Reducing the number of amputations among people living with diabetes in Wessex has been a key aim of the Wessex Cardiovascular Clinical Network (CVD CN). A structured series of projects have been undertaken since 2015, which has included significant engagement with a wide range of clinicians, operational managers, commissioners and patients.
The Wessex Foot Care standards were jointly developed and agreed by local stakeholders including clinicians and commissioners, with the Specialist Clinical Network facilitating the process. They set out the care that people with diabetes should expect based on NICE NG19, 2015 and that commissioners and providers should strive to provide, and were also published in 2015. The implementation of the standards across Wessex aims to reduce variation in care and improve outcomes for people living with diabetes related foot complications. A peer review of all diabetes foot care services across Wessex has recently been undertaken to support regional service improvements and included patient interviews.
The following co-authors are acknowledged: Mike Townsend, Podiatrist, Independent Support; Janice Gabriel, Clinical Lead CVD Network, NHS Wessex Clinical Network; Caroline Cross, Quality Improvement Lead, NHS Wessex Clinical Network
Example
Aims and objectives
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.
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.
Reasons for implementing your project
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.
- Primary Care.
The five standards here focus on risk identification, education and referral.
- 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.
- 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.
- Quality Improvement Actions
The four standards here ensure there is local review, participation in national audit and continuous local improvement targets.
How did you implement the project
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:
- Pre-assessment - to include a self-assessment of how services meet the quality measures.
- 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.
- Action plans with a clear timetable for implantation and follow up agreed.
Key findings
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.
Key learning points
The key learning from this series of projects are identified below;
- 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.
- Lack of understanding of the whole pathway, particularly what happens in the community by CCG’s.
- 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.