Kent and Medway STP have developed a mobile app to support care workers and carers to access information to help them to deliver great quality care. In line with the local care agenda, we wanted to support people to stay as independent and healthy as possible within their own homes. Care workers and carers interact with the people they care for on a regular basis making them ideally placed to identify the small changes which can be the early signs of a problem.

The app is intended as a portable quick reference guide to support those who provide care to know what to look out for and what to do if they do notice the signs of deterioration, encouraging appropriate, timely referrals to NHS, social care and voluntary sector services. We knew from user research that both of these user groups are really pushed for time, so the app had to support them to find information and make decisions quickly on the go.

Given our aim to support people across Kent and Medway provide great quality care, we wanted to ensure the advice the app gave aligned with NICE resources. Each advice and guidance article is mapped to the relevant NICE guidance or quality standard. The app supports users to care in line with relevant NICE guidance and standards without having to access the internet or navigate to them.

Given the national context of the shortage of care workers and the growing demand for services the app also aims to support new people joining the workforce to quickly learn the basics and feel competent to care. We also have more people living with multiple long-term conditions which the app also supports. In the long term, our aim is for the app to support carers and care workers all over the country.

The Help to Care project was inspired by the Stop Look Care booklet created by Brighton and Hove CCG. Knowing that the project was addressing national issues, we wanted to build upon the success of the Stop Look Care booklet and make it an accessible resource for everyone living in Kent and Medway.

The app was designed to be free because we wanted to support consistency of practice that wasn’t dependent on commissioning decisions or budgets. We weren’t aiming to compete with or replace existing training but to complement existing practise. Whilst the care certificate is the professional standard, completion isn’t mandatory which can lead to inconsistent training standards.

In Kent only 21% of workers have completed the care certificate (Adult Social Care Workforce Data Set) and only 50% hold a relevant qualification. Similar challenges exist for unpaid carers, with only 9% reporting that they had received training as part of their caring role (NHS Digital 2018).

Stakeholders and potential users were consulted at several stages of the project. The project was initiated by a scoping workshop in July 2018 where key stakeholders were invited to attend. This helped to determine the key features of the baseline product. During product development, the app was again presented to a both a user group and a stakeholder group. Once the product was published, further engagement work was conducted.

Following publication in April 2019, further engagement and testing took place including focus groups with carers, social services teams, public representatives. The app was also presented at care provider forums and an informal qualitative study with a domiciliary care provider.

This crucial feedback enabled key changes the product before the app was officially launched. Changes included:

• The name was adapted from Help 4 Carers to Help to Care as carers reported the act of ‘caring’ was more universal and relatable than the title of ‘carer’ and better reflected the app as a self-management tool.
• The carers support guide was created, and the services section enhanced to support carers to self-identity and understand the support that was available, both locally and nationally.
• The feedback from carers has informed the development roadmap for the app. According to the 2011 Census there were 176,810 unpaid carers in Kent and Medway. Carers UK have estimated that the number of carers are likely to have increased by about 35% nationally. This also may not account for the number of hidden carers who do not recognised the invaluable support they may be giving to friends and family. Printing booklets for the entirety of this potential user base could have cost around £500,000 without considering distribution costs or issuing new versions. The app presented a scalable solution with the initial build costing less than 10% of this figure. It has also been much more sustainable as annual hosting and maintenance costs have been around 1% of the cost of printing.
• There are another 43,500 jobs in care across Kent and Medway with over 30,000 of these providing direct care to residents. Additionally, there are over 528,000 people living with long term conditions across Kent and Medway, that could be supported to manage their own condition using the app.

The project was initiated by the workforce lead within South Kent Coast CCG who developed a digital Stop Look Care e-book. The vision of bringing the product to the whole of Kent and Medway in a scalable solution was more challenging. Gaining consensus between the 8 CCGs to support the project and agree content standards was difficult. In order to gain traction, the support of Kent and Medway STP was sought. This also enabled the product to be transferred to the Design and Learning Centre within Kent County Council to support with the governance. The initial build of this app including development, testing and project management was delivered by NEL CSU for c£30,000. NHS Vanguard funding and Kent and Medway STP Local Care workstream has facilitated project delivery.

An advantage of the project dovetailing with Brighton and Hove’s project was that the topics for inclusion and the relevant NICE guidance had already been implemented. This made it much easier to ensure the guidance included on the app aligned with NICE with a strong evidence base of value within a social care setting. When new topics were proposed, such as Carers’ Support, we were able to identify the relevant guidance and included this within the governance documents. The purpose of this is to ensure the content can be reviewed in tandem with changes to national guidance.

After the initial build the project required an FTE Project Officer to manage the product. Securing this resource has ensured the product remains relevant and up to date in terms of content and facilitates ongoing promotion of the app into the delivery phase.

What our users thought:

“I absolutely love the app. It's easy to use, informative and signposts for further help. Great for carers, support workers, in fact, as a parent, would love it” Care Provider Training Manager

“I loved every bit of it especially the articles and trainings section, the navigation and font choice is superb as I read through with ease. I wish there was more content.” Social Care Worker

“It’s packed with information that’s readable and useful … the contents are attractively signposted, and it's is easy to navigate and use. The hyperlinks throughout to specialist services are particularly useful” Resident and Volunteer

The app has met is main objective of creating an app for care workers and carers which supports them to provide quality care. As part of the formative evaluation of the product, a domiciliary care provider piloted the app to help test its effectiveness. After 2-4 weeks of using the app, interviews were conducted with the staff to understand the impacts of implementation.

During the pilot study several interventions were enacted which prevented unnecessary treatment / admissions.

• Skin Damage. The pressure sores assessment tool was used to assess the red skin she observed on a client. The app prompted her to call the clients GP to book an appointment. This resulted in the early diagnosis of cellulitis which was treated without complication at home.
• Catheter Care. The catheter care guide was used to improve knowledge and resulted in more regular cleaning, reducing the client’s risk of infection.
• Mental Health. The mental health guide was used to increase confidence to facilitate a conversation with a client that was presenting with a low mood which would otherwise not have taken place. During the conversation, the Mental Health Services section was used to pass on some relevant numbers. Access to these services supported the client to get the advice and support needed and her mood improved.Despite being experienced, the staff interviewed reported the app made them feel more confident and reassured them they were deliver good quality care. Managers within the care services felt Help to Care supported them to create common standards and expectations across the workforce and encouraged staff to respond appropriately to changes in their clients.
• An unexpected finding was that the app was seen to have benefit for those living with long-term conditions because it supports self-management. During engagement activities a carer who had recently been diagnosed with type 2 diabetes highlighted the value of the app for him to manage his own condition and changes to his health. The potential of the app to support clients using inhalers was also identified. In one instance the app could have prevented, phone calls to a supervisor, 111 and the client’s GP as well as a GP appointment, demonstrating a clear efficiency saving.
• In all three examples the care worker felt that without the information, they wouldn’t have sought support from a manager or health care professional in such a timely manner, if at all, supporting lower level interventions and more efficient responses to changes in care needs.

The pilot has demonstrated the diverse ways in which the Help to Care app creates efficiency within the health and social care system and supports carers and care workers to follow NICE guidance. Following this successful pilot, the app was publicly launched on 11^th May jointly by the Kent and Medway STP, Kent County Council and Medway Council.

User testing demonstrated that some people, whilst confident to use apps, didn’t have digital skills to download it without support and would search via the internet, so we added some content and support videos to our website to support people navigating online. We’re also linking in with other projects to support digital skills and access as this is a barrier to using the app.

Every guide gives people the opportunity to let us know if it was useful or not. Our guide on continence pads has been voted most useful so far. Other popular articles include carers’ support, catheter care and the skin damage tool.

Taking an agile approach to project management has been key to enabling success. Some of the more complex features, such as a directory of services and integration with e-learning content, haven’t been able to develop as quickly and are dependent on other pieces of work. In order to overcome this challenge, the decision was made to launch in two phases. Phase one would be a baseline product which achieve the product aims of information and once the product was established, phase two will see the development of more complex features. The benefit of this approach means it is much easier to be user focused during the development phase.

However, there were some delays caused by early publication. Upon wider consultation, it became apparent that the name of the product was causing confusion about the intended audience of the and that it could bring wider benefit that originally anticipated. Having a publicly available app has been challenging for evaluation, for example we haven’t been able to baseline data before people start using the product.

Some of the biggest areas for benefits include the domiciliary care workforce, where workers are generally working alone with limited resources, and unpaid carers who again are providing care with limited support. These groups are very difficult to target as they cannot be captured through place-based evaluation. By delivering the app through the local authority it was possible to target both audiences through pre-existing relationships and build on existing forums.

The Help to Care project enables broad system improvement. By being developed a system level, it was possible to ensure all of the potential benefactors were considered alongside product development. The operational board has representation from social care and health (including local care, workforce and digital leads within the STP).

Further resources:

Help to Care promotional video 

Help to Care website 

• Fast track acute foot patients from A&E to prevent admissions, involve the MDFT if admission is required and ensure no delay in starting treatment

• Establish 7-day service to decrease delay from referral/A&E attendance.

• Ensure correct diagnostics have been implemented to facilitate;

• Earliest possible targeting of antibiotic therapy in line with Trust and National policies to reduce antibiotic resistance.

• Early diagosis of severe tissue infection, osteomyelitis, gangrene etc. requiring emergency surgery.

• Early diagnosis of Charcot’s Neuroarthropathy, requiring immediate specialist casting techniques and/or orthopaedic input.

• Timely revascularisation.

• Earliest possible discharge from hospital (as MDFT is involved directly from point of admission, with no delay in ward referral).

• Establish agreed pathways within RFH to facilitate elective treatment, day case surgery and prevention of admission.

• Establish agreed pathways within RFH for ‘out of hours’ care and follow up patients seen outside podiatry service times within 24 hours.

• Establish agreed pathways with partner hospitals and podiatry community services.

• Improve access to urgent foot care as requested by the RFH Acute Foot Patient Group.

• Monitor and coordinate re-attendances by patients who are already under care of the MDFT allowing rapid review in the AAFS.

• Audit attendances to A&E, clinical outcomes and patient experience.

RFH became a vascular hub in 2012 for North Central London leading to expansion of the podiatry service. The creation of the Vascular Hub increased number of acute diabetic foot conditions referred into RFH.

An audit of inpatients referred to the RFH podiatry service in 2014 showed that 67% of inpatients seen by the MDFT were admitted via A&E. Hospital data shows that over 2800 patients were discharged from A&E following a foot related attendance in the same 6 month period in 2014, of whom, around 900 had soft tissue damage (ie foot wounds) which could have been potentially treated by a podiatrist, rather than requiring an A&E attendance.

There have been a number of recently documented examples of missed clinical opportunities to prevent amputation in patients admitted via A&E, as well as instances where amputation has been promoted as the only solution to an acute foot episode, with subsequent achievement of limb salvage following involvement of the MDFT.

The main aim of this project was for patients with diabetic foot conditions to access the right care at the right time via a podiatry pathfinder, there by reducing amputations, reducing length of stay and improving patient outcomes.

A bid was submitted to the NHSE Diabetes Transformation Fund to gain funding to establish the AAFS and increase capacity for outpatient clinics and ward podiatry.

Meetings were held with interested parties including the RFH MDFT, A&E, Acute Foot Patient Group, community podiatry, partner hospitals, primary care and NCL STP. These meetings established agreed internal and external pathways and criteria for care plans by the podiatry pathfinder.

AAFS is maintaining a detailed clinical audit of all patients and their outcomes as well as the National Diabetic Foot Audit to support on-going funding of the service. It was essential to fill clinical posts prior to starting project. Attracting new staff to central London proved difficult due to high living costs. Also new staff required training in systems which caused delay.

RFH was undergoing an expansion of A&E during the setup of the AAFS and finding space within the A&E proved challenging. Also, as the first 7 day A&E dedicated podiatry service in England, there was no previous model to work from. A&E staff were initially hesitant about podiatry involvement in their cases and education of staff was paramount in gaining their understanding and utilisation of the service.

AAFS has seen;

• An increased number of referrals from A&E.
• Decreased the time from initial referral to presentation of acute diabetic foot conditions and referral to MDT if admitted.
• 93% of patients were seen in AAFS within 24 hours.

Impact:

• Ensuring patients see the right person in the right place at the right time.
• Supporting GPs with direct access to AAFS.
• Integrating pathways for MDT's, partner hospital and community services.
• Delivering evidence based practice from NDFA and NG19 whilst auditing outcomes.

Commitments:

• Commitment to people with diabetes as outlined by the RFH Acute Foot Patient Group.
• Pathways to local hospital or community services or entering elective surgical pathways.
• Commitment to the North Central London diabetes population.
• Compliments from patient carers who feel supported by our service as it allows for same day service.

Priorities:

• Consultant Podiatrist was responsible for making the bid to NHSE and developing the AAFS, pathways and new team.
• The advanced wound care podiatrists have developed skills further to improve autonomous and MDT working whilst in A&E.
• AAFS audit continues to evaluate and measure the impact of our service on acute diabetic foot conditions.
• Podiatry team have developed their own online templates and audit tools.

We have learnt many new skills from implementing our AAFS.

Initially, our business case was strong, evidenced based, well supported by vascular and diabetes consultant colleagues and clearly outlined the reasoning for the service development. The expansion of our reach within the hospital to A&E allowed for relationships to be formed. By increasing the knowledge of podiatry and what we can achieve, we have seen referrals to our outpatient service from services that have not historically referred. Also by increasing the number of team members, this allowed for increased diversity of clinical and personal skills.

As with any new service, there have been hurdles:

• Recruitment - the success of the AAFS may help this.

• Securing the appropriate space was difficult. AAFS model may be of benefit to other organisations to develop a similar service.

• Expanding the detail of our referral pathway may have helped with confusion from the streaming nurse in A&E.

• Receiving regular feedback in a formal manner may have helped with stakeholder engagement of the A&E consultants and staff, but difficult given the time pressures on all concerned.

As the project continues to evolve, we will learn from these challenges and implement strategy to turn these into a positive.

The aim of the project was to reduce preventable foot care complications associated with diabetes including amputation. To achieve this, the objective was to:

• Raise awareness of NG19 with CCGs
• Encourage the CCGs to review the foot care pathways they have commissioned across primary, community and secondary care sectors
• Remind them tondertake any remedial action to ensure the pathways were NICE compliant.

There is a registered population of over 133,000 people with diabetes across the two Sustainability and Transformation Partnerships (STP’s in Wessex, and estimated that at any one time 3000 of these will have an active foot ulcer, the most common indicator of amputation. During the three years 2013-2016 there were 1367 amputations: 354 were major amputations (above the ankle) across our STPs. Foot disease associated with diabetes generated over 5000 hospital stays during that period with an average stay of 17 nights.

The total annual cost of managing foot ulcers in the community and acute foot disease in hospitals locally for the year 2017-18 is estimated to be in excess of £50,000,000 and just a 10% improvement in efficiency would save £5,000,000 across the region.

The economic case for improving foot care for people with diabetes has been described comprehensively by Marion Kerr in 2014 and 2017.

https://www.evidence.nhs.uk/document?id=1915227&returnUrl=Search%3Fq%3DAmputation%2Bcost&q=Amputation+cost

NHS England have prioritised reducing amputations as one of four priority areas for diabetes transformation funding:

https://www.england.nhs.uk/diabetes/diabetes-prevention/diabetes- transformation-fund/

Diabetes UK have championed improving foot care and reducing amputations through their ‘Putting Feet First’ campaign:

https://www.diabetes.org.uk/get_involved/campaigning/putting-feet-first

Public Health England have provided detailed local information for many key diabetes indicators by CCG and practice level data which highlight variations across Wessex at both primary care foot assessment level and amputation outcomes:

https://healthierlives.phe.org.uk/#par/E92000001/ati/153/iid/91044/sexId/4/gid/1938132699/pat/153

The aim of this project was to benchmark all diabetic foot services across Wessex, against the agreed foot care standards and raise awareness of any gaps or challenges within local pathways and to share learning across the whole diabetes network.In the longer term, the objectives are to reduce variations in care and to improve the foot care outcomes for people with diabetes living in Wessex.

The Wessex Cardiovascular Clinical Network (CVD CN) has committed to supporting all commissioning and provider teams to improve foot care pathways and outcomes for people with diabetes.

This led to the production of the Wessex Foot Care Quality Standards, followed by a full Peer Review Programme across its providers, as evidenced by Richard Paisey et al (Diabetic Medicine Jan 2018) in the South West of England.

Local CCG’s benchmarked their commissioning plans and pathways against the Wessex Foot Care Quality Standards at baseline in 2015/2016 and a progress update one year on. The Forum’s Foot Care Subgroup designed a similar data collection sheet for Foot Protection Services (FPS) and Multidisciplinary Foot Services (MDFS). This report provided a summary of both commissioner and provider returns prior to the full peer review visiting schedule.

A major diabetic lower-limb amputation is an adverse outcome of diabetes. The rate at which major amputations occur in a diabetic population can be used as a good overall proxy measure of the effectiveness of healthcare and the diabetic foot care systems. Wessex providers have a history of being in the higher levels of variation outliers. The most recent Diabetes Foot Care Profiles were published in May 2018 by Public Health England.

The Wessex Foot Care Quality Standards were produced in 2015 and reflect the NICE NG19 guidance pathway, which identify critical functions at three key stages of the pathway. A fourth element of quality improvement was also included to ensure there was an on-going outcome measure.

1. Primary Care.

The five standards here focus on risk identification, education and referral.

2. Community Foot Protection Services (FPS)

Four standards which focus on the assessment, prevention, management and monitoring of those who are most likely to develop a foot complication. 

3. Hospital Based Foot Services – The Multidisciplinary Clinic (MDFS) and Inpatient Service.

Eight standards where the focus is on team structure, relationships with related specialists, leadership of the MDFS and access to it. The essential role of a foot care service for inpatients with diabetes is included as this can reduce hospital-acquired ulceration, reduce length of stay and facilitate an early coordinated discharge.

4. Quality Improvement Actions

The four standards here ensure there is local review, participation in national audit and continuous local improvement targets.

In 2015 all CCG’s were asked to rate their commissioned diabetes foot care services against the standards. Although there had been 100% sign up to the standards from local commissioners, rating performance against them required a much more detailed understanding of the locally commissioned pathway.

Compliance with the Wessex Foot Care Quality Standards and national NICE NG19 guidance was not consistent across the two STP’s within the Wessex region. The potential for improvement was identified by all CCGs and providers and comparison with similar organisations would indicate that this is realistic and financial savings as well as improved patient outcomes should be significant.

This baseline review was to provide motivation for commissioners and provider organisations at every level to keep this work area as a high priority for engagement and action so that the quality and cost benefits could be realised. Some local CCGs had received high level media challenge and scrutiny and so welcomed participation in this process particularly the shared learning experience across the Wessex network. One diabetes commissioner responded “I am in the process of writing a service specifications for the new Foot Care provision so this offers us a really good opportunity to use the quality standards as outcomes and monitor against them over the next 12 months.”

Improving foot care outcomes in people with diabetes has been a priority with Wessex Diabetes SCN and has achieved increased awareness and considerable amounts of data by working with commissioners and providers clinicians across its region.  Undertaking a full peer review would precipitate the improvements that the SW has demonstrated. An additional benefit of bringing representatives from across each foot care pathway together, to match quantitative data with practical experience, provides an enhanced three dimensional perspective of the clinical experience for patients.

The peer review programme undertaken by the South West network had three elements, and was adopted for the Wessex reviews:

1. Pre-assessment - to include a self-assessment of how services meet the quality measures.
2. A peer review visit to each local foot service provider by an expert panel of peer clinicians and managers; enabling a more collaborative and qualitative assessment, and review of the supporting evidence for each measure.
3. Action plans with a clear timetable for implantation and follow up agreed.

The short term aims and objectives of the diabetes foot care projects coordinated by the Wessex Clinical Network can confidently be described as achieved.

There is evidence of every CCG across Wessex engaging and agreeing with the development of the Foot Care Quality Standards and participation of both a baseline and 12-month self assessed RAG rating progress review against the standards. Results were formally presented at a regional clinical network event. Pathways have been reviewed, service specifications rewritten and

the 12month reviews identify a much better understanding and knowledge of the whole pathway by commissioners.

Thirty-five participants attended root cause analysis (RCA) training on 3/2/17 and RCA has been implemented in more organisations since then including a successful bid for national diabetes transformation funding for a RCA programme in Portsmouth. The same national funding stream has provided further NG 19 compliant services including additional inpatient podiatry and additional orthotist time within hospital diabetes foot teams.

A total of 98 people attended the eight peer reviews across Wessex in the autumn of 2018. A report has been produced from each review, which includes areas of identified good practice, immediate risks and concerns, and 114 recommendations. The network is aware that some of the recommendations were completed immediately following the review. Each report will be a public document and local organisations are developing their own action plans based on the recommendations of each review. Many examples of improved service provision following the reviews have been reported to the regional team and further evidence will be the focus of the Annual Wessex Stakeholder event in May 2019.

To evidence a reduction in amputation rates based on the successful delivery and completion of these projects will not be possible as the reasons for amputation are complex and multifactorial with a national and local trend showing an increase particularly in minor amputations.

The key learning from this series of projects are identified below;

1. Committed clinical staff working at each stage of the pathway however without a great deal of knowledge of how the other stages work and who is involved.
2. Lack of understanding of the whole pathway, particularly what happens in the community by CCG’s.
3. A lack of awareness by patients with diabetes and those clinicians and managers not involved with active foot ulceration of the real risk and impact of diabetes related foot complications.

The main challenge was to identify the lead diabetes commissioners for the footcare pathway and to encourage them to complete the returns. Recognising this is just one of many pathways was important and a more personal and supportive approach would have provided better results rather than creating additional email communication pressure. Pre meetings with all of the relevant commissioners, not just those engaged with the network would have reduced any concern about how the information would be used and performance judgements made. Where personal connections were made engagement was better and responses more complete.

These projects benefitted significantly from similar work that had been undertaken previously elsewhere in the UK so a major recommendation would be to use what already has been developed. Specific acknowledgement must be made for the work and support from the South West Diabetes Network for the Wessex RCA and peer review projects.

Ensuring patients have a better understanding of risk was a common recommendation in each peer review for primary care teams. There are national and local initiatives to help with this including the National Diabetes Prevention Programme and improved practice education regarding early referral into the pathway.

Successful projects need effective leadership and a small team to ensure tasks are completed and motivation remains high. Inevitably this requires finding some time capacity to deliver within project timescales. Overloading already busy clinicians and managers only creates additional pressures on hugely committed individuals.

Agreement and sign up from senior clinical and organisational leadership provides the necessary level of authority and credibility to ensure objectives are achieved.

Creating the networks and forums that enable people to meet and develop relationships and trust are essential.

Aim: to establish an integrated foot protection service with the capacity to see and treat patients at most risk of developing diabetic foot problems in a timely manner, whilst ensuring that all people with diabetes received an annual foot assessment.

Objectives:

• To train practice nurses in undertaking diabetic foot assessments, enabling those at low risk to remain in primary care for their annual assessments and those at high risk or with an active diabetic foot problem to be seen by the podiatry service
• To provide the training to all practice nurses and other nursing staff to ensure all GP practices in Newcastle can provide the initial foot assessment
• To make more effective use of specialist podiatry resources, enabling the podiatry service to provide assessments and treatment in a timely manner

Due to increasing incidence of diabetes and increasing numbers of people needing foot assessments in Newcastle (as in many areas) the podiatry service was struggling to deliver the number of consultations needed to manage patients at risk of foot problems. Referrals peaked in 2002 at over 2000 in 1 year (40 per week) and the incidence of diabetes was set to rise to 16,000 by 2011.

A podiatry lead was appointed and implemented a foot care pathway to reflect NICE guidance. Providing an annual foot assessment for all patients with diabetes meant there was less time and resources to treat those people at increased risk of foot problems. The introduction of the Quality and Outcomes Framework (QOF) meant that GPs were rewarded for ensuring every person with diabetes received a foot assessment. At this time all were referred to the podiatry service for assessment. Many of the people referred did not need podiatry treatment or have any foot risk factors, thereby not making efficient use of the specialists’ time, and resulting in longer waits for those who did need treatment.

A 3.5 hour/half day training programme for non-podiatry staff to undertake foot assessments was piloted and then rolled out. All nursing and healthcare staff involved in the diabetes annual review process were invited; mostly practice nurses, but also district nurses, healthcare assistants and podiatry assistants.

The curriculum covered:

• Identifying Diabetic Neuropathy using a 10g monofilament

• Palpating foot pulses to identify normal foot circulation

• Being able to identify diabetic low risk feet

• Being able to discuss basic diabetic foot health education with patients who have low risk feet

• Being able to identify diabetic foot problems or risk factors which require referral to podiatry, such as deformities or lesions

An initial investment of £2k each year from the non-medical training budget was required to set up the training and cover the time away from the podiatry clinics. 240 nurses have been trained up since the programme was introduced and an annual diabetic foot assessment is now something that is just part of what practice nurses do in Newcastle. Only 2 training sessions a year are now required to train up new staff and provide a 3 yearly update for staff already doing foot assessments. Regular updates are also provided at other events, such as diabetes training days. The podiatry service provide feedback to staff if inappropriate referrals are received, thereby helping to embed the change in practice and consolidate the training.

Those at low risk who could manage their own foot care remain in primary care and have their annual assessment with the practice nurse. This is more convenient for patients and enables the podiatry service to focus their resources on those people at increased or high risk who needed their specialist input and treatment.

The additional workload for practice nurses meant that there was some initial resistance to the change. However, an important lever was keeping the training simple, with just a brief theory of the pathology of the diabetic foot and a practical competency-based assessment of nurses delivering foot screening, and emphasising that any foot problem identified could be referred to the podiatry service. In addition, communication was key, with staff knowing who they could contact at the podiatry service and having an easy way to refer in. There is one central system for podiatry referrals in Newcastle and a single point of contact, for all of the podiatry clinics, housebound patients and those in residential homes. The ease of communication has helped to support all practice staff who have diabetic foot queries.

In the year following the introduction of the training programme 700 low risk podiatry patients who could manage their own foot care and were assessed to have no foot risk factors were referred back to the GP practice for annual foot assessment. This enabled more time to be dedicated to the care of high risk patients and those with ulcers. By 2009, the service’s caseload profile had changed, with most referrals being for those patients at increased and high risk. The only low risk patients being referred to the service were the frail elderly who could not manage simple nail care, and these patients continue to be seen at the service by podiatry assistants. In 2015 the podiatry service managed 7,047 patients with diabetes, most of whom are at increased risk or high risk of foot disease, or have active foot disease.

Despite the increasing incidence of diabetes the number of patients with ulcers in the 2 Newcastle CCGs has not increased since 2005, suggesting that the foot protection service is well established, and that those at risk of developing foot problems are receiving more effective preventative care. Amputation rates have also continued to fall to an annual rate of less than 0.6 major amputations per 1000 adults with diabetes. Overall rates of diabetic foot examination have been maintained across the 2 Newcastle CCGs.

The service did not initially communicate back to GPs the results of foot assessments for those patients at increased or high risk being looked after by the podiatry service. A feedback system for GPs is important for integrated care and ensuring the GP is kept up to date about their patient. This should have been set up at the start of the initiative. Now an annual report for GPs is sent as a matter of course.

Simple, practical training and two-way communication have been the foundation for the effectiveness of the Newcastle diabetic foot care pathway.