However, these headlines never filter down to the people who are responsible for paying, or if they do, they are often buried among a lot of other important competing statistics, such as cancer and stroke rates.
The difficulty is making the payers sit up take notice and give them an easy-to-use route to see the evidence, the cost and, importantly, in these continued times of austerity, how much can be saved and reinvested.
One means of addressing this evolved from the national audits around diabetes, including the in-patient audit, the national diabetes foot ulcer audit and the foot care profiles.
The College of Podiatry worked with Health Education England and Insight Health Economics to develop an online commissioners’ guide. The aim was to help identify the true costs for individual Clinical Commissioning Groups (CCGs) and clearly identify where money was being spent. The goal was to attempt to end the postcode lottery of poor service delivery and subsequent poor outcomes
The creation of this resource involved the examination and recording of incidences of disease, disease severity, comorbidities, mortality and expenditure in every CCG in England. This initial study exposed the stark differences in amputation rates between regions — differences that signify a deep human cost for patients and their families, as well as a huge cost burden for our already stretched NHS foot services.
It showed, unequivocally, that it is time for commissioners to increase investment in foot protection, to make sure we reduce these unnecessary and appalling personal and financial costs for patients and the NHS.
So the headlines that “one pound in every hundred pounds spent by the NHS in England is for diabetic foot care — more than a billion pounds a year” ring true and, for the first time, this can be demonstrated for each area using one easy-to-use toolkit.
The average CCG currently spends around £5.7m a year on diabetic foot problems; more than the combined cost of the four most common cancers. Reducing the prevalence of severe ulcers by one third would reduce the cost of ulcer care by around £1 million a year per CCG. If CCGs invest in good foot protection services and create seamless and unfettered access to specialist services, a 10% reduction in poor outcomes would release nearly £600,000, which would more than cover the cost of the investment in frontline podiatry services required to support this transformation.
There is both the need and the opportunity for the NHS to ensure a positive change in the landscape of diabetes foot care and to reduce costs.
The online resource (link) supports CCGs in England in commissioning improved services for diabetic foot disease by providing information on:
- The impact of diabetic foot ulcers and amputations on patients’ lives
- The impact of diabetic foot ulcers and amputations on NHS costs
- The potential for improved care to transform lives and reduce NHS expenditure
- What good care looks like and how to restructure services and pathways.
Visitors can search a bespoke database for information, which illustrates the diabetic foot care landscape in their CCG or sustainability and transformation plan (STP), and learn what measures could improve patient care and save money.
Examples of good practice demonstrate how changes already implemented in some parts of the country have made an impact, and commissioners and clinicians who have transformed their services share their experiences of the challenges they faced, the solutions they found, and the impact of improved services on outcomes and costs in their areas.
Since the launch of the toolkit, researchers in both the USA and UK have reported that “appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes”. In a paper published in the American Diabetes Association’s journal, Diabetes Care, William Jeffcoate et al (2018) describe an “urgent need to improve the design and conduct of clinical trials in this field, as well as to undertake systematic comparison of the results of routine care in different health economies”.
Commenting on issues including the effectiveness of existing treatments and incidences of major amputations, the authors discussed why the evidence base on diabetic foot ulcers is so poor, and described it as a “topic that has generally failed to attract the same level of interest by healthcare professionals as other diabetes complications”.
They also suggested that attention must be paid to the structure of the care pathway, stating: “There is strong suggestive evidence to indicate that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes’.
Concurring with the ideals behind the development of the toolkit, the researchers also state that “available evidence suggests that very considerable improvements can accompany structural changes in the way professionals work and in the way that care is delivered”, and that “such structural changes should focus on the creation of clear pathways to enable early assessment of diabetic foot ulcers by a specialist multidisciplinary service and the provision of structured surveillance and care for those who have had a diabetic foot ulcer and are in remission after healing”.
Concluding that “if communities embrace these initiatives, it should be possible to trigger substantial improvement in outcomes relating to diabetic foot ulcers”, the paper underlines and echoes the thinking that underpins what we in the UK are currently trying to achieve and supports the development of our online resource as a supporting tool in creating a shift in diabetes care, where care of the foot is an intrinsic speciality, and not an adjunct.
So I would implore every practitioner who is passionate about diabetic foot disease, whether you are based in England or the wider UK and beyond, to log on to www.improvingdiabeticfootcare.com and see in detail the impact that foot disease in diabetes has on a population, from an economic and a person perspective. If you live in England, have a look at your area and then talk to your commissioners about how you can improve the situation and save them money … it usually grabs their attention.
