In 2023, the Skin Integrity Lead Nurse (now Nurse Consultant) at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH) identified that place-based care, embedded across Doncaster Place through the Doncaster Wound Care Alliance (Moore and Delahunty, 2023), demonstrated how a wound care formulary can reduce variation in care and product use. It also increased the frequency with which patients received the right care at the right time, using evidence-based and cost-effective products. This led to the goal of replicating elements of the work across the South Yorkshire integrated care board (SYICB), aiming for system-wide, collaboratively led improvements to reduce variation and promote cost-effective wound care. After multiple discussions, it became clear that the SYICB Procurement Project Manager shared the same ambition to standardise wound care products.

Initial meetings and discussions between DBTH and SYICB were held at the beginning of 2024, with the formation of a SYICB Tissue Viability Service Improvement Group (SYICB TVSIG) in April 2024. There was membership from all tissue viability services, and additional wound care service leads, such as vascular nurses and podiatrists, and procurement teams within South Yorkshire. This project was backed by all organisations, by the Chief Nurses, enabling the members to have the freedom to focus on quality, using their expertise, creativity and skill to find innovative ways to improve quality of care for patients at risk of or living with a wound. A full list of members is in the acknowledgements at the end of the article.

South Yorkshire has a population of more than 1.4 million people and is made up of nine NHS trusts, four local authorities, five acute trusts, three community/mental health trusts and 170 GP practices. 

Each trust has a tissue viability service, with some providing care to acute services, other to community services and some provided care to both. Each tissue viability service had different policies, pathways and formularies in place; however, some similarities were seen between the two trusts in Barnsley and the two in Doncaster.

Available knowledge, evidence and recommendations

Wound care

Data from 2017/2018 estimated the annual prevalence of wounds increased by 71% between 2012/2013 and 2017/2018. There was a substantial increase in resource use over this period. The estimated total annual NHS cost of wound management is £8.3 billion (Guest et al, 2020), which is an increase of 48% in real terms from 2012/2013. NHS England has estimated that sub-optimal care can cost up to 10 times more than correctly managed care (NHS Right Care, 2017).

Along with the increases in resources in wound management, there is also considerable variation in care across the UK, with underuse of evidence-based practices and overuse of ineffective practices (Guest et al, 2015; Murray and Norrie, 2020). These variations impact directly on patient outcomes, increasing care costs and extending healing times (National Wound Care Strategy Programme [NWCSP], 2023). However, this unwarranted variation offers major opportunities to improve healing rates, reduce recurrence rates, reduce individual suffering, reduce spending on inappropriate and ineffective treatments and the amount of clinical time spent on care (NWCSP, 2023). 

Improvement in the NHS 

There are multiple polices and recommendation from NHS England relating to high quality care and continuous improvement. NHS England supports and encourages continuous improvement for patient care. In 2008, the Department of Health published High Quality Care For All, with multiple proposed visions for the NHS. This involved promoting locally led, patient-centred, and clinically driven care by empowering healthcare professionals to prioritise quality. It enabled frontline staff — both providers and commissioners — to apply their expertise, creativity and skills to develop innovative approaches that improve patient care and address the specific needs of their local communities (Department of Health, 2008).

Additionally, recent recommendations from NHS England in 2023 expanded on care delivery approaches. NHS England advocated for collaborative partnerships with integrated care boards, using a co-design approach alongside clinical leaders to enhance patient care. This included embedding a quality improvement methodology aligned with broader improvement strategies to boost productivity and improve health outcomes.

NHS England also launched the NHS Improving Patient Care Together (IMPACT) approach in 2023 to support NHS organisations and systems to implement continuous improvement to improve patient care and outcomes by creating the right conditions by using the five components that underpin a systematic methodology approach:

• Building a shared purpose and vision
• Investing in people and culture
• Developing leadership behaviours
• Building improvement capability and capacity
• Embedding improvement into management systems and processes.

Rationale

By reducing unwarranted variation in wound care through a collaborative model encompassing products, formularies, pathways and procurement methods, it becomes possible to implement and sustain the right care, in the right place, at the right time across various care settings. This approach may lead to improved patient outcomes and better optimisation of specialist capacity, helping to manage demand and complexity effectively.

The availability of an ever-increasing range of products with unknown effectiveness and potential financial constraints can make it challenging for clinicians to choose the right treatments for the right patients (Stephen-Haynes, 2013; Song et al, 2019). Creating streamlined evidence-based wound care formularies across South Yorkshire that have a high percentage of consistency across the ICB will provide a standardised approach to wound management. Ultimately, formularies help standardise practice; the most important factors that underpin their development are patient safety, patient/staff (user) experience, including patient outcomes, and cost-effective care. 

Consistent practice from a wound care formulary can ease the decision-making process for clinicians proving wound care across SY by providing recommendations and guiding clinicians towards evidence-based and cost-effective clinical practice (Song et al, 2019). Therefore, implementing a formulary can lead to cost reductions and increased staff efficiency (Yeung et al, 2017; Song et al, 2020). 

Interventions: Investing in people and culture to develop leadership behaviours

Building a shared purpose and vision

The ambitions and vision of the group were set as:

• Collaborate to co-create a system improvement plan to enable effective care delivery, social values and sustainable change in wound care procurement which is aligned to the NHS supply chain categories and frameworks
• Ensure membership includes the right skills through stakeholder engagement with strong connections to the ICB Procurement Team
• Ensure commonality and standardisation in line with evidence-based practice where every available in wound care products to reduce variation in care, to ultimately improve patient outcomes and ensure cost effectiveness, social values and sustainable products are available
• Develop processes/pathways where possible for some wound types/patient groups to enable the delivery of wound care to be evidence-based and consistent
• To share multiple sources of information to improve insight and understanding around the current position of procurement services, their processes and usability within the field of tissue viability across South Yorkshire. 

Scoping 

A scoping exercise was undertaken to establish our baseline and current position across South Yorkshire. Figure 1 shows the outcome of the understanding and aims section of the scoping exercise. Across the wound care procurement categories, 39 different categories were accessed throughout South Yorkshire, with at least 153 distinct products in use. 

There was a 72% (28) variation with the categories and an 80% (122) variation in products being used across the different trusts and services. There was also a variation in the routes of purchase that were being used across the area. A total of £4,842,069.92 was spent across South Yorkshire in 2023/2024, with £3,708,111.38 being spent through the NHS supply chain (NHSSC) and prescription (FP10), and an additional £1,133,958.54 being spent on direct purchasing. Wound care products are one of the largest areas of spending and product utilisation within South Yorkshire, with spending in excess of £5m spread across more than 60 suppliers.

Measures and analysis 

• In order to establish a baseline against which future improvements could be measured, the following were undertaken:
• A cost analysis of product usage for wound care products in 2023/2024 to establish the current spend
• A gap analysis for each organisation comparing the products that were used in each organisation in each category to determine the variation and similarities. 

The results enabled the team to:

• Identify variations between organisations to develop targeted actions that reduce discrepancies and standardise care across South Yorkshire
• Enhance the implementation of evidence-based care to increase cost-effectiveness in product use, ultimately achieving overall cost savings across South Yorkshire.

Table 1 shows the baseline measurements that were established. From this, actions around the product usage were formed and developed into a highlight report to track progress and outcomes [Figure 2]. 

Results

Since commencement in April 2024 to June 2025, 33% of the actions have already been achieved, with 7% currently being reviewed and worked on, 3% planned for review over the next few months and 57% to be started over the coming years [Figure 3]. From the 33% completed actions, the following outcomes have been seen:

• A 20% reduction in variation of number of products agreed for use as first-line, second-line and specialist use [Figure 4]
• National Pricing Matrix (NPM) agreements have been established for products that are consistently used across SY. As of June 2025, the estimated saving that will be achieved for the first 12 months post NPM implementation across the region is £18,087.19 [Figure 5] 
• As of June 2025, the estimated saving from the reduction in variation which has resulted in some organisations changing their practice to an agreed standardised more cost-effective option across the region is £20,083.97 [Figure 5] 
• As of June 2025, the total estimated savings are £38,171.16, thereby reducing the overall spend by 1%.
• We have an established a consistent user guide for one product that is used across the whole ICB.
• Three clinical pathways that were established in some organisations have now been utilised over multiple areas to reduce variation in the wound management processes, as well as the wound care product usage.

Limitations

A limitation of the project is that not all healthcare providers involved in wound care delivery are directly represented, due to the large number of healthcare professions involved across South Yorkshire. However, the aim is to include members from a broad range of specialist wound care services, related clinical services, procurement, and medicines management. These members bring extensive experience, knowledge and expertise in their respective fields to ensure that all aspects of the patient journey are considered and reflected in any proposed changes.

Conclusion

Given the annual cost to the NHS for wound management is estimated to be £8.3 billion, and with sub-optimal care further increasing the cost, it is critical that continuous improvement is established within wound care to ensure high quality care for all. By giving services the freedom and time to focus on quality – and to apply their expertise, creativity and skills in collaborative ways – it is possible to reduce variation, improve the quality of care for patients at risk of or living with a wound, and enhance the cost-effectiveness and sustainability of wound care procurement. Utilising NHS IMPACT components will underpin a systematic methodological approach that can successfully be used for system-wide working to drive continuous improvement. Regional ICB system-wide collaborative partnership working can enable improvement led delivery to reduce variation and increase cost-effective wound care procurement products.   

Acknowledgements to, but not excluding:

• Paul Taylor, South Yorkshire ICB Collaborative Procurement Projects Manager 
• Siobhan Gorst, Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust Senior Vascular Nurse Specialist
• Linzi Ray, Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust Procurement Department Clinical Procurement Specialist Procurement Department
• Liam Boyall, Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust Procurement Department Category Specialist
• Amy Jones, Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust Procurement Department Senior Category Manager – Clinical
• Michaela Delahunty, Rotherham, Doncaster and South Humber Foundation Trust Clinical Lead Tissue Viability and Lymphoedema Service  
• Dawn Clifton, Rotherham, Doncaster and South Humber Foundation Trust Tissue Viability and Lymphoedema Sister
• Susan Batley, Rotherham, Doncaster and South Humber Foundation Trust Podiatry Foot Protection Service – Lead
• Karen Jennison, Doncaster Place Senior Medicines Optimisation Technician 
• Tracey Green, Rotherham NHS Foundation Trust Lead for Tissue Viability and Lymphoedema Service  
• Jill Newrick, Rotherham NHS Foundation Trust Tissue Viability Clinical Specialist
• Angela Flanagan, Rotherham NHS Foundation Trust Podiatry Clinical Lead
• Govinder Bhogal, Rotherham Place Deputy Head of Medicines Optimisation
• Justin Seaman Rotherham NHS Foundation Trust Procurement Senior Category Manager – Medical
• Sarah Jones, Sheffield Children’s NHS Foundation Trust Lead Paediatric Tissue Viability Clinical Nurse Specialist
• Rachel Leathwood, Sheffield Children’s NHS Foundation Trust Tissue Viability Clinical Nurse Specialist
• Paula MacDonald, Sheffield Teaching Hospitals NHS Foundation Trust Lead Clinical Nurse Specialist Tissue Viability 
• Nikki Fenwick, Sheffield Teaching Hospitals NHS Foundation Trust Senior Vascular Nurse Specialist
• Michaela Fairest, Sheffield Teaching Hospitals NHS Foundation Trust Clinical Procurement Specialist
• Andrew Moore, Sheffield Teaching Hospitals NHS Foundation Trust Formulary/Pharmacoeconomics Pharmacist
• Stephanie Williamson, Barnsley Hospital NHS Trust Lead Tissue Viability Nurse
• Laura Hallas, South West Yorkshire Partnership NHS Foundation Trust Nurse Consultant Tissue Viability Lead For Tissue Viability and Cancer Related Lymphoedema Services 
• Rebecca Rowlands, South West Yorkshire Partnership NHS Foundation Trust Nurse Community Wound care Lead Podiatrist
• Chris Jones, Barnsley Facilities Services Clinical Category Manager
• Chris Lawson, Barnsley Place Medicines Optimisation