How we halved healing times for leg ulcers
Dr James Heffer describes how the first primary care-led ‘Leg Club’ has improved care and reduced appointments.
We have a high prevalence of patients with leg ulcers – 2.25 per 1,000 population (in the rest of our area it is 1.7) – and were having issues with high recurrence rates and non-compliance. Low mood and anxiety frequently accompany lower limb conditions and leg ulcers, often leading to patients becoming socially isolated. Housebound patients are particularly vulnerable and for some the weekly visit from the district nurse was the only human interaction they received. We have 21,300 patients over four sites so there were lots of patients who could potentially benefit from help.
What we did
We therefore set up a leg club. Leg clubs are a psychosocial model of care where treatment takes place collectively in a non-medical setting on a drop-in basis.
New patients, or leg club members, receive an hour-long full leg ulcer assessment, including an ankle brachial pressure index, blood screening, weight measurement, blood pressure, nutritional assessment, wound review (including measurement and photographs of the wound), full care planning and documentation and application of the appropriate dressing and bandage system.
Follow-up patients receive a 30- to 45-minute appointment depending on their needs. The club opens one day a week at 8.30am and the last patient is seen at midday. There are usually three trained nurses and three healthcare assistants on duty.
The club also runs a Doppler service and many members come back for their six-month well-leg check. While our clinicians provide medical treatment, volunteers create a club atmosphere with refreshments and activities.
We opened in February 2014. It was based at a care home and the Friends of Bradford-on-Avon Community Health Care provided the initial £12,000 to purchase equipment for four treatment areas and a couch for Doppler assessments. The club had to relocate to a town centre community hall just five months after opening, when demand outstripped capacity. The local branch of the Lions service club donated £500 for an additional treatment zone and we recruited an additional nurse. The clinical aspect of the club is funded through the level 2 leg ulcer contract with NHS Wiltshire CCG, which is around £21,000 plus an additional support worker from the community team and regular support from the leg club industry partners. The cost of the venue is currently paid by the Better Care Fund.
Initially some patients were reluctant to attend as they were anxious about the drop-in system and waiting times. Others were uncomfortable about collective treatment and did not wish to interact with other people. Our GPs were able to reassure them that there was a private cubicle and that talking to other patients was not a requirement, but that it could be helpful. Any fears were overcome once they attended their first session and now there are now more than 560 registered members with an average 50 members attending each week. Some attend solely to socialise.
The average healing rate for venous leg ulcers has fallen from 19 weeks to just 10 and recurrence rates have fallen from 76% in 2014 to 25% in 2015. In addition, mental wellbeing has improved beyond measure and social isolation has reduced. Feedback revealed 97% patient satisfaction with the club as a method of treatment – and 100% of staff found working at the club rewarding.
Before the leg club, many patients were seen twice a week in the practice, but around 80% are now seen only once a week at the club.
We estimate that 30 GP or nurse appointments a week have been saved and nurses have been able to reduce the number of treatment areas in the practice from six to four. They are now treating many complex wounds that would have been treated in secondary care as they have acquired skills in specialist leg ulcer care.
Dr James Heffer is a in Bradford-upon-Avon, Wiltshire