Among people with diabetes, foot complications are common. Overall, 20–40% of people with diabetes are estimated to have neuropathy and about 2.5% – approximately 59 000 people in the UK – are estimated to have a foot ulcer at any given time (Kerr, 2012).
Diabetic foot disease is estimated to account for 20% of the total cost of diabetes care in the UK, with the highest cost of care being for the small number of patients needing the most complex care, often within secondary care (Kerr, 2012). The challenge for clinicians is to prevent patients from developing these complications, or containing the complications at an early stage of presentation.
NHS Diabetes launched a National Diabetic Footcare Network in 2012. The aim was to work with individuals, healthcare professionals, and partner organisations to improve the quality of foot care services for people with diabetes across primary, community, and acute care settings. The network represented foot care champions from each region in England (North, South, Midlands, and London) with the laudable aim of establishing a national network of clinicians and commissioners to promote and develop systems and processes leading to improvement in diabetic foot care through communication and shared learning.
The London Diabetic Footcare Network held five meetings and developed a root cause analysis tool, which was collated and presented nationally (Vig and Alchikhali, 2013). In addition, a footcare mapping exercise was undertaken that has evidenced the inequalities across London, allowing individual sectors to consider how these can be addressed. The major change was the engagement of all professions to contribute to the multidisciplinary discussion, freely sharing best practice and ways to overcome challenges.
The decommissioning of NHS Diabetes has challenged established and developing local Footcare Networks to clarify their value within the changing healthcare environment and – without funding or a partnership organisation – many have ceased to exist. The work of NHS Diabetes has now been incorporated into NHS Improving Quality, but rather that concentrating on individual disease processes this organisation has a process view looking at domains of care. These include preventing premature deaths (Domain 1; www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-1) and enhancing quality of life for people with longterm conditions (Domain 2; www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2). There is a risk, therefore, that the focus on diabetes, which has ramifications across all ages and many systems, may be lost.
Previously, NHS Diabetes also developed a website resource with best practice documents from individual local networks as well as aims and objectives developed within each region that were tailored to the individual regions health needs assessment. This resource is archived but available and should be signposted locally as there is a wealth of information which should continue to be utilised (available at http://bit.ly/1d58BpX).
London has a unique advantage with the appointment of a Clinical Director for Diabetes (Stephen Thomas) and a strong Diabetes Strategic Clinical Network developing a Diabetes Strategy. In addition, the London Diabetic Footcare Network was one of the first established and has an enthusiastic committed membership who continued to contribute to improving foot care services across London. The Network has, therefore, continued with limited charitable funding and the willingness of the participants.
The last meeting was supported by speakers including Stephen Thomas (Clinical Director for Diabetes, London), Jonathan Valabhji (National Clinical Director for Diabetes and Obesity), and Charles Gosling (Clinical Director of South London Academic Health Science Network) and enabled the network to clarify the opportunities for clinical engagement with commissioners and patient groups with regard to the needs of patients with diabetic foot complications.
The London Diabetic Footcare Network ratified that the reduction in the variation of care, and the need to implement an integrated foot care pathway to facilitate a reduction of amputations by 50% in 5 years, should be the continued focus for 2013/14.
Collaboration and affiliation with Diabetes UK, the Circulation Foundation, and the All Parliamentary Group for Vascular Disease enabled great discussion and an agreement that there was a need to use the “same language” when describing the longterm vision for the diabetic foot as otherwise there was a risk of conflicting messages. There was also an agreement that there would be great advantages to working together. The Network agreed to develop a range of activities and workshops to coincide with Diabetes Awareness week, 9–13 June 2014.
The clinical champions have developed priorities around the national agenda, by the use of audit work, benchmarking current practice, and developing research protocols. The challenge remains to engage with Clinical Commissioning Groups and ensure that improving diabetic foot outcomes is known to reduce costs and improve patient experience.
The open discussion and decision on work plans within the Network allows a collective commitment and drive to ensure that objectives are deliverable. Disruption to the structure of this group could destabilise this important driver and is a risk with the rebanding of staff groups, the implementation of Any Qualified Provider, and challenges around commissioning.
The support of the London Diabetic Clinical Network is important to London’s commitment to the continual improvement cycle. The clinical leadership of the group maintains the focus and drive, and the clinician’s involvement and contribution enables improvement at patient level as well as generating feedback for further work or research activities.
The next meeting is scheduled for 14 February 2014 and will be funded by charitable monies with administrative support from the London Strategic Clinical Network. We encourage the other Footcare Networks to continue – even if just as an email group – as there is a need for clinical collaboration to ensure the best care for people with diabetes.
