Traditional teaching emphasises the importance of good podiatry care for every person with diabetes. However, in Australia, implementation of this dogma is difficult for many reasons. Our healthcare system is funded at both a national and a state government level. Faced with an ever increasing number of people with diabetes there is understandably a considerable degree of reluctance by either to tackle this area.
Podiatry treatment is not covered by our national health insurance system and even for people with additional private health insurance, very few are in the higher categories that reimburse foot care. Likewise, podiatry services in the state-run public hospitals tend to be very limited. The problem is confounded by the difficulty in recruiting podiatrists to work in the public health system as remuneration is far higher in private practice. These factors combine to bring about the situation of most people with diabetes in Australia not being able to access any form of podiatry care. Furthermore, Australia is a large country and there are very few rural podiatry services which are experienced in looking after acute diabetic foot problems. Much is needed to be done to rationalise and to improve the standard of diabetes foot care in Australia.
Diabetic foot programmes
On pages 172-76 of this issue, we describe a Priority Healthcare Diabetes Amputation Prevention Program that reorganised and restructured acute foot care services in our local area so that scarce resources are best utilised. In addition, the Royal Prince Alfred Hospital Diabetes Centre has developed a Telemedicine Footcare Program that provides training and support for rural healthcare professionals to enable them to manage acute foot problems locally. The essential components of this programme are:
- Involvement of rural sites which serve a population of approximately 50 000–100 000 people.
- A 1-week training programme for each site.
- Imaging of the patients’ foot problems by standardised digital camera photography.
- Transmission of the images by email attachment to facilitate discussion of management over the telephone at an appointed time.
High-risk foot clinics were created along this line at seven rural sites in the state of New South Wales. This telemedicine programme allows people to be treated in their rural centres, thus reducing stress and costs of repeated travelling to the city. By virtue of the case conferencing, it also provides a forum for continuing education of rural healthcare professionals.
Hopefully, these programmes will ultimately reduce the rate of diabetes-related amputations. It is noteworthy that both programmes target people with diabetes and active foot ulceration and/or infection. In other words the focus is on those at extremely high risk of imminent amputation. Some people argue that this is a retrograde step and money is better spent on preventing people from getting to this stage. Obviously, the optimal balance of prevention versus treatment is an important question of philosophy. Both of our programmes are funded by the New South Wales state government. A third programme, the diabetes foot care telephone hotline, is supported by the national government.
Conclusion
It is clear that the government recognises the need to solve the problems of diabetic foot disease but have to do so within available resources. Our approach is a pragmatic one of providing care according to risk, thus containing the cost to a level that governments can be realistically expected to fund.
