Editorial: Leg ulcer care in the 21st century – a major problem with minor recognition


Venous leg ulcers are the most common chronic wound affecting one in 500 people and costing the United Kingdom (UK) National Health Service (NHS) £400 million a year (Simon & McCollum 2004, NHS Choices 2012). With the impact of an ageing population, it is likely that this condition will increase considerably requiring more resources. Furthermore, this is a global problem with countries such as Sweden and the United States (Kerstein et al. 2001, Ragnarson Tennvall & Hjelmgren 2005) supporting research into the cost effectiveness of various treatments but the search for a coherent venous leg ulcer management strategy remains.

Taking the UK as an example, the Department of Health (DoH) indicate that 15 million people live with a long-term condition in England, and this figure is expected to rise significantly in the near future (DoH 2011). The management of long-term conditions and the rehabilitation of patients who suffer them attract significant government funding but interestingly, leg ulceration is not identified as a long-term condition and although the DoH argue that there is no definitive list, it is unusual for scarce resources to be allocated to the condition. This can be compared with the attitude of many healthcare professionals, and patients who would certainly perceive leg ulcers to be ‘long term’ taking into account the intensive and costly treatments that they require; the high recurrence rates and the impact they have on quality of life. Persoon et al. (2004) noted that major limitations such as pain, immobility, sleep disturbance and lack of self-esteem contribute to a significantly poorer quality of life for people with venous leg ulcers when compared with the wider population.

The key arbiter of clinical and cost effectiveness in the UK is the National Institute for Health and Clinical Excellence (NICE), and the guidance they produce supports healthcare professionals and others to make sure that the care they provide is of the best possible quality and offers the best value for money. Nor are NICE guidelines solely a resource for UK practitioners since NICE International provides similar support to other countries on a not-for-profit basis. There is no NICE guidance devoted solely to leg ulceration. There are National Service Frameworks which set out basic care standards for a number of long-term conditions but not one for leg ulceration. In fact, there is little performed to ensure nationwide standards are set or to reduce the variation in services available to patients nationally, and only small effort has been made to evaluate parity of treatment approa-ches across countries (Graham et al. 2005). NHS evidence has produced a Clinical Knowledge Summary on the topic of venous leg ulcers and the Royal College of Nursing have likewise produce clinical guidelines but neither of these resources have the high-impact gravitas of NICE. The clinical evidence is very clear on what treatments should be available to patients and how treatments should be applied; however, we would argue that sometimes, even in the face of clinical evidence, treatment is based more upon clinician preference than research evidence. The development of a formal framework would provide clear guidance and ensure best practice.

The UK government have placed emphasis on increasing patient choice in the white paper ‘Equity and Excellence: Liberating the NHS (DoH 2010), but we would contest to suggestion that patients are truly having a say in the management of their leg ulcers. In order for them to do this, they need to be educated on their condition, so that they can make informed choices and healthcare professionals need to be mindful that the education is given in the correct format for the patient's needs. It is often that nurses report a lack of concordance to treatment especially with regard to compression therapies with little evidence investigating the possible causes (Edwards 2003). It is time for clinicians to ask whether we are providing patients with treatment options that they fully understand, within a bio-psycho-social model of care. After all, if a holistic assessment is not carried out, we cannot expect to achieve partnership working and an agreement of minds with our patients which will inevitably result in poor concordance. Relating this to compression bandaging, it is always worthwhile starting lightly and increasing compression as the patient experi-ences the benefits coupled with positive encouragement and continuous re-assessment from clinicians.

This lack of clear international guidelines and variation in levels of patient support and education is further illustrated by, a lack of training in carrying out Doppler assessments especially in nursing home environments where, it could be argued; patients are receiving non-standard care compared with those on the caseloads of the district nursing team where availability of training is greater. The question of how private sector nurses are to provide high quality, evidence-based care as required by the UK Nursing and Midwifery Council without the opportunity for training is a pressing one. Furthermore, it is difficult to empower these patients and involve them fully in their care when clinicians do not have the knowledge to provide the information required. No one would disagree that patients living in nursing homes with venous ulceration are entitled to the same care as those living in their own homes.

To address this issue, effective wound care practice can only be achieved through education and professional development, and there are an abundance of tissue viability conferences, membership groups and study days on offer throughout the year. We acknowledge that the realities of a global recession can make employer funded attendance at such events difficult; however, the networking and open access education opportunities that are offered by the World Wide Web cannot be over estimated but are resources that many clinicians are slow to exploit.

At the ‘Best practice in tissue viability’ conference in Worcestershire, UK, there were a wide range of disciplines amongst the delegates including a range of nursing professionals across primary and secondary care. Keynote speakers included Professors Jackie Stephen-Haynes and David Gray; respected tissue viability consultants, researchers and educators. Whilst clinician concern was being expressed regarding inequalities in the provision of care for venous leg ulcers, there was an optimistic note to the conference when it was suggested that more governmental attention is ‘finally’ being placed on the management and funding of leg ulceration care and identifying ways to improve care and develop specialist services. Historically, leg ulceration has been seen a low priority (Franks et al. 1995) but with the vast array of evidence-based treatments that improve healing rates and the formation of new clinical commissioning groups; investment and care services should be matched to the population needs and, if so, this a promising step forward.

So, we suggest that it is time for those of use who care about the impact that venous leg ulcers have upon the well-being of our patients and who want to see scarce healthcare resources used in the most clinically and cost effectively ways possible to start to make more noise. When the UK NICE are about to bring out new guidelines, there is always a consultation process and nurses in general are notoriously diffident about participating, such consultations are not necessarily limited to UK practitioners, any interested party can comment. We would also propose that the impact of the global practitioners or patients alliance in terms of exemplifying and communicating best practice cannot be ignored when the importance of both practitioner and patient education is accepted. Venous leg ulcer management needs to progress, and this can only happen with the development of clear guidelines based upon best evidence that are nationally and international relevant coupled with imaginative and accessible provider and user education.