It has always been a passion of ours to ensure across the four nations that patients with diabetes-associated foot complications are reviewed by the right person at the right time with the appropriate skill set. This timely approach has been well documented over the years and the National Diabetes Foot Care Audit (NDFA) has also identified that the more quickly a patient is referred to a specialist team after presentation of a foot ulcer, the better the outcome (NDFA, 2018). This is demonstrated in terms of severity of wound status and quicker healing. Delays in presentation to the skilled teams will be more likely to result in delayed healing, increasing the risk of amputation and associated morbidity and mortality. Historically, Edmonds et al (1986) were one of the first clinics to demonstrate with evidence that by a multidisciplinary/multiprofessional approach to care of the patient with a diabetes foot ulcer has far better outcomes than an isolated practitioner approach to care. Multidisciplinary team approaches are now recognised as gold standard across the UK. NICE CG (2015) and SIGN116 (Healthare Improvement Scotland, 2017) both advocate a team approach to patient care.
The unique role of the diabetes multidisciplinary team (MDT) is to consider the person holistically, addressing all the key areas, including diabetes management, vascular supply, infection control, wound care, pressure reduction etc, and to have access to all the investigations and referrals required, optimising resources reducing hospital admissions, length of stays and optimising outcomes, including ulcer healing times and prevention of amputation. However, while recognising how important the team approach to diabetes-related foot care, it does raise the difficult question for us as clinicians in terms of management of patients with foot wounds that do not have diabetes.
In the UK, the caseload profile of patients with diabetes has changed significantly in the past few years. When I (Joanne) started as a diabetes
specialist podiatrist in Edinburgh 16 years ago, the main characteristic present in diabetes foot ulcers was neuropathy. Neuropathy hasn’t disappeared, but due to patients living longer, we have far more patients that are presenting with additional vascular complications than ever before. Vascular services have undergone a significant transformation recently with the development of hub and spoke models in England leading to the development of a sub-speciality approach with more vascular surgeons presenting as key MDT members and, in many areas, leads of these MDTs. In most geographical areas, neuroischaemic and ischaemic are the predominant pathological backgrounds for our diabetes patients. If the patient profiles are changing, should our services be changing alongside to reflect current demographics?
Podiatrists have seized the opportunity and recognised the role they can have within vascular assessment and triage (NICE, 2016). In the presence of wounds, podiatry are performing toe pressures and ankle-brachial pressure indexes (ABPIs), requesting Duplex Scans and, most importantly, assimilating this information and making high- level clinical decisions. Non-medical prescribing has provided podiatrists with a competency that has also transformed service provision. These are not exhaustive, but this higher-level decision making and triage model takes time; skills are developed in partnership and mentorship with our other consultant colleagues and clinical trust is embedded within the team over time.
We may have the best services available for patients with diabetes, but what about the patients that have neuropathic wounds for other reasons or vascular compromised limbs with foot wounds that cannot access our excellent diabetes foot services, just because they have not got the diabetes diagnosis? So where do they go for care — are there pathways for these patients? Or should we be ensuring ALL patients that have a foot wound should have access to multidisciplinary care and specialist input? Yes, there
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The Diabetic Foot Journal Vol 21 No 3 2018
EDITORIAL[page2image856]are specific components of diabetes that are unique in wound healing, but if we are honest, there are also many parts of our management plans that are the same, such as debridement, infection management and pressure relief as a start. Medical management would also be beneficial in many of these patients and access for vascular patients to the best vascular and orthopaedic surgeons with the wound care team behind them must surely be in the best interest of the patients?
The Manchester Amputation Reduction Strategy (MARS) spearheaded by Naseer Ahmad, vascular consultant in Manchester Royal Infirmary, is already recognising and prioritising some of the inequalities in patient care. This is not exclusive to patients with diabetes, but data emanating from Manchester state that out of 1,000 lower-extremity amputations, half (500) are avoidable if ulcers as a result of either diabetes, peripheral arterial disease, lymphoedema and venous disease are adequately treated. MARS has also identified that across Greater Manchester, amputation rates already vary significantly from Trust to Trust, but one of the consistencies is that half of lower-extremity amputations are non-diabetes related. This is not stating that all amputations are a result of foot wounds, but there will be non-diabetic foot wounds in there that have not had the same access to multiprofessional care.
Again, let us ask the question; is it time then that we started opening our clinics wider to include patients without diabetes? There is, of course, the potential increase in numbers as a result. But, if we create the infrastructure to support this and integrate community and acute services then this is possible. Salford have pioneered and been running a ‘high-risk foot protection service’ model for many years and have built over the years a fully integrated podiatry service. Patients are able to access wound specialists out with the weekly multidisciplinary foot clinic and there are highly experienced podiatrists working across all areas incorporating community, nursing homes and acute clinics. MDT clinicians are accessible to podiatrists at all other times, including consultant podiatry, vascular, microbiology, orthopaedics and diabetology. Many patients attend MDT for a management plan and this can be implemented safely in other clinics out with the MDT. This is critical for true integration and infrastructure to work. Glasgow and many other
areas have also adopted this approach to care and, like Salford, the patient activity is no less and there are high deprivation areas like any city in the UK.
I know many of you will be reading this and thinking already that your specialty is diabetes and there is no capacity to manage patients without diabetes. Additionally, you may be challenged by funding issues and only diabetes is funded in your area. But, if these are our barriers, should we be changing the dialogue with commissioners and service leads to incorporate how patient profiles have changed and we are faced with a whole other tsunami of wounds with non-diabetes patients? We are optimistic, but we believe all commissioners will listen to the dialogue around amputation rates and how these may be prevented, regardless of aetiology.
In my role as national clinical director (Paul), I recognise the need for podiatrists to diversify their treatment population. There is a real danger podiatrists within the NHS will be pigeonholed purely as managing people with diabetes. This has been a strength in the past for the podiatry profession and made us be seen as more than ‘nail cutters’. It has supported the professional transition to leadership roles and leading services. However, we also recognise that the patient profile and demographic has changed and continues to evolve. As a result, our remit is much wider and should include wider populations, including rheumatology, peripheral arterial disease, connective tissue disorders and other conditions that result in wounding. The full range of podiatric practice including pressure reduction gait analysis and key musculoskeletal skills need to be maintained to optimise outcomes for the population and are still often underutilised.
To summarise, we need to ask ourselves if we are doing patients with foot wounds a disservice by refusing to embrace them into our diabetes foot specialist services. I (Joanne) have asked myself many of the questions, but having recently emigrated to England (all the way from Scotland), I have been significantly challenged with this and have had to broaden my horizons and think outside of the diabetes box. I am also aware that many areas have still not got the diabetes foot infrastructure in place to include foot protection services. No service is perfect, but we believe we should be addressing equitable health care for all and we believe improvements are always attainable.
