Health Review Committee Item 7b

Draft Report 30 November 2004

Access to Podiatry Services for People with Diabetes

3

Access to Podiatry Services for People with Diabetes

Draft report

1. Summary

1.1. This review was initially referred to the Health Review Committee in 2003 as an inquiry. A preliminary investigation suggested that there is variability in the provision of this service across Hampshire. It was therefore agreed that this would be the subject of a full health review for the 2004/05 work programme.

1.2. The review was conducted over the summer of 2004 and involved podiatry specialists, Southampton University and the Strategic Health Authority

1.3. The working group identified that ethnic groups, adults with learning disabilities and the elderly are particularly vulnerable groups.

1.4. A set of robust recommendations have been formulated by the working group to provide clear strategic direction for Hampshire services which encapsulates the principles advocated in the National Service Framework and the NICE guidelines.

1.5 The report has been broken into the following headings, clicking on the heading will take you directly to that part of the report

· Scope

· Methodology

· What is Diabetes

· National guidance

· Dr Foster questionnaire

· Review questionnaire

· Conclusions

· Recommendations

2. Scope

2.1 This review commenced in May 2004 with Cllr Dowden and the Review Team Leader meeting to draw up the scope and project plan. The working group was comprised of:

· Cllr Dowden (Review Chairman)

· Cllr Mason

· Cllr McIntosh

· Cllr Mrs West

· Barbara Cummins, Podiatry Manager, North Hants PCT

· Neil Simmonite, Senior Lecturer, Southampton University

· Julie Pearce, Strategic Health Authority

· Mike Townson, Podiatry Manager, Portsmouth PCT

· Penny Velander, Health Review Officer, (Review Team Leader)

2.2 The review was scoped to focus on foot care for diabetics and examine:

· What local processes for the identification of people with diabetes are in place

· What education for self-care and self-assessment is available

· Are foot inspections being carried out as part of the annual health check

· Is access to relevant podiatry services available when needed

3. Methodology

3.1 An initial meeting was held in December 2003 to explore the need for a full health review on this topic. The meeting included Andrew Wilson, Podiatry Manager for Mid Hants PCT and Gillian Parker for the Strategic Health Authority. Gillian had obtained some basic information from PCTs on podiatry services for people with diabetes in Hampshire. This information indicated a variation in services from area to area and questioned the occurrence of regular foot checks. This information was fed back to the Health Review Committee and it was agreed that this topic should be in the work programme for 2004-05

3.2 Electronic desk research was used to access information on diabetes from Diabetes UK, Department of Health, National Institute of Clinical Excellence, World Health Organisation, Dr Foster

3.3 A preliminary interview was held with Mike Townson, Podiatry Manager, Portsmouth City PCT. Mike provided a basic overview to the issues facing podiatry services, explained the structure for service delivery and advised on wording for the questionnaire

3.4 In order to get a more detailed picture of services across Hampshire a questionnaire was sent to each PCT. This information was collated and formed the main part of the working group agenda

3.5 A briefing paper was circulated to each member of the working group prior to the meeting. The aim of this paper was to provide background to the subject, outline information relating to Hampshire services and ensure that all working group members would be operating from the same base line for the meeting

3.6 The working group met mid September to consider all information, discuss issues and identify potential strategies

3.7 The following documents are attached as appendices

· Appendix 1 - Summary of Dr Foster responses

· Appendix 2 - Foot Assessment Tool

· Appendix 3 - Review questionnaire responses

4. What is Diabetes

4.1 Diabetes mellitus is a condition in which the amount of glucose (sugar) in the blood is too high because the body cannot use it properly. Glucose comes from the digestion of starchy foods such as bread, rice, potatoes, chapattis, yams and plantain, from sugar and other sweet foods, and from the liver, which makes glucose. Insulin is vital for life. It is a hormone produced by the pancreas that helps the glucose to enter the cells where it is used as fuel by the body. The main symptoms of untreated diabetes are increased thirst, going to the loo all the time - especially at night, extreme tiredness, weight loss, genital itching or regular episodes of thrush, and blurred vision.

4.2 There are two main types of diabetes. These are:

· Type 1 diabetes, also known as insulin dependent diabetes

· Type 2 diabetes, also known as non-insulin dependent diabetes

Type 1 diabetes develops if the body is unable to produce any insulin. This type of diabetes usually appears before the age of 40. It is treated by insulin injections and diet and regular exercise is recommended.

Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). This type of diabetes usually appears in people over the age of 40, though often appears before the age of 40 in South Asian and African-Caribbean people. It is treated by diet and exercise alone or by diet, exercise and tablets or by diet, exercise and insulin injections.

4.3 The main aim of treatment of both types of diabetes is to achieve blood glucose and blood pressure levels as near to normal as possible. This, together with a healthy lifestyle, will help to improve well-being and protect against long-term damage to the eyes, kidneys, nerves, heart and major arteries.

4.4 The World Health Organisation's (WHO) latest estimate for the global total of people with diabetes is 177 million, a rise of 42 million from 1995. The WHO states that diabetes is projected to become one of the world's main disablers and killers within the next twenty-five years. This will lead to an increasing proportion of national health care budgets being devoted to the treatment of diabetes

4.5 Diabetes UK figures show that around 1.4 million people in the UK are currently diagnosed with diabetes, and that at least a million more are thought to have the condition unknowingly. The growing number of overweight and obese people will lead to a significant increase in the cases of diabetes especially in young people.

4.6 The Department of Health reports that approximately 5% of the overall NHS resources are used for diabetes care. People with diabetes are twice as likely to be admitted to hospital as the general population and are likely to have a length of stay that is up to twice the average. Around 10% of NHS hospital in-patient resources are used for diabetes care and diabetic complications increase NHS costs more than five-fold. It is recognised that effective primary prevention is the key to reducing these burdens.

5. National Guidance

5.1 The two current reports dictating care are the National Service Framework for diabetes and the National Institute for Clinical Excellence (NICE) clinical guidelines for Type 2 diabetes, prevention and management of foot problems.

5.2 The National Service Framework for Diabetes (2001) sets out the Department of Health's vision for diabetes services which:

· Leads to fewer people developing diabetes and better care for those who have it

· Is centred around the needs of people with diabetes, developed in partnership with health care staff, equitable, integrated and focused on delivering the best outcomes for the person with diabetes

· Offers care that is structured and pro-active providing people with the support they need to manage their own condition

· Is encapsulated in standards, key interventions and implications for service planning

The key elements proposed in the delivery strategy are:

· Setting up local diabetes networks

· Reviewing the local baseline assessment, establish and promulgate local implementation arrangements with a trajectory to reach the standards

· Participating in comparative local and national audit

· Undertaking a local workforce skills profile of staff involved in the care of people with diabetes and developing education and training programmes with the local Workforce Development Confederation

5.3 The framework notes that `the burden of diabetes falls disproportionately on members of ethnic minority groups, older people and the poor. If badly controlled it can lead to blindness, coronary heart disease (CHD) and stroke, renal disease and limb amputations. As a most significant modifiable risk factor for Type 2 diabetes, action to tackle overweight and obesity will need to be central to local prevention strategies. Establishing good control of diabetes, including obesity management, will also contribute to better outcomes, reducing inequalities and the number of people with CHD'. Standards 10-12 of the framework deal with the detection and management of long-term implications ie feet, eyes, kidneys and cardiovascular disease

5.4 The NICE guidelines (January 2004) build on the NSF and provide specific guidance on the prevention and management of foot problems. It covers the care of adults and children with type 2 diabetes by primary and secondary healthcare professional. The guidelines advocate a general management approach stating:

· Effective care involves a partnership between patients and professionals, and all decision making should be shared

· Regular (at least annual) visual inspection of patients' feet by trained personnel is important for the detection of risk factors for ulceration

· Examination of patients feet should include

_ Testing of foot sensation using a monofilament or vibration

_ Palpitation of foot pulses

_ Inspection of any foot deformity and footwear

· Arrange recall and annual review as part of on-going care

· Healthcare professionals and other personnel involved in the assessment of diabetic feet should receive adequate training

· To improve knowledge, encourage beneficial self-care and minimise inadvertent self-harm, healthcare professionals should discuss and agree with patients a management plan that includes appropriate foot care education

· Extra vigilance should be used for people who are older (over 70 years of age), have had diabetes for a long time, have poor vision, have poor footwear, smoke, are socially deprived or live alone

· Health care professionals may need to discuss, agree and make special arrangements for people who are housebound or living in care or nursing homes to ensure equality of access to foot care assessments and treatments

· Offer patient education on an ongoing basis

· Classify foot risk as: low current risk; at increased risk; at high risk; ulcerated foot

5.5 Care of people with low current risk

· Agree a management plan including foot care education with each person

5.6 Care of people with increased risk of foot ulcers

· Arrange regular review, 3-6 monthly, by foot protection team

· At each review:

_ Inspect patient's feet

_ Consider need for vascular assessment

_ Evaluate footwear-

_ Enhance foot care education

5.7 Care of people at high risk of foot ulcers

· Arrange frequent review (1-3 monthly) by foot protection team

· At each review

_ Inspect patient's feet

_ Consider need for vascular assessment

_ Evaluate and ensure the appropriate provision of

· Intensified foot care education

· Specialist footwear and insoles

· Skin and nail care

· Ensure special arrangements for those people with disabilities or immobility

5.8 Care of people with foot care emergencies and foot ulcers

· Foot care emergency (new ulceration, swelling, discolouration)

_ Refer to multidisciplinary foot care team within 24 hours

· Expect that team, as a minimum, to:

_ Investigate and treat vascular insufficiency

_ Initiate and supervise wound management

· Use dressings and debridement as indicated

· Use systemic antibiotics therapy for cellulites or bone infection as indicated

_ Ensure an effective means of distributing foot pressure, including specialist footwear, orthotics and casts

_ Try to achieve optimal glucose levels and control of risk factors for cardiovascular disease

6. Dr Foster in Hampshire

6.1 The Dr Foster website launched a questionnaire to all PCT diabetes leads across the UK. Not all PCTs responded but information from those that did was accessible on the web. The questionnaire consisted of a number of questions not all of them relating to foot care. The questions that related to the scope of the review were selected and Hampshire PCT responses collected onto a table. North Hants and Fareham & Gosport PCTs had not responded at all and some of the other PCTs had not answered all questions.

6.2 The collated table was sent out to each PCT with a request for gaps in information to be filled and existing information updated if necessary. The final table (appendix 1) produced an interesting snapshot of services.

6.3 The Dr Foster questionnaire shows that all PCTs have appointed a lead for diabetes and all have implementation or planning groups that include diabetics. Only one PCT had a strategy for early identification of people with diabetes or provided information in other languages but all arranged education sessions with a professional. Only one PCT was able to respond with data on the recall system but all reported providing foot care clinics for those at high risk of developing lower limb complications.

7. Review questionnaire

7.1 The review questionnaire set out to add depth to the information gathered in item 6. The questionnaire was designed with advice from Mike Townson and sent out to each PCT in Hampshire (including Portsmouth and Southampton). Responses were received from 6 PCTs. Portsmouth City PCT provides the service for Fareham & Gosport PCT and East Hants PCT. Most of Portsmouth's answers are common to both areas but with occasional variations. The table of responses can be viewed in Appendix 2

7.2 Each question is listed below with a breakdown showing the PCT responses and the working group comments .

7.3 Question 1. Do you have a community or hospital based service for people with diabetes?

Summary of responses

All PCTs provide either a community or hospital based services with six out of seven stated that they provided both. Portsmouth City PCT provides the service for both East Hants and Fareham & Gosport PCTs. This is a hospital-based service at St James's with community outreach at local health centres.

Working group comments

There is a need to build primary care involvement to increase community-based services with clients only entering an acute setting if necessary. There needs to be specialist community based clinics for foot care in all areas That community based foot health services need to be increased with appropriate pathways into secondary care Consultants encourage hospital based services Foot health of people with diabetes is a whole team approach of which podiatrists are just one element. Podiatrists should be enabled to use their specialist knowledge and skills appropriately Attention should be targeted at the middle band of the needs pyramid as this will free up podiatrists to provide specialist care. Public Health should focus on the first level through information and advice to the general population Specialist care Public Health information

7.4 Question 2 Are foot assessments carried out in your area?

Summary of responses

Again, all PCTs state that they carry out foot assessments using a variety of staff such as podiatrists, practice nurses, district nurses, GPs and consultants. NICE states that all staff should be trained to carry out foot assessments but the answers do not show that this is the case. Three PCTs provide a training and development programme to support this function.

Working group comments

People with diabetes need to know that they should be given annual foot checks and, where possible, should share responsibility for ensuring that this happens Diabetes patients should be encouraged onto `expert patient' schemes Group unsure how public information would reach those potentially at risk. Contact between Jennifer Smith, the Diabetes Lead for the Strategic Health Authority, and the Directors of Public Health would be a starting point Portsmouth, in conjunction with East Hants and Fareham & Gosport PCTs, has developed a Baseline Foot Assessment Tool in the form of a questionnaire. The patient is asked set question and the answers carry a pre-set score. The final score indicates the care pathway appropriate for that patient. The form is a simple efficient and effective tool and the PCTs would welcome the opportunity to roll it out to others in the county. The baseline foot assessment tool won an award in The Diabetic Foot magazine, Autumn 2000. (Appendix 3) There would be a training need attached to the tool to enable all staff to use it in the right way and ensure consistency of approach. PCTs would need to identify this as a priority area to the Workforce Development Confederation (WDC). This training could be eligible for `Hot Spots' funding. The foot tool could be adapted for use by carers of adults with learning disabilities and elderly clients. The tool would give them basic checks that can be carried out on a regular basis to spot any early problems. In addition carers could support and encourage clients with their own foot health plans. Social Services would need to be approached and asked to become involved National core competencies have been developed for foot care. However there is not a national standard for diabetes specialist podiatrists Involving podiatrists in promoting foot health to the diabetic population is only possible by taking time away from patient contact, there is no specialist foot health promotion roles unlike dental health services All PCTs should be encouraged to adopt the Portsmouth baseline foot assessment tool and provide standardised training on its use

7.5 Question 3a. How many patients with diabetes were referred to podiatry services within the last calendar year? 3b Is this number higher than previous years, if yes, by how much?

Summary of responses

4 PCTs were unable to provide this information. Data for the 2 southeast PCTs also included Portsmouth figures so don't give a true representation of Hampshire's population. Again, due to the lack of data most PCTs were unable to respond to question b except for the Portsmouth area that showed a 32% increase in initial referrals between 2000 and 2003.

Working group comments

All PCTs are required, through GPs, to set up a disease register which should enable more accurate collection of data in the future The SHA will be putting a network in place to establish the level of sophistication / data collection that would be possible How can adequate support and provision be made if demand is not known? In addition the growing percentage of overweight and obese adults will lead to an increase in diabetics. Future forecasts need to be produced to predict growth in the number of patients, cost and staffing levels. 3b information for the south east cluster does indicate a growth in the number of referrals for both high and low risk categories

7.6 Question 4. Is there an annual recall system to remind diabetics to have a foot assessment in a) primary care b) in podiatry services

Summary of responses

Responses to this question are rather vague with most PCTs not very clear on what is happening. Only Eastleigh & Test Valley South states clearly that there is an annual recall system in place for both podiatry and primary care services. However anecdotal information for this PCT shows that the recall system is not being carried out. This raises the need for patient feedback to gauge the effectiveness and distribution of recall systems across all PCT areas. This response is disappointing especially considering the emphasis that NICE puts on the importance of annual recall

Working group comments

The working group was in absolute agreement that the annual foot checks should be carried out. Each PCT should take a lead in reinforcing this within it's own locality recognising that most practices will be taking on this role as part of the Quality and Outcomes framework component of the new GP contract. A standard assessment tool should be encouraged and only refer to podiatry those at increased risk as per NICE guidelines

7.7 Question 5. What is the waiting time for high-risk patients to see a podiatrist a) new referrals b) Existing patients c) How is high risk identified at referral?

Summary of responses

Only Eastleigh and Test Valley South PCT was unable to provide a response to parts a and b of this question. The others state that it would depend on the urgency of referral with a serious infection receiving priority and being seen within a maximum of a week. The longest wait would be in North Hants PCT with a maximum of three weeks. These timescales would operate for both new and existing patients. NICE recommends a 24-hour response for emergency referrals. Six out of seven PCTs identify high-risk patients through the referral or assessment process. Eastleigh & Test Valley South issues diabetes guidelines but does not add how this identifies high risk patients

Working group comments

The SHA questioned whether appropriate people are being referred to podiatrists and reinforced the need for threshold of referrals. This would require a whole system approach .Podiatrists should be dealing with increased risk referrals Similar problems exist with GPs as many are unsure what the referral routes are and so refer inappropriately. They should be encouraged to pass to their practice nurse. The practice nurse would then use the baseline assessment A whole systems approach across health organisations and those providing care for adults with learning difficulties and the elderly should be established to share responsibilities for patient foot care. That PCTs provide guidance to GPs on referral procedures and highlighting the important role of the practice nurse

7.8 Question 6. How many people within your PCT have a) Type 1, b) Type 2

Summary of responses

Only Eastleigh & Test Valley South have provided the information requires for this question and show that approximate ratio of 1:3 between type 1 and type 2 diabetes. Four other PCTs gave combined figures and Mid Hants did not respond to that question. Reliable information is important and we need to question why it is not being kept.

7.9 Question 7. How are minority groups with diabetes engaged with in relation to foot health a) Ethnic Groups

Summary of responses

The southeast cluster acknowledges that this is a gap in provision but add that they have `no separate plans for engagement' although interpreters are accessed when necessary. New Forest states that work is in progress but do not inform us what that work is. The three remaining groups state that they treat all groups the same

Working group comments

It was noted that people in Asian and afro-Caribbean communities do not always access healthcare services It was thought that diabetes information had not been produced in other languages. This is a role of the Directors of Public Health, they need to be targeting people at risk and providing appropriate information on assessments It was thought that diabetes information had not been produced in other languages. This is a role of the Directors of Public Health, they need to be targeting people at risk and providing appropriate information on assessments The Diabetes Network has a role to play in ensuring that information being collected on the disease register facilitates identification of ethnic groups who may need specific support

7.10 Question 7b. Elderly in residential care

Summary of responses

New Forest does not work with this group at all East Hants, Fareham & Gosport and Mid Hants all provide some domiciliary care with Mid Hants prioritising `high risk' groups. East Hants and Fareham & Gosport have no special arrangements for people with diabetes in residential care. North Hants again states that all groups are treated in the same way but does not elaborate on what this way is

Working group comments

It was thought that there is a wide variation in the quality of foot care provided in nursing and residential homes with a lack of clarity regarding accessing services It was agreed that elderly in residential care or housebound were an especially vulnerable group and their carers should be checking their foot health on an on-going basis There are training implications in this but Mike felt that it would be possible for a Podiatrist to provide training to social services but this would have to be adequately resourced. The initial training would enable them to cascade it to existing and new staff. The high turnover of staff in this area was recognised Skills for Health is a national training organisation for health and could provide the competencies for the training

7.11 Question 7c. People with learning disabilities

Summary of responses

New Forest has work in progress but doesn't describe what. East Hants and Fareham & Gosport extend their domiciliary care to this group and Mid Hants makes no special arrangements All three of these groups are identified in the NSF as the most vulnerable to foot problems. It is therefore disappointing that in the three years since the NSF emerged more has not been done to tackle these problems locally

Working group comments

It was recognised that enhanced communication skills and sensitivity were needed when dealing with this client group especially with the more seriously disabled adults The Podiatrists felt that these skills grew through experience but acknowledged that new staff needed these skills immediately not in twenty years time. In order for staff to develop these skills quickly additional training would be required It was suggested that this could be an area for continuous professional development (CPD) for podiatrists and could well be an area that social services could support in There could be a reciprocal arrangement between social services and podiatrists for a training exchange project

7.12 Question 8. What specialist provision is there for foot health care of children with diabetes

Summary of responses	Medical clinics for children with diabetes are held in the southeast cluster, however they do not have a targeted programme for working with these children outside of the clinic. The other four PCTs report no direct-targeted programme but use links from other professionals.
Working group comments	Again this age group and their carers must be seen as a priority. Good practice can be established at an early age that will reduce problems later in life. Weight management and physical activity would be a key aspect of this self-care.

7.13 Question 9. What progress has been made towards implementing the NICE guidelines on foot care for people with type 2 diabetes

Summary of responses	All PCTs claim to be responding to the NICE guidelines to some degree either through service delivery, education, LIT groups or training. More specific information matching the guidelines to local progress would be useful. Most recognise the benefits of multi-disciplinary working
Working group comments

7.14 Question 10. Do you have any intention of putting additional resources into podiatry services to support people with diabetes within the next three years?

Summary of responses

New Forest and Eastleigh and Test Valley South both have current applications in with the WDC for funding to improve foot care services, further details of plans would be useful. The other PCTs discuss as part of business review

7.15 Question 11. What information do you share with the Strategic Health Authority?

Summary of responses	It is clear that the SHA are not involved in any aspect of performance management or strategic overview of this service.
Working group comments	Jennifer Smith is the lead on diabetes for the Strategic Health Authority Confusion over PCT /SHA role on performance management of local services, however the SHA must maintain a strategic view It would be interesting to compare Hampshire and the Isle of Wight to other SHA's to establish what is the norm for this performance management role.

8. Conclusion

8.1 The review set out to examine

· What local processes for the identification of people with diabetes are in place

· What education for self-care and self-assessment is available

· Are foot inspections being carried out as part of the annual health check

· Is access to relevant podiatry services available when needed

8.2 The findings show that there is a huge variation in services across the county with no agency or partnership taking overall lead for developing strategic direction. Lead agencies need to share responsibility to develop a whole systems approach

8.3 A Diabetes Health Network is needed to plan and monitor diabetes services

8.4 Inappropriate referrals to podiatrists has created large waiting lists and difficult access for those most at risk

8.5 Public Health information on foot care needs to be accessible for all members of the community, especially ethnic groups, and they should be encouraged to share responsibility for their own foot health

8.6 Certain groups in society are particularly vulnerable, extra support and training for carers is needed to enable them to carry out routine foot checks

8.7 A training and development framework is needed to provide opportunities from basic level through to professional development.

8.8 At the review working group meeting on 22 September Social Services was identified as a key player through their role of providing services for adults with learning disabilities and the elderly. It was regrettable that there was not time to include them on the team however discussions have begun with senior managers to share the review findings and seek their views. It is hoped that Social Services will feel able to fully participate in supporting the review findings and recommendations.

9. Recommendations (see next page)

Health Review Committee

Access to podiatry services for people with diabetes

Review recommendations