Should the NHS do routine nail cutting?

I have always believed that nail care is part of Podiatry, I do not agree with Footcare Assistants

Joseph, why dont you agree with assistants?

 

Quite simple I think that at this time it is an errosion of of services that should be undertaken by Podiatrists.

I do however believe that Foot Health Professionals are more quaified to notice other foot problems that the patient may have that require Podiatrist attenion.

This is purely down to training.

 

Patient A is offered a partial nail avulsion, after which she will be discharged. If s/he declines, they are given advice about self-care and a discharge pack with advice leaflets and a list of HPC registered practitioners.
Your budget does not take into account short treatments.

Patient B is at risk of developing serious foot complications, especially with vascular changes and foot deformity. S/he will be given the care that is needed.

Patient C: Will not require long-term care. The least we can do is go in and provide one or two treatments for nail care if nobody else is willing/able to do it.

All of these are the options given by my local NHS trust.

 

Thank you for your reply Charlie. The problem is though you have just created an overspend on your budget. My local NHS Trust invites all nail care referrals into clinic for a 'keeping your feet healthy' presentation. From what I remember up to 30 patients/carers were invited to attend the talk.

When 'routine nail care' was part of local podiatry provision the podiatry waiting list achieved nearly 2 years. That was across the full spectrum, not just nail care but all referrals. The problem spirals when you offer an NHS service such as routine nail care to one individual & decline it to another. As is often the case in the NHS if an individual complains against lack of what is seen as an entitled provision of a service. Those who shout loudest are those which will gain treatment.

The NHS has no 'Magic Cooking Pot' refilling with on demand funds unfortunately.

Best regards,

Mandy.

 

Wow Twirly did we work for the same Moribund Organisation in 1986 when i joined NHS.

We had 2 year waiting lists then and for several years after 1986.

Women applied on 58th birthday as this meant they were 60 after waitng 2 years on waiting list.

Us poor chaps had too wiat till 65 years young to apply.

Blatant SEX and Age discrimination against us poor chaps:bang:

The other problem was that if the 60 year lived till 100 years they would get their nails cut for 40 years which would be longer than a full working life for the Pod.

This shows what LUNACY the old eligibility criteria was:deadhorse:

regards David in Sunny Warm Comfortable Sydney:drinks

 

Dear All,

To see how the Aussie system works please go to Aus page and look up the Pod Provision for Team Care Arrangements.

It makes interesting reading as to local and regional and national provision of Pod Services.

It also compares the different AHP professions provision of services.

Just do not look at the Medicare fees payable.

GP gets loads of Dosh for his part in referral.

Pod gets a bit for his provision of care.

BUT NO PAYMENT for letters and reports.

At one of our clinics we are up to almost 65% of total caseload Medicare Provison.

At the other we may only see about 1 medicare per day between 2 staff members.

Why the variance?????

I am not Politically Correct so please do not censure the following comments as being racist.

The clinic with high levels of provision is in a Lower Socio Economic suburb. Also it has a high level of recent immigrants from 3rd world countries. Also if you are Indian and have an Indian GP then you will be on medicare.

The other clinic is basically Upper Socio Economic Tertairy level of Education and Professional employment.

Also GP's here wont refer under medicare as a matter of principal.

So we seem to have a high level of social injustice against Middle Class Australia.

regards David

 

Reading through this thread I wasn't sure if was reading comments on the state of government policy on the NHS, a tyraid against immigration, or a comment column from the daily mail. :dizzy:

I'm assuming that when Paul posed the question he was referring to non-pathological / simple nails. If unsure of what this is referring to I try and use the following reasoning.

Could the patient cut their own nails if,

They had the right equipment - (in my experience a lot of patients use inappropriate nail scissors and often just need advice on the type of nippers to use).
or
They did not have a physical/mental disability - (back problems, foot phobia, poor eye sight, arthritis etc, etc).

In general if the answer is yes to these questions then I'm dealing with a personal care issue. Note I have said in general, we all know there are no absolutes when it comes to clinical decision making.

For those of us working within the NHS we have budgetary constraints and we have to target our service at those deemed most at need. This is a situation we may not be happy about but it is a reality nor is it specific to podiatry.

About 15+ years ago in the region I work in, District nurses used to be involved in the bathing/showering of their patients. To much consternation a decision was taken to change this and transfer this aspect of the patients care over to those responsible for providing personal care. 15 years on and our nurses are just as busy dealing with the ever increasing caseload of high risk patients in the community. No one would now even consider requesting that the nurse carry out showerng / bathing.

In my area we are actively working with our social services colleagues to help individuals maximise their benefits and ultimately sign post these individuals to the care they need.

Another similar thread on this forum wondered why the UK seems to be the one country were patients complain about podiatrists not cutting toenails. I think the reasons for this are complex and often very individual, but I have often wonder,

Has the NHS, (envy of the world - allegedly),somehow actively disempowered patients (or perhaps more relevant- relatives). Allowing them to abdigate responsibility for their own (or their loved ones), care, assuming the NHS is there to deal with all the difficulties that automatically come with getting older.

Has podiatry contributed to this complaint culture by withdrawing a service (social nail care), that it probably should never have been involved in the first place thus creating a historical dependacy for a whole generation of individuals.


In an ideal world I would love to be able to provide that personal care service to individuals. I'm not too proud or too qualified to cut nails - I still do these things and as others have said this is a very rewarding service to provide.
Sadly I don't think the ideal situation exists anywhere in the world, so could I justify using my skills to carry out nail cutting clinics to the detriment of those patients in pain or worse? - No.

I don't think NHS podiatry should be involved in routine nail cutting but it may take a generation to fully accept this situation and for UK podiatry to achieve that status enjoyed by other colleagues across the globe.

Of course we will still have lots of pathological nails to contend with and if say nail surgery isn't an option for such patients then where do clinicians develop the skills to treat these patients without necessarily starting out with non-pathological nails first??

Perhaps that's another discussion entirely!!


Michael

 

Having recently returned to the NHS after a few years away, it's comforting to hear that not too much has changed in my absence!

The PCT that I work for has specific criteria for patients who want to access the service. Essentially we'll only see people who have a medical condition that puts their feet "at risk". The PCT uses assistants for "nails only" patients.

 

Michael

For 25 years I had the same crap from NHS managers that you obviously are exposed to an a daily basis. Be careful - it is catching and ultimately fatal. You might like to try this little game next time you're at a staff meeting. Print the attached "Bingo" card and distribute amongst the staff next time your Service Manager is doing a presentation. Tick the box each time he/she/it utters the phrase. Winner is the first one who stands and shouts "Bullsh!t Bingo" with a complete card. It helps - promise!

MR

 

Hi Mandy,
I'm a Grade 7 Podiatrist with 17 years experience of working in the NHS. I am well aware of the budgetary constraints and the fact we have to make choices about who we are able to treat.

The options I chose are the ones that this Trust provides

We do not provide routine nail care to those who are infirm but not at risk of developing ulceration (for example) if we release them to self care, care by relatives or the private sector.

And frankly, I think that stinks since along with not providing routine nail care we also don't provide care for any of the other "routine" problems the low-risk caseload has. They are given one (or two at most) treatments and are then discharged. It seems the elderly in this country, most of whom have contributed in many ways to their country, are at the bottom of the heap when it comes to getting care in their old age. Oh, it's just "routine", tough.
Now, a good few CAN afford private care. Lots can't though - a small percentage amounts to a lot of people. It sucks, big time.

Still, the NHS doesn't have a bottomless well of money and this is the best we can do.

 

OOPs - guilty of "budgetary contraints" and "episode of care"!! Trouble is, I've gotten into so much trouble over the years for speaking frankly and not using management speak that now I watch what I say carefully and ending up using "safe" terminology just to keep my head below the parapet....most of the time. :wacko:

 

The DofH/NHS/PCTs need to recognise that ageing is a systemic problem and needs to be treated as such. Nail trimming to a high standard takes just 3 minutes, rather less time than the administration, and therefore less expense.

 

Hello Johnpod,

Are you arguing for or against?

This 'high standard' nail trimming you describe.

A. Who does it?
B. Who books it?
C. Who assesses the patient?
D. Who pays for the overheads: reception team, clinic room, lighting, instruments, clinical waste.... etc. etc. etc?
E. Which mug pays extra tax to fund it?

Kind regards,

Intrigued of Doncaster.

 

If it can be done by one person in private practice, (and it can and is!!!) it can be done by any podiatry team. In fact, it should be easier due to the economy of scale! Organisation is the key, and ridding yourselves of ridiculous bureauocratic nonsense.

The cost is pushed up by a huge and unneccessary administration far too many layers deep. This country needs a large dose of common sense - it's what we should have... in common. Without it society has no common ground and no coherence.

I find it difficult to justify a university education aimed at teaching critical thinking that leads to a 'job' that demands blind adherence to guidelines. That's really expensive and wasteful!

 

I agree with much of what Simon said; the problem is very much a NHS mentatlity issue - on the approach to the issue and the clinical attitude from the staff. I enjoy the variety of the job. Every patient offers a different challenge. Some simple; some complex - that is the nature of general practice.

You adapt your practice to suit the demand. Take bookings for example. You can manage a bigger caseload by structuring your appointment system appropriately. Don't forward book unless its for short-term management. Let the patient make their appointment as and when they need one. In other words when they are symptomatic. Even in public health, if implemented properly, it is rarely abused - and if it is, often a kind word of guidance suffices. Remember who we serve! Who pays their taxes to fund your wages.

I have to say that anecdotaly, I have found the attitude of some colleagues in public practice rather condescending towards some elderly patients. I even find some comments on these pages distasteful and disresectful towards those in our care. For me, no matter if they were a private or NHS patient - they are equally important to me irrespective of what they present with. As far as NHS eligibility criteria is concerned - it has always been flawed. Those who trumpet the policy on behalf of the profession usually have, in my books, the lowest aggregate IQ and nominally have a perfidious streak more akin than Benedict Arnold.

The government could fund the NHS properly. But it doesn't. Many colleagues in public health simply do not care - and have little incentive do do so. A sizeable number in private practice provide a fantastic range of podiatric care - effectively, efficiently and to the highest standard. Specialist/generalist/call-it-what-you-will.

Another example of NHS stupidity tonight. My sister has H5N1 influenza - a virulent strain. She has been seriously ill for the past 10 days and has menigitis-like symptoms that have not improved. She is a nurse practitioner and missed out on the first wave of vaccination the day she took ill. Her husband has had to take time off work to nurse her. He was refused the vaccine as he has "no underlying medical condition". Even though he is in close proximity - and has been for the duration of the illness. Now, 10 days later, he is exhibiting the first symptoms..... Needless, stupid, bureaucratic sh!te. Much the same as dictated to podiatry depatments over the last 3 decades.

 

I'm with Simon all the way on this one, the somewhat dubious criteria implemented by "caring people" often leaves a lot to be desired like an 80 yo CVA pt with a hemiplegia attending an NHS clinic for routine care only to be met be two podiatrists who were "abrupt and rude" who promptly sat the lady in a chair facing a wall, gave her a long handled file and told her to file her nails in future as she was not eligible any more. when she complained she couldn't reach her feet the podiatrists told her to put her foot up the wall which the lady promptly did and yes you have guessed it, she fell off the chair as the paralysed side of her body could not support her !!:craig:She was still discharged and this story was related to me by the patients daughter when she brought her to my surgery for Tx.

Now how proud does that make us feel ?? she instanced several equally appalling discharges that were done the same day in a similar manner which she witnessed, wont complain though dosent want to make a fuss( another of the too nice people around)

If you want to get more money into the NHS then stop the benefit system that is so abused and yes by people that have paid nothing into it and are bleeding it dry. I was listening to a health minister bleating at the rise in cost of maternity services and they were working out why they were going up ??

Couldn't be the immigrant population has 5/7 kids instead of our 2.5 could it

Cheers
Derek

 

Are we becoming radicalised due to NHS podiatric policy?

 

Hi Simon

Nah just injecting common sense into the Marxist ( communist) government policy that prevails in this nanny "look after all that are non contributors first the rest, thanks for your contributions and now go away ( FO) coz your entitled to nothing "state of ours !! Dont think, dont say, dont do anything unless it has been sanctioned .. blah blah blah ( don't get me started Si pleeeeeeeze dont get me started )
Cheers
Derek

 

Do you know Del, I think that's the first time I've been called Si on this forum.

Cheers,
Spoondog (as a number of my close friends call me)

 

I call my Son it all the time

His names frank BTW

No seriously he is a Simon as well and all my friends call me Del ( or Derek if they have the hump with me )
Be lucky mate great minds and all that bo***cks
Cheers
D

 

Maybe they could start a NHS lottery like they did for sport funding in the UK seemed to work well for the Olympics.

Get some money in the system and people to do the work

 

"While our immigration policy allows those that have paid nothing into the system to access care."

"Immigrant 30 year old female, paid zero national insurance contributions, working as a prostitute, requires treatment for a sexually transmitted disease and heroin addiction. Get's care on the NHS

What is fair and what is right?

Too much Daily Mail today, sorry."



"Couldn't be the immigrant population has 5/7 kids instead of our 2.5 could it"



Considering this is a forum open to public access I'm a little shocked at the vitriol expressed in some of the threads in this debate.
I now can see the reason for the rise in the BNP vote, when such xenphobic and racist remarks are expressed by our "verterans".

They obviously place little regard for the thousands of immigrant workers who are employed in the NHS (probably even in podiatry). Pull up the draw bridge lads!!

Surely immigrants don't actually work over here do they? Why it's a wonder these people have time to do anything, what with their drug taking, promiscuity, queuing up for handouts and determination to outbreed us all.
I do hope that those of you in private practice show those bloody foreigners the door when they turn up at your clinics looking for treatment - or better still get the cane out of the cupboard and give them a damn good thrashing before sending them back under whatever rock they crawled out from!! (note to admin there isn't really an adequate smilie for expressing sarcasm)

To paraphrase Winston Churchill ,(with some artistic licence thrown in),
Never in the field of human suffering has so much sh*t been talked by so few to so many!

 

Daily Mail has this today:
http://www.dailymail.co.uk/news/art...70million-critics-say-wont-help-everyone.html

And also this:
http://www.dailymail.co.uk/news/art...llowed-stay-Britain--Home-Office-knew-it.html

 

Where's that then ??

Why oh why is it that whenever anyone expresses an opinion on the factual things in this country the politically correct lefty members of the society scream racism ??

No one is complaining about anyone that lives here and contributes BUT we all know the abuse that is being taken on the benefits ( and not only by immigrants) if we are to provide funding for services in the NHS then I feel a good way to start would be to review the benefit system and stop it in the main to ANYONE that has not made a contribution not as we do now punish those that have paid into it all their lives and in their old age when they need the services they are being denied them.

Not racist Not Xenophobic just factual and expressing an opinion
Cheers
Derek

 

I'll start slinging mud at asylum seekers and immigrants when our indiginous population ALL have jobs and are contributing to society. By far the greatest number of "drains on our resources" round here are at least 3rd generation English, don't work, have never worked, will in all likelihood will never work and have a better standard of living thanks to all the handouts/tax benefits that I and my ilk (have worked since the age of 15, paid my way through college etc) contribute to.
(I'm not even sure the above is gramatically correct, but its nearly lunchtime so am not checking and I think you will be able to work out what I mean!).

 

This article from Melanie Philips sums up nicely the attutude towards the elderly that sadly pervades.

http://www.dailymail.co.uk/debate/article-1228768/The-state-cares-old-WE-care-them.html

 

My feelings exactly

Cheers
Derek

 

"Couldn't be the immigrant population has 5/7 kids instead of our 2.5 could it"

Why would a supposedly intelligent individual not believe that making such a remark might, just might, be interpreted as racist.
I'm not a fan of the government's Social or Health Care policies but I'm not about to blame the immigrant population for the country's woes - I blame the MPs and at the next election everyone should make their discontent count!

Never mind an NHS lottery - how about we get back some of those MPs expenses, or start targeting some of the taxes (particularly those on fags and booze) back into the NHS.

As far as quoting the Daily Mail as some sort of justification for these remarks - well I rest my case. If I am ever reduced to reading the Daily Mail to form my opinions I know its time to shoot myself.

Stephen Fry put it very well when he said,
"It's like opening a piece of used lavatory paper, reading newspapers"

and Thomas Jefferson
"The man who never looks into a newspaper is better informed than he who reads them"

 

Yet another fact foot posture i'm afraid , and one made in comment on the governments apparent lack of understanding as to why the cost of maternity services have risen,nothing at all to do with racism .

Unfortunately we are now in this communist country unable to voice an opinion the dosen't suit the politically correct as factual as the statement may be.
I'm not a fan of this Marxist government either and even less so of the nanny state they and the EU have created , but I fear we are going way off topic here and getting into politics so.........
Cheers
Derek

 

Who is quoting the Daily Mail to justify the remarks?

The great thing about the UK is that it is a democracy and we are free to vote for the political party of our choosing. If there is a growing vote for the British National Party (they will not be receiving my vote by the way) why do you think this is? No-one is forced to vote here. We are also free to openly discuss and debate governmental policy. If you find the issues of UK immigration policy and UK health policy difficult subjects to discuss, without accusing those who are discussing it as being xenophobic and racist, then perhaps you should not enter into the discussion.

Alternatively, you could have the courage of your convictions, stop hiding behind your pseudonym and enter into a reasoned discussion.

I assume Mr, Mrs, Miss, Ms. foot posture, that you do live in the UK?

 

For the record, or mine.
Cheers
Derek

 

Would that be the same Stephen Fry who is allegedly now seeking U.S. citizenship?

And the same Stephen Fry who enraged Poland over his comments regarding the holocaust?

 

Ah, the comedy of timing. Just had a visit from a lady who's two elderly parents are likely being discharged from NHS podiatry soon. Her 94 year old father has been receiving appointment at the local NHS clinic for a series of what sounds like sub-ungual breakdowns. He was being seen weekly, now three weekly, but because her fathers "neurologic status has not deteriorated" apparently "in all likely-hood he will be discharged at the start of December".

Her mother is also in her 90's.

What were those predictors in Prof. Campbell's model?

How much in £'s does the discharging of patients like this really save the NHS?

 

I'm not sure it saves any money at all...

I know that before we introduced a scoring system to try and identify patients at higher risk, the ones designated "low risk" were only being treated once or twice a year. We also had waiting lists of 2 years or more for the "routine" referral.

Now the routine patients (because yes, we still do nail care and callus/HD reduction on the patients who scored high enough to be kept in service) are seen every 3 months. More frequently if they need it. And the longest waiting list is 13 weeks.
Nail surgery referrals get their assessment within 3 weeks and surgery the week after.

The service has improved imeasurably for those who scored highly enough to be kept in the service for long-term care and for those having a short course of treatments (Nail surgery and biomech).

As we're just as busy as we ever were, I doubt any money is being saved at all - except that the comissioners haven't had to increase our budget to that we could increase our staff levels to take care of everyone who needs our service.
As to your chap, if he's getting recurrent subungal aseptic necrosis then surely that's linked to nail thickness and/or footwear? Once these are addressed he's at no higher risk of breakdown than anyone else is he? And if he is still at risk of breakdown: why? Is there a vascular element? Here, anyone who's got impaired peripheral circulation stays with us - the risk of problems developing after discharge are too large to let go... I think there's more to the recurrent breakdown than you're mentioning here and I'd question whether the gentleman will actually be discharged once fully re-assessed. Mind you, I could be wrong since different Trusts have totally different ways of deciding who gets treatment and who goes (that's another thing really: there should be one system that determines who's "eligible" and who's not because at the moment its a total postcode lottery...one that will get worse as Trusts devolve into Commissioners and Providers).
And then there's the thorny question of age - where do you say "you're old enough to receive free treatment"? 65? We had that and Podiatry was seen as a nail cutting/callus whacking service you get automatically once you retire. But half the people we saw were quite capable of looking after their own feet and anyone with a biomechanical problem wasn't eligible for treatment. If you make it 75 - why? 80? 90? Where do you draw the line?
Because the line has to be drawn when there's a finite amount of money/Podiatrists/free appointments. It sucks, but thats the reality.

 

When a patient of ANY age becomes incapable of self care be that from disability or old age

IMHO they should get proper foot care free from the NHS, which can take a new direction perhaps say the NHS /GP's funding IPP's to provide the service if the NHS cant do it directly ?.

Cheers
Derek

 

What predictive models are used to define your scoring system? How is each component weighted and what evidence is this based upon?

 

I can only tell you what I was told by his daughter, who also said that he had previously been discharged before only to have to be "re-admitted" to NHS podiatry when his foot health deteriorated soon after being discharged. It struck me that the daughter had a sound grasp of the system and had obviously been discussing the future care of her parents with the NHS staff, which had led her to come to me to plan ahead for her parents care.

This is why you need to look at your predictive models and then determine your acceptable risk. If we took age as a predictor in isolation we could look at the model and work out the risk of the patient developing foot related problems requiring medical intervention. The more predictive variables you add into the model the more accurate your predictions are likely to be.

For Robeer, a bit of Moody Blues- I Know You're Out There Somewhere:
"The words that I remember
From my childhood still are true
That there's none so blind
As those who will not see
And to those who lack the courage
And say it's dangerous to try
Well they just don't know..."

Jackie's model is there for all to see and employ. Hands up all those who use this model as part of their discharge policy-?

I'd be really interested in taking a look at the varying models used within the trusts and the data they are based upon, I just can't seem to find anything published in this field other than the ones I highlighted at the start of this thread.

Perhaps it's something NICE should be looking at?

As I don't work in the NHS, perhaps someone who does could enlighten me, are data being collected regarding discharge and what happens to the patients that were discharged in order that better discharge models may be created, or are they just discharged and forgotten about? If not, why is this precious source of potential data that may be used to better inform decision making being ignored? Is it because:

a) it's not in my job description
b) I ain't got time, mate.
c) what's a predictive model?
d) A.N. Other?

 

Here is an NHS eligibility criteria I found for Cambridgeshire: http://www.cambridgeshirepct.nhs.uk...nt criteria.pdf?preventCache=27/09/2006 13:52

Lets take a look at the "category I - high risk" criteria

A chronic debilitating condition of the patient’s lower
leg/foot or acute systemic disease which threatens life or
limb and/or is having a major impact on their mobility and
function
Measurable signs of this are:
1. Impairment of circulation
-Marked temp gradient/demarcation line
-Marked venous insufficiency
-Absence of two identifiable pules on each foot
-Capillary filling time greater than 4 seconds
2. Serious impairment of neurological function
(sensory or motor)
-Insensitive to 10g monofilament
-Vibration testing
3. Serious structural deformity
4. Medication with potential side effects eg. steroids
5. Immunological disease/immunosuppressed
6. Infection/ulceration

Anyone want to critique this before I do?

 

Crikey Simon, you don't ask for much from someone posting on a message board, do you?
All I can tell you is that when we were told to discharge a % of our caseload so we could manage patients effectively, we looked at what other Trusts did, including their scoring systems.
We decided that age was not a good enough criteria, given that it is so arbitrary.
Anyone requiring biomech. treatment or nail surgery gets it.
As to the people requiring "routine" care, we award points according to medical conditions, foot deformity, ischaemia, neuropathy and history of foot ulceration. Anyone scoring above a certain score is given treatment for as long as needed - often for life. They are asked to do what they can to look after their own feet, even if that is only getting/wearing appropriate footwear and making/attending appointments.
We cannot unfortunately care for everyone who is unable to care for themselves: trying to is what got us into the situation of long (very!) waiting lists and people not being seen as often as they needed treatment.
As to whether the discharged are followed up, we're in the process of doing a survey on a selection of those discharged to find out what problems (if any) they have had. We've already contacted all GPs/nurses/physios/OTs to see if they've noticed an impact on their patients and if so, what.
The results may help squeeze some more funds out of comissioners so we can re-introduce the lower-risk (lower risk of developing foot ulceration, for example) caseload. Or the results may show that actually, most people are coping fine and that just as free dentistry has become a thing of the past for most adults, so has Podiatry.

 

Hi DDT
I'm not sure I would entirely agree with your statement regarding where to draw the line,
"When a patient of ANY age becomes incapable of self care be that from disability or old age"
Realistically I think that is too broad and simplistic a definition. Imagine I become incapable of self care through accident or illness. I can no longer carry out my own simple routine nail cutting. Am I really going to contact my podiatry department to come and do this for me? I wouldn't expect that, nor would most people I would have thought.
I think we have to seperate out what is social care and what is podiatric care and for too long the podiatry profession has, for the best of intentions, carried out too much social care.
Certainly my interpretation of the original question posed by PAUL UK regarding routine nail care was referring to social nail cutting.

Thanks Simon for recommending the articles By Jackie Campbell - very interesting. I noticed that she too is careful to seperate out social care from her studys.
I wouldn't even begin to understand logistic regression analysis but her findings are certainly thought provoking.
Interestingly searching for those articles led me to a related article on FOOTSTEPS a project aimed at encouraging patient self-mangement for exactly these kind out routine patients.
The inital results from that seem promising.

Glad we're back to discussing podiatry again - was there a full moon or something!!


Michael