My editorial this issue is in two parts, both focusing on quality of care for those with diabetes. The first part is a personal reflection on the benefits of informal continuing professional development. The second part is a look at the latest update on the progress of the National Service Framework for Diabetes. If there is a link between the parts, it is the relationship between healthcare professionals and systems of care. Patients can only receive the benefits of a skilled diabetes workforce if seamless systems of care are in place. Conversely, the systems of care may appear to be excellent, but without a skilled workforce, the outcomes can be suboptimal. With a dedicated workforce and a workable system of care in place, progress can truly be observed and measured.
Continued professional development is essential to delivery of high quality care
The multidisciplinary diabetic foot care team has been referred to many times in this journal over the last 10 years. Membership and structure of such teams differ widely throughout the UK and the rest of the world. In a previous editorial (McInnes, 2007) I commented on a report by Stephan Morbach (2006) which provided evidence of the significant difference that the foot care team can make on the burden of morbidity associated with diabetic foot disease.
Despite the often fragile structure of the multidisciplinary team, and the unique bureaucracy that surrounds the NHS, the care that is offered to high-risk patients with complex foot problems is often exemplary. The knowledge, skills and dedication that typify a successful team, with good working relationships and mutual respect, all contribute to that success.
Continued professional development is a key aspect of clinical governance and is an essential activity for all professionals involved in foot health. The type of continued professional development undertaken may be in the form of formal education forums, attendance of conferences, website access or journal access. Informally, continued professional development may be achieved in an ad hoc fashion and I suspect that many readers of this journal will have developed a network of friends and colleagues who are willing to share their clinical experience and expertise in the field of diabetic foot disease. This informal knowledge sharing often proves to be invaluable.
Over the past two decades, I have been fortunate to meet many experts who have been willing to share their expertise and knowledge with me. Their contribution has been of immense value to my own continued professional development and has positively impacted on the management of many of my patients with diabetes and complex foot problems.
One expert who has made a significant contribution to the world of wound care is Professor Richard White. I had the good fortune to collaborate with Richard when he held a research appointment with a commercial wound care company during the late 1980s and early 1990s. Richard has subsequently taken up a fellowship with Grampian NHS Trust, and is now the first chair in tissue viability in the UK at the University of Worcester. Richard is one of the leading experts in the field of tissue viability and wound repair and has published extensively, including a recent book chapter with myself (McInnes and White, 2007).
In his role, Richard is fostering closer links between those disciplines with shared interests in the areas of wound care and skin protection, and in the delivery of these services to the community. This means that podiatry, with its involvement in foot ulceration, comes under the broad umbrella that Richard envisages tissue viability to be.
Bringing together various disciplines involved in wound management is not a matter of ‘empire building’, but rather one of sharing expertise and education, especially in primary care. It is through such links that we progress as clinicians and researchers, so increasing our knowledge and improving the delivery of care to our patients.
Reflecting on: Five Years On – Delivering the Diabetes National Service Framework
Measuring the quality of care for people with diabetes is essential practice. The Department of Health (DH, 2008a) publication Five Years On – Delivering the Diabetes National Service Framework provides many examples of improvements in diabetes care.
It is certainly true that, as the Secretary of State for Health Alan Johnson (DH, 2008a) puts it: “We still have a long way to go to ensure that every person with diabetes is receiving the kind of care set out in the National Service Framework.” But there is no complacency in this document, which places a significant emphasis on prevention. Further, plans for a programme of vascular risk assessment and management are to be applauded in light of the morbidity and mortality that is associated with cardiovascular disease (DH, 2008b).
However, it is rather disappointing that Five Years On – Delivering the Diabetes National Service Framework makes few references to the evidence of improved diabetic foot services. One service that is highlighted is in Ipswich where there was an impressive decline in amputation rates between 1995 and 2000. The service at Ipswich was compromised when the hospital’s foot care team was withdrawn in 2000, a subsequent rise in amputations being the result. A diabetes specialist nurse was later reinstated and the amputations rates began to decline once more (DH, 2008a).
I suspect there is abundant evidence of improvements in diabetic foot care throughout the country that could have been mentioned. However, to be fair, there is a limit to the size of the document and therefore the number of examples that can be covered.
The document makes reference to Professor the Lord Darzi’s High Quality Care For All – NHS Next Stage Review Final Report (2008) that emphasises the role of care planning for everyone with a chronic condition. It is stated that all will have a personalised care plan over the next 2 years. If this ambitious aim is achieved perhaps there will be a commensurate decrease in foot ulcers and amputations.
Reflecting on Five Years On – Delivering the Diabetes National Service Framework, one can see that the enthusiasm, dedication, innovation and talent of the healthcare professionals in the UK is quite astounding. I hope Mr. Johnson really appreciates the skills of the diabetes workforce!