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Improving diabetic foot services in Scotland

Foot ulceration is the most common reason for people with diabetes to be admitted to hospital in the UK (Boulton et al, 2005). If an ulcer becomes infected it can lead to the surrounding area becoming gangrenous and may necessitate amputation. People with diabetes are 15 times more likely to require an amputation than people without the condition (NICE, 2004). In addition to the severe impact on individuals, the impact of these complications will inevitably lead to a significant financial burden on NHS services.

In the past, diabetic foot care in Scotland has had insufficient ‘champions’ which has resulted in vastly differing levels of service being provided throughout the country. Consultants, podiatrists and other allied health professionals are spending an increasing amount of time ‘at the coal face’ due to the increasing burdens being placed on an already stretched service. This results in committed and enthusiastic practitioners only able to ‘fire fight’ their very demanding and busy clinical commitments. Such a situation means they are unable to take a step back and look at the overall service being provided and how effective and efficient the service being provided is.

Diabetes policy in Scotland has been shaped by the Scottish Diabetes Framework (Scottish Executive Health Department [SEHD], 2002) which was published following a commitment in the White Paper, ‘Our National Health’ (SEHD, 2000). A review of the Scottish Diabetes Framework recommended that more attention should be paid to foot care (SEHD, 2004). This recommendation was reflected in the Scottish Diabetes Framework Action Plan (SEHD, 2006) which included a commitment to ‘support initiatives to ensure that all patients receive regular foot screening and that access to specialist foot care services is readily available to those patients who require such input.’

The cornerstone of good diabetic foot care is screening with clearly defined pathways of care according to risk level. For this to be carried out efficiently in Scotland there has to be a fundamental change in how this is delivered.

At present, most routine foot screening is carried out by skilled podiatrists. This inevitably reduces the time available for them to treat people who are at high risk of developing an ulcer or those with existing ulcers. With appropriate training and support all members of the healthcare team could safely undertake routine screening with the implementation of a nationally accredited training programme to teach both theory and competences in basic foot screening techniques. Although there are examples of good practice in the efficient delivery of foot screening throughout the country, there is currently no leadership to promote and co-ordinate the implementation of these practices nationally. Improving the implementation of foot screening and delivery of specialised services is crucial if access to specialist foot care services is to be improved.

A new initiative in Scotland provides an opportunity to address these issues and to take forward these initiatives. A Diabetes Foot Advisory Group has been established under the auspices of a national co-ordinating committee, the Scottish Diabetes Group, and the author has been appointed on a 2-year secondment as the National Diabetes Foot Co-ordinator for Scotland.

The national co-ordinator is required to support, encourage and help drive forward initiatives to increase the capacity and quality of foot care services in Scotland, which will include the undertaking of a survey of the availability of specialist foot services in Scotland to identify current service patterns and highlight examples of good practice.

The initiative will also ensure the appropriate stratification of foot risk in all people with diabetes using the online Scottish Care Information – Diabetes Collaboration (SCI-DC) foot screening tool. Recent research has validated the screening tool and has been shown to improve diabetic foot stratification (Leese et al, 2006; McCardle and Young, 2006).

This work will be carried out in consultation with the Scottish Diabetes Specialist Podiatrists Group, Foot in Diabetes UK (FDUK), all interested healthcare specialists and NHS Quality Improvement Scotland. The project will also contribute to the forthcoming revision of the Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the management of diabetes.

Foot ulceration is the most common reason for people with diabetes to be admitted to hospital in the UK (Boulton et al, 2005). If an ulcer becomes infected it can lead to the surrounding area becoming gangrenous and may necessitate amputation. People with diabetes are 15 times more likely to require an amputation than people without the condition (NICE, 2004). In addition to the severe impact on individuals, the impact of these complications will inevitably lead to a significant financial burden on NHS services.

In the past, diabetic foot care in Scotland has had insufficient ‘champions’ which has resulted in vastly differing levels of service being provided throughout the country. Consultants, podiatrists and other allied health professionals are spending an increasing amount of time ‘at the coal face’ due to the increasing burdens being placed on an already stretched service. This results in committed and enthusiastic practitioners only able to ‘fire fight’ their very demanding and busy clinical commitments. Such a situation means they are unable to take a step back and look at the overall service being provided and how effective and efficient the service being provided is.

Diabetes policy in Scotland has been shaped by the Scottish Diabetes Framework (Scottish Executive Health Department [SEHD], 2002) which was published following a commitment in the White Paper, ‘Our National Health’ (SEHD, 2000). A review of the Scottish Diabetes Framework recommended that more attention should be paid to foot care (SEHD, 2004). This recommendation was reflected in the Scottish Diabetes Framework Action Plan (SEHD, 2006) which included a commitment to ‘support initiatives to ensure that all patients receive regular foot screening and that access to specialist foot care services is readily available to those patients who require such input.’

The cornerstone of good diabetic foot care is screening with clearly defined pathways of care according to risk level. For this to be carried out efficiently in Scotland there has to be a fundamental change in how this is delivered.

At present, most routine foot screening is carried out by skilled podiatrists. This inevitably reduces the time available for them to treat people who are at high risk of developing an ulcer or those with existing ulcers. With appropriate training and support all members of the healthcare team could safely undertake routine screening with the implementation of a nationally accredited training programme to teach both theory and competences in basic foot screening techniques. Although there are examples of good practice in the efficient delivery of foot screening throughout the country, there is currently no leadership to promote and co-ordinate the implementation of these practices nationally. Improving the implementation of foot screening and delivery of specialised services is crucial if access to specialist foot care services is to be improved.

A new initiative in Scotland provides an opportunity to address these issues and to take forward these initiatives. A Diabetes Foot Advisory Group has been established under the auspices of a national co-ordinating committee, the Scottish Diabetes Group, and the author has been appointed on a 2-year secondment as the National Diabetes Foot Co-ordinator for Scotland.

The national co-ordinator is required to support, encourage and help drive forward initiatives to increase the capacity and quality of foot care services in Scotland, which will include the undertaking of a survey of the availability of specialist foot services in Scotland to identify current service patterns and highlight examples of good practice.

The initiative will also ensure the appropriate stratification of foot risk in all people with diabetes using the online Scottish Care Information – Diabetes Collaboration (SCI-DC) foot screening tool. Recent research has validated the screening tool and has been shown to improve diabetic foot stratification (Leese et al, 2006; McCardle and Young, 2006).

This work will be carried out in consultation with the Scottish Diabetes Specialist Podiatrists Group, Foot in Diabetes UK (FDUK), all interested healthcare specialists and NHS Quality Improvement Scotland. The project will also contribute to the forthcoming revision of the Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the management of diabetes.

Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J (2005) The global burden of diabetic foot disease. Lancet 366: 1719–24
Leese GP, Reid F, Green V (2006) Stratification of foot ulcer risk in patients with diabetes: a population-based study.International Journal of Clinical Practice 60: 541–5
McCardle J, Young MJ (2006) The SCI-DC form: Does its use improve diabetic foot stratification? The Diabetic Foot 9: 25–32
NICE (2004) Type 2 diabetes: Prevention and management of foot problems. NICE, London
Scottish Executive Health Department (SEHD; 2000) Our National Health: a plan for action, a plan for change. SEHD, Edinburgh
SEHD (2002) Scottish Diabetes Framework. SEHD, Edinburgh
SEHD (2004) Diabetes In Scotland: Current Challenges And Future Opportunities. SEHD, Edinburgh
SEHD (2006) Scottish Diabetes Framework: Action Plan. SEHD, Edinburgh

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