Training practice-based staff to provide foot assessments in primary care ensured that the specialist podiatry service had the capacity to provide the necessary care and treatment for those at higher risk of developing diabetic foot problems. Those at low risk could be seen at the GP surgery and have their annual foot assessment with the practice nurse. Seeing people in the right place at the right time is more convenient for patients, a more effective use of resources, and meets the needs of those with low risk diabetic feet while enabling the foot protection service to focus on prevention and management of patients at increased or high risk of foot disease. It supports the recommendations in NICE Guideline 19 (NG19) about having a robust protocol and clear local pathways for integrated care of people across all settings.
Aims & Objectives
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.
- 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.
Results and evaluation
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.
Key learning points
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.