As Diabetes Foot Co-ordinator for Scotland, one of the core elements of my remit was to develop, promote and implement quality, standardised patient information across the NHS Scotland, in line with the Diabetes Action Plan (Scottish Executive Health Department, 2006). With this in mind, a set of nationally agreed information and education leaflets for people with diabetes in Scotland has been developed by the Scottish Foot Action Group.
The development of these nationally agreed leaflets was a long, but very worthwhile, process. I would encourage the other nations of the UK to try and achieve a similar agreed standard of patient information. As such, I hope that the Scottish leaflets, and the development process detailed in this editorial, will be helpful to anyone looking to devise similar documents in the future.
Developing the leaflets
Prior to the development of the leaflet series, a wide range of patient information was available in Scotland for people with diabetes. This material had been developed locally, and, in some cases, had been sponsored by the private sector. After an initial evaluation of all the patient information that was available, the best aspects of these documents were brought together to form one set of nationally agreed leaflets.
The creation of these leaflets was achieved after wide consultation with the 14 Scottish Health Boards (SHBs) that constitute the Scottish NHS. In trying to gain a consensus on what these documents should contain, and how they should be presented, the advice of a wide range of healthcare professionals with a stake in diabetic foot care was sought – from podiatrists to district nurses – and, of course, people with diabetes were consulted in the process.
Development and publication of the leaflets was made possible only by the willingness of the SHBs to work together, and not be too “protective” of any locally produced literature. Without allowing the documents to become disjointed, the Foot Action Group sought to ensure that all stakeholders’ thoughts and comments were noted and incorporated where possible.
In the end, the graphics and layout for the leaflets was adopted from Ayrshire & Arran, and the colour-coding system from Lanarkshire. Some of the wording from publications by the Greater Glasgow & Clyde and other SHBs were also used. The leaflet series was Crystal Marked for readability by the Plain English Campaign.
This process culminated in the publication of six, colour coordinated, nationally agreed leaflets (Figure 1) that are linked to a foot risk and triage flowchart (Figure 2) that utilises the widely used and easily recognisable “traffic light” system. The leaflet series includes information for people at high, moderate and low risk of developing diabetic foot conditions, guidance on holiday foot care and footwear, and looking after a diabetic foot ulcer. Two further leaflets are currently in production, on Charcot foot and neuropathy, which will be made available in 2009.
Leaflets in action
Screening and risk stratification, the cornerstones of good diabetes foot care, should determine what risk a person with diabetes has of developing a foot ulcer (Leese et al, 2006). Scottish healthcare professionals have been encouraged to provide each person who receives a screening or an assessment of their diabetic foot condition with the leaflet that corresponds to their individual level of risk.
It is hoped that this new system of patient education and information will encourage people with diabetes, and their clinicians, to understand their individual level of risk, and ultimately to implement appropriate management plans and minimise the risk of developing further foot problems (Leese et al, 2007).
The Scottish government has undertaken to provide hard copies of the leaflet series, free of charge, to all healthcare professionals in the NHS Scotland for distribution to their patients as necessary. The leaflets are also downloadable for anyone interested in reading through them from the FDUK website (http://footindiabetes.org/node/123). I hope they will also be informative for healthcare professionals outside of Scotland.
Reflection
The leaflets were launched in the Scottish parliament in May, 2008. The Deputy First Minister and Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon MSP, referred to them as being “an example of best practice”, and commended their production and implementation, agreeing to centrally fund the printing costs. The leaflets have been greeted enthusiastically both by clinicians and people with diabetes throughout Scotland, and as such they are currently in their third reprint.
While the process of pulling these leaflets together was a very time consuming one, the result is a set of documents that I hope will genuinely enhance diabetes care and patient education in Scotland. Time will tell!
