A number of diabetic foot care specialists, dismayed by the widespread neglect of the condition across the UK, have developed a pathway of care and a service specification entitled Putting Feet First. Supported by a partnership between FDUK, Diabetes UK and NHS Diabetes, this document details how rapid access to healthcare professionals with the necessary skills and experience to manage the care of people with diabetic foot problems, at every level of risk, can be achieved.
Gerry Rayman (Consultant Diabetologist, Ipswich and Clinical Lead for Inpatient Care, NHS Diabetes) headed the Putting Feet First (Diabetes UK, 2009) working group, and welcomed attendees to its launch. Douglas Smallwood (Chief Executive, Diabetes UK) and Rowan Hillson MBE (National Clinical Director for Diabetes) gave opening addresses, both offering their praise to the document’s authors.
Douglas described the challenges for successful implementation: (i) all people admitted to hospital with diabetes are identified at the time of admission as having diabetes and their needs, including those of the foot, being assessed from there; (ii) specialist foot care teams must be located in or near to hospitals; and (iii) specialist foot care teams need to be known to, and work seamlessly with, general ward and diabetes staff.
Rowan spoke of the lack of understand about diabetic foot disease among both generalist healthcare professionals and people with diabetes. She expressed her hope that the attendees would take the day’s messages back to those who “don’t know what they don’t know.” Michael Edmonds (Consultant Diabetologist, London) Chaired the next session that asked: Where are we now in diabetic foot care? Gerry spoke in this, saying “we are a very long way from where we need to be.” Diabetes UK provides us with alarming statistics on the extent, and consequences, of diabetic foot disease, and the gravity of its outcomes, and Gerry estimated that some 20% of all NHS spending on diabetes is attributable to foot disease.
Following this, attendees formed discussion groups and were asked what issues in diabetic foot care were problematic in their local areas. Attendees raised a range of issues, with the failure of commissioners to “get” the diabetic foot problem as central. Many attendees also reported that admission and ward staff were often reluctant to take a patient’s socks off and become involved in actively preventing ulceration or seeking out specialist foot care.
In the final morning session, Chaired by Louise Stuart MBE (Consultant Podiatrist, Manchester), William Jeffcoate (Consultant Diabetologist, Nottingham) said that, until now, nothing has defined for patients, clinicians and commissioners what should be happening over the threshold of the hospital door for diabetic foot care. William described how implementation of Putting Feet First would ensure that vulnerable diabetic feet receive gold-standard care, be it preventative (in cases of admission for an illness unrelated to their feet), or rapid treatment from a specialist team if admitted for active foot disease, or illness concomitant to it. William stressed that, despite the organisational difficulties it poses, diabetic foot care must be person-centred, and be undertaken by a specialist foot care team.
In the afternoon, Stella Vig (Consultant Vascular Surgeon, Croydon) Chaired a session in which attendees heard from three people who have established successful diabetic foot clinics: Cliff Shearman (Professor of Vascular Surgery, Southampton), Michael Edmonds and Gerry Rayman. The results achieved at these three centres of excellence show commissioners that the pathways of care in Putting Feet First are evidence-based, and significantly improve outcomes for people with diabetic foot disease.
Next, attendees were invited to suggest how implementation of Putting Feet First might best be approached. A variety of responses were elicited, with some focusing directly on implementation of the guidance, while others looked at raising the profile of diabetic foot disease more generally. Gerry, along with many attendees, hoped that each Trust would find a diabetic foot champion, as experience has shown that leadership drives change and produces positive results. In this vein, Gerry encouraged people to invite non-specialists, undergraduate students, registrars and interns to spend time in the foot clinic to widen understanding of this complication.
Participation of people with diabetes and the media were seen as central to making diabetic foot care a priority. Some suggested that league tables should be circulated to “name and shame” those centres with the worst foot care records.
In the final session, Chaired by Geraint Jones (Consultant Diabetologist, Blackburn), Simon Hunter (Assistant Director of Public Health Programmes, Hull) reminded attendees that commissioners were tasked with (i) improving health outcomes, and (ii) reducing healthcare inequalities. All of the speakers from this session encouraged attendees to engage with their commissioner and to use NHS Diabetes’ assistance to build cases for funding.
A number of launch events are planned across England, and NHS Diabetes and Diabetes UK will be working together on the implementation of the guidelines. Louise and Gerry closed the day’s proceedings by encouraging the attendees to take Putting Feet First back to their hospitals and be a part of the change so desperately needed in diabetic foot care.
