New governance for the diabetic foot: QOF and NICE

The new QOF indicators introduced on 1 April 2011 were only published in March 2011 (British Medical Association and NHS Employers, 2011), which is considerably later than usual. A new indicator DM29 has been introduced:

“The percentage of patients with diabetes with a record of foot examination and risk classification: 1. Low risk (normal sensation and palpable pulses); 2. Increased risk (neuropathy or absent pulses); 3. High risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcers); 4. Ulcerated foot within the preceding 15 months.”

The minimum threshold to earn the available 4 points is 40% with the maximum 90%.

Indicator DM10, which is the percentage of people with diabetes with a record of neuropathy testing in the previous 15 months, and which has a minimal threshold of 25% and maximum threshold of 90% to earn the full 3 points, is retained; but indicator DM9, which related to the presence or absence of peripheral pulses and which was worth 3 points, seems to have been “retired”. This means that the total points for diabetic foot care have risen from 6 to 7 for the 2011/12 period.

The new indicator requires the practice to allocate a risk category based on foot inspection and foot examination for pulses and neuropathy, which is a step forward from just having to feel the foot pulses and check for neuropathy. It does not, however, require the practice to make the appropriate referral to the local foot protection clinic based on the level of risk. Referral to appropriately trained and resourced foot protection clinics is the intervention that reduces ulceration risk. In my opinion, an indicator that helps to achieve such a referral should be introduced.

NICE guideline
NICE published clinical guideline 119 in March 2011 on the inpatient management of diabetic foot problems (NICE, 2011). The full guideline gives an up-to-date evidence assessment of all aspects of inpatient diabetic foot care. The quick reference guide summarises the evidence into a helpful care pathway and lists 40 recommendations. Some of these are listed as key priorities for implementation. They include:

• Each hospital should have a care pathway for patients with diabetic foot problems who require inpatient care.
• The multidisciplinary foot care team should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist, and a tissue viability nurse. The team should have access to other specialised services as needed.
• There should be a named contact to follow the individual through the inpatient care pathway and be responsible for offering them information about their diagnosis, treatment, care and what support they can expect, and information about discharge planning and follow-up.
• There is a recommendation that stresses the importance of the detection of diabetic foot problems in people with diabetes who are already in hospital and urgent referral to the multidisciplinary foot team within 24 hours if a foot problem is found.
• Each hospital should have antibiotic guidelines for the management of diabetic foot infections.
• When choosing wound dressings, the foot team should take into account their clinical assessment of the wound, patient preference and the clinical circumstance, and should use wound dressings with the lowest acquisition cost.

The guideline offers a very clear and concise account of best practice in the detection and care of people with diabetic foot problems in hospital. The recommendations for implementation, if enacted, will improve care, increase the number of foot ulcers that heal up and so reduce the number of foot and lower limb amputations across the UK.

Together, the new QOF indicator and the new inpatient guideline give further impetus to the detection and appropriate management of diabetic foot problems.