Are you putting your best foot forward?

Following the news headlines on diabetes amputations in March (Brimelow, 2012), it is disappointing to learn that the amputation rates for people with diabetes are 10 times higher in some parts of England than in others, according to a newly published study (Holman et al, 2012). Another postcode lottery! 

The study’s authors say the figures highlight the importance of ensuring the right specialist care is available. The study, published in Diabetologia, compared lower-leg amputation rates for primary care trusts across England over 3 years (Holman et al, 2012). The paper concluded that, compared with the general population, people with diabetes were over 20 times more likely to have an amputation. It reports a huge variation in the rates of both major (above the ankle) and minor amputations for people with diabetes, both types 1 and 2. For major amputations these range from just over two to 22 for every 10 000 patients each year. In England every year there are about 6000 diabetes-related amputations, many of which could have been prevented by improved education and access to specialist foot teams (Holman et al, 2012).

We all know that the foot examination is an integral part of the annual review, but one of the main authors, Professor William Jeffcoate, a consultant diabetologist at Nottingham City Hospital, thinks the problem lies in the way services are organised.

He told BBC News: “Foot disease is very complicated and a single professional hasn’t necessarily got the skills to manage every aspect of it. That’s why I believe that only if you can gather a multidisciplinary team and make sure that people have rapid access to assessment by such a team, it’s only in that way that we think you can provide the best service.” 

Unfortunately, many hospitals in England still do not have foot multidisciplinary teams (MDTs) – these include podiatrists, surgeons and specialist nurses. 

The new findings complement previous research suggesting that the majority of diabetes-related amputations could be avoided. The publication of this study coincided with new NHS Diabetes figures on the annual cost of foot ulcers and amputations in England (Kerr, 2012). The report puts the annual cost of diabetes-related amputations at £120 million. 

NHS Diabetes sets out the shocking cost to both patients and the NHS of poor-quality diabetic foot care. The report shows that each year around £650 million (or £1 in every £150 the NHS spends) is spent on foot ulcers or amputations. It also highlights the devastating consequences of foot problems in people with diabetes. Around 7% of people with diabetes currently have, or have had, a foot ulcer, which can lead to amputation. Half of those who have a major amputation die within 2 years; many of these amputations could be avoided with the right care.

NHS Diabetes is calling on the NHS to set up specialist diabetes foot care MDTs as a matter of urgency. Besides the benefits such teams bring to patient care, MDTs can generate savings for the NHS that substantially outweigh the cost of the team. One example shows how a local hospital team costing around £33 000 a year generated savings of almost £250 000 a year for the local trust. Most importantly, MDTs have been shown to reduce amputations by up to two-thirds (Kerr, 2012).

On the launch of the report, Anna Morton, director of NHS Diabetes said: “It is not acceptable that thousands of people with diabetes lose a limb each year because of poor quality care.”

Diabetes UK has also launched a campaign to bring an end to the “national disgrace” of thousands of preventable amputations in people with diabetes (see page 86). The Putting Feet First campaign highlights the fact that across the UK people with diabetes are 30 times more likely to have a lower limb amputation than the general population. With correct foot care and education, many cases of limb loss can be avoided. 

How is your area performing?