Should the NHS do routine nail cutting?

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Just been having a conversation with a collegue and the topic of routine nail cutting in the NHS came up. Do you think the NHS should supply this service or do you think we should be concentrating on diabetic ulcers, biomech referrals etc?

Also, does your NHS trust provide nail cutting?

 

It would be nice, but no.

The NHS has limited funds. There are treatments which it cannot afford. Its not a question of whether we should spend money on routine care, rather is that the BEST use of the money. I'd say the answer is resoundingly no.

In the context of limited resources, if NHS podiatry departments were to carry out routine social care we'd have to stop something else. There seems little sense in that to me.

I think routine nail cutting falls under the catagory of social care, and that is not what the NHS is for.

Regards
Robert

 

I'm in agreement with Robert on this.

If the NHS do/will provide routine nail care to patients it will undoubtedly come out of the 'Podiatry' budget. Thereby reducing available care to those requiring specialist treatments.

Only my 2p worth.

Kind regards,

Mandy

 

http://linkinghub.elsevier.com/retrieve/pii/S0958259201907254

http://linkinghub.elsevier.com/retrieve/pii/S0958259206001076

BTW, Prof. Campbell was one of my PhD supervisors- fantastic lady- check out her CV.
http://www2.northampton.ac.uk/healt...arch/thepodiatryresearchgroup/jackie-campbell

 

Thank you for those links Simon.

However, I am interested if you personally believe the NHS should provide routine nail care?

Kind regards,

Mandy.

 

I think you need to look at the model Jackie developed. The three predictors for the development of medium to high-risk pathology were low levels of independence , age at discharge and a diabetes/age interaction. This model, or similar models should be employed to determine the risk. Ultimately, the cost saving of discharging patients in these categories from "routine" care can be exceeded many times over by the consequences of discharging such patients.

I remember a chat I had with Jackie when they were doing this research: one of the subjects that was discharged had recently had a hip replacement, in trying to cut her own toe-nails she had screwed up the hip replacement, subsequently had to go back for revision surgery- the cost of which would have paid for routine nailcare for many patients several times over.- Anecdotal I know, but interesting none-the-less.

Personally, I benefit from the NHS policy as I pick up many of the discharged patients. Moreover, as I don't work in the NHS, I can't comment upon the pressures such departments are under. I do however find it odd when the very old and/ or diabetic patients are discharged and come to me. Then when I treat them they say things like- the NHS chiropodists never: cut my toenails, reduced my hard skin etc etc. Sometimes, I just wonder.................... but then some countries don't have a free health service that the majority of these people have paid into all their working lives, but are then told they "don't meet the criteria". While our immigration policy allows those that have paid nothing into the system to access care. I can see why this generation might be a bit disappointed. Xenophobic I know, but nobody's perfect- not even the elderly. Rant done on their behalf- I listen to it on a daily basis; today being no exception.

Hope this answers your question.

 

I agree with both Simon and Robert.However I do believe that its not just a cse of yes we do or no we dont.The criteria/decision should take into consideration medical and Podiatric need.Surely an 80 year old who has poor eyesight,arthritic hands etc cant be expected to trim their own nails when they cant do other basic functions? Furthermore,thats why there is Pod ass posts,voluntary nail cutting services and need I say basic grade/newly qualified pods to help with this service.I say this about newly qualified pods as nail cutting helps develop a number of manual dexterity skills that alot of newly graduated pods lack because they dont do much nail cutting and therefore cannot do basic skills expertly.
I work as a specialist POD in a multi-disciplinary Team and yes besides managing wounds and off-loading etc I do cut pts nails if tehy are long.....Its absurd for me and time wasting to refer them elsewhere when I can easily do it and have been trained to do so.It really makes me cross when colleagues refer the old girls and boys to other people because specialsit PODs dont cut nails!!

Anyway...Ive had a bit of a rant sorry!!

 

Unfortunately, experience dictates that specialist pods often forget where they came from; I'm glad to hear that you are an exception to this rule. Out of interest what are consultant podiatric surgeons registered with the HPC as? Chiropodist / Podiatrist -right?

I LOVE A BIT OF NAIL CUTTING AS IT NOT ONLY DOES THE PATIENT GOOD, IT IS FAR EASIER ON THE BRAIN THAN THE MUSCULOSKELETAL SIDE OF MY PRACTICE- fact, so any newbie pods that are out there thinking they want to be biomechanics specialists and that nail cutting is beneath them, you heard it from my mouth- when you have a successful biomechanics practice, you'll know what I'm talking about.

"It's no secret that ambition bites the nails of success"- The fly U2

Aren't ego's fantastic things. As my late father used to tell me, "you still get up and **** in the morning just like the rest of us, Simon". He was working class.

 

Doesn't provision always depend on available money?

There is a finite amount of resources available within the NHS. Although laudable to facilitate a service providing nail care to 'those in need' who would decide on the line of definition?



Pensioner A. In good health. Active although has arthritis in her left shoulder. Podiatric referral states: Involuted L hallux nail.

Pensioner B. Deteriorating health. Rheumatoid arthritis, Diabetic. Housebound. Excellent support network including family & carers. Podiatric referral states: Peripheral vascular changes. Plantarflexion deformities both PMA with H/Ds & callosities.

Pensioner C. Terminally ill. In hospice. Podiatric referral states: Requires nails cutting.



In our imaginary budget for Podiatry provision there is £60.00 left in the kitty.

Current cost of imaginary provision within the NHS:

Nail surgery: £20.00
Routine nail care: £20.00
High risk ongoing T/X £40.00

Any takers?

I understand that this is just an imaginary exercise but without funds you cannot run any service.

Only my thoughts.

Regards,

 

Mandy here's another hypothetical:
87 year old British born male, fully paid-up national insurance contributions, fought in world war 2, sustained gun-shot damage to left leg- tortured as a prisoner of war at the hands of the Japanese by repeated beating of said injured leg. Abnormally high pain experienced upon merely touching the foot, let alone trying to cut the nails- requires nail cutting. A real patient of mine that passed away recently, who did not apparently "qualify" for NHS chiropody provision.

Versus
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.

 

Sack the NHS pen-pushers on circa £60K per annum, frees up funding to treat all of them. Better still, use the "erroneously claimed expenses" of MP's to fund podiatry services and employ their "employed" relatives to do the nail cutting :drinks

To quote my father-in-law: "the state of this country, I'm surprised there is not more civil unrest"

Only his thoughts and perhaps dreams.

 

One more radical thought for the night, before I lean so far to the right that I fall over I'll counter it with a lefter view: What about if everyone in NHS podiatry departments took a £1000 per annum pay cut? Would this free up enough money to provide routine nail cutting to the communities they serve......

To Quote Vic Reeves: "only joking.... or, am I?"

 

Ah Simon, A truly altruistic notion.

Unfortunately in todays society egoism appears to be the order of the day.

The sad part is that as usual, those who make the rules are rarely those who have to comply with them!

Any numbers on politicians queueing for NHS care?

Kind regards,

Mandy

 

It should be done on the NHS in my view as this can be a significant problem for the eldely. However it should not be done by us. I believe this is what is happening in my trust.

Nobody Podiatrist who has trained full time for 3+ years to degree level (or equivalent) should do routine nail cutting or callus debrision on the NHS or privately. It is a manual task (skilled I admit). It is a waste of your training and public/private money. Furthermore it degrades our profession and devalues those of us that want a challenging career in preference to a dead end job. You dont get dermatologists offering hair cuts do you?

Old argument, contreversial and designed to ruffle some feathers. Lost this battle in UK I know. Grrr...

 

OH COME ON FOLKS.

Routine NON ESSENTIAL NAIL CARE has ABSOLUTELY NO PLACE IN NHS.

Private Practice is the place for this to be provided.

The NHS is there to provide health care where there is a definite medical pathology placing the lower limb at risk.

PERIOD:bang:

I do not accept that most pensioners in UK cannot afford to pay for their nails to be cut 4-5 times a year.:deadhorse:

I graduated in 1986 and this argument is still prevalent today.

The day that Hair Dressing Emporiums go broke is the day i will accept that Pensioners are broke.:bash:

The amount of money that has been wasted on this argument is appalling.

We are a paramedical health care profession, our role is to prevent reduce morbidity and admissions to Hospitals for lower limb pathologies for the at risk limb.

Have we met the need for our rapidly increasing Diabetic populations, or even our R/A and PVD and Neuro populations. I do not believe that with current NHS funding we can meet the clinical needs of these groups.

Here in Aus there is a mechanism whereby Private Practice can reduce the burden on the Hospital Service via the Medicare Rebate System.

This unfortunately is severly abused and will probably be reduced in provision next year. Many referrals under this system DO NOT CONFORM to the guidelines. The GP's and pts are the ones abusing the system NOT THE PODS.

The GP refers the pt to a Pod Practice so the pod is not the initiator of the episode of care and therefore not resposible for the ABUSE.

But this would be, if properly done and managed, the way to provide Social Nail Care to those groups who have a need for basic care but are not able to access this via NHS.

David
incredulous that this argument is still running:drinks

 

Hey David

I tend to agree, however I would sound one note of caution.

If somebody does not have their hair cut for a year, they have long hair.

If someone does not have their toenails cut for a year, they develop a medical need even if they did not have it before. So "social" nail care is only social care if it gets done. If it does'nt it becomes medical care. I bit like the wiping of the A**e which simon is so conciencous about. And patients who cannot wipe their bottoms get state funded care...

Great Idea! Suggest it and they'll set up a working part to look into it and report after 12 months.

Cheers

 

Funkster, I don't know you, but I suspect I am more highly qualified than you and have spent much longer in training than you too. I cut toe-nails and debride callus every working day. I enjoy it, my patients find it helps- that's why the come back to me, that's one of the reasons why I have a successful practice. Good luck in your future career, I hope you find it challenging.

 

Congratulations Funkster - that is the most stupid comment I have seen on Podiatry Arena for a long time!

 

I have been following this thread with some interest.I agree with Simon-you are a Podiatrist to my own heart.

I must express my concern,wherein I believe,taht more and more newly qualified Podiatrists believe taht after a 3 or 4 year Bachelor degree they should not be cutting nails or debriding callous....they are destined for more loftier job descriptions-try going into PP and see what happens.

Also I would like to pose a question to some of these PODs.Its all well and good only doing MSK Podiatry....you get a patient who cannot ambulate normally because they have very long nails and massive amounts of HK (caused by abnormal mechanics mind you)...after sorting out the abnormal mechanics with orthoses etc are you not going to cut their nails and reduce the HK to offer them some form of palliative relief? Surely this is also part of patient management? its like telling me taht you will not do P&S for a pt because who really does it?
This is some of teh comments Ive heard from studenst and newly qualified peopel and I wonder if you cant master the bnasics how you think you gonna be a super specialist?

Simon I agree...nail cutting and callous debridement takes some of teh pressure off when you see a great number of complex patients and allows you to breathe a little bit more and actually have a bit of a social chat with your patient.

 

Mandy - I tend to agree here - having said that a local politician has been diagnosed as diabetic and had to wait 14 weeks for an initial assessment for his future foot care. (I shall call him Bob here).

Bob wasn't at all pleased at having to wait so long for an assessment. I explained the situation with regards to high risk patients, low risk patients and no risk NHS/social care patients, needless to say whilst I was assessing/treating him he was taking things onboard. At the end of the assessment I advised as to his treatment plan, he thanked me and said he would look into changing things locally.

18 months down the line and big suprise nothing has changed. We are still doing no risk/social nail care.

They just don't seem to care even if they are forced to listen and see it for their own eyes (in my experience), maybe they have got bigger fish to fry but Podiatry is my world and I care about it.

Just to add my $0.02:

The NHS should be prioritising anything OTHER THAN routine nail care - which is what this pole is about.

Said patients should be treated because they have a need (although not medical) - the need is definitley there. I have no problems offering them that treatment as a Podiatrist I am trained to do so and as Simon said its enjoyable and it helps the patient - last time I checked this job was about helping people, but as an NHS Podiatrist with waiting lists and with people having greater needs (medically) I do not believe it has a place in NHS life.

NHS medical care is free at the point of need.

No medical NEED then (in my opinion) the government and other agencies should be making provision for that. I would never dream of going to my doctor and asking to recieve (*plucks a random thing out of the air*) a regular supply of insulin just incase I became diabetic.

Done now.

Duncan

 

Hi

First time poster here so please be gentle with me!

I do not belive that routine nail cutting has a place in the NHS. What I would also like to add, is that the majority of over 65's who cannot manage their nail care are probably entitled to claim attendance allowance which would more than cover a private fee every 8 weeks or so. This allowance is a minimum of £47 per week so, add this up over 8 weeks and hey, "I can't afford private" gets blown out of the water. This allowance is to cover "personal care" which a normally healthy person would be able to undertake. If we continue to undertake nail care on people who are already in receipt of this, then the government are in effect paying twice for nail cuts!!!

Cheers

Lesley
x

 

"Attendance Allowance, sometimes referred to as AA, is a tax-free benefit for people aged 65 or over who need help with personal care because they are physically or mentally disabled" so I don't think this applies to the "majority" of over 65's.
http://www.direct.gov.uk/en/DisabledPeople/FinancialSupport/DG_10012425

 

I think that's a bit harsh.

Private practice wise, I grant you its a bit of a dumb thing to say. In PP you can do exactly what you damn well want to and if you enjoy a bit of good ole fashioned chiropody, which helps patients, keeps them safe, comfy and happy then more power to you! Nobody can tell you what services to offer.

In the NHS though, technically we are all paying the bill. Were Simon to be employed in the NHS he'd be on the fat end of band 7 or band 8. Is the NHS getting good value for its money if its paying Dr Simon Spooner PHD that high rate for a task which could be effectively undertaken by a band 5 pod, or even an Technician? I don't think that would be the best use of resources. Personally I love a bit of routine work or nail surgery, unfortunately my boss won't pay me to do it when she has a dept full of people who can do that and few / none who can do biomech.

Regards
Robert

 

Yeah Robert, but the funkster did say: "Nobody Podiatrist who has trained full time for 3+ years to degree level (or equivalent) should do routine nail cutting or callus debrision on the NHS or privately. " Note the private bit in there.

Your post is interesting though. When I was head of the Plymouth School of Podiatry some years ago, there were a number of statements from the HPC, QAA and from the academic arm of the Society of Chiropodists (JQAC) which deemed an individual as fit for purpose and fit to practice. My memory of these documents is dim, but I still have them and could look this up, but as I recall scalpel skills in removing callus and nail cutting skills were among them. So if you are employed in a situation in which these skills are no longer employed it is inevitable that they will be lost. In this situation you would no longer meet the "fit for purpose" benchmarks- Just a thought.
Here's the HPC: http://www.hpc-uk.org/assets/documents/10000DBBStandards_of_Proficiency_Chiropodists.pdf

Which clearly states that in order to be fit for purpose and fit for practice a chiropodist should
"be able to use a systematic approach to formulate and test a
preferred diagnosis, including being able to:
– carry out mechanical debridement of nails and intact and
ulcerated skin"

Although what this has to do with formulating and testing a preferred diagnosis is beyond me- that's another story.

So if you do think that "Nobody Podiatrist who has trained full time for 3+ years to degree level (or equivalent) should do routine nail cutting or callus debrision on the NHS or privately" You should take that up with the HPC.

Here's the QAA: http://www.qaa.ac.uk/academicinfrastructure/benchmark/health/Podiatry-final.asp

BTW, as a PhD (small h), we are entitled to use either the title Dr prior to our names or PhD after them but to use both together is incorrect unless you are a medical doctor who also has a PhD. Note that I rarely use either here because I still get up and **** in the morning, just like everyone else. Up the working classes!

Lots of love,
A "Nobody Podiatrist"

 

BTW, I'm considering starting a thread and poll titled "should the NHS do routine Biomechanics?" Think about it...

 

Funkster

You obviously do not have a private practice- if you did you would do nail cutting as pat of your remit.Maybe with a little more experience you will arrive in the real world.

Lesleysanson- you obviously know very little about attendance allowance.

Simon- thank you for your posts- a little common sense goes a long way.

The truth is there is a huge great canyon between NHS pods and PP- cant see that ever changing.


Cornmerchant

 

BTW, BTW, BTW: I've posted nearly 2000 times here and I've never received so many thanks in a single thread as here. Interesting, since personally I think I'm better at biomechanics than NHS policy- but just goes to show what little I know. Just goes to show what little we all know- hey funkster?

Anyway, thanks for your thanks, I really do appreciate it as like many others here I give too much time with little reward, and your little rewards help my alter-ego.:butcher:

WolvesCat- On my birth certificate it say's: "Place of Birth: Wolverhampton" Although I grew up just outside of Cannock and support WBA. However, if you are living there give my love to the Mander Centre. Ruby Red Records has long since gone, but I spent many an afternoon in there. From me to you- Wolverhampton's finest (after black sabbath etc)- The Wonderstuff (before they went mainstream and crap and Miles Hunt's ego got too big- for those who don't know their work "eight legged groove machine" is all you really need in your collection)
http://www.youtube.com/watch?v=y5hMTci71tk

 

Simon... Superb! Intimate little venue, must be the Wulfrun hall!
Our paths may have crossed once in the wonder that was 'Ruby Red'.....

 

When I was on placement during my degree course, the Trust I was with had a framework where routine nail care - with no underlying conditions and no callus, was done by a Foot Care Assistant (FCA) in 15 min slots on 2 set mornings a week. While the Pod treated other clients.
Then nail care with callus was done by a Pod with a FCA 2 mornings a week in a "two chair clinic", where the FCA cut the nails and the Pod debrided callus, etc while the FCA set up for the next client, in 15 min slots.
This meant that routine care was provided for those unable to self-care, without removing too much time or attention from other more complex clients.
It seemed to work well and both staff and clients were happy. The Pod I was with enjoyed having 2 mornings where she could just enjoy a "brain break".

Where I am now in Oz, we are setting up a similar framework and fingers crossed it will be just as successful.

Even in Oz we **** in the mornings !! :drinks

 

Saturday night disco's at the civic...

 

So having a s*** in the morning is fast becoming a negative euphemism.

I can see how conversations will run at Harrogate in a couple of weeks; " So, do you s*** in the morning?" "Nah, I have an FCA".:wacko:

 

I don't think of it as negative blinda, I think of it more as waking the soul to the realities of life. As for FCA's, you can have people to wipe your arse for you, but ultimately you've got to **** for yourself. Unless you go for a manual evacuation, which is messy and another story entirely.

 

of course, I`m sure you realised that when I said "negative euphemism" I meant the opposite to the usual substitution of a less offensive expression in place of one that may offend.

Cheers,
Bel

 

Nope, way too clever for a working class boy. Me, I know nothing of the women's mind. Although, I do find the term "Harrogate" slightly offensive.

 

:drinks




Looks like you found me
Now I know why
I felt like [a] s*** when I woke up this morning - Nickelback

 

OK here we go another way of looking at things.

You have a population of 100 thousand.

12% are Diabetic

3% are R/A

35% PVD

30% are elderly ie over 65

please note some will be in more than one group

etc etc you get my drift.

You look up morbidity, days in Hospital due to complications with lower limb disease. Costs of medications due to complications with lower limb disease.

etc etc.

You are tasked with establishing a modern Podiatry Service with the express intention of reducing admissions to Hospital and Burden on District Nursing Service and reduce prescription of drugs to manage said lower limb complications.

So how would you design your dept?

Invest in high quality highly trained staff to run at risk foot wound clinics, supported by Bio Mech staff and Specialist footwear.
Access to Anti Biotic drugs

or Here we go

Cut as many nice old ladies nails as possible with the max no of ancilliary staff one can squeeze out of the budget.

And surrender our skills to the Specialist Nurses, Specialist Physios and O/T's etc etc.:bang:

I wonder why we train to a BSc level and then do not use these skills on the at risk patients who can best benefit from our skills and training.

The use of Ancilliary grades is a misnomer as it presumes you have the spare budget to squander on ancilliary staff and and have the resources available to provide SOCIAL Non Essentail Nail Care.

Currently this is provided at the expense of the AT RISK limb as resources are removed from this aspect of care and diverted to nail care.:butcher:

We are talking about the NHS here and not Madam FiFi's Pedicure Salon.

Private Practice is where most care should be provided and referral from PP to NHS when there is an acute problem. This is what we do here in my practice here in Sydney. We manage minor ulceration which will resolve easily.

Critical acute infected ulceration is referred to the Hospital At Risk Foot Clinic for intensive management. When resolved the At Risk Foot Clinic discharges said patient back to us in PP.

Is this not a better use of Valuable and Finite resources within the Hospital Health Care System.:drinks

It also leads to a much more rewarding life in PP as your caseload is very varied ranging from Nail Care through Bio Mech, Nail Surgery, Diabetic . R/A, PVD and minor wound care.

regards david
They are coming to take me awayy HAHA HEE HEE:deadhorse:

 

Robert,

You never said - I'll re-jig the timetable today. I'm sure a few of the others would love to cover your paeds reviews................

Rie.

 

This thread has turned into a nice debate, but one I feel will not be resolved for some time.

My personal oppinion on this is that there should be a service for routine nail cuts on the high risk patients who need treatment. For example you elderly patient with severely involuted nails on a whole cocktail of medication with severe PVD etc so nail surgery is not an option.

I agree with others that there are 2 groups of people needing Podiatry, those with a medical need and those with a social need. I have a lot of patients who enter the clinic complaining they are unable to get to their feet due to arthritis but are otherwise in good health. Now I am of the opinion that most of these people are, put frankly and dont linch me, just old. As we get older we cant bend down as well or do jobs we used to do, that is a fact of life. But should we be seeing everyone that cannot cut their nails or should they be referred into PP? I can't reach my toes, should I receive routine physio to sort this?

This thread links back to the one about what, we as a profession, are aiming towards in respect to what treatment we offer. I believe we should be seen as the forefront specialty in lower limb biomechanics, diabetic foot care, nail surgery and not just as "cut and come again".

I like how David is doing things, routine care is done in PP and when a problem arises the patient is sent into the NHS to have this sorted before being discharged back out into PP. Everyone wins, PP get a nice varied case load and the NHS has more time to spend on the chronic wounds, biomech clinics etc

 

I have always believed that nail care is part of Podiatry, I do not agree with Footcare Assistants.
If Podiatry was put on the High Street and Private Podiatry was allowed to undertake NHS work whether part paid by NHS/patient I think HPC reg Pods would.

1. Clear the back log of patients waiting for NHS.
2. Provide quicker access to Podiatry.
3. Provide a full routine service.

NHS should to maintain high risk patients as part of a MDT so as easy accesss to full hospital services are maintained.

There would need to be a referral pathway between private and NHS Podiatry.

The door between NHS and private has to close even more in the future, remember it is our profession and we are HPC approved.

 

morning all
yes it is a sevice we should provide but it should not be abused and its the abuse of the system that is the problem. i agree its not best use of a band 7 or 8 to be cutting nails but thats why we employ assistants/technicians.

every patient should be asssesed on an individual basis and retained/discharged as a result. it shouldnt be age related or whether youve " paid your stamps for years" or any other of the reasons and excuses we have all been hearing for years. it should be based on need and we should have provision available if the need is there.

its a contencious issue that wont go away.
cheers
JB