Diabetes specialist nursing: A pivotal role to play in care of the diabetic foot

The central vision for NHS Diabetes, the Association of British Clinical Diabetologists and Diabetes UK is that people with diabetes have access to high-quality, integrated care at the right time and are seen by the appropriate healthcare professionals. 

Although some crucial improvements in diabetes care have been achieved (NHS Diabetes, 2012a), the burden of diabetic foot disease on the NHS and those affected can no longer be ignored. The combined costs of ulceration and amputation are estimated to be in the region of £600 million per year, and are associated with a substantially reduced quality of life and high mortality rate (NICE, 2011a); these complications may be preventable in many cases. 

DSNs play an increasingly crucial role in educating people with diabetes and healthcare professionals, and are pivotal in ensuring a truly integrated pathway between acute and community care.

Disseminating the message
Many patient education tools mention diabetic foot complications only briefly, if at all; as a result, people with diabetes often do not recognise the early warning signs of foot disease. Likewise, the deterioration of an infected ischaemic diabetic foot ulcer, worsened by neuropathy, is scarcely taught at nursing or medical school. Although the media and healthcare professionals are promoting the need for rapid interventions for myocardial infarction – a “FAST attack” – they are not aware that the “foot attack” is just as costly in terms of quality of life and budgetary spend in the NHS. It must be hoped that Diabetes UK, NHS Diabetes and the Society of Chiropodists and Podiatrists’ 2012 campaign to ensure that people with diabetes have access to good footcare is successful in raising the profile of diabetic foot disease as a life- and limb-threatening disease process.

The importance of foot checks (with shoes and socks off) cannot be sufficiently highlighted, and there are many missed opportunities both to check and to educate. Practice nurses who screen for diabetic foot disease should ensure that people with diabetes are aware of their current risk status of developing foot disease and document their findings, as recommended by NICE (2004). DSNs should ensure that people with diabetes understand the importance of their foot status; it only takes a few hours for a foot ulcer to deteriorate, so swift action is vital. It is therefore imperative to stress the importance of an acute referral by a member of the team to the specialist, thus empowering the team to refer appropriately. By doing this nurses can help reduce the number of amputations and play a pivotal role in enabling people with diabetes to maintain their quality of life and independence (Moulton, 2012). 

Delivering gold-standard care
The NHS Atlas of Variation in Healthcare (Right Care, 2011) revealed significant variation in amputation rates across England, with a two-fold variation at strategic health authority level increasing to as much as a six-fold variation at primary care trust (PCT) level. These marked variations have many possible explanations, but variation in service provision and the attitude and behaviour of those providing the service are among the most important factors. These variations may be amplified with the development of clinical commissioning groups and new legislation on service provision by “any qualified provider”.

What has been clearly demonstrated is that management by a specialist multidisciplinary foot team can reduce amputation rates and improve outcomes rapidly and dramatically in the diabetic foot (Apelqvist and Larsson, 2000). The DSNs, practice nurses and district nurses are vital components of the foot protection and multidisciplinary diabetic foot teams, meeting National Minimum Skills Framework guidelines (Diabetes UK, 2011). However, the number of DSNs is not increasing despite the rising diabetes population. According to Amanda Cheesley, the Royal College of Nursing’s long-term conditions adviser, “There is no doubt that all over the country DSN care is diminishing,” and the current workforce survey suggests that 43% of posts were unfilled in 2010 (Diabetes UK and NHS Diabetes, 2011). 

This sparked a House of Commons Early Day Motion in 2011, where the House noted that:

“[…] the number of diabetic specialist nurse posts unfilled across the NHS had doubled within a year, leaving 218 vacant posts at a time when the number of people with diabetes is rising by 150 000 a year […] diabetic specialist nurses play an important role in helping patients manage their condition and reduce the costs of complications later in life as a consequence of poor diabetic control […] the quality and safety of patient care must come first and that all efforts should be made to fill these vacancies” (www.parliament.uk, 2011).

Yet in the current political climate, with its emphasis on reductions in spending, many clinicians feel unsupported in implementing the range of best-practice guidelines, policies and NICE standards that relate to the care of the diabetic foot.

One of the great barriers to achieving gold-standard diabetic foot care is the lack of a cohesive approach to service delivery. The integration of acute and community services, and now of PCTs, gives healthcare providers a great opportunity to develop pathways that ensure the right patient is seen by the right clinician at the right time. Crucial to this is the primary care team’s role in foot screening, because people with diabetes need to know their current level of risk of ulceration. Most importantly, primary care teams need to refer those at high risk to a foot protection team for management (NICE, 2011b). 

The Royal College of Nursing suggests that while it is common for GP practice nurses to manage people with diabetes who have no complications, they often lack the in-depth knowledge to take on those individuals whose diabetes is more unpredictable or complex. Those individuals who require this specialist support are potentially the 24 000 people who have been identified as unnecessarily dying from the condition every year (Healthcare Quality Improvement Partnership, 2011). There is also evidence to show that support by a specialist diabetes team can reduce NHS costs; a 1000-bed hospital that employs a diabetes specialist team – including DSNs – with staffing costs of £170 000 a year can save between £1.5 million and £4.4 million annually on other NHS costs, which includes reducing hospital stays for these patients by 1.4 days. The benefits may be greater for both patients and commissioners if these costs can be integrated into acute and community care.

Diabetic footcare networks
Based on the success of the 28 NHS cancer networks (Department of Health, 2011), as well as other clinical networks, NHS Diabetes has undertaken an initiative to launch a national clinician-led footcare network (NHS Diabetes, 2012b), comprising four regional sectors – Northern, Midlands, Southern and pan-London. The footcare network provides support for clinicians who care for the diabetic foot to establish best practice and implement national guidelines locally. Through this network there is also the potential for data collection, research and the early adoption of new technologies. Furthermore, as the network develops and strengthens it will become a powerful voice that will inform clinical commissioning groups. Nurses and DSNs must have a voice within these networks as they are champions of diabetes care, and have the key skills that are symbiotic with those of podiatrists to develop and sustain high-quality diabetes service provision.  

The London diabetic foot network has now held three successful local meetings. As Chair of these meetings, the author has seen that excellence in practice already exists in a number of areas, as does a great willingness to share innovations and support colleagues. DSNs are a scarce resource and have not attended in great volume, but the DSN network is pivotal in the success of the footcare network. If the reader is a DSN or nurse interested in diabetes, NHS Diabetes (2012b) gives further information about national and local footcare networks, the work these networks are undertaking and how to get involved.

Conclusion
It is imperative that people with diabetes have access to services that fulfil NICE clinical guidelines and Quality Standard Statement 10 (NICE, 2004; 2011b; 2011c; 2011d), and local footcare networks can support DSNs in achieving this goal. Failing to provide such a service is to allow a true “postcode lottery” and the continuation of the unacceptable variation in care of the diabetic foot that currently exists in the NHS.