Why are some patients failing to engage with foot services earlier and have frequent hospital admissions and/or amputations?

Since the onset of the COVID-19 pandemic, we have become aware of an uncomfortable and recurrent situation in the podiatry clinic and that is the frequent hospital admissions, long-standing ulcerations resulting in amputations and even death in some patients.

The characteristics of the patients we are seeing in clinic leans towards an older, white British, overweight, lone-male population, who are often manual workers (eg. security guards, chefs, cleaners). It is apparent that the regular health promotion campaigns (eg. iDEAL group’s ACT NOW campaign, Diabetes UK’s Putting Feet First, Royal College of Podiatry Foot Health Week) to raise awareness and education regarding foot problems are not being heard by this cohort. They are often not aware of 5-to drive, eat 5 portions of fruit and vegetables a day, check your feet every day or walk 10,000 steps initiatives. They frequently do not access public health materials and they ignore the social media platforms, magazines, newspapers and do not pick up health promotion materials.

Quite simply, these positive public health care messages and campaigns are passing them by. Thus, when they present in clinic, often after an emergency appointment with their GP, or an attendance at A&E, there is significant soft tissue damage or systemic infection, frequently catastrophic tissue loss and serious comorbidity (often in the form of renal or cardiac failure).

Many of these patients require immediate hospital admission, intravenous antibiotics, surgical debridement, vascular intervention or amputation. Unfortunately for some, their comorbidity is too serious to permit for any surgical options or their cardiovascular status is too precarious to allow for anaesthesia. And upsettingly for many of these people, early mortality (often from an overwhelming cardio-vascular event) is the reality before they get as far as a major amputation.
So where is it all going wrong?

Walsh et al (1975) found that a proportion of newly diagnosed people with diabetes had characteristics that composed a distinct syndrome. These people were predominantly male and presented with retinopathy and foot problems that were often chronic in nature. In addition, many of them manifested with a profound indifference towards their diabetes. This study indicated that the prognosis is poor for people with diabetes who have retinopathy and foot disease at diagnosis.

Research published by Robbie et al (2020) further demonstrated that middle-aged white men had increased admissions to hospital in small-scale audit of podiatry-initiated admissions into an acute hospital, and recent research from Scotland found that patients with high rates of missed appointments (on average more than two per year) were more likely to be socio-economically deprived, and live in an urban setting (McQueenie et al, 2019).

Patients with more long-term conditions had increased risk of missing GP appointments (after controlling for number of appointments made) and were at much greater risk of all-cause mortality. The starkest finding was that patients with long-term mental-health conditions who missed >two appointments per year had >8x risk of all-cause mortality compared with those similar diagnoses who missed no appointments (McQueenie et al, 2019).

So, why are these patients not accessing services sooner to help prevent foot complications? Multifaceted factors may include:

• Education — the health education message is just not getting through to them
• COVID-19 — difficulties accessing medical help (e.g. can’t get through to GP surgery over the phone, get medical appointments, delays in accessing appointments, no face-to-face GP appointments)
• Social deprivation, including financial poverty and limited sick pay (patients continue to stand/walk on their feet despite medical advice resulting in poor compliance), housing issues with lack of exercise due to areas being unsafe, lack of leisure facilities, low education — leading to lower pay/manual jobs, postcode lottery — some GPs have more resources and are easier to access
• Lack of access to or difficulties accessing technology — digital poverty/ mistrust of telemedicine
• Mental health issues (diagnosed or undiagnosed) ­— Diabetes UK state that as many as 40% of people with diabetes say they have struggled with their psychological wellbeing since being diagnosed. Although diabetes does not directly cause depression, the nature of diabetes can be a factor in developing it, and depressed patients are less motivated to be proactive in contacting health services. Mental health services discharge patients who do not engage (did not attend; DNA) as it is assumed that patients do not want to make changes (Diabetes UK, 2022)
• Poor family support — not supporting compliance and conflicting priorities in a household so the diabetes message gets lost
• Drugs/alcohol misuse
• Learning difficulties — There is a huge issue of ‘missingness’ in those with mental health/learning difficulties at all levels. They are difficult to engage and often fail to attend (DNA) appointments or are lost to follow-up for long periods and re-present with increasingly serious problems (McQueenie, 2019)
• Busy healthcare professionals can get frustrated by patients who do not engage with their advice or attend their appointments, resulting in people not being followed-up or are discharged from services after non attendance.

Additionally, there is a huge issue around inclusivity. Many of our clinic patients do not feel represented by the mainstream and charity health campaigns. The people in the advertising campaigns do not ‘look’ like them so they do not identify with the message. Also, they are less likely to access the digital or media platforms which include healthcare messages.

And this is where we can all make a difference: please take the time to reflect on this article. It is designed to make you think, and it may even make you feel uncomfortable. You may recognise the situation. You may think of certain patients. I can guarantee that one!

And I would like you to respond … with your thoughts and ideas:

• What have you noticed?
• What have you tried?
• What has worked for you?
• Where do you think we can, as foot protection teams, make the biggest impact?
• What can we do?
• What should we do?

This is not simply about reducing amputations but it is about saving lives. Surely that is the best outcome of all for people with diabetes?

Access the FDUK survey and provide your valuable feedback on the themes addressed in this article here.