropriate publicity material appears not to be supported by the majority of the responding contractors, although stipulated in the service specifications. There is an opportunity to stipulate use of a standardised template to ensure consistency of core information. In addition, several patients perceive supply through a DAC as an non-NHS service. This misunderstanding should be clarified and addressed.

(16) NHS National Services Scotland NP and NHS Boards should work with appliance contractors to implement a standardised template listing core services, complaints procedures, key contacts and what patients can expect from this key NHS service.

6.19 Training

"Although pharmacists are trained, staff would benefit from update training at some point at a local level to cover recent advances."

"More training required."

"Counter staff need some basic training."

6.19.1 Stoma appliance contractors were asked if staff dealing directly with patients or healthcare professionals have a basic understanding of colo/ileo/urostomy normal function. Of the 132 contractors who responded to this section of the audit:

• 82% answered Yes;
• 9% answered No; and
• 9% answered Not applicable.

6.19.2 While responses show a good level of basic understanding of colo/ileo/urostomy normal function, the responses to other aspects of training suggest that patients may be experiencing a lesser standard of service in some locations where practitioners may not be meeting the required level of training.

6.19.3 There was also a suggestion that a list of the various support groups in place should be developed (see also recommendation 3).

6.19.4 Specific training requirements expected of appliance contractors are detailed in the training section of the audit questionnaires completed by DACs and community pharmacies (see Appendices 4 and 5). Further work will be required to establish the principle that both strands of provision are equitable and that patients experience no disparity in their care whichever contractor they select to provide the service.

6.19.5 The responses from the DACs suggested that training and development of staff is higher than that of community pharmacies, with nearly all staff trained to the level expected of the Specification of Requirements.

6.19.6 Community pharmacists and pharmacy technicians have professional responsibility to keep practice, knowledge and skills up to date. There was also comment that there should be recognition of the pharmacist role in identifying interactions with medicine that may have an adverse effect on patient's ability to manage their stoma.

(17) It is essential that all staff are fully knowledgeable and competent to comply with the Specification of Service Requirements. Working with NHS Education for Scotland (NES) community pharmacists should assess their current level of knowledge and expertise and undertake further training where this is identified. NES should consider potential increase in activity in this area.

6.20 Legislation

6.20.1 Stoma appliance contractors were asked to confirm that only those stoma appliances listed on the Information Services Division (ISD) website are supplied. Of the 138 contractors who responded to this section of the audit:

• 81% answered Yes;
• 12% answered No; and
• 7% answered Not applicable.

6.20.2 The responses from community pharmacists and patients suggest that this element of the supply function works well with no major difficulties encountered.

6.21 Disposal bags and wipes

6.21.1 Stoma appliance contractors were asked to confirm that disposal bags and wipes are provided free of charge and without the payment of a dispensing or delivery free. Of the 141 contractors who responded to this section of the audit:

• 92% answered Yes;
• 3% answered No; and
• 5% answered Not applicable.

6.21.2 This has been established practice for DAC suppliers for some time. Anecdotal comment had suggested that pharmacies were not routinely offering free disposal bags and wipes unless requested by the patient. The responses suggest that the majority of patients routinely receive supplies of these items without challenge. This issue was also raised in comments from contractors with one suggesting that pharmacies should provide wipes and bags without the patient having to specifically ask.

(18) NHS National Services Scotland NP and NHS Boards should ensure that all elements of the specification of requirements are adhered to and ensure that appliance contractors fulfill these obligations.

6.22 Prescription supply

6.22.1 Stoma appliance contractors are asked to ensure that no items are provided without obtaining a prescription beforehand. With regard to compliance with this requirement, of the 140 contractors who responded to this section of the audit:

• 91% answered Yes;
• 5% answered No; and
• 4% answered Not applicable.

6.22.2 In exceptional circumstances, such as an urgent requirement for the patient, items can be dispensed without a prescription but this should only be done if agreement of the prescriber has been obtained in advance by telephone with the prescription to follow retrospectively. Under previous arrangements, in a number of cases prescriptions were routinely requested after supplies had been dispensed.

6.22.3 As indicated above, the current specification requires contractors to obtain a prescription prior to placing or fulfilling any order for stoma products. Introduction of this revised procedure followed a previous review, and represented a major process change for DAC suppliers in particular. Criticism of the delays perceived to be associated with this revised procedure needs to be investigated by NHS Boards locally to determine the extent of the problem and how this can be resolved satisfactorily.

(19) NHS National Services Scotland NP and NHS Boards should ensure contractors place particular emphasis on the handling of prescriptions and the need to follow due process, as set out in the specification for the service.

6.23 Disclosure Scotland

"Have not been asked for customisation."

"Patient numbers not routinely supplied to National Procurement every 6 months."

6.23.1 Stoma appliance contractors were asked if basic disclosure records from Disclosure Scotland have been obtained for all personnel who may have unsupervised contact with patients (i.e. a driver delivering into a patient's home). Of the 137 contractors who responded to this section of the audit:

• 62% answered Yes;
• 15% answered No; and
• 23% answered Not applicable.

6.23.2 All stoma appliance contractors are required to comply with this principle and ensure that staff attending a patient's home have Disclosure Scotland clearance. The reported compliance needs to be further investigated, amongst pharmacy staff in particular, who may be required to routinely undertake unsupervised visits to a patient's home.

(20) NHS National Services Scotland NP and NHS Boards should ensure appliance contractors place emphasis on the need to obtain Disclosure Scotland clearance for relevant staff, as set out in the specification for the service.

6.24 Administration

6.24.1 Stoma appliance contractors were asked if they complete a form from PSD claiming customisation and delivery fees if they have an activity level of more than 1200 items per month. Of the 114 contractors who responded to this section of the audit:

• 50% answered Yes;
• 10% answered No; and
• 40% answered Not applicable

6.24.2 Responses indicate a low level of adherence to the timely submission of claims for payment, which may impact on the accuracy of prescribing data and late settlement for contractors. Furthermore, most contractors do not routinely supply patient numbers to National Procurement as stipulated in the specification.

6.24.3 It is important that the administration function supporting the service is effective and that claims for reimbursement are submitted on time as late submissions affect payment schedules, skew supply statistics, remuneration and reimbursement monitoring.

(21) NHS National Services Scotland NP and NHS Boards should ensure appliance contractors comply with the administration requirements as crucial to the governance of the specification of requirements.

6.25 Quality

6.25.1 Stoma appliance contractors were asked if they maintain a list of appropriate self-help and support groups for patients. Of the 134 who contractors who responded to this section of the audit:

• 62% answered Yes;
• 26% answered No; and
• 12% answered Not applicable.

6.25.2 Although one respondent indicated they would refer the patient to their GP for details of support groups, this information should be available from all healthcare locations the patient is in contact with for stoma care. GPs may not necessarily be the best referral point for this type of information.

6.25.3 Stoma appliance contractors were also asked if they have contact numbers for patients' key healthcare workers e.g. Stoma Nurse. Of the 139 contractors who responded to this section of the audit:

• 62% answered Yes;
• 28% answered No; and
• 10% answered Not applicable

6.25.4 The responses suggest that little progress has been made in collating and maintaining a directory of key workers involved in this specialty.

See recommendation 3, 4, 6 and 16.

6.25.5 Stoma appliance contractors were asked if they facilitate the supply of sample packs by order, or appropriate products to allow patient/Stoma Nurse to select the most appropriate solution to the individual's needs. Of the 140 contractors who responded to this section of the audit:

• 60% answered Yes;

• 24% answered No; and
• 16% answered Not applicable.

6.25.6 The responses suggest an issue for community pharmacies in either obtaining samples or their understanding of how to source these items. Current guidance on how the process operates may need to be more specific to better facilitate community pharmacy's ability to access product samples. Several pharmacists report a decline in activity in this area resulting in a reduced awareness of current developments and their skills and knowledge of products and processes as result.

6.25.7 Stoma appliance contractors were asked if complaints regarding Stoma Services are included in the totals submitted quarterly to the Health Board. Of the 135 contractors who responded to this section of the audit:

• 79% answered Yes;

• 13% answered No; and
• 8% answered Not applicable.

6.25.8 The audit results indicate that all aspects of complaints handling and processing are dealt with appropriately. However, current legislation^[9] regarding Patients' Rights does not require DAC suppliers to report complaints data to the NHS. The principles apply equally to this type of service provider and the procedure should extend to include DACs. (See recommendation 9)

Manufacturers

6.26 Summary

6.26.1 A total of 8 manufacturers responded to the audit survey. 4 of them had also submitted responses in their dual capacity as Dispensing Appliance Contractors. The audit survey asked manufacturers to submit a response on the level of compliance with the specifications for the service. It also provided an opportunity to record any additional comments about the service.

'Limited list' process for the addition of new products

6.26.2 As part of the 2 year Framework Agreement^[10] National Procurement has in place processes for the addition of new products to both the Community Stoma List and for products being made available in the hospital setting^[11].

6.26.3 Manufacturers were asked whether they thought the process for adding products to the Community Stoma List is efficient and fair. 6 respondents deemed the process currently in place to be efficient and fair. Comments received from the 2 respondents expressing an opposing view indicated concerns over the speed and level of bureaucracy associated with the process which significantly added to the related costs.

6.26.4 They were also asked whether they thought the process for products being made available in the hospital setting is efficient and fair and works well for stakeholders. 6 respondents were of the view that it was neither efficient nor fair, commenting that the current arrangements limited patient choice and restricted opportunity to consider new and innovative products that may be more suitable and better value for money.

6.26.5 Manufacturers were then asked if they believe the 'limited' list has resulted in any cost savings for NHSScotland. Only 3 respondents completed this section and were of the view that the introduction of a 'limited list' had not resulted in any cost savings. They cited the purchase of samples and restricted access to innovative products in managing problematic stomas as areas where additional costs may have been incurred.

6.26.6 They were also asked if the use of a 'limited list' has had an impact on patient care. All 8 manufacturers completed this section and were of the view that restriction in choice imposed by the use of a 'limited list' has had a negative effect on patient care. They believe that use of a 'limited list' prevented patient access to products they could benefit from. The addition of products that do not require to be customised could result in savings. Respondents were of the view that the care provided by the service may be compromised by restricting choice at the initial stage of product selection.

6.26.7 Manufacturers were asked if they felt there should be an annual price increase mechanism in place similar to current arrangements in England. All respondents supported this concept.

6.26.8 NHS National Services Scotland NP has responsibility to manage the frameworks and processes for both hospital and community on behalf of NHSScotland acknowledging the different arrangements for the supply of stoma care products within each respective country.

(22) NHS National Services Scotland NP should regularly engage with the manufacturers' representative body to discuss any issues concerning the frameworks relating to the 'Community' and 'Acute' product lists that apply in Scotland.