The conference was opened by Chair, Louise Stuart MBE (Consultant Podiatrist, Manchester), who said that the programme was designed to challenge delegates to question whether they are delivering best practice diabetic foot care.
In the first session, Dr Mike Edmonds (Consultant Physician, London) presented a series of complex clinical cases. Dr Edmonds reminded delegates that it is estimated that 80% of diabetic foot-related amputations are preventable, and that the cornerstone of this prevention is the multidisciplinary team (MDT). The cases presented challenged the delegates, using digital keypads to vote on what their clinical decision making would be, to interpret X-rays, microbiology, blood results and dermatological conditions.
Jacqui Fletcher (Honorary Fellow, NICE and Principal Lecturer, University of Hertfordshire) next investigated the question of what can we learn from past mistakes to prevent future amputations? She described the use of “critical event analysis”, or “root cause analysis” (RCA) as it is also known. The process, Jacqui said, tries to reduce variation in performance, and by asking a series of questions about why poor performance has occurred attempts to unearth the root cause of an a poor outcome or critical event. Only 10% of the delegates indicated that they had been involved in an RCA, but Jacqui stressed that RCAs will become a part of practice for every clinician in the NHS in the near future.
In the next two sessions, Sarah Pritchard (Clinical Negligence Barrister) and Lindsay Wise (Partner, Irwin Mitchell Law Firm) discussed litigation and the diabetic foot – and actions and precautions to protect yourself against litigation. Sarah stressed that the number of claims against clinicians managing the diabetic foot are increasing dramatically, and that the sources of litigation are primarily adverse outcomes and patient expectations not being met. Sarah provided detailed notes to the delegates on the process of litigation in clinical negligence cases, but said that they are drawn out and distressing for both sides. Lindsay reported that the professional, their reputation, skills and competencies, will be scrutinised in such cases, and that clinical notes are central to establishing the case. She encouraged the delegates to keep clear, detailed and up-to-date patient notes. These should include notes on questions raised by the patient, and how they were addressed, and advice given. Effective, honest communication with patients – along with provable skills and competencies in your profession – are the best defences against litigation.
After lunch, Louise Stuart and Paul Chadwick (Principal Podiatrist, Salford) discussed the foot protection team’s (FPT’s) role in the management of the diabetic foot. Louise said that the definition of an FPT has been under confusion for some time – despite the fact it was first described in the 2004 NICE guidance on diabetic foot care, but that the concept has been reconfirmed by the recent NICE Quality Statement 10: “People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours.”
The audience was asked whether they had, or had access to, an FPT at their place of work and – using the digital keypads to vote – 81% said that they did, and an even greater number (96%) said that they had, or had access to, an MDT. Despite this, only 62% believed the service in their area provided seamless care between community and hospital diabetic foot care, and only 37% believed that their service would be able to meet Quality Standard 10.
Paul and Louise stressed that we now – between the Quality and Outcomes Framework (British Medical Association, NHS Employers, 2011), the National Minimum Skills Framework (Diabetes UK et al, 2011) and the two new pieces of NICE (2011a, b) guidance – have the documentation to develop integrated pathways for diabetic foot care.
In the final session of the day, a debate was held on the topic: “This House believes that major lower-limb amputation is always a marker of poor care”. Mr Cliff Shearman (Consultant Vascular Surgeon, Southampton) took the for position and presented data showing that during the 5-year period (2003–2008), 25578 major amputations occurred in the UK and 44% of them were diabetes-related; stunningly, more than 56% had received no prior clinical intervention (Moxey et al, 2010). This cannot, Mr Shearman said, be considered good care. Next, Miss Stella Vig (Consultant Vascular Surgeon, Croydon) took the contra position and presented data on a number of examples in which amputation is considered best practice, and the advanced state of tissue destruction in some cases of ulceration makes the removal of the limb a decision that will save the life.
