Report on Podiatry Service Provision in Bexley
14th June 2006
1.
Local background in context of current position
In 1996 the podiatry service (which was then under the aegis of Oxleas NHS Community & Mental Health Services) had a waiting list for new patients of 2 years.
This was deemed unacceptable by the SHA and the service underwent external review with the result that a further 2 podiatrists were employed resulting in the waiting lists reducing to acceptable levels.
This raised the establishment to 10.4 WTE podiatrists and 2 WTE technicians.
These staffing levels were eventually eroded due to financial constraints and the waiting times for new and existing clients rose unacceptably.
In 1999/2000 the Bexley podiatry service became part of the Department of Health pilot scheme into Access via Capacity and Demand analysis.
The findings showed that Bexley processes could not be improved, and that the
increase in waiting times for the case load and the new referrals was due to under-funding and lack of needed capacity.
The publishing of the National Service Frameworks for Diabetes and the Older Person resulted in an increase locally in client expectations and referrals.
It became apparent that there was no new funding provision in the system and in order to manage demand the access criteria for the podiatry service was tightened.
The criteria for access became medical and podiatric need with the effect that all clients who remained on the list were ‘high risk’.
Medical conditions with the potential to cause tissue to breakdown (such as chronic degenerative Rheumatoid Arthritis sufferers), or podiatric conditions severe enough to cause immobility (such as diabetic foot ulceration).
Of the remaining caseload, those whose foot condition was deemed to be less severe were discharged and those who required nail care were referred to Age Concern who has a nail cutting service for the non risk sector.
2.
National context of changes in service provision
In 1989 representatives from Government Health Departments and patients organisations from all European countries along with the World Health Organisation and the International Diabetes Federation met in St Vincent in Italy.
There it was unanimously agreed that the recommendations they made would be implemented throughout all the countries in Europe.
In order to do this 5 year targets were set. One of these targets was the implementation of effective measures for the prevention of costly complications.
• Reduce new blindness for diabetes by one third or more
• Reduce numbers of people entering end-stage renal failure by at least one third
• Reduce by one half the rate of limb amputations
• Cut morbidity and mortality from coronary heart disease in the diabetic by vigorous programmes of risk factor reduction
• Achieve pregnancy outcome in the diabetic woman that approximates that of the non-diabetic woman. (St Vincent Declaration 1989).
The National Service Framework for Diabetes was built around this declaration.
Research has shown that the diabetic foot is greatly at risk from ulceration and possible amputation.
Risk factors for foot ulcers and amputation are: duration of diabetes, poor glycaemic control, microvascular complications (retinopathy, nephropathy and neuropathy), peripheral vascular disease, foot deformities leading to callous and corn formation and previous foot ulceration (Hunt 2005).
“Diabetes is the most common cause of non-traumatic lower limb amputation” (Fox & Mackinnon 1999)
“15% of all people with diabetes develop foot ulcers and 5% to 15% of people with diabetic foot ulcers need amputations” (University of York NHS Centre for Reviews & Dissemination 1999).
Prevention of diabetic foot ulcers begins with screening for the loss of protective sensation and for peripheral vascular disease, which is best accomplished in the primary care setting. Locally: GP’s or Practice Nurses provide this service in Bexley through GMS, something which the podiatry service has already implemented to improve the efficiency of the service.
These measurements combined with history taking and physical examination enable the clinician to stratify patients based on risk and to determine the type of intervention.
Educating patients about proper foot care, daily foot examinations, providing intensive podiatric care and the debridement of callus all help to maintain tissue viability. (Singh et al 2005).
Costs of healing ulcers are high and even higher for ulcers resulting in amputation, due to prolonged hospitalisation, rehabilitation, and need for home care and social service for disabled patients.
Therefore one of the most important steps to reduce cost in the management of the diabetic foot is to avoid amputation. (Apelqvist & Larsson 2000).
Screening and treatment are highly cost effective if targeted at those at high risk (around £4000 cost/QALY) but cost ineffective if untargeted (around £38,000 cost/QALY). (YHPO 2005).
3.
Local affects of service capacity on diabetes provision:
At a Bexley Diabetes Network meeting in January 2004 the minutes show that the Podiatry Department, due to staff shortages, had to withdraw from providing patient education.
Shortage of staff was also impinging on foot treatment for the established caseload, as well as prevention.
The Consultant Diabetologist remarked that toe amputation rates had risen as well as patient transfers to Kings because of this direct implementation.
4.
Other high risk cases
Diabetes however is not the only chronic condition which can lead to tissue viability problems.
People who have chronic conditions such as Rheumatoid Arthritis and Peripheral Vascular Disease develop ulcers on areas of the foot subject to sheering forces which cause callous.
Prevention of these involves the debridement of callous.
Failure to provide regular treatment for this client group will result in increased A&E attendances, increased bed days, increased use of IV antibiotics developing further problems with antibiotic resistance and resulting in a higher on cost for PCT and social services teams such as district nursing and rehabilitation.
People with illnesses such as Pernicious Anaemia, Chronic alcoholism, Spinal injuries and HIV develop peripheral neuropathy.
People on steroid therapy, anti-retroviral therapy and some antipsychotic drugs are equally at risk.
A study showed that out of 1000 people over 65, who did not have diabetes, 64% had loss of sensation, 81% showed signs of arterial insufficiency and 64% had one or more foot deformities. (Helfand 2004).
Plummer & Albert (1996) found that 38% of non diabetic patients older than age 60 had one or more of these major risk factors and would be considered high risk of developing foot ulcers.
5.
Outcome of reducing high risk service even further:
In 1997 Cambridge and Huntingdon Health Authority imposed drastic cuts in the podiatry contract.
Patients were discharged having been categorised as high, medium or low risk.
NHS care was withdrawn from 5,000 longstanding patients categorised as low risk (about half the total case load), most of whom were over 65.
195 of these patients were assessed one year following their discharge.
It was found that during the year 12% of those discharged were now categorised as medium or high risk.
(Campbell et al 2000).
6. Service Aims
The main purpose of a podiatry service is preventative and palliative care.
A viable podiatry service will help the NHS save money by maintaining tissue viability, thus preventing hospital admission.
Podiatric problems can lead to an increase in falls; a viable podiatry service will enhance quality of life and prevent immobility. (Davidovitch 2003).
Regular exercise is an important factor in the prevention of osteoporosis and helps to maintain the proper functioning of the cardio-vascular system, (Osterman & Stuck 1990).
A viable podiatry service will prevent deterioration in long term conditions and will in many cases assist in the diagnosis of early diabetes and deteriorating circulatory problems.
7.
Conclusion
In conclusion I submit that although I am aware that the trust is in financial deficit, a cut in the podiatry service of the amount proposed is a short-term, short-sighted solution, which can only lead to greater expenditure in the long run.
Anne Cummins, Head of Podiatry, Bexley Care Trust.
14th June 2006.
References
Apelqvist J. & Larsson J. (2000); What is the most effective way to reduce incidence of amputation in the diabetic foot. Diabetes/metabolism research & reviews 2000 16(1) 575-83
Campbell J.A., Bradley A., Milns D., White D., Turner W. & Luxton DE..A. (2000) Do low risk older people need podiatry care? – preliminary results of a follow-up study of discharged patients. British Journal of Podiatry 200 3(2) 39-45
Davidovitch O (2003); An overview of the Painful Geriatric Foot. Geriatrics & Aging 2004 6(8) 26-29
Fox C & Mackinnon M (1999); Vital Diabetes. Class Health 1999
Helfund A.E. (2004); Foot Problems in Older Patients – a focused podogeriatric assessment study in ambulatory care. Journal of the American Podiatric Medical Association; 2004 94(3).293-303
Hunt D (2005); Foot ulcers and amputations in diabetes.
Clinical Evidence 2005
Osterman H.M. & Stuck R.M. (1990); The Aging Foot. Orthopaedic Nurse 1990 9(6).
Plummer E.S. (1996); Focused assessment of foot care in older adults. Journal of American Geriatric Society 1996 44:310-313
Singh N. Armstrong D.G. & Lipsky B.A (2005); Preventing foot ulcers in patients with diabetes. Journal of American Medical Association. 2005 293(2):217-28.
St Vincent Declaration (1989); Diabetes Mellitus in Europe: a problem at all ages in all countries. WHO 1989
University of York NHS Centre for Reviews & Dissemination (1999); Complications of Diabetes, Effective Health Care Bulletin 1999 5:1-12
YHPO (2005); Diabetes Key Facts. Clinical Governance 2005
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