HTN sat down with Kumbi Kariwo, equality and inclusion project lead at Birmingham Community Healthcare NHS Foundation Trust, to learn more about her research into wound care in darker skin tones and how this has translated into practice in Birmingham and beyond.
Identifying health inequalities
On what inspired her to start looking into wound care for darker skin tones, Kumbi shared that the focus initiated during the pandemic, when Birmingham Community Healthcare introduced chief nursing fellows for the first time to explore health inequalities.
“The challenge was to identify an area of nursing that I’d never looked at before,” said Kumbi, “and as a learning disability nurse by background, I looked at adult nursing and the issues that were present. Pressure ulcers at that time were costing the NHS £3.8 million per day. We looked at that from the angle of a health inequality, seeing what pressure ulcer care looked like for someone with skin that looks like mine.”
This initial interest highlighted some of the gaps in education and training around pressure ulcers in darker skin tones, Kumbi shared, since it did not match the community the trust served in Birmingham.
Starting out by looking at training packages and their performance for her own skin, Kumbi said that a lot of focus was placed on identifying “red patches or redness”, which did not show up on her own skin tone; yet this is still what clinicians were being trained to look for with all skin types.
At the very heart of tackling inequality, Kumbi stressed, is the need to think outside the box. “What might be obvious to the patient or individual experiencing something may not be immediately obvious to the people sitting at the table. Identifying where the needs of patients are not being met, and why that is the case, is the first step in making change. Sometimes in the NHS the patient fits with the service rather than the service asking whether it is meeting the needs of the community – in Birmingham, as an organisation we use the Equality Act 2010 and look at the nine protected characteristics to complete equality impact assessments to be sure we are taking that into consideration.”
The role of technology in tackling health inequalities
Technology can play many different roles in tackling health inequalities, Kumbi noted. “With things like electronic patient records, we have noticed that clinicians often use different language or terminology around what they’re seeing. That’s where having an app like Isla which focuses on images has helped us, because a picture can often speak a thousand words.”
One of the useful features of the app for wound care is the ability to track wound progress over time. “You can look at pictures uploaded at different times to see whether that wound is getting better or worse, which helps to start to evidence the care we’re providing.” The overall impact, Kumbi considered, is that “it has made us more proficient at doing that, and the technology has helped widen the lens in terms of how we’re currently practicing.”
Another benefit offered by having wound images readily available is that it facilitates multidisciplinary working. “Our community teams work in such a way that you don’t get the same practitioner going in to see the patient. If I see the patient today, my colleague can go in tomorrow and see what I saw. That is a more accurate representation than a written description, and that has increased our accuracy.”
Key findings on health inequalities
One of the activities carried out during the initial phases of her research was a baseline assessment on the confidence level of staff, looking in particular at staff experience according to years of practice. A major finding indicated that regardless of level of experience or the staff member’s own ethnicity, “the darker the skin tone, the less confident people got around the identification of pressure ulcers”.
With this finding in mind, Kumbi worked with the trust’s performance management team and research and innovation team to look at the organisation’s incident reporting system, examining data over time. “We found that the darker the skin tone, the later the identification of the pressure ulcers. Whereas patients with light skin tones were being picked up early at stage one or two, those with darker skin tones weren’t being picked up until stage three or four.”
Given this evidence of an existing inequality, the chief nurse and risk management team decided that patients with darker skin tones should be considered vulnerable patients with more frequent checks in this area. Training packages were altered to build staff confidence, with training provided specifically for darker skin tones.
Since the trust began this work, Kumbi highlighted how a number of clinicians have been in touch from trusts across England, with Birmingham happy to share their insights and help to deliver training.
Encouraging self-management with support from technology
Technology has played a sizeable role in helping patients to manage their own care, Kumbi told us. “We’ve really seen that with Isla. The beauty of Isla is that it doesn’t need a log-in, there’s a link that you send to the patient’s phone; they click on that and straight away the camera comes up for them to take a picture or video.”
Patients can choose the best time for them to upload their images, and it encourages them to consider self-care of their own wounds. “They start to have that curiosity of what it looks like, why it looks a certain way,” she said, “or whether they need to do something different about it. We’ve seen people being more proactive about it, for example going to a GP at an earlier point because they think they have seen an issue. Having those images there helps with trying to articulate a problem.”
What the team have seen, according to Kumbi, is that “people are being more proactive, and they’ve gone to their GP at an earlier point, because they’ve seen something they think is an issue, and having those images there works better than trying to articulate a problem to try and describe what’s going on”.
Challenges
Kumbi considered some of the challenges with implementing technology in care pathways, noting that interoperability is a significant challenge.
She also reflected: “With digital health, at the beginning we went from paper records to digital; but that didn’t necessarily mean that it worked better. Over the years I think we’ve realised that whilst we’re putting a lot into these systems, we don’t seem to be able to get much intelligence out of them, and we’ve started redesigning them to do that.”
An integrated digital pathway platform is the key, she continued, “because that will allow a seamless journey for the patient. My hope is that one day we’ll get to a place where the patient will always be treated in the right place, at the right time, by the right service. When we get to that point, that will be what digital health should look like for our patients.”
There has been good progress, she acknowledged, and there is a need to celebrate achievements within that. “People tend to see what happens when things go wrong, but we need to celebrate when we’re doing well. For me there’s a question around how we change our culture to reflect that.”
Talking about her work as chair for the Midlands Digital Shared Decision Making Council, with the Florence Nightingale Foundation and with the Shuri Network, Kumbi also highlighted the need to ensure opportunities are there for those with ideas or innovations. “Those on the shop floor understand the pain points and most likely have ideas on how we can solve those. We’re having lots of spaces being created to allow for digital innovation, and it’s integral that we offer those platforms for people to come and experiment, giving them the confidence to try out their ideas.”
Truly inclusive wound care
Truly inclusive wound care would look like a patient walking in to visit a practitioner and them being able to start treatment right away, Kumbi said, without the need for multiple referrals. Her suggestion for getting to this point would utilise a database displaying images of different wounds and how to identify them, with the database available across England as a whole.
Collaboration is a major factor, Kumbi added. “To tackle regional variation, NHS England needs to play a bigger role in standardising what we do, as lots of teams are led by governance in their area. We’ve also got the National Wound Care team; I’d pose the challenge to them to look more closely at digitising the way we work in wound management.”
Ultimately, encouraging more innovation is key. “We don’t have the psychological safety in the NHS to go ahead and just break things, and fail; and failure can be what makes the difference. It’s how we change our culture, our thinking, and the environment in the NHS to allow people to experiment and discover the next big thing. My fellowship gave me the license to go ahead and experiment, and look at the change that that has brought.”
Next steps
Looking to the future for wound care and where the gaps still exist, Kumbi again raised the need for an image database, particularly one which would offer more insight into what different conditions look like for darker skin tones. “I believe Bristol have started looking at that,” she said, “and my colleague from our clinical illustration team is looking to start to establish those images of different conditions.”
The continued spread and impact of these findings on care for pressure ulcers and other conditions is important, Kumbi emphasised. “If you go onto the NHS Choices website, they now talk about conditions like measles, and point to what to look out for in darker skin tones, so it’s great to see different skin tones represented in how different conditions present.”
For Kumbi, a further step on this journey would be to start looking at the role of artificial intelligence in this space. She noted the fear which often exists around the use of AI, adding that “one of the things we started looking at in this project was the wound validation process, which involves three separate people looking at a wound to come up with diagnoses. My question is: could AI start to look at the early identification of some skin conditions? For me, that’s where the vision is – could we use our image collection to create a tool which really helps us?”
Practical tips
Kumbi offered some practical tips for anyone within the NHS looking to pursue similar projects, encouraging them to start by looking at their organisation and quality improvement. “We started with that mindset – collaborating with universities, getting our research and innovation team on board. The other thing is identifying whether there’s an appetite to change the problem or challenge you’re looking at, and how you would start to change that. Then you need to get buy-in across the organisation.”
Identifying the right technology or supplier to support a new project or initiative is also important, as is identifying what is out there in terms of technology. Kumbi explained that her team initially had the choice of nine suppliers in the imaging space. Isla was selected on the basis that “they met most of our essential criteria, and the solution didn’t require download or login – that overcame a barrier for us as a region as we have so many spoken languages and dialects and an ageing population.”
On the importance of privacy and data protection, Kumbi said: “We liked that with Isla the images don’t stay on the phone, they come straight back to the organisation. They were also flexible when we wanted to put more in place around consent forms; so patients can consent to the use of their data for treatment, for research, for education, and so on.”
Success is “quite hard to measure”, Kumbi acknowledged, but “for me it’s about knowing that patients with darker skin tones now have a clinically defined identifier. Hopefully in years to come people with darker skin tones will be having their pressure ulcers identified earlier.”
As for the future: Kumbi and her team are currently working on developing a blueprint for NHS England. “It will look at how we implemented the programme, and will hopefully be out later this year.”
We’d like to thank Kumbi for her time in sharing her findings and insights on wound care with us.
