A diabetic foot ulcer or lesion has a major effect on a person’s life, affecting their social and work life. There are many opportunities, during the progression from the healthy foot to the foot in crisis, for healthcare professionals to intervene, but this depends on the existence of clear guidelines for good practice, educated staff and people with diabetes, rapid access to expertise, and most importantly, good communication and integration between all involved.
There are clear national guidelines about good practice in annual assessment, and access to emergency care (SIGN, 2001; NICE, 2004), but it is important that these are linked into clear local guidelines about accessing the pathway of care for people with a foot problem. These need to be readily available to everyone caring for people with diabetes, with reliable systems of communication either by fax or telephone. In NHS Birmingham East and North (BEN), we have included the referral pathway in our local diabetes guidelines that are distributed to all practices and district nursing teams.
Healthcare professionals managing the diabetic foot should be competent, and the National Minimum Skills Framework for Commissioning of Foot Care Services for People with Diabetes (Foot in Diabetes UK et al, 2006) covers the skills required for staff involved in the routine assessment and care of feet without ulceration, expert assessment of the at-risk foot, expert assessment and management of foot ulceration or lesion, and the management of a person with a healed ulcer or lesion.
In NHS BEN, we provide a diabetes education programme for all levels of staff, including a study day for healthcare assistants, a diabetes foundation course, and the Warwick University Certificate in Diabetes Care (CIDC). Diabetes podiatry input, providing education in the care of the diabetic foot and recognition of problems and action required, are included in them all. The training of district nurses and healthcare assistants is important as they may be the main carer for people who are housebound, homeless or in residential care, who often have high risk for developing diabetic foot problems. The involvement of podiatrists in the delivery of education also promotes networking with primary care staff.
A practice nurse in particular can have a significant role in identifying problems through the annual foot screening requirements included in the Quality and Outcomes Framework indicators. Depending on the action taken, the nurse seeing the person with the red swollen foot on a Friday evening in the practice can make the difference between still having a viable foot on Monday morning or not. The education works both ways: general podiatrists attend the foundation and some the Warwick CIDC courses to enhance their work with people with diabetes, particularly in the recognition and management of hypoglycaemia, for example.
Even when in hospital, the diabetic foot can be mismanaged if there is a lack of knowledge, poor communication, no guidelines, and absence of inpatient podiatry services. Putting Feet First (NHS Diabetes and Diabetes UK, 2009) has laid out good practice for the management and prevention of diabetic foot disease in hospitals.
Educating people with diabetes, both in self-management skills and how to access help when problems occur, is essential. In NHS BEN, foot advice is incorporated in all our education programmes for people with diabetes. The podiatrist stall at health events is always popular, with practical examples of how to care for feet, including (among other things) examples of “good” and “bad” footwear and distribution of foot files. Written advice is also included in the diabetes handbook available to all people with diabetes who read English or Urdu living in the area.
Linking it all together is our lead diabetes specialist podiatrist, Louise Mitchell, who works in community clinics and the multidisciplinary foot clinic at both hospitals in our area, and who is also involved in the patient and healthcare professional education. Enthusiastic, strong leadership is essential in bringing all the components of care together, to ensure an integrated service.