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A new campaign to put feet first

Despite its clinical burden and cost, disease of the foot has been the most neglected complication of diabetes and this is evidenced by the widespread differences in the outcome of management. In an attempt to address this problem, a new integrated care pathway has been launched by Diabetes UK for the management of people whose feet are at risk because of diabetes, and encompasses prevention, treatment and long-term care. This pathway hinges on heightened professional awareness of the size of the problem, and prompt and effective communication, leading to care for individuals that crosses conventional professional boundaries. 

Background
Disease of the foot in diabetes does not rank high in the minds of non-specialist doctors and nurses. One reason is that few have had any specific training in the field and therefore many have restricted insight into what is involved in both assessment and treatment. When this is combined with a professional reluctance to look at feet (often matched by an individual’s reluctance to have their feet examined), it is hardly surprising that the diabetic foot tends not to be well managed. A rash of guidelines have been published in an attempt to grapple with this situation, but in the current top-down culture that prevails in the NHS, many professionals feel that they have been exposed to more guidelines than they can currently handle and have adopted a coping strategy which is largely based on putting a telescope to a blind eye. 

A Nelson-like approach is, however, inappropriate in a condition such as the diabetic foot – which can threaten both limb and life, and which needs early, expert assessment. The risk of missing major treatable disease is quite considerable, and there is evidence that ulcer duration at the time of first referral correlates directly with healing time (Margolis et al, 2002; Ince et al, 2007). 

A person with diabetes who develops an inflamed foot needs more than the repeated courses of flucloxacillin that are as much as many will be offered; the mistaken diagnosis of infection is commonplace in limb-threatening conditions such as critical limb ischaemia, or the acute Charcot foot. There is one simple maxim for any healthcare professionals who are uncertain about the speed with which a person with foot disease should be referred for expert advice. They should ask themselves what they would do if the individual was their own mother or father: they would pick up the phone.

New integrated care pathway
The need for a speedy referral to a specialist team has been encapsulated in the new integrated care pathway released by Diabetes UK at their Annual Professional Conference on 7 March 2012, under the banner of Putting Feet First (Diabetes UK, 2012). The pathway collates guidance from the four key documents that preceded it: the NICE (2004) clinical guideline (CG10), Diabetes UK documents Putting Feet First (Diabetes UK et al, 2009) and the National Minimum Skills Framework (Diabetes UK et al, 2011), and the latest NICE  (2011) guidance on the management of the inpatient diabetic foot (CG119).

Despite the wide brief of the pathway – which has been endorsed by NHS Diabetes, the Society of Chiropodists and Podiatrists, Foot in Diabetes UK, the Association of British Clinical Diabetologists, the Scottish Diabetes Foot Action Group, the Welsh Endocrine and Diabetes Society and the Primary Care Diabetes Society – its entire content is contained on only two sheets (click here). Diabetes UK has also produced patient information on footcare as part of this campaign (visit http://bit.ly/yhXxHu). 

Together, these documents summarise the care that every person with diabetes should expect with regard to the prevention and management of foot complications, including ulceration, infection, ischaemia and the acute Charcot foot, but not painful neuropathy – for which separate NICE (2010) guidance exists (CG96). The pathway is broken down into three parts: (i) prevention of active disease of the foot in those at increased risk; (ii) treatment of active disease of the foot; and (iii) management of the person whose foot disease has been treated.

Part 1: Prevention: Referral to the Foot Protection Team for people at increased risk
All people with diabetes should already expect to have their feet examined by a competent practitioner each year (NICE, 2004), but the change to Quality and Outcomes Framework (QOF) indicators from April 2011 now also requires that their individual risk of future ulceration is documented (British Medical Association and NHS Employers, 2011). Some commentators regretted that the 2011 changes to QOF did not include a requirement to refer those found to be at increased risk of ulceration (Gadsby, 2011). Although this is indeed unfortunate, it should make little difference in practice for three reasons: (i) the requirement to refer people at increased risk is already covered by preexisting NICE guidance (NICE, 2004); (ii) people with diabetes will be increasingly aware that this is their right; and (iii) healthcare professionals who fail to refer risk litigation should things go badly wrong.

Podiatrists providing care under the new “any qualified provider” (AQP) scheme will not – in the majority of cases – be sufficiently skilled for care of the diabetic foot at increased risk of ulceration, which is reflected in the AQP Podiatry Service Specification: “[this specification covers] elements of core podiatry defined as the scope of practice obtained at graduation … excluding … people with diabetes assessed under NICE CG 10 as [being] at increased risk or above” (Department of Health, 2012).

What, some may ask, should general practice staff do if there is no Foot Protection Team in their area? The answer is simple: there should be one, and they should be aware of how to contact that team. A Foot Protection Team should be in the portfolio of services provided by those who are commissioned to provide specialist diabetes care, and it is the responsibility of commissioners to make sure it is available.

Part 2: Active disease: The key role played by commissioning in implementing the pathway 
Commissioners also have to ensure that those providing specialist diabetes care have access to an established multidisciplinary footcare team (MDFT), as outlined in the National Minimum Skills Framework (Diabetes UK et al, 2011) and NICE (2011) guidance (CG119; 2011). The creation of such teams has previously been shown to reduce the incidence of diabetes-related amputation to between a fifth and a quarter of its former level (Canavan et al, 2008; Krishnan et al, 2008). Anyone who presents with newly occurring, or newly deteriorating, disease of the foot should now expect to be referred to a member of the MDFT within 24 hours of being seen. In some cases this will be inappropriate – especially in older, frailer people, and those with multiple disabilities. However, prompt referral should be the default.

Part 3: Long-term management
The third and last component to the pathway relates to long-term management of the person with foot disease, even after healing. The person with diabetes who has had a foot ulcer faces two major threats. The first is the onset of new ulceration, which occurs in up to 40% at 12 months, even when specialist preventative footwear, podiatry care and education are provided (Lincoln et al, 2008). The second is early cardiovascular mortality; mean 5-year survival of people presenting with a new foot ulcer is only 50% – the same as with carcinoma of the colon, and three times worse than with carcinoma of the breast (Robbins et al, 2008) – and there is evidence that mortality risk in this population may be improved by aggressive attempts to reduce cardiovascular risk (Young et al, 2008).

This increased mortality risk is not limited to those with peripheral arterial disease; there is an average 14-year reduction in life expectancy among those with a history of diabetic foot ulceration, even in the relatively younger population with a neuropathic foot ulcer (van Baal et al, 2010). This means that the person who has had an episode of foot disease should remain under continued close surveillance (in community or secondary care, or both).

Conclusion
It is obvious that the needs of the person with diabetes who has (or is at risk of) foot disease not only are complex but have been relatively neglected in the past. This may be one reason for the enormous variation in outcome that exists throughout England, with the incidence of major amputation currently varying 10-fold between PCTs, from the lowest to the highest (Holman et al, 2012). Such variation probably results mainly from variation in the provision of care and would not be tolerated in any other condition, especially not in one associated with such high mortality.

Despite its clinical burden and cost, disease of the foot has been the most neglected complication of diabetes and this is evidenced by the widespread differences in the outcome of management. In an attempt to address this problem, a new integrated care pathway has been launched by Diabetes UK for the management of people whose feet are at risk because of diabetes, and encompasses prevention, treatment and long-term care. This pathway hinges on heightened professional awareness of the size of the problem, and prompt and effective communication, leading to care for individuals that crosses conventional professional boundaries. 

Background
Disease of the foot in diabetes does not rank high in the minds of non-specialist doctors and nurses. One reason is that few have had any specific training in the field and therefore many have restricted insight into what is involved in both assessment and treatment. When this is combined with a professional reluctance to look at feet (often matched by an individual’s reluctance to have their feet examined), it is hardly surprising that the diabetic foot tends not to be well managed. A rash of guidelines have been published in an attempt to grapple with this situation, but in the current top-down culture that prevails in the NHS, many professionals feel that they have been exposed to more guidelines than they can currently handle and have adopted a coping strategy which is largely based on putting a telescope to a blind eye. 

A Nelson-like approach is, however, inappropriate in a condition such as the diabetic foot – which can threaten both limb and life, and which needs early, expert assessment. The risk of missing major treatable disease is quite considerable, and there is evidence that ulcer duration at the time of first referral correlates directly with healing time (Margolis et al, 2002; Ince et al, 2007). 

A person with diabetes who develops an inflamed foot needs more than the repeated courses of flucloxacillin that are as much as many will be offered; the mistaken diagnosis of infection is commonplace in limb-threatening conditions such as critical limb ischaemia, or the acute Charcot foot. There is one simple maxim for any healthcare professionals who are uncertain about the speed with which a person with foot disease should be referred for expert advice. They should ask themselves what they would do if the individual was their own mother or father: they would pick up the phone.

New integrated care pathway
The need for a speedy referral to a specialist team has been encapsulated in the new integrated care pathway released by Diabetes UK at their Annual Professional Conference on 7 March 2012, under the banner of Putting Feet First (Diabetes UK, 2012). The pathway collates guidance from the four key documents that preceded it: the NICE (2004) clinical guideline (CG10), Diabetes UK documents Putting Feet First (Diabetes UK et al, 2009) and the National Minimum Skills Framework (Diabetes UK et al, 2011), and the latest NICE  (2011) guidance on the management of the inpatient diabetic foot (CG119).

Despite the wide brief of the pathway – which has been endorsed by NHS Diabetes, the Society of Chiropodists and Podiatrists, Foot in Diabetes UK, the Association of British Clinical Diabetologists, the Scottish Diabetes Foot Action Group, the Welsh Endocrine and Diabetes Society and the Primary Care Diabetes Society – its entire content is contained on only two sheets (click here). Diabetes UK has also produced patient information on footcare as part of this campaign (visit http://bit.ly/yhXxHu). 

Together, these documents summarise the care that every person with diabetes should expect with regard to the prevention and management of foot complications, including ulceration, infection, ischaemia and the acute Charcot foot, but not painful neuropathy – for which separate NICE (2010) guidance exists (CG96). The pathway is broken down into three parts: (i) prevention of active disease of the foot in those at increased risk; (ii) treatment of active disease of the foot; and (iii) management of the person whose foot disease has been treated.

Part 1: Prevention: Referral to the Foot Protection Team for people at increased risk
All people with diabetes should already expect to have their feet examined by a competent practitioner each year (NICE, 2004), but the change to Quality and Outcomes Framework (QOF) indicators from April 2011 now also requires that their individual risk of future ulceration is documented (British Medical Association and NHS Employers, 2011). Some commentators regretted that the 2011 changes to QOF did not include a requirement to refer those found to be at increased risk of ulceration (Gadsby, 2011). Although this is indeed unfortunate, it should make little difference in practice for three reasons: (i) the requirement to refer people at increased risk is already covered by preexisting NICE guidance (NICE, 2004); (ii) people with diabetes will be increasingly aware that this is their right; and (iii) healthcare professionals who fail to refer risk litigation should things go badly wrong.

Podiatrists providing care under the new “any qualified provider” (AQP) scheme will not – in the majority of cases – be sufficiently skilled for care of the diabetic foot at increased risk of ulceration, which is reflected in the AQP Podiatry Service Specification: “[this specification covers] elements of core podiatry defined as the scope of practice obtained at graduation … excluding … people with diabetes assessed under NICE CG 10 as [being] at increased risk or above” (Department of Health, 2012).

What, some may ask, should general practice staff do if there is no Foot Protection Team in their area? The answer is simple: there should be one, and they should be aware of how to contact that team. A Foot Protection Team should be in the portfolio of services provided by those who are commissioned to provide specialist diabetes care, and it is the responsibility of commissioners to make sure it is available.

Part 2: Active disease: The key role played by commissioning in implementing the pathway 
Commissioners also have to ensure that those providing specialist diabetes care have access to an established multidisciplinary footcare team (MDFT), as outlined in the National Minimum Skills Framework (Diabetes UK et al, 2011) and NICE (2011) guidance (CG119; 2011). The creation of such teams has previously been shown to reduce the incidence of diabetes-related amputation to between a fifth and a quarter of its former level (Canavan et al, 2008; Krishnan et al, 2008). Anyone who presents with newly occurring, or newly deteriorating, disease of the foot should now expect to be referred to a member of the MDFT within 24 hours of being seen. In some cases this will be inappropriate – especially in older, frailer people, and those with multiple disabilities. However, prompt referral should be the default.

Part 3: Long-term management
The third and last component to the pathway relates to long-term management of the person with foot disease, even after healing. The person with diabetes who has had a foot ulcer faces two major threats. The first is the onset of new ulceration, which occurs in up to 40% at 12 months, even when specialist preventative footwear, podiatry care and education are provided (Lincoln et al, 2008). The second is early cardiovascular mortality; mean 5-year survival of people presenting with a new foot ulcer is only 50% – the same as with carcinoma of the colon, and three times worse than with carcinoma of the breast (Robbins et al, 2008) – and there is evidence that mortality risk in this population may be improved by aggressive attempts to reduce cardiovascular risk (Young et al, 2008).

This increased mortality risk is not limited to those with peripheral arterial disease; there is an average 14-year reduction in life expectancy among those with a history of diabetic foot ulceration, even in the relatively younger population with a neuropathic foot ulcer (van Baal et al, 2010). This means that the person who has had an episode of foot disease should remain under continued close surveillance (in community or secondary care, or both).

Conclusion
It is obvious that the needs of the person with diabetes who has (or is at risk of) foot disease not only are complex but have been relatively neglected in the past. This may be one reason for the enormous variation in outcome that exists throughout England, with the incidence of major amputation currently varying 10-fold between PCTs, from the lowest to the highest (Holman et al, 2012). Such variation probably results mainly from variation in the provision of care and would not be tolerated in any other condition, especially not in one associated with such high mortality.

British Medical Association, NHS Employers (2011) Quality and Outcomes Framework Guidance for GMS Contract 2011/12. NHS Employers, London. Available at: http://bit.ly/iIAWlP (accessed 13.03.2012) 
Canavan RJ, Unwin NC, Kelly WF, Connolly VM (2008) Diabetes Care 31: 459–63
Department of Health (2012) Podiatry. Any Qualified Provider Implementation Pack. DH, London. Available at: http://bit.ly/I9bs3A (accessed 19.04.12) 
Diabetes UK, Foot in Diabetes UK, NHS Diabetes et al (2009) Putting Feet First. Diabetes UK, London. Available at: http://bit.ly/nOsPlK (accessed 13.03.2012)
Diabetes UK, Foot in Diabetes UK, NHS Diabetes et al (2011) Putting Feet First: National Minimum Skills Framework. Diabetes UK, London. Available at: http://bit.ly/ma8fbq (accessed 13.03.2012)
Diabetes UK (2012) Integrated Footcare Pathway. Diabetes UK, London. Available at: http://bit.ly/A6yqDf (accessed 13.03.2012)
Gadsby R (2011) Diabetes & Primary Care 13: 140
Holman N, Young RJ, Jeffcoate WJ (2012) Diabetologia Mar 8 [Epub ahead of print]
Ince P, Game FL, Jeffcoate WJ (2007) Diabetes Care 30: 660–3
Krishnan S, Nash F, Baker N et al (2008) Diabetes Care 31: 99–101
Lincoln NB, Radford KA, Game FL, Jeffcoate WJ (2008) Diabetologia 51: 1954–61
Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA (2002) Diabetes Care 25: 1835–9
NICE (2004) Type 2 Diabetes: Prevention and Management of Foot Problems. CG10. NICE, London. Available at: http://bit.ly/k6lZmi (accessed 13.03.2012)
NICE (2010) Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-Specialist Settings. CG96. NICE, London. Available at: http://bit.ly/zRrcBM (accessed 13.03.2012)
NICE (2011) Diabetic Foot Problems: Inpatient Management of Diabetic Foot Problems. CG119. NICE, London. Available at: http://bit.ly/ndmLJA (accessed 13.03.2012)
Robbins JM, Strauss G, Aron D et al (2008) J Am Podiatr Med Assoc 98: 489–93
van Baal J, Hubbard R, Game F, Jeffcoate W (2010) Diabetes Care 33: 1086–9
Young MJ, McCardle JE, Randall LE, Barclay JI (2008) Diabetes Care 31: 2143–7

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