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

8. Findings and Recommendations

8.1 Patients have a high regard for all aspects of the service and come to rely heavily on the contractor they engage with to obtain their ostomy requirements. Findings from this exercise identify a number of minor changes that may be required to fine tune the service provided and enhance the patient's experience.

8.2 At national and at NHS Board level, the service is perceived as lacking leadership and profile. Selection of a Stoma Care Champion within each Board is an option to consider in developing leadership amongst practitioners.

8.3 As detailed throughout the report, the Review Leads have made a number of recommendations to in order to help improve the overall quality and cost effectiveness and the sustainability of the stoma appliance service and associated care into the future.

8.4 The vast majority of the recommendations are for NHS National Services Scotland and NHS Boards to effect in partnership with stoma appliance contractors. The Scottish Government should continue to engage with the Scottish Stoma Forum as a national reference group on policy and service delivery.

8.5 The Review Leads have formulated 26 recommendations and these have been categorised as follows:

Stoma Appliance Contractors - Supply Arrangements

(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.

(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.

Advice, Help and Contact with Healthcare Professionals

(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.

(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.

Satisfaction with Service, Range of Products and Complaints Procedures

(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) 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.

(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.

(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.

(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.

NHS Board structures, planning, staffing and resources

(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.

(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.

(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.

(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.

(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.

Services and Information for Patients

(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.

(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.

Compliance with Key aspects of the Specification of [Service] Requirements

(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.

(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.

(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.

(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.

(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.

(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.

Cost Effectiveness

(23) NHS Boards should maximise effective prescribing through a system of review of Stoma prescriptions to ensure that expenditure is appropriate and thus ensure that resources available to patient care can be maximised.

(24) NHS Boards should develop a system of 'Trigger Tools' in line with protocols in England to ensure there is no oversupply and to minimise potential wastage.

(25) NHS National Services Scotland NP and NHS Boards should bring the provision of non-bag products or accessories into line with standard protocols established in the NHS in England:

• There is potentially a cost saving to boards from more rigorous reviews of outliers.
• While desktop Non clinical Review has some use it is more appropriate that the review should involve Stoma Nurses although it is recognised that these resources are limited.
• It is possible that locally NHS Boards could consider investment in Stoma Teams to facilitate this work. These reviews would not be purely financially driven and would give a route into developing patient centred approaches.
• It is noted that 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. This needs to be considered.

(26) NHS National Services Scotland NP and the Scottish Government, in consultation with NHS Boards, should maintain the fees for dispensing, delivery and customisation. Fees need to ensure that all providers of all sizes get a fair share of the remuneration global sum. It is proposed that the current quarterly review continues to ensure the total funding for fees is distributed equitable and not overcommitted. The fees should remain as a fixed total and be adjusted to take account of volume changes on a quarterly basis. The fees should remain capped with discretion to uplift in line with the community pharmacy funding uplifts where these apply.