The NHS Plan (2025) places a clear emphasis on delivering consistent, evidence-based and cost-effective care, with a particular focus on reducing unwarranted variation and improving patient outcomes. Within wound care, formularies play a central role in achieving these aims by standardising product selection, supporting equitable access to appropriate treatments and ensuring alignment with current clinical evidence.

The tissue viability teams at Hampshire and Isle of Wight Healthcare NHS Foundation Trust have developed a wound care formulary that is robust, evidence-based, cost-effective and widely accepted across both primary and secondary care. Its effectiveness is further strengthened by the integration of digital, evidence-linked pathways that support consistent decision making and reduce unwarranted variation. Informal initial evaluations have indicated reduced wastage of dressings, fewer inappropriate dressing changes and positive staff feedback reporting that the formulary is easy to use and clearly outlines treatment pathways. The formulary was launched through a series of Trust-wide events, scheduled at varying times and on different days to maximise clinician attendance. It is available for community nurses in a PDF format on their phones.

UK demographics
In 2024, an estimated 625,000 people in the UK were aged 90 years or over, representing a 53.7% increase since 2004 and a further 2.2% rise since mid-2023. Among this group, 84.5% were aged 95 years or younger, although the most rapid growth has occurred at the highest ages. The number of centenarians reached 16,600 in 2024, double the 8,300 recorded in 2004. Demographic change has been more pronounced among men than women. Between 2004 and 2024, the number of men aged 90 years or over more than doubled, whereas the number of women increased by approximately one third. Consequently, men accounted for 33.7% of those aged 90 years and over in 2024 and 18.5% of centenarians. Across the UK, Wales recorded the highest prevalence of centenarians at 25.9 per 100,000 population, although all four nations experienced increases in centenarian rates over this period (Office for National Statistics [ONS], 2021).

As the population ages and the incidence of comorbidities such as diabetes continues to rise, the prevalence of chronic wounds can be expected to increase. Harding and Queen (2024) reported that one in 50 people in the UK is currently living with a chronic wound and fewer than half of these wounds will heal. Drawing on government datasets, population statistics and evidence from multiple research groups, they highlighted the scale of the wound care burden across the UK. Their analysis estimated that the total cost of wound management in 2022 reached £8.8 billion, comprising £6.8 billion in England, £719 million in Scotland, £411 million in Wales and £249 million in Northern Ireland.

Unwarranted variation in practice
Evidence indicates substantial unwarranted variation in wound care across the UK, characterised by the underuse of evidence-based interventions and the continued use of practices supported by limited or no empirical evidence (Gray et al, 2019; NHS Digital, 2019; Wounds UK, 2023). Formularies offer a consistent and standardised approach to wound management and can support clinical decision making by providing clear recommendations that guide clinicians towards evidence-based and cost-effective practice (Song et al, 2019). Evidence demonstrates that implementing a formulary can reduce expenditure and improve staff efficiency (Yeung et al, 2017; Song et al, 2020). However, advances in wound care, the expansion of products with uncertain effectiveness and increasing financial pressures can make it difficult for clinicians to select the most appropriate treatments for individual patients (Song et al, 2019). Within this context, the selection of cost-effective products remain a critical component of high-quality wound care (Wounds UK, 2023).

Formularies
The development and implementation of wound care formularies is now commonplace across the UK. Wound care formularies are designed to provide clinicians with comprehensive, evidence-based information on products and to support informed treatment selection, thereby providing the best chances for wound healing. Wounds UK (2023) emphasise the importance of maintaining formularies as fluid and dynamic resources that are regularly reviewed and updated in line with emerging evidence, evolving guidance and the introduction of new products. Ensuring formularies are publicly accessible is also essential, enabling patients and service users to understand the treatments available locally within the NHS. Ultimately, formularies play a central role in standardising practice, and their development is underpinned by three core principles:

• Patient safety
• Patient and staff (user) experience, including clinical outcomes
• Cost-effective care (Wounds UK, 2023).

Managing change management effectively when embedding new formularies
Embedding equity as a strategic priority requires organisation wide strategic and operational involvement. A strong commitment to quality improvement and patient safety is essential, as both aim to deliver high value, safe care for all populations. Identifying and narrowing gaps in quality and safety across different population groups is a critical step and one that can also engage staff at every level in advancing health equity (Kotter, 1995; Doherty et al, 2022).

Within Kotter’s eight step model for change management, ongoing training and education are emphasised as essential for enabling staff to develop new skills, adopt a shared language and maintain continuous learning in support of a common vision. Effective data collection and analytics are also required to capture patient level information and understand the needs of different communities, enabling informed and equitable decision making. Central to effective change management is strong stakeholder communication, engagement and collaboration. Transparent and sustained dialogue across stakeholder groups creates the foundation for meaningful partnerships that support change both within and beyond organisational boundaries (Kotter, 1995; Doherty et al, 2022). In line with this, the Hampshire and Isle of Wight tissue viability teams an inclusive, co-produced approach with efforts to ensure consistency, equity in care provision to assist in the facilitation of positive system change.

Developing the formulary
Prior to developing a wound care formulary there are various items that the clinician needs to consider [Table 1].
Developing the formulary required substantial fact finding and information gathering to ensure that product selection and pathways were grounded in appropriate and robust evidence.

Its development has been highly collaborative, involving clinicians, patients, partner organisations and specialist teams, resulting in strong clinical ownership and sustained engagement. Governance is a central feature of the formulary’s lifecycle, ensuring that it is appropriately represented, consistently reviewed, assigned clear review dates, supported by targeted education, audited and embedded within organisational risk management processes. Such governance structures are essential for facilitating formulary development and maintenance at organisational level and this value driven approach contributes directly to the delivery of high quality, safe care (Veenstra et al, 2017; Wounds UK, 2023).

A centrally imposed model can hinder local improvement efforts, whereas an approach developed from frontline experience and collaborative practice is far more likely to deliver meaningful, sustainable change (Wounds UK, 2023). Because staff have contributed directly to the formulary’s design informal staff feedback has identified it is trusted, widely used and closely aligned with real world clinical practice. The current formulary has already secured support from key professionals and patient representatives. This level of engagement is critical: clinicians are significantly less likely to adopt a new system that they have not helped to design, which increases the risk of disengagement, reduced adherence and diminished ownership.

The format of the formulary is modern, user friendly and digitally enabled. QR coded links provide immediate access to best practice guidance, clinical pathways, product information, and training resources at the point of care. The digital structure makes ongoing updates simple, transparent and cost efficient. Version control and live links mean the formulary remains current without reprinting or redistributing physical materials.

Inclusion of visual pathways further enhance clarity, supporting clinical decision making and improving communication with patients, thereby strengthening shared decision making and overall patient experience. These features align closely with recommended best practice guidance for the design and implementation of wound care formularies. A best practice statement highlighted that incorporating images can make a formulary more visually engaging and increase clinician uptake, while the inclusion of QR codes and interactive links, such as those directing users to wound assessment tools or documentation, enhances accessibility and usability (Wounds UK, 2023). The importance of ensuring accessibility for diverse patient populations, which may include translating key components into multiple languages or providing the resource in alternative formats has been identified as good practice (Wounds UK, 2023). As such the tissue viability teams converted the formulary into portable, condensed formats (e.g. small booklets attached to lanyards or key rings and PDF versions available on smart phones) has supported ease of use in clinical environments.

Implementation
Before implementing the formulary, the tissue viability teams undertook a comprehensive review of recommendations from the National Institute for Health and Care Excellence (NICE), alongside evidence from clinical trials, randomised controlled trials (RCTs) and relevant experiential insights.

Education was central to the implementation phase to ensure the formulary was used appropriately and consistently. Industry partners represented within the formulary supported the launch event and contributed to education on product evidence and mechanisms of action. They were not involved in the development of the event itself but were present to provide advice relating to their own products.

The event provided clinicians with an opportunity to familiarise themselves with the clinical pathways, engage with company representatives and ask questions. Ongoing education remains essential. Clinicians require training not only in how to use the formulary but also in wound assessment, wound management and differential diagnosis to ensure safe, effective and evidence-based care. Effective product training is integral to supporting safe and appropriate clinical use, with wound care companies holding a clear responsibility to provide robust, evidence-informed training programmes (Surgical Dressing Manufacturers Association, 2018).

Staff consistently reported the formulary is easy to navigate, intuitive and supports timely decision making at the point of care. Embedding the formulary across several organisations promotes consistency in product selection, clinical pathways and patient management throughout the entire care journey. By linking pathways to evidence and standardising product choice, the formulary reduces unwarranted variation while preserving clinical judgement within a clear governance framework. This ensures that patients receive equitable, high quality care regardless of the care setting.

Evaluating the impact
Ensuring the efficient use of resources is fundamental to delivering a formulary that maximises value and supports financial sustainability. Given the duty to manage finite public resources, decision makers have a responsibility to ensure that taxpayers’ money is used judiciously, necessitating careful and evidence-based consideration of both clinical and cost effectiveness for all product inclusions.

When evaluating its impact, it is important to assess the improvements and benefits generated by the formulary in relation to its associated costs, for example, through cost effectiveness analysis. Clinicians should consider long term costs as well as immediate expenditure, including those related to patient outcomes, staff productivity, formulary compliance and increased patient adherence to care plans. Engaging relevant stakeholders in this process can help identify areas for improvement and highlight potential opportunities for cost savings. Clearly defining the scope and purpose of the formulary, such as improving patient outcomes or reducing expenditure is crucial, enabling clinicians to determine whether the clinical benefits outweigh any potential risks or costs. While individual products may appear cheaper outside the formulary, real savings come from accelerated healing, fewer dressing changes and reduced complications.

Clinicians can minimise unnecessary wastage by checking packaging carefully for the correct product, size, format and expiry date before opening. They must also be familiar with appropriate product use and adhere to storage and temperature requirements. The formulary directs clinicians to correct procedures for the safe disposal or return of faulty or expired items, helping to reduce waste. Central to the formulary is an ongoing audit process designed to ensure adherence, monitor the effective use of resources and identify new products that may warrant review and potential inclusion. Continuous auditing supports good governance, maintains consistency in practice and ensures the formulary remains current, evidence based and responsive to emerging innovations. Selecting the most appropriate product during the initial assessment, supported by comprehensive product training, is a key way for reducing unwarranted variation and minimising waste.

Guest et al (2017) demonstrated that unhealed wounds incur significantly higher costs to healthcare systems than healed wounds. This highlights the importance of comprehensive assessment and adherence to evidence-based pathways to reduce time to healing. Faster healing not only improves patient outcomes but also reduces the number of dressing changes required, helping to lower cost, efficient resource use, reduced waste generation and reduced energy associated with travel to and from patients’ homes.

This approach supports sustainability while enabling more productive delivery at significantly lower cost, aligning with the NHS 10-Year Plan (Department of Health and Social Care, 2025). Evaluating whether products are environmentally sustainable can help identify opportunities for carbon reduction. Using products manufactured within the same country can further support environmental goals. To align with national net zero strategies (NHS England, 2020), each healthcare organisation should have an accountable lead and a Green Plan outlining objectives and actions for environmental improvement and carbon reduction. Wound care formularies often involve high cost items, necessitating a formal tendering process and an appropriate impact assessment. Procurement and sustainability teams can provide essential guidance on the questions and criteria required for product specification. Suppliers are also expected to submit their corporate Green Plans, demonstrating commitments to reducing carbon emissions and contributing to social value.

Summary
Effective change depends on transparent communication, stakeholder engagement and collaboration across organisational boundaries. Continuous audit ensures the formulary is adhered to, remains fit for practice and evolves in line with emerging evidence and service needs. Providing education on how the formulary should be used ensures that clinicians understand its purpose and application, while engagement with industry partners helps clarify product evidence and appropriate use. Joint working between tissue viability teams to develop and implement wound care formularies supports standardisation of practice and ensures patient care is safe, effective and seamless.