Sailor put on 1 year NHS waiting list – to have his toenails cut

Somewhere, deep in the NHS, lurking behind a desk, is Mr Jobsworth - you know the chap, he always starts sentences with

"Look love, it's more than my job's worth......."

You can see him shaking his head and pushing the file to the end of his desk.

Wonderful, what could we do without the bureacracy.

cheers,

Felicity

 

Hi All

Now whilst I agree this gentleman at this age SHOULD be treated free of charge and in a reasonable time by the NHS and to put him on a 12 month waiting list is frankly nothing short of crass stupidity by the bureaucrats I would put perhaps another angle for discussion :-

The gentleman's SON is paying £15 a month to get his fathers toenails cut WHY ??

Does his father not get benefits which come in various forms TO BE SPENT AS THE GENTLEMAN WISHES FOR MAINTAINING A QUALITY OF LIFE ?? not as many who still live in the past do , take the benefit , bank it for a rainy day (or a relatives) and then still expect every service for free.

Why does the nursing home (assuming it is privately run) not include the cost of footcare in their fee's ?? they could perhaps negotiate a group rate ??

Most of the honest elderly I speak to tell me they have never been so well off as they are today because of the benefits available to them!!

We all know the service to the elderly for routine footcare provided by the NHS is on the way out people have to pay for some services themselves and how they spend their money is up to their own priorities.

Just one last point to give as an example .

I had a 91 year old living in Cornwall who died a few years ago who was an ex chindit decorated for bravery in the war .He was also denied footcare and was so mean he would not pay for it or anything else for that matter unless it was for his social enjoyment.
I provided footcare for him and my wife did about everything else in looking after him on a 6 weekly basis for over 15 years ( a 500 mile round trip) after he had a heart attack and was sent home in a remote cottage alone.

So I do have first hand knowledge of the frustrations in dealing with this age group on a personal level.

My advice is perhaps the full facts should be examined before we get too emotional over what I assume is a newspaper article ( and remember the day and the date at the top of the page is all that is factually true in most)

Just another perspective

Cheers

Derek

 

I thought NHS stood for National Health Service .... where is the health gain from cutting toenails? Why does th NHS even provide this service?

 

Hi Craig,

In answer to your question above, Quote, "Where is the health gain from cutting toenails?" Possibly,

1. Could it be Chiropodists in the past Kingdom building in the NHS.perhaps?

2. Could it be that was what Chiropodists used to do in the same way that Dentists examined perfectly health mouths and Opticians examined eyes?

3. Could it be that this is where the work was discovered and dealt with before it became something rather nasty? (Preventative medicine in Chiropody perhaps?).

Regards,

Colin.

PS. I'm innocent! I was not there at the time, so who was responsible for this preventative medicine? Aunt Sally perhaps?

 

Hi Craig

Ok I'll rise to the bait

Prevention is better than cure. Wound prevention from unkempt nails is the obvious one but a patients general mobility and well being is another ,not to mention safety of care staff .

I think when any infirmity prevents the patient from attending to their own bodily needs and there is an obligation to provide an alternative.

I'm sure someone out there has the figures for the cost of treatments in ulceration / wound care / falls in the elderly with the nails being a factor in the cause, and how that equates to the cost of provision of basic footcare??

Whichever way you look at it this is a funding issue along with many others ,perhaps a 2p in the £ on income tax would help to fund the NHS properly so that no one was denied functional health care however minor the need.

Cheers

Derek

 

Cutting toenails might not be rocket science, but you just try going without having your nails cut. The chauxic nail under the pressure of the bed clothes can result in a subungual ischaemic wound, the involuted nail - needs no description. The elongated nail - sure it's no medial emergency, but it has a lot to do with shoe fitting, thus comfort, thus mobility, thus independence.

I don't think that nail care is the be all and end all of podiatric work, but during these palliative care sessions there is often the opportunity to detect underlying medical, and in the older population, social and emotional problems.

Sorry Craig, I'm not with you on this one. I believe that cutting toe nails should be seen as part of the overall health care given to people in need of this service.

cheers,

Felicity

 

Thats the crux of my comment. When resources are limited (and societal resources are) then the resources directed toward health care, in general, and podiatric care, specifically -- should be directed at those services that provide the greatest health gain. Societal resources for health care are limited and podiatry's share of those resources is also limited in the face of unlimited (and growing) demand. I agree with DTT's comments re prevention and yours re chauxic nails etc ..... BUT (and there is always one of those), is providing a toenail cutting service (when resources are limited) in those with no or minimal risk a good use of those resources when there is no real health gain from providing that service? The resources allocated to podiatry can be much better spent (ie in high risk services) to achieve greater health outcomes.

While I agree with the sentiments expressed above re prevention, but we actually have no idea if its a cost effective use of resources (especially when society is paying for the resources) .... I do have certain doubts it would be cost effective, primarily because those who really need it, never seem to get it.

 

Hi Craig

So are you suggesting we leave this group until they are high risk or fall into a different statistic category ie A&E visits through falls at home ,physio for mobilisation , drug care for depression etc ?????

We cannot just ignore on your criteria otherwise where do we stop ??

Lets close all maternity units natural thing childbirth 9 months notice and all that ??
Lets close all geriatric care down , they are all old and going to die anyway leave them at home and let them get on with it .

Is that acceptable ?? of course not, but that is where your argument will ultimately lead.

I think never is too broad a term .

Some won't as it would appear this chap didn't in the article but when you are dealing with a large number mistakes will always happen .

What irks me is the fact that this was brought to the attention of the bureaucrats and nothing was done about it !!

Perhaps if we got rid of these Muppet's then perhaps the money saved would fund a proper service?? but here we go again on the funding spiral again
Cheers

Derek

 

Didn't say I agreed with it. It just a fact of life at the moment in all publically funded health care sectors. What you are speculating could happen, is and has been happening for a while now, across the board. Its a natural consequence of limited societal resources having to be prioritized - why are so many services discharging the low risk non-pathological toe nail cutting?

 

Hi Craig

Perhaps the beurocrats are being advised to by those with similar thoughts in senior positions to your own ??

Nail cutting does not as a rule draw national headlines inasmuch as say new advances in heart/cancer care does.
It is easy to sweep under the carpet and after all it's only the elderly that complain ??

Or do they??:-

I get an overdose of moaning on certain lists I do but when I ask them "did you write to your MP /local councillor about it ??" I'll let you guess how many actually do.

We are thoughout this profession eager for advancement in status and all that brings BUT (yes we are agreed there is always one):-

We must never lose sight of the fact we treat a PATIENT not just feet(of which nails are still a part) and we all have a duty of care to that patient .

So Felicity has it quite right I think , and my words "prevention is always better than cure" must be maintained for the long term benefit of the patient and the profession.

I know I am talking in "ideals" and there is only so much money which has to be prioritised but preventative care must feature in that

Cheers

Derek

 

By crikey all the arguments have merits. I am right (of course!) that toenail cutting is an important part of healthcare, and Craig is right - it's a part of healthcare that we just can't afford under the current funding situation (at the risk of failing to offer services to patients with more severe medicopodiatric needs).

So, now comes the time to discuss Pod assistants/Footcare assistants etc. In Australia the move is to have them well trained and under the direct supervision of a Podiatrist. And in many ways their task will be to offer care to those people who need it - but at the toenail cutting need level.

Apart from all the scope of practice arguments, the essential economic argument is this: they will be paid less and thus provide a service that will cost less (public and private), and stretch the budget further.

Now- is this a good idea? How much less are they paid to ensure economic feasibility. Is that appropriate? Given the ageing population yadda yadda yadda, are we right to introduce a new species of foot carer for this purpose? Or should we be working to get the authorities to recognise the genuine need for greater funding for foot healthcare?

cheers,

Felicity

 

The question is who should be the beneficiary of free State care and who should pay? There are no clear guidelines on who can and cannot receive NHS treatment and eligibility varies from one Trust to another. Certainly there is no argument that many elderly have a 'need' - even if it is just simple toenail cutting. Who else do some of our old folk have to turn to when they have no family left, no carers and no income to pay for private care?

I am ashamed to say that my profession has let many frail and vulnerable people down in the last few years by embarking on a programme of discharging 'low risk' patients when the demand for podiatry services increased - often without any consideration to whether these people could fund or even access private care in the first place.

I agree that podiatry is a great deal more than just cutting toenails, but elderly care is an important facet of our practice and as Felicity points out, routine nail care and foot health checks in this demographic very often provides the clinician with an insight and early warning of other systemic and lower limb disorders.

The problem is not the patient or the presenting condition Craig, it is how we as a profession structure and establish out practice to meet the demand effectively. I would suggest that providing podiatry services through a salaried model of direct employment is not the best solution for either the patient or the profession and I could cite numerous reasons - as I'm sure you could too - for this.

I share similar fears with Felicity over the introduction of 'assistants' as there is speculation that this grade could take over what has been described as 'routine chiropody'. Certainly within the NHS there is a tacit acknowledgement that this is desirable if not essentail. I have to say that as a general practitioner, I am appalled by that suggestion - it has taken me twenty-five years to build up the body of knowledge that I hold and I am learning still - and to suggest that an assistant could and should take over the work I do after an NVQ six month course is frightening and not a little insulting.

Are we saying here that general practice podiatry has no value as such?

If however assistants were introduced to assist me as a clincian then that is a different matter. If I had a three-chair surgery with two or three healthcare assistants to prepare the patient, complete the notes, change instruments, complete paperwork, dictate letters, make appointments & etc I could quite easily increase my output from 25 patients/day to 75 patients/day. Extrapolate that on a national basis and provided we had clear guidance on who is eligible for State care, we would have no capacity issues in the NHS...... However, I am not convinced that a directly-employed salaried model of employment is the best model for the profession. It might be the cheapest option but does it provide real value for money and does it enhance the working lives of clinicians who are engaged in its care? I would suggest not and I would certainly not be seeking to increase my output unless I had a similar increase in salary - something the current model would not allow.

Mark

 

Hi Felicity and All,

The flood gates are about to open in the UK. We are good at cutting a part of a field of health off and then wondering why someone else moves in!!!

FHP's and assistants are getting to be a Thorny subject over here. But never mind the HPC. cometh! I think they will have something to say about it after the 8th July 2005 when they assume their powers of who can and who cannot cut toe nails etc.

Debating it here from the UK point of view may just add fuel to the flames I fear? But it seems that what happens in Australia is of interest because the health cultures seem similar. Even if some of you do not love us anymore, come to think of it some of our lot do not love us anymore also!

Regards,

Colin.

 

No Colin, that is incorrect. The HPC cannot and will not determine who can 'cut toenails'. It is only concerned with the use and misuse of titles and does not seek to protect the practice, unlike dentistry which enjoys functional closure.

 

Hi Mark,

Your picking on me again!

I think we might find that when the HPC. starts registering FHP's and possibly NHS. Assistant Footcare Technicians they will have a direct influence on nail-cutting!

Regards,

Colin.

PS. See what I mean Felicity!

 

In response to the above comments

Although I have followed this forum for some time this is the first posting I have put on it, when I saw the posting on this subject last week, I decided to wait to see what comments were placed on it before I made any comments.

Well looking at them I will let you decide if I am “Mr Jobsworth” or a bureaucrat guilty of “crass stupidity” as some previous postings have made out, I think I am a Podiatry Services Manager trying very hard to get resources into Podiatry in an environment where the valuable work we do is not top of the political priority list.

Yes the patient was referred to our service and in fact I am very happy that we have been criticized, I am just sorry that the son went straight to the press and did not contacted us directly at all as such I can't follow up with a individual response to the patients Son.

My first feeling was, as several postings have said that this should not be a Podiatry need at all but a social need, but were unable to say that is such blunt words when responding to the press query. In short we received a referral, we triaged it deemed it a routine non urgent referral and the patient received an acknowledgment letter.

To give you some background

In Selby and York PCT we provide around 57000 patient treatments per year, we have a good reputation for both Musculo-Skeletal and Diabetes and High risk service, in addition we provide service from 20 odd community locations and about 8% Domiciliary.

We have to balance the need to see the new patients referred to us with the obligation to provide safe follow up treatments for those who need follow up, I am aware of a number of UK NHS Trust who see all new patients with in a few weeks, but are unable to provide any form of follow up appointment for 6 months, I do not feel that this can be morally or legally justified as I believe as soon as you say a patient has a need for a treatment, you have an obligation to provide such treatment in a safe way.

As such we prioritise our referrals. Like a number of other Trust we have next working day access for urgent referrals (Ulcers etc) 6-8 week for soon, but this is at the expense of routine, this may not be liked, by those with lower need but, I think it is the right priority and if we could turn the story back on the press, I think they would say preventing an amputation on a diabetic patient with an ulceration is higher priority than cutting toenails, however old the patient.

We do employ 3 Foot care assistants and have had assistants working in York for about the last 20 years they are an integral and valuable part of our team, however it still requires an assessment and treatment plan to be drawn up by the Podiatrist to enable a patient to be seen by one of the assistants. The majority of their work is on pathological nail conditions and the non pathological work is referred back to carers be that relatives or paid carers as in the case of nursing homes, we are happy to provide training to either type of carers.

I don’t ever think that assistants will replace the diagnostic or treatment skills of a Podiatrist, but we should look at their current role and ensure it is used effectively to enable the Podiatrists to undertake more complex work. I know that there are many high-risk diabetic patients that my specialists are keeping out of hospitals, who 20 years ago when I was a Diabetic specialist myself would have gone straight to surgery. The same is true for the advance in Musculo-Skeletal service.

Podiatry has been criticized in the past “people are on your books until they die” For a number of our patients this is true as treatment is more about preventing deterioration than being able to cure. Over all I feel we have good discharge figures, with 65% active discharge against 35% due to death, it is just that overall we discharge about 10 patients a month less than we take on, hence the increasing waiting list. You could say that the simple answer is to increase the discharge rate, but if we are then discharging patients purely to meet then incoming demand and not on clinical judgements this is not defendable.

On the question of prevention, I do not want to focus on this one patient, or toenails, but I would say that Podiatry has a valuable role to play in improving mobility and prevention of other more complex and expensive intervention, be that the range of surgical interventions associated with ulceration, orthopaedic or for that matter you could argue that if you are not mobile there is a whole range of social or medical interventions that are needed. As such I take every opportunity to ensure that the cost of NHS Podiatry is viewed in context of the whole of health and not just with in the current Podiatry resources.

So the more of these press articles the merrier as far as I am concerned, it is just a shame it is about toenails not "proper Podiatry". It all helps bring the issue to the attention of the PCT Directors/Board and reinforces the work I do internally to get resorces.

As with a lot of these things it is simple for the press, or other outsiders to say “that is ridiculous, how much would it cost to treat one patient” it is just taken out of context of the whole balancing act we have, both with the others on the waiting lists and the huge number of current patients we have who have benefited from treatment, better mobility, limbs saved etc

For that matter, with limited NHS resources it is the same as others above me are doing, should we pay for one heart bypass and save one life, 3 IVF treatments and enable a childless couple conceive or several hundred Podiatry treatments to improve the mobility of a significant number of patients? All I do know is that the press would get headline either way!! .

What I do believe is that with all the work we have done in our service to be efficient and effective, the current waiting list of up to a year for Routine is a commissioning issue for the wider health community and not just an issue for Podiatry

Finally I can see the patient’s sons point (taking account his misplaced belief that this is an NHS job, it is a simple thing to cut toenails and he can see public money being spent on celebrations, which he thinks is less important)

I have made my points, your comments please.

Robin Hull
Selby and York PCT

 

Hmmmm

You know this oh so sounds like the sort of reply that you get when you have a "*^% hoilday.....statistics thrown at you then followed up by the "number of satisfied customers we have"

Sorry to have a go, but even I can read a date of birth!....or am I missing the point here..........(I am in a mood because i am revising for an exam and it's not going well).

Cheers

DavidD (reaching for the tin hat of previous fame, must be my turn)

 

Robin

Clearly the issue here is funding demand and expectation. Even if we were to be in a position of demonstrating unmet need, we still have to address the shortfall in capacity that under-funding creates if we are to satisfy that demand in future. Whether we can persuade government to allocate more monies is open to question – even if we provide the evidence.

Perhaps we should consider other ways of funding podiatry care – such as the introduction of charges for some treatments. Have the State pay for acute and specialist work and for all necessary care for patients on low incomes, and introduce a national fee scale for the rest.

Using the ‘choice agenda’ proposed by government, create a network of affiliated practices, commissioned and inspected by local health authorities, and divert the non-acute/specialist work to them – rather than charitable volunteers or care workers or even assistants – and everyone involved with the profession benefits.

The patient has access to clinicians of their choosing, comfortable in the knowledge that their clinician has been validated to have standards of proficiency equal to that – if not better – than the NHS. You, as a service provider, will have increased your capacity substantially, freeing up valuable clinical time for critical care. And your colleagues in private practice gain too – providing their contracts are constructed in a fair and equitable manner and are not sold short like what happened in the 1970’s.

The government have never, and will never, fund podiatry care in its entirety. But it might be persuaded to increase funding providing we can demonstrate the benefits of regular skilful intervention by clinicians of proven standard and competency. There are currently over 10,000 registered podiatrists in the UK of which 3,978 are engaged in practice through the NHS. Why don’t we make more use of the other 6,000 before we start training a lesser skilled workforce?

Kind regards

Mark Russell

 

The Dreaded Toenail!

Hi All,

Our first objective here could perhaps be to define the question,

"Is cutting toenails a MEDICAL TREATMENT or a SOCIAL TREATMENT?"

MEDICAL.

1. Medical:- Does the cutting of toenails fall within:- Disease or Surgical Treatment?

2. Why does anyone cut toenails? Is there a medical reason?

3. Medicine:- The art of restoring and preserving health, [The Concise Oxf. Dict.]. Does this apply to TOENAILS?


SOCIAL.

1. Social:- Having to do with the rules, arrangements and habits of community or group. [Chambers Compact Dict.].

2. Why does anyone cut toenail? Is there a social Reason?

3. Social:- The living in companies or organized communities, gregarious. [The Concise Oxf. Dict.].
Is the cutting of toenails an element of society?

Would Society become upset if we all walked around without having our toenails cut?
Would a Society with uncut toenails be a medical or a Social Problem?
If it is a Medical Problem, the NHS. is stuck with it! Unless as some have intimated it is to be privatized and paid for by individuals! Or perhaps as a society we should produce a National Insurance Stamp for toenails among other things?

A discourse on the lowly TOENAIL??? Yet I am typing this in the late evening because of having had a dreaded attack of cutting Toenails!!! Somebody must like short Toenails, I wonder what it could be!

Regards,

Colin.

PS. I liked your Post Robin, quality absolute real quality, and this was on toenails and things that are a little higher than toenails perhaps!!!

 

Hi Robin

”

If you were the person that made this decision then YES YOU ARE in my opinion

Stories like this may please you they do not me .

I am heartily sick and tired of making excuses to patients and patients relatives over the shortcomings in the NHS and why they are not getting the service they require and have to pay me to get it.


I do it daily not to slag off the NHS podiatrist , but to make excuses for them and the pressure YOU put them under with targets, statistics and the increasing bureaucratic nonsense overtaking their treatment time.

I suppose I should be happy about it as it increases my income but I have a serious failing in my personality , I care very much about people and I cannot stand seeing anyone bullied or deprived in genuine need .

So if you came to this site expecting sympathy wringing your hands and moaning what a tough time you are having of it ? Come to the sharp end with us and see what it is really like !!!

Why don't you start a movement within the NHS to fight these ambulance chasing lawyers charging extortionate fee's (mainly from the public purse) and bleeding the likes of the NHS dry ??

I have been in hands on patient care for 39 years and I can honestly say I have never wantonly , willingly or intentionally done any harm to any patient I have ever treated , and I don't know any practitioner that has.

So why then should I have to be bound by litigation avoidance and all that goes with it which ultimately stops me doing what I do TREATING PATIENTS.

Bring back common sense to the equation free up some of the money these people get out of your budget , put it back into podiatry care to make a constructive improvement in general health care in this country.

But please don't ask for sympathy, work to my rules (as an IPP) if you can't do the job you will go out of business simple as that.

(I unlike David am not studying for exams I am grumpy all the time !!!)

Cheers

Derek

 

Hi All,

Now careful Derek or this Forum is going to get itself labelled the Seven Dwarfs! We must loosen up while we can? Some are way past it though I'm afraid! They may need referring to the British Psychology Society or some such group? It's gone quiet about them to, I wonder what happened in England's largest County?

Regards,

Colin.

 

Robin - my apologies for referring to you as Mr Jobsworth - you were restrained in your response! Your lengthy and well constructed response does demonstrate the difficulties inherent in balancing any medical and welfare system. You are right - how do we balance situations such as one heart transplant versus potentially many #NOFs from falls which might have been prevented through early intervention. And what happens to a goodly percent of patients with #NOFs? Sadly, an early demise. One life or many....

The ethics of distribution of funding is complex, and ultimately we will never construct a system which can be fair and feasible simultaneously. I agree with you, however, that this kind of public media attention is good! A sad story such as this raises enough public opinion to often stimulate a politician into shoving some money around to ensure that public opinion figures remain favourable. (OK, a wee bit cynical, but if you get the drift...)

We are only on the very verge of Footcare Assistants in this country - plus we do not have an NHS system. But I am still intrested to see if FA's make any difference in the distribution of care in our medical system.

Anyway - I am not grumpy, I am sadly optimistic!

cheers,

Felicity

 

Hi Felicity

We are all aware of the balancing act that has to be done in the NHS and the common sense of prioritising care.

My point is if we can't give nailcare to the elderly SAY SO.

The point of this thread is the wisdom of the reply given to the old chap.

It helps no one at the sharp end having to continually explain away insensitive politically correct replies

Cheers

Grumpy Derek !!

 

My guess is the bypass and the childless couple will get the front page...the toenails might get 3 lines in the "In Brief" column.

Did the paper question the ethics of the Private Podiatrist who is happily visiting the man and taking the son's money each month? He could just as easily go bi-monthly with NO adverse effect on the gentleman's toenails or health. Nope, no dramatic headline there.....

Personally if I was already working in the nursing home I'd find a way to fit the man in.

This situation wouldn't arise here in Australia primarily because if you're in a nursing home, your position has funding allocated to it to provide allied health services....and these services are generally not provided by Public Pods (metropolitan areas at least)

Every member of the community who wants to be assessed should be able to get an assessment and education. (hopefully in a timely manner)

BUT

Bottom Line, regular nail reduction for non-path nails in no / low-risk clients is not a health priority. If there are any "what if"s about tearing skin, ischaemic pressure, bed bound, immobile, etc, then more than likely the client is not low-risk.

 

The argument is that elderly footcare is no longer a health issue but a social care problem therefore these patients are discharged to the capable and welcoming arms of the social services.....

http://news.bbc.co.uk/1/hi/health/4713873.stm

...and it's not our problem anymore. Is it?

 

Hi Mark, (Short holiday?),

Question:- If Elderly Footcare is no longer a health issue but a Social Care Problem, "How many Podiatrists are now being made redundant, or are they being promoted?"

Regards,

Colin.

 

None. The majority are involved in advanced clinical practice including wound care management with maggots (podiatrists such as Gaynor Richardson and Denise Prestwich have been leading the way with this for some years), gait & rehabilitation, surgery & etc. Services have had to refocus their priorities due to stagnation in funding, restrictive working practices and spiralling demand across the board.

Mark

 

Hi Mark,
Very good! I have one small problem? If, Quote:- "The majority are involved in advanced clinical practice including wound care management ................ ." How many are there in the small minority cutting just how many nails, etc. of old people? or are they to small in number to matter?

Bearing in mind the majority by inference are no longer cutting nails!

Regards,

Colin.