Health review of Podiatry Services to people with Diabetes

Questionnaire responses - September 04

	NFPCT	ETVS	NHPCT	EH (through PCPCT)	F&G (through PCPCT)	MHPCT
1. Do you have a community or hospital based service for people with diabetes	Yes	Yes - both	Yes - both	Hospital based service with outreach to Primary Care with podiatry team working in both. Community service is based at local health centres with supporting domiciliary service for housebound	Hospital based service with outreach to Primary Care with podiatry team working in both. Community service is based at local health centres with supporting domiciliary service for housebound	Community based service (main health centres and some GP surgeries) but also in main hospital as part of multidisciplinary team. Limited domiciliary service available
2. Are foot assessments carried out in your area	Yes - podiatrists and District Nurses	Yes - by practice nurse and podiatrists	Yes - by podiatrists, practice nurses, GPs, consultants	Yes- By any trained person. The podiatry service provides training as part of the PCT shared services T&D programme. Assessment tool validated and published	Yes- By any trained person. The podiatry service provides training as part of the PCT shared services T&D programme. Assessment tool validated and published	Yes-by any trained personnel. Rolling programme for training available with emphasis on detection and management of long term complications
3. How many patients with diabetes were referred to podiatry services within the last calendar year	Information not available	Unable to get data in time	Information not collected in this way	(All 3 PCT's) 2003- 1603 initial referrals high or at risk =296 (18.5%) low or mod risk= 1305 (81.5%)	(All 3 PCT's) 2003- 1603 initial referrals high or at risk =296 (18.5%) low or mod risk= 1305 (81.5%)	Not able to provide this data at present
b) Is this number higher than previous years, if yes, by how much	IT system not set up to record but would expect it to be higher	No regular reporting of data back to PCT		2000- 1212 initial referrals high or at risk = 196 (16%) low or mod risk = 1016 (84%)	2000- 1212 initial referrals high or at risk = 196 (16%) low or mod risk = 1016 (84%)
4. Is there an annual recall system to remind diabetics to have a foot assessment in a) primary care	Not know but would assume there is a system as part of the new general medical system	Yes	In most practices	Not directly but practice nurses are trained to do assessment and foot care questions would be normal part of annual review	Nothing specific across all practices	In some GP surgeries an annual recall system in place
b) In podiatry services	Yes	Yes	No, but many seen annually	Yes, in some clinics for some patients who we believe may not be receiving an assessment elsewhere	Yes, in some clinics for some patients who we believe may not be receiving an assessment elsewhere	Yes, in some clinics for some patients who we believe may not be receiving an assessment elsewhere
5. What is the waiting time for high risk patients to see a podiatrist a) new referrals	Max 4 days	Unable to get data from service	With lesions 24/48 hours, without lesions 3 weeks	Depends on the urgency of referral. For example where infections/ulcerations are indicated a next available appointment would be offered. This can be same day where possible, but ideally within a week	Depends on the urgency of referral. For example where infections/ulcerations are indicated a next available appointment would be offered. This can be same day where possible, but ideally within a week	Depends on the urgency of referral. For example where infections/ulcerations are indicated a next available appointment would be offered. This can be same day where possible, but ideally within a week. Critical foot clinic established at RHCH
b) Existing patients	24 hours (except week-ends)	Unable to get data from service	As above	As above	As above	No reply
c) How is high risk identified at referral	Dependent on GP information on referral form	All practices have Winchester or Soton Diabetes Guidelines	By information on the referral	Through assessment by referrer a score of 25+ on assessment tool is an indicator of potential clinical risk. Or by description of clinical need on referral communication	Through assessment by referrer a score of 25+ on assessment tool is an indicator of potential clinical risk. Or by description of clinical need on referral communication	Through assessment by referrer by description of clinical need on referral communication
6. How many people within your PCT have diabetes a) Type 1	c360 newly-diagnosed each year	930	For both types 5543	For both types 7,100	Type 1 4499	No reply
b) Type 2	c360 newly-diagnosed each year	2,603	Do not have breakdown		Type 2 1151	No reply
7. How are minority groups with diabetes engaged with in relation to foot health a) Ethnic groups	Work in progress	Through usual primary care routes	All groups treated the same way	This is a know gap, however training in foot assessment is available to all a) no separate plans for engagement, Interpreters accessed when needed	This is a know gap, however training in foot assessment is available to all a) no separate plans for engagement, Interpreters accessed when needed	No separate or specific plans for engaging with ethnic minorities
b) Elderly in residential care	The service doesn't accept this group	Usually seen by district nurses	All groups treated the same way	b) Domiciliary service is available, however this is limited and no special arrangements for people with diabetes	b) Domiciliary service is available, however this is limited and no special arrangements for people with diabetes	Limited domiciliary service available, prioritised to `high risk' groups
c) People with learning disabilities	Work in progress	Through usual primary care routes	All groups treated the same way	c) Above applies, however we have previously undertaken targeted general foot health education programmes in this area	c) Above applies, however we have previously undertaken targeted general foot health education programmes in this area	No special arrangements
8. What specialist provision is there for foot health care of children with diabetes	Work in progress- not comprehensive	Children under care of specialist diabetes secondary services	Referrals received from paediatric diabetes nurse specialist and paediatric consultant	Medical clinics for children with diabetes. Specialist service for children which concentrates particularly on gait abnormalities and pain. No targeted programme for working with children with diabetes	Medical clinics for children with diabetes. Specialist service for children which concentrates particularly on gait abnormalities and pain. No targeted programme for working with children with diabetes	No targeted programme for working with children with diabetes, although links are established with the paediatric team regarding referrals
9. What progress has been made towards implementing the NICE guidelines on foot care for people with type 2 diabetes	Service running as specified in NICE guidelines, patients with podiatry risk assessed by multiprofessional foot team from primary and secondary care	Education and training of nurses in foot assessment. Launch of foot protection team June 2004	LIT group set up and foot sub-group being organised	Presentations to diabetes LIT. Revised advanced assessment form to match guidelines. Training on baseline foot assessments. Steps to minimise duplication and annual assessment happening. Encouraging podiatrist professional development in diabetes. Development of multi-disciplinary preventative strategy *	Presentations to diabetes LIT. Revised advanced assessment form to match guidelines. Training on baseline foot assessments. Steps to minimise duplication and annual assessment happening. Encouraging podiatrist professional development in diabetes. Development of multi-disciplinary preventative strategy *	Establishment of Foot Focus Group to oversee implementation of NSF and NICE guidelines. Revised assessment form and educational material. Training on baseline foot assessment and enhancing specialist skills. Revising clinical audit process.
10. Do you have any intention of putting additional resources into podiatry services to support people with diabetes within the next three years	1.4.04 WDC bid for 3 years, to be reviewed then. Not aware any other plans	Successful WDC bids over past 2 years to improve footcare in hospital, acute foot clinics and diabetes foot clinics in the community	The podiatry department directs it's resources appropriately. PCT has not offered extra resources due to current financial constraints	No immediate plans within next 3 years but discussing with PCT as part of diabetes care in the community strategy	None identified but will form part of the priority and business case setting	From a service perspective, business cases will be made for additional resources to meet NSF and NICE requirements
11. What information do you share with the SHA	Through WDC	None is asked for	Whatever is asked	Nil direct from service	Nil direct from service	Nil direct from service

* Full response from EH and F&G for Q9

Presentations to local diabetes implementation teams (LIT's). Revised advanced assessment form to fit in with categories identified in guidelines. Providing training to support health care practitioners with baseline foot assessments for people with diabetes. Working with primary care to minimise duplication of assessment and ensure that people with diabetes receive the recognised assessment as part of their annual diabetes check.

Encouraging and supporting podiatrists to be identified and trained as advanced practitioners in diabetes care through education (post grad Cert in diabetes care) and support (clinical supervision) and practice (undertaking advanced assessments and complex caseloads).

The NICE guidelines stress importance of prevention; the podiatry service plan identifies a framework to work towards this. For those identified as high risk increased multidisciplinary working through joint clinics is a priority. Continued work on foot referral pathway to accommodate recommendations within NICE guidelines to ensure low risk receive education, the at risk receive prevention and support to minimise their risk and those who are ulcerated receive timely and appropriate intervention by the MD foot team. Improved working across the region is occurring through the podiatry diabetes leads within each of the PCT's who have formed a specialist interest group for multi centred sharing, learning audit and research.

Barriers to achieving the guidelines in full are linked to inappropriate use of podiatrists. Inconsistent standards, education, communication and understanding between primary care and podiatry. There is no funding for the comprehensive training that is provided which comes out of podiatry patient contact time.

There are resource issues across all areas of primary care with increasing numbers of people with diabetes. This is particularly relevant for podiatry services where 50% of caseload is with this group putting pressures on service delivery to other at risk groups and reducing response rates.

Foot health education and assessment for people with diabetes is not resourced separately.

The specialist multidisciplinary foot health team needs clinical commitment and leadership to develop and maintain high skills and standards. There are also funding issues for diagnostic equipment and modern evidence based dressings.