News headlines that the NHS faces a ‘diabetes time bomb’ resulted from an audit of patients in England and Wales that highlighted the fact that more than 2 million patients have raised blood sugar levels and are at risk of developing complications. With the rise in the UK population with diabetes to a predicted 6.25 million by 2035 (Hex et al, 2012), and the estimated cost of diabetic foot care to be between £639 million and £662 million a year (Kerr, 2012), the health and economic burden resulting from diabetic foot disease is daunting.
Information is power
The National Diabetes Information Service provides a comprehensive range of information products that include the National Diabetes Audit (considered to be the largest clinical audit in the world), which provides quality data to aid in the implementation of the Diabetes National Service Framework (NSF) and is pivotal in improving clinical services for people with diabetes. In addition, the National Diabetes Inpatients Audit provides much valuable information – including data on the provision of foot care. It is from these data that gaps in provision can be identified and strategies for improvement developed.
This revolution in diabetes informatics is a fantastic development and I give my congratulations to those involved. They have provided the diabetes community with the information that is needed to ensure that provision of diabetes services – including for the foot – is secured for the future.
The contribution of professionals
While the podiatry profession has made an undeniably significant contribution to the delivery of diabetic foot care, the collective contribution of the profession lags somewhat in contributing to the bigger picture; there is a requirement for the profession to step up to the mark to contribute to the informatics revolution. The medical profession have integrated the generation of health data into their practice for many years, which has enabled policy makers, managers and clinicians to make informed decisions in the delivery of high quality health care. The podiatry profession must follow suit.
From the results of a UK pilot survey of the diabetes specialist podiatrist workforce (Stuart and McInnes, 2011) identified some key concerns about the workforce, which included potential manpower shortfall, training and education issues, working in isolation and the effects of ‘cost savings’ from vacant posts. Broadly, the survey results highlighted just how little we know about the podiatry diabetes workforce – including the structures, process and outcomes for podiatry diabetes foot care.
The NHS podiatry diabetes workforce needs to consider employing national standards for the purposes of audit and research, and a mechanism to collect data that complements the existing diabetes health information products. The obvious areas include ulcer classification (e.g. National Foot Ulcer Audit, NHS Diabetes), ulcer healing outcomes (time to heal, amputation rate, health-related quality of life, mortality), provision of foot health education and reported concordance, orthotics, footwear and mobility.
Currently, podiatrists who specialise in diabetic foot care may work across teams including the foot protection team (FPT) and the multidisciplinary team (MDT), but are often found working in isolation. Where MDTs exist, there will be a lead physician who will take responsibility to gather important foot care data. However, there remains a requirement and obligation to demonstrate that best podiatry care is being delivered to our patients. While there is evidence that podiatry input can contribute significantly (Apelqvist and Larsson, 2000), we remain in the dark about the precise nature of podiatry practice that positively impacts on our patients, to say nothing of cost-effectiveness data.
The excellent Podiatry Competency Framework for Integrated Diabetic Foot Care (TRIEPodD-UK, 2012) launched at the recent Diabetic Foot Journal Conference in Glasgow is a positive step towards achieving our goals from a podiatry perspective. We need a competent workforce and we need to demonstrate that our practice is effective to make the maximum contribution to the FPT and MDT to ensure the best care for our patients. The podiatry profession needs to join – and actively contribute to – the diabetes informatics revolution.
The Society of Chiropodists and Podiatrists are currently gathering examples of best practice to aid in the commissioning process. They have also made representation to Paul Burstow, the Minister of State for Care Services at the Department of Health and highlighted the contribution that the Podiatry profession has made to diabetes foot care. The representatives discussed their concerns over the existing and future manpower requirements and were invited to provide further examples of innovative podiatry practice to the Department of Health for consideration in the QIPP (Quality, Innovation, Productivity and Prevention) initiative.
Future focus
It is heartening that the Society of Chiropodists and Podiatrists, Diabetes UK, NHS Diabetes and FDUK are working towards improving diabetes foot care services and reducing unacceptable amputation rates. However, there is a lot more work to do.
We need a comprehensive survey to determine the podiatry diabetes workforce in both FPTs and MDTs; we need to aid our podiatry colleagues to acquire the best possible competencies to deliver best quality care; and we need to mobilise the profession to collect robust data that can be integrated with the mainstream diabetes health informatics programmes.
The Society of Chiropodists and Podiatrists are developing an audit database called PASCOM (Podiatric Audit in Surgery and Clinical Outcome Measure), which could be developed to include the data that is required in diabetes foot care.
Finally, an amendment to the NICE diabetes in adults quality standards was announced in July (NICE, 2012). The standards for foot care have been split into two for clarity:
- Standard 10 – People with diabetes at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance.
- Standard 11 – People with diabetes with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours.
Small steps, but all in the right direction.
