Foot In diabetes UK

Louise Stuart & Neil Baker

Diabetes related foot ulceration is not in itself a diagnosis but is only one manifestation of a spectrum of comorbidities.
All patients presenting with foot ulceration should have timely access to care provided by specialist teams with the appropriate knowledge, skills and facilities to manage them effectively.
Nurses, doctors and podiatrists may do their best to manage a foot ulcer, but in truth many find themselves working in poorly resourced
and fragmented services often working in isolation.
This is particularly the case for those working in community
care.
A milestone in diabetes care was achieved more than 20 years ago when the first paper demonstrating the benefits of a specialist multidisciplinary team was published. (1)
Since then others too have shown the effectiveness of
hospital based multidisciplinary teams. (2,3 )
Clear evidence shows that if foot ulcer management is undertaken by a
specialised team, the outcomes not only significantly reduce major amputations, hospital admissions and bed days, but also improve ulcer healing times and quality of life issues (4–6) Furthermore, this type of service has also led to significant health care developments and reduced health care costs.

Shift towards community based services
One of the recent changes within the NHS is the devolution of hospital to community based services, which in some places has included foot ulcer care.
This raises a question that must be addressed: ‘Should diabetic foot
ulcer management be totally or partly undertaken within primary care?’
At the Diabetes UK Annual Professional Conference a specialist session was devoted to debating this question.
Interestingly, at the beginning of the debate the audience voted almost entirely in support of diabetes related foot ulcers being treated in the hospital setting, but surprisingly by the end of the debate the
majority of the audience abstained. The change in view reflected the recognition that the geography of patient management was not directly relevant to its quality. To meet the needs of patients, primary and secondary care diabetes teams need to work in partnership, combining their skills and expertise.

Multidisciplinary specialist teams
The National Institute for Health and Clinical Excellence (NICE) provides a consensus framework (7) for the management of those with diabetes related foot problems.
This guideline recommends that all people with a diabetes related foot ulcer should be referred to a multidisciplinary specialist foot team. In the past, hospital based consultants have voiced concerns regarding the potentially substandard care provided by community based practitioners (8).
This criticism may have had some validity, but it is not universal.
Whilst the assumption is that such teams exist purely in hospitals, there are a number of diabetes teams who adopt hybrid systems of care that involve both community and hospital based specialist teams working together.
In Salford Primary Care Trust (PCT) the community specialist teams have shown that up to 50% of foot ulcerations can be treated in the community without having to access the hospital based services.(9)

More recently, Manchester, Tameside, Southampton and Trafford PCTs have established community based systems of care for people with diabetes, which meet NICE requirements in collaboration with hospital
based care.
As time passes, these newly formed hybrid systems of care may show similar clinical impacts to those already described within the traditional secondary care model.
It can also be argued that for the more complex foot ulcers immediate access to hospital based care is a requirement. However, does this mean all foot ulcers, or do we now need to define which patients require hospital based care?
Clearly, the ingredients of successful foot ulcer management lie not purely in the location of the care but in the skills and ability of the team to respond to the needs of their patients, wherever that may be.

Thus, care pathways should be flexible enough to utilise optimal local
resources effectively wherever they are based.(10)
In truth, there is no uniform gold standard of care for the diabetic ulcerated foot within the UK, and care remains patchy irrespective of where it is delivered. There are often system and clinical failures wherever people with foot ulceration are treated. Sadly, we still seem to be suboptimal at reducing unacceptably high amputation rates
in diabetes, although there are a few models of care where this is not the case. This is in part because there are too few clinical champions to lead the management of diabetes related foot complications that cross all service levels. Thus, intra-locality levels of care can vary significantly so that there may be a high quality diabetic foot service within either a primary or secondary care setting, but not in both. This is a tragedy as this type of service provision should be seamless and equitable nationwide, and not a postcode lottery.

Integrated specialist foot services
Hospital and primary care based diabetes foot-care teams need to be flexible to the evolutionary challenges, which the modernisation of the NHS poses. In the future, with the ever rising prevalence of diabetes, the key to effective management is likely to lie in the provision of modern integrated specialist foot services.
Such services need to rapidly respond to the requirements of people with foot ulceration regardless of location. We must avoid sniping
between primary and secondary care at all costs.
The gauntlet is thrown wider to include managers and commissioners, as well as practitioners, who must be committed to a clear model of care which recognises and supports the crucial input of specialist services working together.

Defining specialists?
Perhaps concerns around who manages patients with diabetes related foot ulceration could be partially addressed by clearly defining criteria for a specialist foot practitioner.
The Department of Health’s ‘Agenda for Change’ banding level 6 describes a podiatrist as specialist, but this does not necessarily dictate a clinical background in diabetes for example. Of even more concern is the lack of a nationally recognised postgraduate route for the training of specialist foot-care practitioners.
In the previous leader article, the Chief Executive of Diabetes UK highlighted the difficulty of defining the term specialist involved in the care of diabetes.(11)

National Minimum Skills Framework for the commissioning of diabetes foot care services
The respective skills for managing foot ulceration, and in fact all levels of foot care, are now clearly spelled out in the National Minimum Skills Framework.(12)
The NICE clinical guideline on the prevention and management
of foot problems recommends that: ‘Healthcare professionals and other personnel involved in the management of the diabetic foot should receive adequate training.’(7)

In the absence of a nationally recognised route for training specialist diabetes foot care practitioners what is now needed is a competency based national curriculum for foot care provision in diabetes. The introduction of such a curriculum would ensure that all practitioners
have access to the necessary knowledge and skills, which in turn would ensure that people with diabetes receive the appropriate standards of care.

Louise Stuart, Consultant Podiatrist/Lecturer in Podiatry, Manchester Primary Care Trust, and University of Salford, UK
Neil Baker, BSc, DPodM, MChS, Diabetes Specialist and Research Podiatrist, Ipswich Hospital, Ipswich, UK

References
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2. Thomson FJ, Veves A, Ashe H. A team approach to diabetic
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3. Rayman G, Murali-Krishnan STM, Baker N, et al. Are we
underestimating diabetes-related lower extremity amputation
rates? Results and benefits of the first prospective study.
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9. Salford Audit data presented at the Malvern International
Foot Conference, May 2006.
10. Baker N. Practical issues in diabetes foot care: podiatry –
linking primary and secondary care. In The Foot in Diabetes,
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12. http://www.diabetes.org.uk/Professionals/Education_and_skills/Competenci...