Providing better footwear and foot orthoses for people with rheumatoid arthritis

There are many systems where a Pedorthist is referred from, and each usually have either a review system in place (eg hospital,or Dept of veteran's Affairs etc) where an ongoing process allows for a "check" for 1 payment, 2 meeting expectations, 3 possible changes if required.
Dept of Veterans Affairs requires the patient receiving the footwear to attend a "final fit" with the prescribing Podiatrist, who also reviews at ongoing appointments.
Private patients are either reviewed at a later date, or detailed information is provided to the patients, where travel distance (and in Australia there is a lot of that) is an issue. This information usually involves a check process over a period of several weeks and any concerns by the patient of carers --to contact the Pedorthist.
External clinics _for some Pedorthists up to 1000 km, will sometimes be reviewed by the local Health Professional as these may only be attended by the Pedorthist, bi-monthly, and for neuropathic patients might be "too long between drinks" as we say here..

"Halfway"

 

Hi Toughspider.
I know "Boots and All" has said you are welcome in Melbourne, but keep this in mind. There will be a great example of what we do, in France in 2015.( Bit of a skip from where you are.)
This year in 2012 we were fortunate in "good old Australia" to host an international Pedorthic/ Orthopaedic Footwear Congress.
There were about 6-8 Podiatrist who attended, however many more were invited, and over the last few months I have spoken to most of them.

I was more impressed by their co-workers/collegues comments where I have a prevention diabetic /footwear clinic.
These, didn't attend and said those that did, have not stopped talking about it since and asked if there were other similar events scheduled in Aussie soon..
So who knows, you may meet some Aussie Pods if you attend the France Congress.
I am sure you will hear of this on this Forum.

Halfway

 

This is an interesting discussion!

I like to throw in my thoughts if I may,

Do we need better footwear provision? In the UK state sector certainly.
Is the poor outcome experienced by patients in part due to unrealistic expectation? Yes
Is also due to how services are arranged and provided? Yes

How to improve things? Create a new practitioner called a "Pedorthist" - no. No such thing exists in the UK in a regulated way and from what I see those that do exist in the UK are unregulated foot orthotic providers working independently, quite different to the role of orthotic/shoe provider acting on a medical/podiatric prescription in the US/Canada/Australia.

Personally I dont think creating a new practioner is the way to go - it will cost too much money. The expertise is already there, it is just poorly organised.

Orthotists that are prepared to specialise in foot/ankle bracing and footwear should work in clinics/departments with Podiatrists and where needed Physiotherapists, seeing patients jointly and with clearer treatment pathways.

The idea of Orthotists commercially employed by the Orthotic manufacturers should end. They should be salaried by the NHS with no ties to any commercial enterprise. Moreover the decision to provide footwear should be arrived at in tandem with patient.

Where this collaborative approach has been applied in the UK already, it has been shown to work. If you work multi-disciplinary you achieve a reduction in the numbers of shoes provided overall, a reduction in custom shoes as a percentage of provided shoes, reducing costs. Also patients involvement increases acceptance.

 

Simon, I thought you would ask that. Firstly, different countries have different pathways which have different meanings in different languages. If you speak a second language you will know that translations do not always translate the meaning straight forward. Some may not mean the same in translation as the cultural expectations do vary. Like a podiatrist is a valued member of the health team in English speaking countries it is just emerging from Chiropody other countries and does not exist in other highly advanced counties. Yet as you try to translate from one language to another some of that implied meaning is altered.
The OSM and other allied health educational pass ways in Germany and other countries on the continent are based on a government regulated apprenticeship and college system. The profession and the educational pass ways for OSM are government regulated and recognised. http://www.gesetze-im-internet.de/orthschausbv_1999/BJNR078900999.html
It is outlined in federal law "Verordnung über die Berufsausbildung zum Orthopädieschuhmacher/zur Orthopädieschuhmacherin vom 21. April 1999 (BGBl. I S. 789)" and http://www.gesetze-im-internet.de/orthschmstrv/BJNR109600008.html
(Orthopädieschuhmachermeisterverordnung - OrthSchMstrV) V. v. 24.06.2008 BGBl. I S. 1096 (Nr. 26); last amended through 40 V. v. 17.11.2011 BGBl. I S. 2234; in force since 01.09.2008.
It is full time apprentice based and the college time is government colleges and government accredited private colleges. When I did it from 1979 onwards, I spent about 2500 hours in colleges over a full time period of 7 years. The non college times where spent on the job training based on a government prescribed training plan for the first 3 years and then work placements in accredited facilities. I believe the work placement times have been shortened now.

The OSM is the same educational pathway as the Prosthetist&Orthotist Meister and the later is recognised by ISPO (International Society Prosthetics Orthotics) as schooling level 1 and on par with in the UK National Centre for Prosthetics and Orthotics, University of Strathclyde (NCPO). It is therefore reasonable to equate both. There were also bachelor pathways established in Germany for OSM and P&O education over the last 10 years as well as in the Netherlands and Belgium. Both pathways run concurrent now for some years.

Podologie became a government recognised allied health field in 2001 though the federal law "Podologengesetz vom 4. Dezember 2001 (BGBl. I S. 3320). The education is at college level 2 year’s full time. Colleges are private and need to be government accredited. The examination is done through a government examination board. The scope of practice encompasses most of what I have seen podiatrist practice on a day to day basis in the UK, USA, Canada and Australia with the exception of bone surgery, prescription of pharmaceuticals and ordering of diagnostic investigations like X-rays. This remains to be the domain of medical doctors. I would imagine that the medical lobbyist will not allow podiatry in Germany to flourish to the levels it did in the UK.

I spent time over the years visiting the NCPO in the UK, Australia, and its equivalent in Japan, the Netherlands and Korea. I visited numerous P&O facilities in different countries. I attended podiatry training facilities at universities in the UK and Australia and spend time in Podiatry practices in different counties including a full working day with a Podiatrist in the New York in his practice to see the day to day workload.
Having said all that, we are now establishing the 3 year bachelor program at the government funded Southern Cross University as I mentioned before. We believe that strong university based education is the way forward in Pedorthics. About 12 years ago, Podiatry in NSW Australia moved from a technical college based system to a university based system and we think that this improved the service provided to the public and we think the same improvement will be achieved when Pedorthics is established at university levels.

 

Karl

When I hear "Pedorthists" talking about their trainning, they say it is very long and in depth. Why - because they cover foot anatomy, gait analysis, foot pathology, orthotics etc.

Well, what do you think I did in my Podiatry training?

Did I cover footwear prescribing and manufacture? No but Orthotists do, they just dont specialise in footwear-only.


In other countries the "pedorthic" model may work but most countires spend more on healthcare!! The cost of training and having duplication of manpower is borne by the individuals and the patients directly in other countries.

Here in the UK It is clearly cheaper to me to use existing manpower. Take an MSK Podiatrist, put them together with a footwear specialising Orthotist, hey presto youve got it covered. No additional cost. In fact the bringing together reduces costs.

 

Lawrence, perhaps part of the problem is that the orthotist and podiatrist are just the prescribers and can't actually manufacture shoes themselves. I know you like to make your own foot orthoses. And with good reason. it's cuts a link out of the chain.

Perhaps the area to look at are the shoe design degrees like:
http://www.dmu.ac.uk/study/courses/...wear-design-ba-degree/footwear-design-ba.aspx

I wonder how much of this programme focuses on orthopaedic footwear?

 

And there is your answer, we involve the patient in ever step a long the way, from the design through to the charges, at each of the 5 or so consults we ask for their opinion. We show shoes and or sketch the design in question before we start, offer a choice of colours and guide them through the process.

There is no shock when we deliver the final product for fitting because they saw it at every stage from concept to completion, including any changes they/we thought were needed.

This Pedorthic model is the way forward, as it will reduce the cost to the health system by making the client pay a portion of the cost and wearing the footwear.

Ownership is more than just paying for it.

 

Lawrance
Podiatry training in the UK is of a high standard as far as I understand it, no question. Further if or if not a Pedorthic system is installed in the UK is entirely up to you guys over there. The report that opened this discussion suggests that there is room or need for improvement in the UK. I feel that those that provide and make the medical graded footwear should be asked what they think would be a way forward.
Pedorthic systems are established in a number of countries like the USA, Canada, Australia and much of continental Europe. Most of those countries do have an established P&O system, many a Podiatry system and in Australia we have a good working cooperation with the P&O professional on a personal level as well as on an Association level. Podiatry is a key referral base for many Pedorthists in Australia. Prior to our Pedorthic Association talking to SCU about a Pedorthic bachelor course we spoke to the Australian P&O national training centre and used their facility a few times for short Pedorthic courses. The Pedorthic Bachelor in Australia will run alongside a Podiatry program as well as other allied health. In Japan one of the P&O schools established a Pedorthic/orthopaedic footwear full time program over 10 years ago with the support of the local P&O profession. Japan does not have a podiatry profession.

 

Hi Lawrence . Good points and for you a good outcome. So are you saying the system you have works well . That is a good outcome for all if it is so.

Your comment about the Pedorthic training in comparison to Podiatry training is correct, however the word "training" is the important one.

4 years of training in any vocation is surely only an insight into it's ultimate complexities.
Can one learn all facets of Podiatry in that period of time? --I think not. Those 4 years are surely to provide an insight only and the next 4 , 6 , 8 12, 20 years would provide you, the experience, via thousands of patients to make one a capable practitioner.
It is no different with Pedorthics, and more time- consuming with a Custom Making Pedorthist where hand making of the footwear is required. This process in itself , without any clinical knowledge required, encompasses 3-4 apprenticeship time frames..

Reducing cost in item provision is good, as long as it reduces costs on overall health care. Many of our hospital dept's are introducing preventative footwear care in association with their Podiatry Services to reduce re-admittance of high risk (non -compliant) patients with diabetes etc. Only time will tell what the result will be .
Cheers

"halfway"

 

Having worked here in the UK for 10 months in footwear I can only say that the amount of people we see in our shop, not wearing their NHS provided shoes, is appalling. There is no magic wand to wave here, yes, there are plenty of pre-fabricated shoes which could have provided a better outcome in patient compliance; with modifications where necessary. The person actually making the footwear never sees the patient. There are many shoes simply not fitting. The whole system needed an overhaul a long time ago, the sad thought now is... where does it go from here? People needing footwear just have to pay themselves now for the desired outcome - perhaps they were willing to pay all along - but that's another discussion!

 

Liisa,

I guess you do not want to say where you are working, understandably.

However I think you have added a good point.
No disrespect to our colonial cousins but we are stuck with the UK model.

My feelings are that 'we' should be looking at how 'patients' cope with their disabilities and trying to work around that.

However please excuse me on this thread, I'm a very basic Pod with little knowledge of the expertise being debated.

However I'm interested in the ideas of involving the end us er.

Good thread lets keep moving towards what possible and not the ideal?

Joe

 

Sounds good!!!! Combined with a trip home can claim it back on tax!

 

Good discussion.

I have an intrinsic problem with the report. I am pretty much with Simon in the respect that I cannot take a foot that is shaped nothing like a shoe and fit it into somthing that looks like a shoe.

More than most other practitioners that prescribe footwear that I know, I try to give real consideration to the footwear I am prescribing and I do not lightly embark upon modular or MTM footwear.

My primary job when seeing somone with a foot that is frankly hideous is to make sure that they understand that I cannot make a shoe that is fashionable. On occasion, I have to be up front and say that I cannot make a shoe that even looks like a shoe.

I emply many of the tactics that David does - lines that elongate the foot and combination colours/materials that narrow the sihouette. I also use quite a lot of strategically placed stretch leather panels to allow me to use a narrow last but have the stretch within the material to reduce pressure/friction in prominences.
The company who I do a lot of work for hate this as it involves ordering footwear from external contractors and I know many orthotist who are not fortunate enough to do this.

Is creating a pedorthost model a good idea. Like Lawrence, I think that the skills are already there, they just require channelling.

Multi disciplinary clinics allow a joint approach to explaining the limitations of footwear manufacture and design with a given foot. I'm pretty sure that his has a positive effect on outcomes, well it has wherever I have worked
My 2p

 

One other thing I would like to add is that the "glass slipper thing is a good idea as it allows patients to see the blanching of skin and pressure that is created by having a shoe that is too narrow/shallow. This is something that was done when I was a new graduate but has gone out of fashion.
However, this is an extra fitting stage and at present, I am being encouraged to have as few fitting appointments as possible and going straight to being finshed. The shoe cost is less important than the fact that my next available appointment to fit shoes that I receive back toady is not until the end of July.

My routine waiting list is also at 20 months. The time cost is greater that the direct cost in this case

 

It doesn't work like that in the NHS, that's what people are trying to tell you.

 

And this in my opinion is possibly why you are getting such a negitive response from the client..."l didnt think it would look like that"

Just back from a country clinic today, the clients love to see their shoes at the diffent stages of production, as did the pods, they feel part of the whole thing rather than a victim.

 

Hi David,
Sun-tan! more like rain drenched.... can't believe I have actually sold sandals, there's the fantastic British optimism for you! Loving the challenge though, and finding my way around the footwear world here in the UK.
thanks Joe, haven't said where I am and the business name as don't want to use this forum to promote myself & my services, but if you want to email me on lisajanepreston@hotmail.com happy to meet up and chat footwear with you, depending on where you are - I am in the Midlands region but do get out and about a bit.
Prices David are roughly £80 - £150 here including 20% VAT. I have had no problem whatsoever with prices - people are willing to pay if the product fits and looks acceptable to them. In that aspect no different to Australia. I also do know my limitations to refer on when somebody does require complete custom made footwear. Also to send people off and back into the NHS system, as today, when they present with amputations and no off loading foot orthosis at all.
I would dearly love to be part of a multi-disciplinary team and can see this as a future development in the private field - what better patient service could you give than all under one roof? With everybody knowing their area of expertise and when to refer on.
Oh well better go and do some work but it's great to read all of your comments and views. Regards, Lisa.

 

Good on you Lisa.

Nothing wrong with putting your details in your thread, that way people know who they are dealing with.

A multidisciplinary team is the way to go as you know from your experience here in Oz, you have a lot to offer our friends in the UK.

 

Lisa,

Not my place to say what you can and cannot say or promote on this forum but I agree with David, if you are happy with your product or service and it can help the members of the community there should be no problem.

I think we can all see as Simon said the way it works in the UK is very different to other countries, there are lots of Pod groups most of which welcome speakers on 'new' topics, often a refreshing change from diabetes!

Joe