During the past year, I have attended and participated in four important conferences: the Diabetes UK Annual Professional Conference in Glasgow, The Diabetic Foot Journal Conference in Edinburgh, the Society of Chiropodists and Podiatrists Annual Conference in Harrogate, and the launch of the inpatient diabetic foot care guidelines Putting Feet First (Diabetes UK, 2009) in London that Professor Phil Wiles called a “masterpiece of brevity and clarity … [that] will allow us to make a real impact.”
The Scottish Diabetes Foot Action Group have also been very active this year. They have developed a national screening programme, and published a consensus document on the antibiotic management of the infected diabetic foot in this journal (Leese et al, 2009; Young, 2009). Currently, they are in the process of developing a national competency framework.
From a global perspective, the Diabetic Foot Care Education Working Group (part of the International Diabetes Foundation’s International Working Group for the Diabetic Foot) have developed a programme that aims to address the podiatry shortage in the developing world by training diabetic foot care assistants (Tulley et al, 2009).
I hope that the snapshot of activity described above has captured the enthusiasm, endeavour, skills and knowledge of the dedicated healthcare professionals who are striving to improve diabetic foot care in the UK and beyond. Inevitably, there are challenges ahead in the implementation of best clinical practice. However, the diabetic foot care community are developing strategies to see their plans come to fruition.
There are lessons to be learnt from the previous attempts to put diabetic foot care on the political agenda. In 1992, a small group from the then British Diabetic Association (now Diabetes UK) met with Kenneth Calman, then Chief Medical Officer of Health, to discuss the shortage of chiropody (podiatry) services for people with diabetes, and to develop a joint task force to address some of the goals of the St Vincent Declaration (World Health Organization and International Diabetes Federation, 1989) in the UK.
I attended the meeting to share my experiences with regard to chiropody (podiatry) services and the need to increase the workforce. The key members of the group – namely Professor Emeritus Harry Keen, Dr Geoff Gill (now Professor) and Michael Cooper (then Chief Executive of the British Diabetic Association) – proposed the joint initiative that led to the publication of St Vincent Joint Task Force for Diabetes: The Report (Department of Health and British Diabetic Association, 1995).
This report influenced many diabetes services throughout the UK, and the Amputation and Foot Group Report (Edmonds et al, 1996) provided a template for multidisciplinary diabetic foot services. However, there were no increases in resources, nor any requirement for the NHS workforce to actually implement the recommendations.
This time around, the circumstances are different for a range of reasons:
- The launch of the key initiative Putting Feet First has been widely publicised – our own journal has included a meeting report (2009) and an editorial written by key players in the guideline’s development led by Dr Gerry Rayman, Professor William Jeffcoate, Dr Mike Edmonds, Louise Stuart MBE and colleagues (Rayman et al, 2009).
- Professor William Jeffcoate and Dr Mike Edmonds have not only contributed to Putting Feet First but have also published leading articles that promote care of the diabetic foot in other journals. The excellent editorial by Professor William Jeffcoate (2009) that appeared in Wounds UK sets out the challenges ahead in a clear, coherent fashion, and is supported by a debate article in which the contributors demonstrated an increased awareness of the complexities of the NHS and the political manoeuvring that has to be carefully circumvented (Timmons et al, 2009).
- Putting Feet First is highlighted on the NHS Diabetes and Diabetes UK websites.
- There are a number of organisations that are working together to provide the support for Putting Feet First that has been absent from past campaigns. These include the Association of British Clinical Diabetologists, Foot in Diabetes UK (FDUK), the Joint British Diabetes Societies Inpatient Working Group, the National Diabetes Inpatient Specialist Nurse Group, Primary Care Diabetes Society, the Scottish Diabetes Foot Action Group, the Society of Chiropodists and Podiatrists, the Vascular Society of Great Britain and Ireland, the Welsh Endocrine and Diabetes Society, Diabetes UK and NHS Diabetes.
- Louise Stuart MBE masterminded the National Minimum Skills Framework for Commissioning of Foot Care Services for People with Diabetes (FDUK et al, 2006), contributed significantly to Putting Feet First, and continues to champion the cause and bring organisations together.
- The Scottish Diabetes Foot Action Group have major players in support, including Dr Graham Leese, Dr Matthew Young, Mr Duncan Stang, Dr Brian Kennon and Mr William Munro.
- An All-Party Parliamentary Group for Diabetes has been established to raise the profile of diabetes in the political arena.
This is a completely different situation compared with 1992. The strategies for the successful implementation of Putting Feet First will involve an implementation strategy (well on its way), a political strategy (to increase awareness at all levels and influence the commissioning process) and a strategy to engage the clinician to adhere to this important guideline.
Grimshaw and Russell (1994) provided strategies for successful implementation of clinical guidelines, which include specific educational interventions required for dissemination and a patient-specific reminder at the time of consultation. The provision of an information card, as outlined in Putting Feet First, may serve as a useful tool to prompt the clinicians in the hospital to “think feet”! One key recommendation from Professor William Jeffcoate (2009) is that: “The guidelines for clinical care and the criteria which underpin the commissioning of services must be superimposable.”
For sustainability, communication between all of the stakeholders is paramount; between primary and secondary care, PCTs and commissioners, and all of the supporting organisations. The architects of Putting Feet First, and all diabetic foot protection teams, will want to measure the effects of the implementation of the guideline and regularly review them over the next decade.
Finally, I would like to return to the Diabetic Foot Care Education Working Group’s training initiative. Mr Stuart Baird and I commented on the programme in a previous issue of the journal (McInnes and Baird, 2009), and received a response that can be found on pages 160–3 of this edition.
We have nothing but admiration for the diabetic foot care that the group’s members provide in developing countries. Our constructive comments on the training programme arose from the passion, enthusiasm and commitment that we have for diabetic foot care education. Hopefully, our opinion has been somewhat informed by our 30 years of experience in diabetic foot care and education. We always welcome the opportunity to work together with colleagues as there is added strength through unity – which is why Putting Feet First will work.