Specifying a foot care service for people with diabetes

Service components

The key components of an effective foot care service for people with diabetes are:

• appropriate foot care management and referral
• developing a high-quality foot care service.

Appropriate foot care management and referral

All people with diagnosed diabetes should have an annual review, which should include an examination of their feet to detect risk factors for ulceration.

While this guide does not describe the diagnosis and general management of people with diabetes, as this is covered in a range of NICE clinical guidelines and technology appraisals, it is clearly important to identify people with diabetes to ensure they all receive foot care and education according to need. See the NICE foot care guideline algorithm.

The NICE quality standard for diabetes in adults includes the following statements which relate directly to diabetes foot care:

‘People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately' (statement 8).

‘People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours' (statement 10).

The key priorities for implementation, outlined in the NICE clinical guideline CG10 on type 2 diabetes - foot care, are:

Care of people at low current risk (normal sensation palpable pulses)

• Agree a foot care management plan including education.

Care of people at increased risk of foot ulcers(neuropathy or absent pulses or other risk factor)

• Arrange regular review, 3-6 monthly, by foot protection team.
• At each review:
  • inspect patient's feet
  • consider need for vascular assessment
  • evaluate footwear
  • enhance foot care education.

If a patient has had previous foot ulcer or deformity or skin changes manage as high risk.

Care of people at high risk of foot ulcers(neuropathy or absent pulses plus deformity or skin changes or previous ulcer)

• Arrange frequent review (1-3 monthly) by foot protection team.
• At each review:
  • inspect patient's feet
  • consider need for vascular assessment
  • evaluate and ensure the appropriate provision of
    • intensified foot care education
    • specialist footwear and insoles
    • skin and nail care
  • Ensure special arrangements for those people with disabilities or immobility.

Care of people with foot care emergencies and foot ulcers

• Foot care emergency (new ulceration, swelling, discolouration)
  • Refer to multidisciplinary foot care team within 24 hours
• Expect that team, as a minimum, to:
  • investigate and treat vascular insufficiency
  • initiate and supervise wound management
    • use dressings and debridement as indicated
    • use systemic antibiotic therapy for cellulitis or bone infection as indicated
  • ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts
  • try to achieve optimal glucose levels and control of risk factors for cardiovascular disease.

Ensuring that people with diabetes at risk of foot ulcers are referred for appropriate foot care is important both in terms of reducing the risk of foot complications, but also in managing service demand.

Care of people with a diabetic foot problem whilst in hospital (refer to CG119 for full details of the key priorities for implementation)

• Each hospital should have a care pathway for patients with diabetic foot problems who require inpatient care.
• The multidisciplinary foot care team should consist of healthcare professionals with the specialist skills and competencies necessary to deliver inpatient care for patients with diabetic foot problems. This should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist and a tissue viability nurse.
• Refer the patient to the multidisciplinary foot care team within 24 hours of the initial examination of the patient's feet. Transfer the responsibility of care to a consultant member of the multidisciplinary foot care team if a diabetic foot problem is the dominant clinical factor for inpatient care.
• Each hospital should have antibiotic guidelines for the management of diabeticfoot infections.

Developing a high-quality foot care service

The NICE clinical guideline CG10 on type 2 diabetes - foot care recommends the following general management approach as a key priority for implementation.

• Effective care involves a partnership between patients and professionals, and all decision making should be shared.
• Arrange recall and annual review as part of ongoing care.
• As part of annual review, trained personnel should examine patients' feet to detect risk factors for ulceration, which should include:
  • testing of foot sensation using a 10 g monofilament or vibration
  • palpation of foot pulses
  • inspection of any foot deformity and footwear.
• Classify foot risk as: low current risk; at increased risk; at high risk; ulcerated foot.

The contributions of the various professional groups, competences required by team members, and skill mix of the overall team should be considered when setting up a foot care team. The NICE clinical guideline CG10 on type 2 diabetes - foot care on the prevention and management of foot problems recommends that ‘healthcare professionals and other personnel involved in the assessment of diabetic feet should receive adequate training'.

It also states that the ongoing care of people with foot ulcers ‘should be undertaken by a multidisciplinary foot care team' which ‘should comprise highly trained specialist podiatrists and orthotists, nurses with training in dressing of diabetic foot wounds and diabetologists with expertise in lower limb complications. They should have unhindered access to suites for managing major wounds, urgent inpatient facilities, antibiotic administration, community nursing, microbiology diagnostic and advisory services, orthopaedic/podiatric surgery, vascular surgery, radiology and orthotics.' Likewise the NICE clinical guideline CG15 on type 1 diabetes also recommends ‘referral to a specialist diabetes foot care team incorporating specifically trained foot care specialists.'

A locally placed, responsive, safe and effective foot care service for people with diabetes could be delivered in partnership between primary care, podiatry services and secondary care, with the different teams being responsible for specific steps in the diagnostic, treatment and monitoring process, according to risk categories.

Education is considered a fundamental part of diabetes care, the ultimate aim of which is to improve:

• control of vascular risk factors, including blood glucose, blood lipids and blood pressure
• management of complications, if and when they develop
• quality of life.

Structured patient education should be made available to all people with diabetes at the time of initial diagnosis, and then as required on an ongoing basis, based on a formal, regular assessment of need. See the NICE technology appraisal TA60: guidance on the use of patient-education models for diabetes.

Local stakeholders including service users, should be involved in determining what is needed from a foot care service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with diabetes.

The service specification needs to consider:

• Review and assessment service
• service at each risk level
• required competences of, and training for, staff responsible for providing foot care at each risk level
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access
• location of the service
• information and audit requirements, including IT support and infrastructure
• service monitoring criteria.

Useful sources of information may include:

• The NICE Pathway for diabetes care provides an information resource which visually organises NICE recommendations about diabetes management.
• The NICE Quality Standard for Diabetes in adults is a set of specific, concise statements which sets out high quality, cost-effective diabetes care.
• NHS Diabetes supports healthcare professionals to implement the Diabetes National service framework standards. The NHS Diabetes website contains a range of service examples and other resources
• The ‘Diabetes commissioning toolkit' provides useful advice for all commissioners of diabetes services. It describes how to carry out a health needs assessment for a local diabetes population and provides a generic specification for diabetes care, signposting recognised quality markers and suggesting key outcomes for the service.
• Clinical Knowledge Summaries provide clinical knowledge about the common conditions managed in primary and first contact care. See management of foot problems in people with type 2 diabetes.