In the first issue of The Diabetic Foot Journal in 2017 (Vol 20 No 1, 2017), Simon Breed (Director and Co-owner of OmniaMed) wrote a superb editorial outlining and mapping the 20-year history of the journal. As a mere podiatrist and ‘scalpel pusher’, I am not going to try to emulate Simon’s literary prowess, but I do want to recognise that although the Scottish Diabetes Foot Action Group (SDFAG) is not even a teenager yet, it is now approaching double figures and by the end of this year will be 10 years old; this milestone should be recognised.
In 2007, I drove to Ninewells Hospital in Dundee to be interviewed for the post of Diabetes Foot Coordinator for Scotland. This was a new post being created via the Scottish Diabetes Group with the support of the Scottish Government. I was lucky enough to secure the post. The remit of this position was to action the ‘foot part’ of the Scottish Diabetes Action Plan and deliver the recommendations set out in it.
One of the first tasks undertaken by myself and Prof Graham Leese (Chairman of the SDFAG) was to set up a network of likeminded professionals across Scotland who were passionate about the diabetic foot, and dedicated to improving service delivery and outcomes for patients with diabetes.
So the SDFAG was formed … the membership consists of podiatrists, consultant diabetologists, orthotists and patient representatives from of our 14 health boards across Scotland.
What has the SDFAG achieved to date?
Foot screening
One of the first tasks that needed to be addressed was the poor figures associated with diabetes foot screening in Scotland. Diabetes foot screening is widely regarded as the cornerstone for all good diabetes foot care services. In Scotland, in 2008, the delivery of diabetes foot screening was mainly undertaken by podiatrists, with the information being retained within the podiatry notes and, in some cases, being forwarded to the GP practice to enable it to be recorded separately on the GP system. Only 25% of screenings were recorded on the online Scottish Care Information-Diabetes Collaboration (SCI-DC) system.
Given the fact of the sharply rising incidence of diabetes among the population, and no extra podiatry resources being recruited, it was soon recognised that the way foot screening was being delivered was not only a waste of scarce and valuable podiatry resources, but was also unsustainable.
The main challenge when carrying out foot screening is for it to be performed in a standardised, quality assured way, with the information recorded only once and capable of being shared with all healthcare professionals associated with the individual.
In Scotland, diabetes care is delivered in both primary and secondary care. The online SCI-DC system consisted of the Scottish Care Information Network (for use in primary care) and Scottish Care Information Clinical (for use in secondary care). This system has now been superseded by SCI Diabetes, which is a single, integrated system linking primary and secondary care.
The foot screening module on SCI Diabetes is a simple tool which takes into account all the risk factors that predispose a person to develop a foot ulcer, which could lead to amputation. The SCI Diabetes foot screening programme adopts the ethos of risk stratification, which includes examining pulses and nerve function, and also includes other predictors of foot ulceration, such as previous ulceration, significant structural foot deformity, presence of significant callus, and self-care ability, combining them into an integrated foot risk score.
When this information is recorded on the foot screening module within SCI Diabetes, the system automatically calculates the risk status into ‘low’, ‘moderate’, ‘high’ risk of ulceration, ‘in remission’ or ‘active’ foot disease. The Scottish Intercollegiate Guidelines Network (SIGN) guideline 116 advocated the use of the Scottish foot risk score.
In Scotland, a cultural change has been achieved, moving away from the concept of foot examination towards a concept of foot risk stratification. This robust screening programme has built a solid foundation for the rest of the diabetes foot service delivery to be built upon.
As a result of the work carried out by the SDFAG, the target — set out in the Scottish Diabetes Action Plan by the Scottish Government — of 80% of the diabetes population of Scotland being recorded on the SCI system with an allocated risk score, was successfully achieved by the end of 2012.
FRAME website
The transformation in foot screening could only have been achievable in a safe and quality-assured manner if the healthcare practitioners (HCPs) delivering the care had the knowledge and competence to carry out the simple task of foot screening. The online Diabetes Foot Screening training module (www.diabetesframe.org) was developed by the SDFAG in association with the E-Learning Department of Edinburgh University and supported by the Scottish Government. This online resource has allowed all HCPs dealing with people with diabetes to gain skills, knowledge and confidence through interactive learning and to carry out the simple task of diabetes foot screening in a standardised manner. The website has been an outstanding success, with more than 52,000 visits and in excess of 32,000 unique visitors since the NHS Scotland launch. It has recently been adopted by NHS England and there is further interest from abroad in using the system.
Traffic light system
The aforementioned risk stratification was the result of a lot of head scratching by myself in my office, help from the Medical Illustration dept of Hairmyres Hospital and consultation with Prof Leese and the members of the SDFAG. This resulted in the production of our Diabetic Foot Risk Stratification and Triage-Traffic Light System. This has now become one of our most recognisable pieces of work (updated in November 2016). The system now risk stratifies patients into five distinct groups ‘Low’, ‘Moderate’, ‘High’, ‘In Remission’ and ‘Active’. This system is not only very visual and easily understood by patients as it defines what their risk actually means, but also guides service deliverers on the level and kind of service the patient requires according to their risk.
The original Traffic Light System was launched in the Scottish Parliament in May 2008 by the then Minister for Health and Wellbeing Nicola Sturgeon.
Risk-targeted and colour-coordinated leaflets
To coincide with the launch of the Traffic Light System, risk-targeted and colour-coordinated patient information leaflets were also launched. These leaflets were the result of a wide consultation process with members of the SDFAG, patients and other healthcare professionals involved in diabetes care.
We also consulted with the Plain English Campaign to gain Crystal marks for readability and translated them into the most popular five non-English languages. These leaflets, like the traffic light system, have been ‘adopted’ by most other areas of the UK and many other countries around the world. They are currently going through an updating process to not only bring them up to date and to reflect the changes to the Traffic Light System, but also to emphasise in a stronger manner to the ‘At Risk’ groups the increased risk of ulceration and amputation.
Competency framework
The SDFAG recognised there was a need to define the skills and competencies required to treat and manage the diabetic foot. To this end, a subgroup was commissioned by the SDFAG to explore and develop such a Framework which, after a major amount of work and dedication from the group, ultimately led by Dr Joanne McCardle, the Podiatry Integrated Career and Competency Framework for Diabetes Foot Care (TRIEPodD-UK, 2012) was developed in response to the need to identify and standardise clinical competencies in diabetic foot care, from clinical practice through to research and leadership.
It is the first podiatry clinical competency framework underpinned by theoretical components. The framework is the product of collaboration between a number of individuals, professional bodies and organisations with an interest in diabetic foot care. TRIEPodD-UK recognises that podiatrists and podiatry assistants are key HCPs in the delivery, monitoring and design of diabetic foot care services, and are increasingly leading these services in the UK. This framework is an important tool that will facilitate benchmarking of existing skill sets, and guidance for the professional development of podiatrists who are keen to become specialists and service leaders within diabetic foot care. As it spans all levels of practice — from healthcare technicians to consultant practitioners — managers and services providers can use the framework to assess the scope and competency of their workforce. Many of the competencies are transferable, and the framework can be adapted and used by other HCPs involved in diabetic foot care. The overarching goal of the framework is to ensure that people with diabetes have their feet cared for, based on their level of risk, by HCPs with appropriate skill sets, regardless of where in the UK they live.
Ulcer management system
The SDFAG has worked very closely with the SCI-Diabetes team to develop a comprehensive system and clinical record for recording the treatment and management of diabetes foot ulceration. This national system is constantly being refined to make it more user-friendly and effective in the recording of treatment and management episodes.
This system integrates with the screening system and shares necessary information to ensure that the patient’s current status is up to date and accurate. The system is not currently being used by all health boards in Scotland for various reasons, such as its ability to interface with currently used systems, but many of these issues are currently being addressed.
It is hoped that in the future all recording and treatment of diabetic foot ulceration across Scotland will be carried out on this system which will allow accurate and robust data to be collected and published annually in the Scottish Diabetes Survey.
CPR for feet
The SDFAG is currently working on a national initiative called CPR for feet. This initiative is to try and make sure all patients with diabetes who are admitted to hospital have their feet Checked on admission, if they are at risk of developing a foot ulcer their feet are Protected and if they have a current foot ulcer they are Referred appropriately; hence, CPR. The need for this initiative was recognised following an audit carried out by the SDFAG of 1,048 in patients with diabetes. The results of the audit revealed that 2.4% of in patients with diabetes developed a new foot lesion while in hospital. More than half (57%) of inpatients report they had not had their feet checked on admission to hospital. Sixty per cent of those who were discovered to be at risk of developing a foot ulcer did not have any pressure relief in place.
In March 2017, Prof Jason Leitch (National Clinical Director for Healthcare Quality and Strategy) sent a letter to the Chief Executive of each health board throughout Scotland requesting that the CPR initiative was adopted and implemented in all hospitals. This was followed by Shona Robison (Scottish Cabinet Secretary for Health and Sport) announcing in the Scottish Parliament, during a patient safety debate, that CPR for feet should be adopted by every health board across Scotland in a drive to save bed days.
The SDFAG have produced a variety of support materials to assist with the ‘rolling out’ of this initiative which include CPR posters, algorithms to direct ward-based staff in the appropriate pressure relief and mirrored CPR cards to aide with the checking of the most vulnerable areas, especially the heels. An online awareness and training module called ‘CPR for diabetic feet’ is available to NHS staff in Scotland on our LearnPro system, which is an online learning platform containing all e-learning for NHS staff in Scotland.
Future direction
With the unrelenting march in the rise of the diabetes population, the SDFAG is trying to help and support NHS boards throughout Scotland with initiatives in an effort to help ‘future proof’ their services to enable them to continue to deliver quality treatment and management plans effectively. In 2017-2018, the SDFAG will produce a Service Specification document outlining how and to what level diabetes foot services should ideally be delivered. This should allow each health board to ‘map’ their services according to the document, highlight areas of best practice, but probably more importantly, highlight areas where standards in service delivery are not meeting the recommended standard and hopefully concentrate on addressing these.
Podiatry resources are not being increased in line with the rise in this very vulnerable and resource-consuming group of patients, which is the reason why we, as a profession, have to look at how we deliver our services to ensure our valuable time is appropriately utilised in a manner that best benefits our patients and their needs.
