Implementation: getting started

This section highlights 3 areas of the diabetic foot problems guideline that could have a big impact on practice and be challenging to implement, along with the reasons why change is happening in these areas (given in the box at the start of each area). We identified these with the help of stakeholders and GDG members (see section 9.4 of the manual).

The challenge: competently undertaking routine assessments to determine the risk of diabetic foot problems developing

See recommendations 1.3.3−1.3.7.

Ensuring that all assessments and, where necessary, referrals to foot care services, are undertaken by skilled and trained healthcare professionals will reduce the risk of complications associated with diabetic foot problems (such as ulceration, infection, amputation and death) and their associated costs.

Ensuring that staff are competent in carrying out routine foot assessment for people with diabetes

It is important that healthcare professionals responsible for undertaking routine assessments to determine a person's risk of diabetic foot problems have the skills and knowledge to meet the requirements for examining people's feet and take the recommended actions described (see recommendation 1.3.4). This may be particularly challenging for healthcare professionals working in general practice who are responsible for caring for people with a wide variety of conditions and who therefore may not have expertise in this area.

To do this, managers of services responsible for carrying out routine annual foot assessments could:

  • Increase staff awareness of locally available diabetic foot problems services, by making links to:

    • Foot protection service.

    • Multidisciplinary foot care service.

    • Other practices carrying out routine annual foot assessments.

  • Support staff to develop and maintain the necessary skills. This could include regular training events with the local diabetic foot problems service.

To do this, commissioners could:

  • Review their incentive systems for annual diabetic reviews to support staff to carry out foot assessments in line with the recommendations, and to take appropriate actions with the results.

  • Establish an 'integrated interdisciplinary foot care service' for people with diabetes, incorporating the foot protection service and multidisciplinary foot care service, in order to support the skills of those carrying out routine assessments.

  • Use service specifications to ensure that assessments are standardised across all the integrated services.

The challenge: establishing a foot protection service

See recommendations 1.2.1, 1.2.2, 1.3.8–1.3.12, 1.4.2, 1.7.8.

Improved patient outcomes (such as reduced rates of foot ulceration, infection, gangrene, hospital admissions, amputation and length of hospital stay) and significant cost savings are likely to be achieved in the long term across all care settings where there is access to a foot protection service or multidisciplinary foot care service.

Ensuring healthcare professionals have the appropriate skills and competencies to deliver the foot protection service:

It may be challenging to ensure that staff in the foot protection service have the necessary skills and competencies because:

  • Staff working in some foot protection services may need extra training if the remit of their current foot protection service differs from what is recommended in this guideline.

  • Complex, active foot problems are managed by the multidisciplinary foot care service, therefore staff in the foot protection service may find it challenging to maintain their skills and competency in assessing and triaging more complex cases.

  • It could be difficult to recruit and retain skilled podiatrists to lead this service at this level.

To do this, lead podiatrists and managers of foot protection services could:

  • Invest in long‑term development of podiatrists with the relevant skills and competencies by:

    • providing learning placements and opportunities to undergraduate and postgraduate podiatrists

    • liaising with the multidisciplinary foot care service to establish a programme of secondments and rotational placements for qualified podiatrists between services.

What could commissioners do to help?

  • Support members of the multidisciplinary foot care service to be flexible, and provide access to their skills for the foot protection service. This would promote shared learning and training, and increase service capacity.

Ensuring timely access to the service for eligible patients

Achieving the recommended timeframes for triaging, assessing and reassessing people with diabetes may be a change to current practice for some areas (see recommendations 1.3.9, 1.3.11 and 1.4.2) and may increase demand on capacity.

To do this, lead podiatrists and managers of the foot protection services could:

  • Review people under the care of the (diabetic) foot protection service and ensure that they meet the criteria identified within this guideline. See the QIPP example podiatry education to empower patients to self-care.

  • Use the NICE costing report and template to develop a business case for local commissioners to secure support for development or enhancement of a foot protection service with capacity to meet demand.

What can commissioners do to help?

  • Be flexible with resources when establishing a foot protection service to maximise patient access to healthcare professionals with skills in diabetology, biomechanics, orthoses and wound care when clinically required.

  • Ensure that service specifications about which patients should be cared for within this service meet those recommended in this guideline.

  • Consider creating an integrated interdisciplinary foot care service that starts at the point of diagnosis of diabetes and continues indefinitely. This will streamline the service and allow for rapid referrals, fewer delays and better communication. Service specifications could be used to develop robust protocols and local pathways clearly defining the relationships between services.

The challenge: establishing a multidisciplinary foot care service, which consists of specialists with skills in the recommended areas

See recommendations 1.1.3, 1.2.1, 1.2.3, 1.4.1, 1.4.2.

The presence of multidisciplinary care with a well‑designed team reduces rates of amputation and the length of hospital stay.

A culture of sharing of information, skills and abilities will be created by integrating the multidisciplinary foot care service with other services responsible for caring for people at risk of, or with, diabetic foot problems. This could lead to people with diabetes becoming better informed, having faster access to treatment, and fewer mistakes being made.

Ensuring that people with diabetic foot problems have access to the multidisciplinary foot care service

There are variations in availability and access to this service across the country. Centralisation of vascular services may mean that some hospitals do not have on‑site access to vascular specialists.

To do this hospital managers and the named healthcare professional could:

  • Work creatively to provide a flexible approach that focuses on core membership and achieving access to services when clinically needed, for example, through a network or vascular hub. One idea could be a weekly multidisciplinary foot care service meeting where members of the surgical and radiological teams are present.

  • Use the NICE costing report and template to develop a business case for trust senior management and local commissioners to secure support for establishing or developing the multidisciplinary foot care service. This should include recognition that likely savings will be to the wider health economy.

To do this, commissioners could:

  • Support the development of a multidisciplinary foot care service through commissioning arrangements. Ensuring access to high‑quality vascular services and support from those services will be an important part of this.

  • Use service specification to support integration of the multidisciplinary foot care service with the foot protection team and services responsible for the routine annual assessment of the risk of diabetic foot problems.

  • National Institute for Health and Care Excellence (NICE)