The annual foot check is an essential part of diabetic care. But if a clinician picks up a problem, the next stage could be difficult. A report for Diabetes UK has revealed there’s a lack of the right services – a third of hospitals don’t have a multidisciplinary foot care team and ‘in many areas of the country there are no clear pathways for referral of patients to appropriate specialist services’.
Yet the NHS could save up to £262m a year by improving care for these patients. Improved services could reduce the number of foot ulcers by a third and prevent many of the 7,000 amputations carried out every year, the report says.1 Diabetes is recognised as a major problem for the NHS; there are more than 4.5m people with the condition. So why is there such a lack of the right foot care?
Nikki Joule, policy manager at Diabetes UK, says: ‘The commissioners are not aware that they are spending this money.’ The cost of treating foot ulcers in primary care are hidden.
Hospital foot care costs are clear because they are easy to code, and amputation is one large bill. ‘But in the community and primary care it is thousands and thousands of individual transactions: antibiotic prescriptions and wound dressings and podiatrist time, community nurse and practice nurse time,’ Ms Joule says.
The Diabetes UK report ‘Improving foot care for people with diabetes and saving money: an economic study in England’ has been ‘a real eye-opener’, she says. It reveals the cost of treating ulcers in primary, community and outpatient care is between £629m and £786m. Inpatient care for amputation costs up to £443m.1
The costs aren’t just financial. Foot ulcers impair mobility and are very painful, leaving people isolated and at risk of depression. They are the largest cause of amputations in people with diabetes.
Yet access to specialists varies dramatically around the country. Patients face a ‘post-code lottery’, Dr Marie-France Kong, consultant diabetologist at University Hospitals of Leicester NHS Trust, says. Almost a third of hospitals have no diabetes inpatient specialist nurse available according to the National Diabetes Inpatient Audit.2
Where there are multidisciplinary foot care teams, they can reduce amputations by up to 50% according to a paper by Dr Jonathan Valabhji, the national clinical director for diabetes.3
He welcomed the Diabetes UK research, saying: ‘This report is well timed, just as we at NHS England are about to invest £40m per year over the next two years in specific areas of diabetes treatment and care. One of the specific areas for investment is improved access to the multidisciplinary diabetes specialist teams to which this report refers.’
Yet there is a shortage of 7000 podiatrists and a lack of multidisciplinary teams. So it’s not clear that just a slice of the new funding will plug the gap. It has to cover the three workstreams in the NHS Diabetes programme, drawn up following the Five Year Forward View: prevention of type 2 diabetes; treatment and care; digital schemes to support prevention and self-care.
Dr Kong says funding for diabetes foot care ‘can be difficult to get as the diabetic foot is the Cinderella of diabetes complications’.
However, the National Diabetes Audit is encouraging commissioners to invest, she adds: ‘It’s like a league table, so people realise we’d better improve things.’
The audit found that many patients faced long waits for specialist foot care. Almost a third of patients presented themselves to specialist services without a referral.
Of the rest, almost two-fifths were not seen by the foot care service until at least two weeks after the first health-care contact for their ulcer – instead of one working day for people with an active problem, recommended by the NICE guidance.
So what does a multidisciplinary team look like? Dr Kong says: ‘For a successful MDT foot service you need skill mix, people who are passionate about looking after the diabetic foot and working over and above, as well as good leadership.’
University Hospitals of Leicester has one of the largest multidisciplinary diabetic foot care teams in the country. It includes a wide range of professions, from diabetologists, specialist diabetes nurses and cast nurses (who put a cast on to the feet for offloading pressure), to specialist podiatrists, podiatric surgeons, orthotists and micro-biologists.
They alternate three or four foot clinic outpatients a week.
Rachel Berrington, specialist diabetes nurse, says the vascular surgeons will take direct referrals straight from outpatients, seeing the most urgent cases immediately.
So what is it about the team that makes a difference? ‘We work cohesively together,’ says Ms Berrington. ‘We are all trying to get the same outcome for that individual to get healing to occur as soon as possible, or if they need intervention to achieve that
so they can get function and quality of life back.’
The team will accept referrals from primary care professionals, including practice, community, tissue viability and learning disability nurses. ‘If we have concerns about dressings we can send letters out to the practice or community nurse to ensure continuity of dressing change and frequency of that change,’ Ms Berrington says. ‘Sometimes the dressing needs to be on for up to three days to have any effect.’
There’s no evidence that one kind of wound dressing is superior to any other, she adds, and NICE guidance recommends using the one with the lowest acquisition costs.
The Diabetes UK report highlights the importance of training for practice nurses and GPs. It cites a county-wide integrated diabetes pathway in Somerset. Taunton and Somerset NHS FT, Somerset CCG, Somerset Partnership (community) trust and local GPs established the service. There are eight emergency clinics, offering appointments within 24 hours for people with active foot disease and direct referral into hospital where necessary. Community podiatrists received specialist training, and GPs and practice nurses were trained. The major amputation rate fell by 43%, saving 19 amputations a year and inpatient days fell by 23%. The estimated annual saving was £926,000.
But what if you don’t have access to a multidisciplinary team? In areas without specialist teams and good community links, it’s often down to GPs and practice nurses to care for wounds and it’s practice nurses who often do the annual foot review.
Ms Joule of Diabetes UK says: ‘it’s about being educated and trained in how to do the annual check.
‘We know the mechanical bits are being done well, checking for sensation and circulation but the bit that people often say they didn’t get is the advice about how to look after their feet, what their risk is and where to go if they have a problem.’
Practice nurses need to know more about their local diabetic services, and know where to go for a rapid referral, she adds.
Amanda Cheesley, the RCN’s professional lead for long term conditions, says: ‘Practice nurses need to be able to understand the red flags of a foot care crisis and know what to do when someone is approaching a diabetic emergency.
‘You can’t afford to wait in some of these cases, there’s
no point saying ‘We’ll refer you and you’ll be seen next week’ because next week could be too late.’
Every patient should have all the information they need to recognise when something is not going well, Ms Cheesley adds. Information leaflets are available from the RCN and Diabetes UK’s Putting Feet First campaign.4
But the vigilance of the clinician is paramount. Nurses and GPs should also seize every chance to look at a diabetic patient’s feet. ‘If
they come into surgery or you do a home visit, always take the opportunity. It only takes two minutes and it could save their foot.’
1. Kerr M. Improving Footcare for People with Diabetes and Saving Money: An Economic Study. 2017. Diabetes UK
2. NHS National Diabetes Inpatient Audit 2015-16
3 J Valabhji. Diabetes and the NHS in England. British Journal of Diabetes. 2016. 16(4) 151- 53
4. Diabetes UK. Putting Feet First campaign. https://www.diabetes.org.uk/putting-feet-first