Foot In diabetes UK

Laurie King
Lead specialist podiatrist in the diabetic foot for Oxfordshire.

I have worked as a podiatrist for the NHS for 27 years and specifically in the field of diabetes for the last 20 years.
At present I am employed by a Primary care PCT and I am seconded to run the Diabetic Foot Clinic at the Oxford Department of Diabetes, Endocrinology & Metabolism in Secondary Care, but also help plan Primary Care at a county level.
In practice this means I head a team of 5 podiatrists who work both in hospitals but also in the community where we have set up a 2nd tier of specialist care (we call it intermediate care) which has been running for a couple of years now (but needs investment to cope with local care for local people).

Within the hospital this means we can refer for an x-ray look at the x-ray (on PACS) there and then, plan treatment, be it antibiotics, offloading, Charcot care, admission to ward, or access to vascular, bone infection, or orthopaedics, provide specialist footwear (we hold the budget and the clinics), or refer back to Primary care, or share care, so the opportunity to cross boundaries and set up multidisciplinary working between Secondary and Primary care podiatry/other members of the team exists but is now threatened by “Payment by Results”, & the mantra “local care is better care” when it should read “appropriate care is better care, where ever & from whom ever” provided they know what they are doing and are resourced and employed by their PCT to do so.

Describe your typical work day

No day is exactly the same I start at 7:30 read e-mails start the clinic; we may have 20 plus patients in a morning, 20 in the afternoon we provide about 5,500 treatments a year.
We have a three chair clinic & a separate MRSA room.
The clinic runs all day Monday, Tuesday pm, Tuesday am we run a Shoe/orthoses clinic with an orthotist, a clinic all day Wednesday, but I may have to do a formal ward round with the consultant either on the ward, or in our clinic.
Thursday I do paper work, Friday am we have another clinic. However at any time I may leave the clinic to teach either in the centre, or in the community, come back and pick up where I left off.
I have just finished training all the PN/DN across 3 PCTs on foot assessment for the QOF. I also have to attend meetings at county level, PCT level, hospital level, department level etc. I am on call to GPs, PN, DN, podiatrists in Primary care, and any ward staff/departments in the John Radcliffe Hospital, Churchill Hospital, Radcliffe Infirmary, Nuffield Hospital for advice or cross referral.

We also have a continual shadow program for all podiatrists in the department who spend Tuesdays and Wednesdays with us, we also have community nurses, and most other medical staff spending time with us. I have input at Brooks University into nurse training on both wound healing & the diabetic foot. Oxford University into SPr training, & Warwick University via the diabetic foot module.
I have case discussions with the consultant on a regular basis and moaning sessions on a daily basis. Now & again we do some foot related research.

How did you first become interested in working with the foot in diabetes?

My grandmother developed diabetes then a foot ulcer ….you can guess the rest.

Why does this speciality appeal to you as a career choice, and who, if anyone influenced / motivated / guided you in this area of work?

Early influences would be William Jeffcoate (he has the nerve to say what a lot of us think, and has original thoughts) Ali Foster, Mike Edmunds (who proved a specialist diabetic foot clinic was worthwhile) Keith Harding a rude GP at the time who told a room full of surgeons “of course these wounds will not get better with surgery like this”. A…… a podiatrist who is knowledgable, professional but self-effacing you have to guess who I mean. But mostly the patients I meet motivate me.

What have been your best and worst moments working in this area and why?

The worst moments have been our receptionist Suzie (been with us 9 years) dying of cancer within three months of becoming ill (this year), at the same time that our purpose built diabetes ward being was closed. Due to the finical situation that the health service is in.

Another low moment was a podiatrist at a major conference saying “I can manage all diabetic foot problems in Primary care”. The Primary care v Secondary care bit is sad. We need both! A narrow view will harm any progress.

It has been very frustrating this past 12 months and the movement of patients from Secondary care to Primary care could mean a backward step if resources are not put into place. I tell myself that the NHS runs in cycles if you wait long enough.

Best moment, well today just before I wrote this, a patient saying, “thank you for getting me better”.

Do you have any coping strategies you can share with us that get you through the worst bits?

I watch the Matrix every couple of months this confirms the idea that reality is an illusion and “spin” is the order of the day. Light can be a wave or a particle depending on the observer, how does light know you exist?

I am quite stoical and cynical (my protective coating) but enjoy the over work, the lack of resources and would be bored if everything was ok. I have a very supportive clinical director, consultants, senior registrars, podiatry colleagues, nurses, GPs (mostly) and patients. The patients mostly get us through the worse bits oh! and I moan a lot, it makes me feel better!

Do you have any new related projects in development at the moment?

I am undertaking the non-medical prescribing course at m level at the moment, and trying to influence the commissioning of services.

What do you feel are currently the most challenging issues for people working with foot in diabetes?

I would say the problems will be practice based commissioning (the 1st year should be ok) but I would expect the government will be pushing private provision of care in year 2.

The upskilling of FCAs to replace Podiatrists (managers can employ 2 FCAs for the price of 1 podiatrist).

An increase in litigation as the public expectations are increased (“It must be someones fault as my foot did not get better”). Patient Empowerment without responsibility results in “someone is to blame”.

“Payment by results” (PBR) and the need for PCTs to break even, may result in the death of the hospital clinic by less referrals, loss of post graduate training and a medical interest in diabetes and the diabetic foot, lack of patients for research etc.

Primary care being resourced adequately to provide diabetic foot clinics. If a hospital MDFC could be paid £214 for a 1st consultation under PBR how much will a Primary care clinic be paid?
There is one government approved podiatry service held up as a model to copy on a web site that claims it can treat patients for under £8 per treatment? Progress or ignorance?

This is where I see the FDUK taking a lead, through representation on relevant government bodies and influencing policies and practice. The web site should encourage communication, and education (via CPD).