Guest blog: Richard Leigh, Consultant Podiatrist, Royal Free London NHS Foundation Trust and Chair of English Diabetes Footcare Network
In the NHS Resolution recent publication ‘Diabetes and lower limb complications A thematic review of clinical negligence claims,’ the foreword by Professor Michael Edmonds advises: “It should be compulsory reading for those who are involved with care of the person with diabetes including healthcare professionals, commissioners and policy makers.”
The report highlights failings in the healthcare system relating to diabetes and footcare.
These included absence of integrated multidisciplinary care despite multiple disciplines being involved and that the guidance recommending prompt referral and review by a specialist footcare service typically within 24 hours of pathology arising was not followed.
From 92 negligence claims other findings were 52 per cent of patients reviewed had no multidisciplinary footcare team (MDFT) input at any stage, 98 per cent of patients who underwent a major amputation did not have the decision to proceed to amputation reached through an MDFT and only three per cent of patients were seen in an MDFT that involved podiatric, medical, surgical and either microbiologist or infectious disease input.
The National Diabetes Foot Care Audit (NDFA) has consistently found that faster referral to the specialist foot care service is associated with fewer severe ulcers and better 12-week outcomes.
The recent NDFA publication ‘Interval Review: July 2014-March 2021 Report of outcomes of 108,450 foot ulcer episodes in 76,310 people with diabetes in England and Wales’ also highlights gaps in service provision, particularly in MDFT integration with renal services and recommends that specialist clinical services which care for foot ulcers in diabetes are accessible everywhere.
It seems somewhat inconceivable that multidisciplinary foot teams, foot protection services and direct pathways to specialist multidisciplinary footcare services do not exist in all parts of the UK considering the published guidance in ‘The NHS Long Term Plan’ (2019), ‘GIRFT Programme National Specialty Report: Diabetes’ (2020) and ‘NICE Guidelines: Diabetic foot problems: prevention and management’ NG19 (2016).
In fact, all this guidance was pre-empted by the much earlier publication ‘NICE Type 2 diabetes, Prevention and management of foot problems’ in 2004.
So, why is there variation? Why does the outcome of diabetes related foot disease, amputation and mortality depend on where you live?
All the current guidance and findings by NHS Resolution and the NDFA advise and show the necessity of defined service provision for footcare services.
Why is this so important?
The NDFA reports ‘it is notable that almost one in five people (18 per cent) presenting with a severe ulcer are dead (15 per cent) or have undergone major amputation (three per cent) within one year.’
Currently the NHS is undergoing major change. The Health and Care Act 2022 provides for the establishment of Integrated Care Boards (ICBs) across England, as part of the Act’s provisions for Integrated Care Systems (ICSs).
NHS England proposes to establish 42 ICBs on the 1 July 2022. Hopefully, the ICB leads and commissioners will heed Prof Edmonds’ advice and then ensure they prevent failings in their healthcare system relating to diabetes and footcare.
NHS Resolution recent publication ‘Diabetes and lower limb complications’ (2022)
NDFA National Diabetes Foot Care Audit, NDFA Interval Review: July 2014-March 2021 (2019)
GIRFT Programme National Specialty Report: Diabetes (2020)
NICE Guidelines NG19: ‘Diabetic foot problems: prevention and management’ (2016)
NHS Long Term Plan (2019)
The Health and Care Act (2022)