Reflecting on the efforts underway throughout the UK to improve diabetic foot services and reduce the incidence of diabetes-related amputations, I am struck by the parallels between the various campaigns.
The Scottish Foot Action Group has led the way with the launch of the CPR for Feet programme (“Check, Protect, Refer”). At the launch, Michael Matheson, Scottish Minister for Public Health, declared the Scottish government’s commitment to the programme that will ensure a foot care check in hospital for everyone with a diagnosis of diabetes to determine risk, and provide information and support (Scottish Government, 2013).
In England, we have also been working with our government to recognise the needs of people with diabetes. The sterling efforts of NHS Diabetes, Diabetes UK, and the College of Podiatry, in collaboration with the All-Party Parliamentary Group on Diabetes, has led to Parliament identifying diabetes care as a priority and endorsing the aims of the Putting Feet First campaign (Diabetes UK, 2012a). I had the privilege of attending a diabetes stakeholders meeting with Anna Soubry, Parliamentary Under-Secretary of State for Health, who, by the end of the cordial meeting, was under no illusion with regards to the impact that diabetes has on the health of the nation.
The Parliamentary and Stakeholder Diabetes Think Tank’s Annual Report (2012) considers the impact of the Department of Health’s Quality, Innovation, Productivity and Prevention (QIPP) programme on diabetes care and has made several informed recommendations. These include advice to Clinical Commissioning Groups (CCGs) to seek to commission the diabetes services in their entirety, rather than the constituent parts of a service in isolation. This supports Diabetes UK’s (2012b) Putting Feet First: Commissioning/Planning a Care Pathway For Foot Care Services for People with Diabetes; a publication that reinforces and promotes the integrated care model across different healthcare settings. If diabetic foot care services are to provide the comprehensive service that people with diabetes need, CCGs must navigate the commissioning process to ensure that an integrated model is commissioned.
Other relevant publications pending include Best Practice For Commissioning Diabetes Services and a further addition to the Putting Feet First stable of documents, both from Diabetes UK. Both documents will be made available to CCGs to help direct the commissioning process. Together with the information that is available from the National Diabetes Audit, the NHS Diabetes Footcare Network, and the National Diabetes Information Service, CCGs should have the data and tools needed to make the best possible decisions when commissioning foot care services.
However, some key challenges remain. The changing landscape of the NHS – with significant efficiencies to be made and the dismantling of Primary Care Trusts underway – is not the ideal platform to launch major reforms. During this period of transformation, we also face a potential podiatry manpower shortage if NICE (2011) guidelines on diabetic foot care are to be followed. The National Diabetes Inpatient Audit 2011 (Health and Social Care Information Centre, 2012) revealed that 40.5% of hospitals and Trusts in England did not have a multidisciplinary diabetic foot care team (MDT), and that, shockingly, 31% of hospitals had no podiatry provision at all. The College of Podiatry warned that podiatry services have, at best, been frozen and, in some cases, are being reduced. Clearly the role of the podiatrist is pivotal in the care of the diabetic foot. This loss of manpower does not bode well for our patients.
The advent of the any qualified provider (AQP) agenda for the provision of certain services, including podiatry, could adversely affect diabetes foot care services. Diabetes UK has been sufficiently concerned that it has scheduled the publication of a position document that will outline the issues.
These are challenging times, but in the 30 years that I have been involved with diabetes foot care, we have never before had the extensive media coverage, the level of support from Parliamentarians, nor the number of foot care experts to champion our cause. We have the evidence. We can save limbs, lives, and money. In popular parlance, “it’s a no-brainer!”
However, if we look only to commissioners to be the saviours of our services, we are looking in the wrong place. While the NHS may incentivise CCGs to achieve cost-effective, positive outcomes, it is clinicians who will drive the quality of care. For every excellent diabetes foot care centre across the UK, there is a dedicated diabetes physician who champions the service and every member of the MDT needs to be working as a team and be in possession of the necessary competencies. In short, we have to make sure that our collective houses are in order. There are key issues of organisation, training, education and continued professional development, provision of preventative care, orthotic services, and rapid access for critical care that still require improvement.
The diabetes community has worked tirelessly to raise awareness around diabetic foot care. It is time to mobilise and empower our patients, families and carers to continue to support our campaigns to ensure they receive the care they need and deserve.