Preventing unnecessary amputations: A booklet to empower people at risk and help with care planning

Since Diabetes UK launched its Putting Feet First campaign 2 years ago, there has been a greater focus on diabetes-related amputation. Decision-makers are finally recognising that, as up to 80% of amputations are preventable with the correct management (Right Care, 2011), they can play an important role in reducing this rate.

Successfully challenging the system
The campaign has encouraged more hospitals than ever before to provide access to a multidisciplinary foot-care team (MDfT). The most recent National Diabetes Inpatient Audit (Health and Social Care Information Centre, 2013) showed 31% of hospital sites participating in the audit are recorded as not having access to an MDfT, a significant reduction on the 41% the previous year. Despite this reduction, there is still considerable room for improvement, and Diabetes UK are continuing to campaign for MDfTs. Evidence shows that the provision of an integrated foot-care pathway, including trained staff in foot protection services in the community and speedy access to MDfTs, can reduce amputations by over 50% (Kerr, 2012).

The current situation
Unfortunately, more than 6000 leg, foot or toe amputations are still being carried out each year on people with diabetes. This is more than 100 amputations a week. If current rates continue, the number of amputations will rise from more than 6000 in 2011–2012 to more than 7000 in 2015–2016 in England (Diabetes UK, 2013). Amputations and foot ulcers have a huge impact on quality of life, and up to 80% of people die within 5 years of having an amputation (Khanolkar et al, 2008).

Amputation rates vary widely from one area to another; in the worst areas, a person with diabetes is 10 times more likely to have a major amputation than in the best areas (Health and Social Care Information Centre, 2013).

Driving amputation rates down
So, how can you help us drive amputation rates down? The starting point is making sure individuals get a good-quality annual foot check. We have heard from some people who supposedly received their foot check, but reported that they were not even asked to remove their shoes. Currently, 15% of people with diabetes are not even getting their annual foot check and this figure has not improved in recent years (see Figure 1; Health and Social Care Information Centre, 2010). It is essential that there are enough people who have been trained to deliver the foot checks – whether that is in a primary or secondary setting. People at high risk also need to be reminded about the importance of the foot check by all healthcare professionals in order to encourage better uptake.

We also want you to make sure at-risk individuals understand the implications of their risk status, know how to look after their own feet and realise the importance of urgently seeking medical attention in the event of any problems.

Your toolkit
In October 2012, Diabetes UK and the College of Podiatry brought together experts in diabetes foot-care from across the UK to a think tank in Westminster, London, where we shared views on how to take forward the aims of the Putting Feet First campaign. A major issue we wrestled with was how to ensure that people with diabetes get the right care, at the right time and in the right place through an integrated foot-care pathway, wherever they live. A number of ways of promoting and supporting an integrated foot-care pathway were discussed, and one proposal that had considerable support was taken forward and developed by Diabetes UK and campaign partners: How To Spot a Foot Attack.

How To Spot a Foot Attack
A problem identified by many people at the think tank event was that people with diabetes who have acute foot problems – a “foot attack” – are often not assessed and treated quickly enough by a member of the MDfT, as recommended by NICE. In addition, it was reported that people could present with advanced foot disease without ever having being known to foot-care services.

That is why Diabetes UK produced a new booklet aimed at people with diabetes who are at high risk of a foot attack. How To Spot a Foot Attack is based on the information in the integrated foot-care pathway and gives people with diabetes the vital information they need to access help fast. It also includes a card, which can be kept in a wallet, where the person can write the emergency contact numbers of their GP, MDfT and available podiatry or foot-care services. If they do not know who these are then it is important that healthcare professionals help them fill this in.

Spotting a “foot attack”
A foot attack is said to be taking place if the foot is red, warm or swollen, or if there is a break in the skin or any discharge. It is especially important that the person experiencing the foot attack seeks urgent medical attention if they are also feeling unwell.

A person is at high risk of a foot attack if they have a previous history of foot ulcers or previous amputation, or two or more of the following: neuropathy/loss of sensation, peripheral vascular disease/poor circulation or deformity (such as bunion and claw foot).

People with diabetes are up to 20 times more likely to have an amputation than the general population (Holman et al, 2012) but this does not need to be the case. If an integrated foot-care system is in place, with access to specialist care as quickly as possible, and at-risk individuals have a better understanding of what they need to do, then potentially thousands of amputations could be prevented.

The booklet has been sent to every GP surgery in England and Northern Ireland, but you can also order your own copies at the Diabetes UK online shop. Spare a few minutes to place your order and discuss it with your patients. Your action could make all the difference.

Further information

• To order your own copies of How to Spot a Foot Attack for distribution, please go to https://shop.diabetes.org.uk/go/red-card-foot-booklet.
• For more information and resources to download for free for your patients, including our Touch The Toes Test and 10 Steps for Healthy Feet leaflets, please go to www.diabetes.org.uk/putting-feet-first. All materials are also available at our online shop.