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Podiatric Practice: Organisation and Establishment

Discussion in 'General Issues and Discussion Forum' started by Mark Russell, Nov 9, 2010.

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    Following on from the comments in the verruca thread and from various other comments during the past couple of years, I think it might be worthwhile to have a discussion to see if we can reach an agreed viewpoint on the best way to organise and establish the practice of podiatric medicine on a national – or even international basis. Practice varies from country to country as does podiatric training – and there are merits and drawbacks in all systems – but the objective of this thread is to design a practice system in its entirety, from undergraduate teaching and research through to clinical establishment and regulation, building on the positive facets of the various systems and addressing the [many] problems that face the profession today. The goal is to create (theoretically at least) a practice system that is:

    • Sustainable
    • Accessible
    • Independent
    • Authoritative
    • Creative

    Easy headings, but within them there are plenty avenues for debate – how undergraduate courses are funded and where and by what methodology; how practice is funded – the correct balance (if any) between state and private practice; how to build practice income without restricting access – affordable insurance schemes for patients; how we are regulated and by whom; the skill mix within the profession; marketing and promotion and clinical development – take your pick. Some areas will hold greater interest than others and some people will have no interest at all, preferring purely clinical debate – yet without a strong, established and growing profession, our true clinical potential may not be readily realised.

    Now I recognise that such a topic may be emotive and potentially disruptive. Some will have ideological and political influences in their contributions, so a plea at the outset to be reflective rather than reactive; objective rather than subjective. Let’s see if we can have a constructive debate without any of the destructive comments that often characterises this sort of thing – especially on UK topics.

    It’s thirty years since I first embarked on this career as a student at the Edinburgh Foot Clinic and School of Chiropody and for the most part, it’s been a hugely enjoyable experience. I’ve met many wonderful people – patients and colleagues who have enriched my life enormously. Many of the latter have been just as enthusiastic and more - as myself – and yet, certainly in the UK, there’s a tacit acceptance that the profession hasn’t progressed as much as it could have done during the last quarter of a century, and in some aspects the standard of care has actually deteriorated.

    Every new year brings new challenges. As money has become so central to every aspect of life it was only a matter of time before politicians cocked things up so badly that it endangered even our own professional existence. Like many, I was fortunate enough to undertake my podiatric training with the assistance of a student grant at a school that was funded by entirely by the State. Not so today, where students must fund their own accommodation and living costs and in some cases even their tuition fees. A question that was asked recently is apposite. Should podiatric training schools in the UK still receive NHS funding when so few graduates still go into NHS work upon graduation?

    As Dylan Thomas once remarked – “To begin at the beginning” – with undergraduate training. How best to deliver this, by whom and how funded? From podiatry assistants to foot and ankle surgeons – over to you. ….
  2. Hi Mark Massive topic and a good one - It´s almost as if this needs it´s own Forum where teaching course breakdown, funding etc gets its own thread then for private v´s state Podiatry, international outlook etc.

    Podiatry course LL started a thread on this I may have changed my views etc, but I believe that the course should be 5 years 3 basic undergrad program similar to what is the norm in countries except the US - people can finish up here and begin practice in an hospital environmental, or private practice but with strict limitations on scope of practice - General palliative care, Bio-mechanics if they want, basic diabetic care, nail ops etc as we have it now.

    But others may want to specialize which is what the next 2 years are all about -

    3 areas
    Dermatology and Diabetes with a surgical component related manly to skin
    Surgery Skin, soft tissue and bone

    These people will them come out with a degree in ...(POD) and then a masters or Doctorate in .... and will be the specialists in this area.

    this group will have all completed research and have greater rights to medication and diagnostic tools.

    Theres for a start....
  3. Thanks Michael - it will be interesting to hear from some in academia as to how they consider course content to be structured and balanced with practical clinical sessions. You omitted a couple of issues - assistant/pedicurist level practitioners (FHPs Foot Nurse Clinicians) and pedorthists/orthotic technicians and whether they can access the undergraduate programme and exit at say end of Year 1 or 2 with an appropriate qualification and level of training. The other issue is that of funding. In the UK we are heading towards a very immovable brick wall with alarming speed presently - 14 schools of podiatry funded exclusively within a NHS budget that will more certainly be looked at with great scrutiny over the coming few years. There are very few graduate places within the NHS these days - and haven't been for the last few years either. If they were to close....then what? I think I would like to see a greater level of independence within the profession and have say two or three colleges of podiatry - funded independently - and established as centres of excellence for every aspect of podiatric practice - from assistant practitioners and undergrads, post graduate continuing podiatric education facilities - to sports injury and performance centres and foot & ankle surgery clinics.

    Not everyone want to be a surgeon or biomechanic specialist. But by simply having one training aspect of the whole foot health market we limit our potential as a profession and prolong much of the division. Out of interest, how do the US and Oceanic colleges fund themselves?
  4. W J Liggins

    W J Liggins Well-Known Member

    Hi Mark

    Agree with Mike in the essentials. However, I do think (as I have remarked elsewhere) that right from the very start the educators should inculcate the idea that WE (emphasis not shouting) are the experts in the treatment of feet. That being the case, the isolation of the pp (I've been there) should become a thing of the past. The concept of referring to colleagues should be part of the student mindset from day 1.

    I would simply add to Mike's list full prescribing rights as a 'specialism' (in the UK), since it is going to happen anyway and progression on to bone surgery via a doctorate.

    Big subject though!

    All the best

  5. Hi Mark,

    I left the assistant thing out as I though it just might become a FHP fight, but I agree with the 1-2 training at the same institute- better relations etc. with a must work with Reg. Pod as part of the Job set.

    For those who don´t want to be specialist Pods then as I suggested the 3 year course or thinking now maybe with an honors 4th year of extra hands on plus some basic research might be the go.

    I payed for my course in NZ, in aust they have HEX´s (or they did might have changes names) These are student loans type programs . This provides some of the money to run the course and I guess the rest comes from Uni or government funding.

    This NHS system always confused me - I´m a fan of user pays . the students seem more focused.

    On an International outlook It would be great if the more settled uni´s helped to develop the programs in other countries. There was a small amount of this when Sweden started with some uni´s in England and If I thinking correctly when Podiatry started in Spain there was a large input from a Uni in the US with teacher exchange etc
  6. LondonPod

    LondonPod Active Member

    Great post and some insightful replies, I agree this is a HUGE topic!

    A few points below on how I feel we as a profession should be going (some similar points from other members).

    • Regulation by newly formed: General Podiatric Medical Council, in close association with the SOCP. No more HPC
    • SOCP – renames to British Podiatric Association – close of function, amalgamation of IOCP and BCPA – no FHP’s
    • A two tier Podiatry education that is joined with Medical schools of universities not colleges who suffer with a chronic lack of resources, texts and investment.
    – Current BSc (Hons) Podiatric Medicine updated with extended scope practice such as post tibial block LA etc (possibly not currently covered in most schools as the NHS have no use for this skill)
    •Reduce the current number of schools of Podiatry in the UK. The USA has around 5/6 I believe, yet we have 13! NHS funding wont last for ever and the NHS can't afford to employ those whos training it pays for. A privately funded education will improve standards and won't be affected by the malaise of our NHS.
    - 5 Year degree Doctor Podiatric Medicine DPM (Same as USA)
    • Title of “Chiropodist” will remain a protected title to prevent “FHP’s” from using it.
    • Protection of function of practice possible to protect public from “FHP’s”
    smaller divisions in the profession may not be a bad thing as long as its all under the Podiatry banner - look at dentistry (Dentist/Dental Surgeon, Dental nurses, dental technicians, hygienists)

    • Good public relations and PR educates the public on our professional title of “Podiatrist” and “Doctor of Podiatric Medicine” (Advanced training exactly the same as DPM in the USA enabling extended scope of practice and bone/tissue surgery)
    • Improving relations with Medical Doctors and Dentists
    • Allying ourselves with the world of medicine and dentistry, collaborate our POMS (which should include indepandant prescribing) in the BNF like the dentist formulary
    • There are ONLY 3 professions that can operate on the human body
    • Show doctors our professional and forward thinking attitude, not just to improve our image but to educate them on who we are/what we do- referrals to us will start coming through. Same goes for with the public.

    I don't have all the answers and this progression isn't going to happen over night but I think if we keep educating patients on ALL the different treatments we offer and up the game on professional standards we will start to get the respect we deserve.
  7. Without trying to be too negative, While the DPM program maybe seen by some as the future. I would like to think that we could look at that program setup and say heres what we would do different in this discussion, ie wipe the slate clean and begin again with knowledge . From a bio- mechanical prospective it seems from my understanding for posts from the US members that the US is in some areas quite laking.

    Also a question for Mark Mr TS while there will be country specific questions and ideas, do you want this thread to focus on the UK or to be more about Podiatry the future wherever your from.

    If its about the UK I´ll jump out if it´s more about Podiatry wherever your from but with some specific country to country stuff from time to time - then I would think that people need to be careful with expression so it does not become a FHP v´s Podiatry which is a UK issue and done to death.

    Just my 5 krona worth.
  8. Thanks Bill - agree completely. I'm fortunate enought to have two very good podiatric foot & ankle surgeons in my area - Philip Gowlding and Lewis Stuttard (and George Flanagan as a trainee with the former) and regularly refer - probably two or three patients a week either through the NHS or privately. It's a two-way street as I see more and more of their patients for orthotics that the NHS cannot prescribe. Quid Pro Quo. With these referrals the GPs are always copied in on correspondence and as a result we see more direct private referrals from Primary Care. That is how it should be. I spent part of this afternoon with Lewis and as ever he has a good Lancashire phrase for us - Feet-r-Us! Maybe we should get some badges done.....;)

    Best wishes
  9. Hello London Pod (do you have a name?)

    Thanks for taking the time to submit your views. I think if I had been asked the same question 20 years ago I would have written something very similar but looking at this issue from different perspectives over tha last two decades has changed my outlook somewhat. As Michael has touched upon, the issue of FHPs or assistant grades practitioners or Foot Care Nurses - tends to be an overly emotive one, and when debated on a public forum, the discussion often degenerates into an "us and them" argument which gets us nowhere. The non registered sector exists simply because there is a demand for it - that the, for want of a better term, established profession has failed to service. Not everyone wants to be a specialist of even general podiatric practitioner. Not every patient needs a specialist or GPP either. So it's hardly surprising that independent non-registered "schools" exist. And I have to say that some of the practitioners who graduated from those establishments have gone on to be far superior practitioners than many colleagues who graduated from the established schools. Let's keep the personal emotive stuff on the side if we can. ;)

    I too have some issues with the private trainers around course validation and inspection - but that's another issue for another day. But if we look at the problem as one of servicing a need and demand, then we have to consider how we fulfill that obligation - hence the suggestion of a multi-tiered education program. Not sure about aligning more closely with the established medical schools either - I think to retain our identity and status, our education program should be completely independent - preferably independent from the NHS too.

    Can we also leave the points about regulation and representation until later - all valid and cogent - but we run the risk of exploding this topic into a myriad of directions unless we stick to some sort of structure?!

    Thanks again....
  10. Can someone (Craig?) enlighten me how the podiatry schools are funded in Oz and who determines student numbers/course content etc?
  11. Tuckersm

    Tuckersm Well-Known Member


    Podiatry Schools in Australia are funded via the Australian Government, with students paying a fee or obtaining a government loan to support the program (known as HELP: Higher Education Loan Program). I think it works out about a 50-50 split.

    Currently the number of students in any given course are negotiated between the government and the university, though this is currently under review.
    more here

    The course content is decided by the university in consultation with stake holders, but must be approved by ANZPAC on behalf of the Podiatry Board of Australia.

    So what students learn should be fairly consistent, but the way they learn it may vary.
    Last edited: Nov 10, 2010
  12. I guess the next important question would be how much money does it cost to provide education for 1 student at the moment.

    ie student A does a 4 year course in Podiatry and X $ or £ or Kr is how much money is used by the Uni to provide education for student A.
  13. Hello LondonPod - reread your post last night and have a few other comments to make. How I wish the Society had moved with the times and were as proactive with the profession as you suggest! I fear that not only have they alienated the private practitioner in recent years, they will likely denegrate the profession further by acceding to DoH wishes and drop the title "surgeon" from those colleagues who have graduated in Podiatric Surgery. It's not greater integration with the DoH and medical schools that is needed - but greater autonomy and independence. The Podiatry Association certainly broke new ground three decades ago in both surgery and biomechanics - if such an organisation were around today I would suspect it would be overwhelmed by applications for membership! As far as showing doctors what we do and educating them - I recall this same cry when I graduated. Doctors don't care what we do - unless (and they are a minority I guess but a vocal one at that) you count some of the orthopods who consider what we do as territorial encroachment and regard us as much the same way as you do the FHPs. Therein lies the real problem in the UK!
  14. Hi Stephen - thanks for this. What percentage of podiatry graduates then go on to work for government health programs - in other words, does the governemnt expect a return for their investment in podiatric education?
  15. Tuckersm

    Tuckersm Well-Known Member


    In Australia only about 15% of podiatrists work in the public sector. But most of the private sector are providing "public services" at some level with rebates available for those with chronic illness through our national insurance scheme (Medicare).

    But the government also funds places for Lawyers, Accountants, IT and Business etc. where the return to the government may not be so obvious.
  16. Tuckersm

    Tuckersm Well-Known Member

    The current full fee cost for an OS student wishing to study a "laboratory based" science degree is about A$15,000 per year, so a 4 year podiatry course would be about $60-$80K

    Ref: http://www.studyinaustralia.gov.au/Sia/en/StudyCosts/TuitionFees
  17. Thanks Stephen. Last questions - for now! Which patients or what categories of patients/conditions are eligible for government podiatric care and are all podiatrists expected/obliged to undertake some government work upon graduation say through a residency/preceptorship program?


  18. Tuckersm

    Tuckersm Well-Known Member

    Which patients or what categories of patients/conditions are eligible for government podiatric care:
    Everyone is eligible, but there are priority groups, and it varies between states. In Victoria a co-payment is required for communinty health services, based upon income status from $10 to full cost recovery. This pretty much limits community health to the low income earners.

    Each centre will develop their own priority criteria to suit their local population based on government guidelines as there is not the capacity to see everyone how requests a service.

    Public hospitals are a bit different, and depending on the funding program may or may not charge a fee. The funding program will often affect the patient eligibility. (Sub Acute v Acute services)

    Again government policy states that everyone has access, but for acute service patients usually have diabetes with associated foot pathologies (High Risk foot clinic type patients), but in some cases may be linked to an Orthopeadic, Rhuematology or Neurology service.

    Sub Acute are often Falls and Balance, Rehab and Amputee patients, though some service include chronic wound services.

    Are all podiatrists expected/obliged to undertake some government work upon graduation say through a residency/preceptorship program?

    No. Even if they wanted to, there are currently limited new graduate programs around Australia (maybe 10-20 across the country). Most Public sector podiatry dept. will employ between 1 and 5 podiatrists (some exceptions), so there is often limited ability to properly support a new grad (one of the reasons for the high burn out rate for Australian Podiatrists)
  19. So it's essentially the same model as the UK with a provision through the national insurance scheme (medicare) to reimburse some qualifying patients through approved practices - qualifying either by specified condition (regional criteria) or where patients are means tested. Can every podiatry practice access the medicare scheme and is there controls on how much is claimed - ie do you have to approve Rx in advance of treatment?
  20. Tuckersm

    Tuckersm Well-Known Member

    Any pesom with a chronic illness can access the enhanced primary care program (medicare for allied health) which is capped at 5 AH visiys per calander year, but not otherwise capped. for private practice services
    A GP refferal is required
  21. Forgive my ignorance but to clarify what you say - elgible patients can be referred to any podiatrist - in state hospitals/clinics and private practice - but with the latter the patient can claim for 5 interventions each year. Otherwise when visiting the private podiatrist additional Rx must be met by the patient - just as non eligible patients must meet their own costs of care. Is that correct?

    Are there any podiatry specific insurance schemes in Aus which provide costs of care reimbursments to the private podiatrist?
  22. Mark Podiatry is covered by private insurance in OZ and each fund will allow different amount to be reimbursed, and the % they pay or reimburse the patient. Some have a celling on moneys reimbursed and some will only allow big ticket items ie orthotics every x years.

    This is the same for all allied health in Australia.

    Heres a link to a large health insurance company might give you an Idea on how it works - http://www.hba.com.au/public_insurance_sales/vic/home/index.htm

    and here a link to the extras cover - ie Podiatry, physio etc -http://www.hba.com.au/public_insurance_sales/vic/content/cover_for_extras.htm

    The private insurance is if fact encouraged by the Government as you will see if you check out the website - Tax reimbursements.
  23. Cheers Mike - appreciated. I know how podiatry is organised in the USA and what care is government funded - would be good to hear how other countries support podiatry services - ie Spain, Sweden, Germany etc - are you completely private in Sweden?
  24. Mark, I´m heading for the Hills this weekend will come back with a post early next week. But yes I´m totally private no insurance or government funding totally user pays , but there is Public funded as well - more details next week.

    Have a good weekend folks.....

    maybe Ken or Joris can discuss Belgium if they see this.

    or Björn if you want to comment on Sweden - you probably have more idea of how the public system works than me.
  25. Cheers Mike - have a good one. I've had a couple of emails from colleagues enquiring what the purpose of this thread is..... by way of explanation.

    Whilst every region is different, few will have escaped the dire predictions to the global economy in recent weeks - this following on from the banking crisis last year. One patient, who was, until two weeks ago, a chief economist at the Treasury - and has now taken early retirement and is moving to Norway over Christmas - has suggested that the UK finances are even more perilous than the most pessimistic predictions in the media and elsewhere. In all likelihood, the British currency will collapse in early 2011 when a substantial number of short and medium term government bonds are due to be repaid - and there is nothing in the coffers to meet these payments. This being the case, everyone on the State payroll will be severely impacted - emergency measures have already been drawn up seemingly. Normally I would discount anything an economist may say as no two ever agree about anything, however the impact on the market is already being felt. Had one friend whose mortgage term with the BoS/Halifax finished last month - an interest and endowment mortgage - and the endowment - which was projected to mature at £64,000 to cover his mortgage capital sum of £51,000 - matured at £7,200. The bank has now demanded the balance within 30 days or they will commence repossession proceedings!

    How this will affect public health services is difficult to predict, but one thing is for sure, podiatry will not be a protected service in the NHS - at least not at the same levels as we have currently. There may well be a similar picture in every developed country, irrespective of the healthcare system utilised. When medicare and Blue Cross/Blue Shield stop issuing payments and Further Education Schools stop paying salary cheques then those presently insulated from the economic downturn may well have to consider a somewhat different future....

    So the purpose of this thread is to look beyond the immediate and to examine what the best way may be in future to establish and develop podiatry care systems which are autonomous and as independent from external influences as far as possible. Whatever way the world turns, people will always have painful, dysfunctional feet and will always seek the best care as they can afford. How we facilitate and accommodate them is the new challenge for the profession.

    Have a good weekend....
  26. Sorry Mark got caught up.

    So heres my take on Podiatry in Sweden.

    Podiatry Started in August 2006 with a 3 year ´degree´program (the ´´are due to it not being called a degree in Swedish) and Private practice started the same week. The day I opened to doors to the practice after 6 months getting going after moving here from Australia. So Podiatry just had it´s 4th birthday in the land of vikings.

    A little background - Sweden is a socialist country moving towards a more market approach. Healthcare was covered by the tax system, due to the changes that have occurred over the 10 years less and less is covered by the Governmental medical department.

    Before Podiatry foot care was undertaken by

    * Foot therapist - the palliative care
    * the issue of foot beds - the P & O departments
    * Diagnosis of conditions - orthopedic surgeons - no one else can diagnosis with the Government departments
    * Physio´s may also be called into play here as well.

    Up until 3 years ago if you had diagnosis of " pes planovalgus " you could get P & O orthotics for free. Now days if you are diabetic or have a diagnosis of Rheumatoid arthritis you get shoes and foot beds payed for by the Government - even if you don´t need them.

    When they started planning the Podiatry education about 5 years ago there was no Swedish word for Podiatry it was invented - Podiater .

    We have about 30 Pods in Sweden now the 1st 2 years from the school- not all are working, many studying . The Pods that are working most I believe are working within the Foot clinics at the hospitals a fantastic system for high risk patients. These Pods are at the coal face, but with a limited scope of practice. They do not issue any forms of Foot orthotics - this must be done by the P & O departments, it´s in the contract you sign. Their higher learning and qualifications are not yet recognized and so work officially as Foot therapist - but within the individual teams many a recognized as having a higher education base.

    They still work very much within the hierarchical system of Dr at the peak then the flow down from there.

    Private Practice Not that many of us 3 I think.

    User pays for everything
    - no government help even if diabetic patient.
    - very little insurance coverage - due to Podiatry not being an official medical practice in Sweden yet.

    Scope of practice

    I am not able to use local aesthetic - only Drs so no PNA and the Like
    I am not able to request Xrays, MRI - only Drs and MRI can only come from certain Drs ie not your local GP. The x-rays and MRI are covered by the Government, which means sometime patients are told no and having both feet X-rayed to compare one to the other no chance.

    I work with MSK and Biomechancis with some Palliative care, and after 4 years of hard going am seeing the light at the end of the tunnel, but when people complain about people don´t know what we do blah blah they have no idea.

    Due to various reasons this is the last year that the Podiatry program at university will be running, unless things change. The last Pods to graduate in Sweden will be in the summer of 2011 due to funding issues the school is being closed down. People are working to get a new education started but ........... Money.

    Thats it for now, sorry it took so long.
  27. I've purposely left this thread alone for a few weeks in the hope that some of the UK lecturers might submit their own views in podiatric education. Given that Pod Arena is by far the most authorotative and widely read online forum I would have thought such a topic might have attracted some interest from academia. The lack of contributions has made me wonder just how many staff from UK podiatric colleges actually contribute to this forum. Aside from Simon Spooner and Cameron Kippen and Bill Donaldson - all ex-academia - is there any current staff who submit to threads either here or on JISC Mail?

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