ANNUAL DIABETES

FOOT CARE REPORT

Foreword

South East Diabetes Clinical Network Footcare Subgroup was created in 2014 .

The purpose of this document is to provide commissioners and providers with an overview of the current data on the provision and outcomes of footcare across Kent, Surrey & Sussex.

The report highlights that despite improvements nationally,

both major and minor amputation rates across the South

East have not improved. Our third annual gaps survey showed that little has

changed over the last 3 years in addressing the gaps in the NICE Guidance

that would support improvements to outcomes being achieved.

There is no doubt that targeted investment is required but the survey results

clearly demonstrated that some of the issues are about coordination and

communication rather than finance. I.e. having clear published foot care

guidance widely available.

In particular, vascular hubs or aspiring vascular hubs (Arterial Hubs) must

ensure that they have a robust Multi Disciplinary Foot Care Team and referral

pathways in place.

The South East Diabetes Clinical Network Foot Care Subgroup has now been

established and well attended for 3 years. Collectively there continues to be

good participation in the annual gaps survey and in particular the Network have

received national praise for having the highest number of sites registered for

the new National Diabetes Foot Care Audit.

• The NHS Mandate in Objective 4.2.8 outlined that in addition to introducing a

national diabetes prevention programme that the NHS would also do more to

“improve the management and care of people with diabetes”.

The recent “STP Diabetes Aide Memoire” also encourages renewed focus on

improving foot care outcomes: “CCGs should ensure they have a footcare

pathway with adequate capacity to enable early referrals of people at risk of

diabetic foot disease to foot protection teams and people with active disease to

multidisciplinary footcare teams. CCGs should take NICE’s footcare pathway

guidance into account in developing the pathway”.

I would like to thank all those who have continued to contribute and support the

South East Foot Care Network and I commend this report to you. Best wishes,

Dr David Lipscomb

South East Diabetes Clinical Network Lead

National Overview

“I am faced for the rest of my life with the situation where I have to cope with an amputation through no fault of my own” (person with diabetes)

• There are currently 3.2 million people with type 2 Diabetes in England with

around 200,000 new diagnoses every year. (Diabetes UK 2015) There are a

further 5 million at high risk of developing type 2 Diabetes. (NHS England 2016)

• An estimated 5-7% of people with diabetes are thought to have current or past

foot ulceration. (Kerr et al 2014)This would suggest that there are around

86,000 people with foot ulcers across the UK (Diabetes UK 2015).

• The cost of diabetic foot ulcers and amputations to the NHS in England in 2010-

11 is estimated at £639-£662 million. Approximately £1 in every £150 the NHS

spent was for diabetic foot ulceration and amputation (NDIS 2015).

• Data from Public Health England (PHE) show that diabetes -related amputation

rates in England have now reached a record high of 135 per week

• Public Health England has shown that major amputations have decreased from

7,187 in 2007-10 to 6,758 in 2011-14. However, minor amputations have risen

from 10,893 to 14,367 over the same time period.

• Mortality Rates are high with up to 70% of people dying within 5 years of having

an amputation and around 50% dying within 5 years of having a foot ulcer.

(NICE 2015)

Kent, Surrey & Sussex

The prevalence of adult diabetes in the South East is 7.3% of the population, an

estimated 266,350 people. This number is expected to rise to 371,487 by 2030.

The rates for major amputation across the SE Clinical Network for 2011-14 are higher

than the national average in 11 out of 21 CCGs. The national average having fallen

from 0.9 per 1,000 patients with diabetes to 0.8. The rates for minor amputations

across the SE Clinical Network are higher than the national average in 7 out of 21

CCGs. The national average for minor amputations being 1.8. (SE average of 2.02)

See Appendix 2.

National Diabetes Audit

A report from the National Diabetes Audit (2013-14 and 2014-15) provides a

comprehensive view of Diabetes care in England and Wales and measures the

effectiveness against NICE Clinical Guidelines and NICE Quality Standards. Report

1 : the NICE recommended eight care processes and treatment targets. One of

the care processes is the Foot Risk Surveillance (foot examination for foot ulcer

risk)

Foot Risk Surveillance Kent, Surrey and Sussex

From the NDA 2015 report, there were 14 CCGs that fell below the England national

average for foot surveillance.(see Appendix 3 for Type 1 and Type 2 Diabetes) This

is disappointing as identifying foot ulcer risk is key to people with diabetes receiving

appropriate care along the integrated foot care pathway. Having an integrated foot

care pathway in every diabetes service is of paramount importance to ensure people

with diabetes receive the right care at the right time from the right people. Dr. David

Lipscomb has highlighted the pathway in the Foreword of this document. For more

detail, see Appendix 3. (Foot Surveillance).

National Diabetes Inpatient Audit (NaDIA)-2015:Hospital-level analysis for

England 2015

The National Diabetes Inpatient Audit provides a snapshot of diabetes inpatient care.

The Audit from September 2015 was conducted in hospitals across England and

Wales. Data was collected on characteristics of the hospital including staffing

structures, patient clinical data and patient experience information. The table below

includes hospital data relating to diabetes foot care across Kent, Surrey and Sussex.

Admitted with foot disease

Admitted with foot disease

Seen by the MDFT within 24 hours

Foot risk assessment within 24 hours

Foot risk assessment after 24 hours only

Foot risk Assessment during stay

Admitted with foot Ashford and St Peter's Hospitals NHS Foundation Trust

3.3% 50.0% 3.5% 1.7% 5.2%

Conquest Hospital

4.4% 0.0% 51.1% 0.0% 51.1%

Darent Valley Hospital

6.5% 0.0% 13.6% 3.4% 17.0%

East Surrey Hospital

10.3% 30.0% 31.8% 3.5% 35.3%

Eastbourne District General Hospital

1.8% 100.0% 25.0% 0.0% 25.0%

Frimley Park Hospital

12.6% 50.0% 47.0% 2.4% 49.4%

Frimley Sites - Including Wexham Park Hospital and Heatherwood Hospital

16.2% 90.5% 22.3% 2.7% 25.0%

Kent and Canterbury Hospital

13.6% 0.0% 20.5% 0.0% 20.5%

Medway Maritime Hospital

15.3% 0.0% 6.7% 1.7% 8.3%

Princess Royal Hospital (Brighton and Sussex)

2.5% 0.0% 0.0% 5.0% 5.0%

Queen Elizabeth the Queen Mother Hospital

7.3% 20.0% 23.6% 5.5% 29.1%

Royal Surrey County Hospital

7.3% 40.0% 14.6% 3.6% 18.2%

Royal Sussex County Hospital

23.1% 4.6% 26.7% 1.1% 27.8%

St Richard's Hospital

5.9% 75.0% 15.4% 1.5% 16.9%

Tunbridge Wells Hospital

1.8% 0.0% 18.6% 3.4% 22.0%

William Harvey Hospital

17.4% 28.6% 41.3% 2.2% 43.5%

Worthing Hospital

9.5% 33.3% 22.2% 3.2% 25.4%

England 8.9% 58.0% 28.7% 5.4% 34.0%

The percentage values relate to the percentage of inpatients with diabetes, who were

admitted with foot disease. For example, in 2015,Eastbourne DGH had 1.8% of all

patients with diabetes admitted to hospital with a foot problem.

National Foot Ulcer Audit (NDFA)

The National Diabetes Foot Care Audit Report for England and Wales was published

in March 2016 and nearly 130 clinical foot care teams and 129 CCGs and Local Health

Boards have participated in the first Audit. The first cycle of the NDFA includes data

on over 5000 people presenting with an episode of a new foot ulcer between 14th July

and 10th April 2015. There were 3 key questions asked in the Audit:

• Structures Survey: are the nationally recommended (NICE) care structures in

place for the management of diabetic foot disease?

• Processes: does the treatment of active diabetic foot disease comply with

nationally recommended guidance?

• Outcomes: are the outcomes of diabetic foot disease optimised?

The nationally recommended (NICE) basic care structures include: a skilled

workforce for assessing people with diabetes to ascertain their risk of

developing a foot ulcer; a Foot Protection Service available for the prevention

and management of diabetes foot problems and an integrated foot care pathway

for access to the Multidisciplinary Footcare Team and the Foot Protection

Service.

The national results

(Structures survey) showed:

Almost 40 per cent of participating commissioning organisations were unable

to give a definitive response (yes or no) to all of the NDFA Structures

Survey questions.

More than 40 per cent of localities who could respond to all three questions

did not have all three of the basic NICE recommended systems for preventing

and managing diabetic foot disease.

The national results (Processes) showed:

Annual foot checks

The audit found that people with diabetes presenting with a foot ulcer are just as likely

to have had a NICE recommended routine foot check in the preceding year as other

people with diabetes (85 per cent in both groups).

People with a newly occurring foot ulcer should be referred and triaged within

two days

The audit found that:

Almost 30 per cent of patients self-presented. Two fifths of patients who did not self-

present were not seen by the foot care service until two weeks or more after

the first healthcare contact for their ulcer.

More than one in 10 of those who did not self-present were not seen for two months

or more from the first healthcare contact.

The longer the delay before being seen by the diabetic foot care team, the more

likely were the foot ulcers to be severe.

The national results (Outcomes) showed:

One half of all patients were ulcer free at 12 weeks from first expert assessment.

Patients who self-presented or who were seen by the specialist foot care service

within two weeks of first assessment by another healthcare professional had higher

rates of ulcer healing than those seen later.

Patients presenting with more severe ulcers were almost twice as likely not to be ulcer

free at 12 weeks after first expert assessment.

Kent, Surrey & Sussex Results

The South East Coast had excellent participation in the Audit with 11 services

submitting data to the Audit with 317 episodes of a new foot ulcer.

Observed 12 week healing rate for less severe ulcers (SINBAD score <3), by

strategic clinical network, England and Wales, 2014-2015 (table below)

Care must be taken with interpretation of the results in terms of performance as

there has not been a case mix adjustment.

Observed 12 week healing rate for severe ulcers (SINBAD score >=3), by strategic clinical network, England and Wales,

2014-2015

Care must be taken with interpretation of the results as there has not been a case mix

adjustment

The NDFA is ongoing and will be able to provide useful data to all the foot care

services. Comparison with other services will be possible when there are casemix

adjustments made in the analysis of the data. Importantly the use of the SINBAD ulcer

classification will improve all the services and provide standardisation for both local

and national audits.

Gaps Analysis Summary From the 2016 survey, there remain structure and process gaps across the Network.

Structures

1. Two services reported no access to Vascular surgeons; three services reported

that they have no access to Intervention Radiologists; one service reported that

they have no access to Tissue Viability Nurse; three services reported no

access to orthopaedic surgeons and two services reported no access to

Orthotists

2. Three services reported that they do not have a ‘dedicated’ MDFT. This

response may require further investigations e.g. job descriptions, contract

spec.)

3. Eight services reported that they do not have a dedicated Foot Protection

Team.

Processes

4. Ten services reported that they do not see patients with an active foot ulcer that

are referred to the MDFT within 24 hours.

5. Six services do not have agreed published guidelines for the referral of patients

to the MDFT

6. Three services do not have a published form for referral of patients to the MDFT

7. Five services do not have agreed published guidelines/pathways for the

prevention, early detection and management of diabetes foot disease.

8. Only two services reported that all patients with diabetes admitted to hospital

have a foot examination recorded.

9. Three services do not have published guidelines for the referral of patients from

primary care and secondary care to vascular services.

10. Ten services do not have a standard practice for ulcer classification used by

the MDFT. ( despite registration for the Foot Ulcer Audit)

11. Twelve services do not hold regular clinical governance or audit meetings.

(See table below for more information. Appendix 1)

Uncertainty

A number of the questions had the response of ‘uncertain’. There may be a

number of explanations for this response. Despite guidance notes, some of the

questions may be ambiguous for the respondents or members of the MDT

(respondents) are unaware of certain aspects of the service. Further follow up

may be required to further interrogate the ‘uncertainty’ responses to determine

the status of parts of the service. The frequency table below highlights the

questions that received the greatest number of ‘uncertain’ responses. It is a

significant concern that 11 respondents (2015 and 2016) were uncertain about

patients with diabetes admitted to hospital having a foot examination recorded

in the hospital notes and that 8 respondents (2015 and 2016) were uncertain

about published guidelines for key aspects of their services. (combined

responses for 2015 and 2016).

The key gaps described above give rise to concern over variability in foot care

provided across the network. This is particularly the case where there is no

access to vascular or orthotic services which are key requirements for patients

who present with foot ulceration. (The questionnaires have been completed by

Diabetologists, Vascular surgeon and specialist podiatrists. The responses of

‘no access’ may require further clarification)

Concerns also remain over the availability of agreed published pathways,

guidelines and protocols (NICE rec)

Variation in the services profile are provided in the tables provided (see

Appendix 1)

78

6

11

78

6

18

0

2

4

6

8

10

12

14

16

18

20

Is there apublishedpathway

agreed withtrust for theprevention,

earlydetection &

managementof diabetic

foot disease?

Are therepublished

guidelines forprevention,

earlydetection &

managementof diabetic

foot diseaseused in bothoutpatient &community

settings?

Are riskassessedpatients

reviewed atintervals

compliantwith the NICE

guidelines?

Do all patientswith diabetesadmitted to

hospital havea foot

examinationrecorded

(documentedin patientnotes)?

Are there sub-24 hourvascularservices

available forpatients withdiabetes andcritical limbischaemia?

Are thereagreed,

publishedguidelines forboth primary

andsecondary

care regardingaccess tovascularservices?

Is there anagreed

structured,tailoreddiabetes

educationprogramme

including footcare to all

patients withdiabetes?

Will fundingbe made

available in2014/15 forall members

of the MDT toaccess

continuingeducation in

diabetescare?

Questions with the highest number of "Unsure" responses-All Years

Commissioning and Support Provision

National Support

• Reducing amputation rates nationally remains a priority for NHS England and

is reflected in the Diabetes STP Aide Memoire.

• The national charity, Diabetes UK, continue their ‘Putting Feet First’ campaign

to lobby the Dept. of Health and draw media attention to the unacceptable level

of amputations in England given that up to 80% can be prevented by structured

foot care and education.

• The National Diabetes Foot Care Audit Report 2014-2015 (HSCIC 2016) which

has provided a valuable insight into the links between the structures and

processes of care and the clinical outcomes of people with diabetes foot ulcers

in England and Wales.

• The publication of the Operational Delivery of the Multi-disciplinary Care

Pathway for Diabetic Foot Problems (April 2016).The document provides a

framework for the operational delivery of the hospital Trust based diabetic foot

services. The pathway complies with NICE clinical guidelines: Diabetic foot

problems: prevention and management (August 2015).

• The publication of the Provision of Services For Patients with Vascular Disease

(2014) from the Vascular Society of Great Britain and Ireland. There is universal

agreement that Diabetic Foot Services must be organised to enable access to

vascular expertise for the diabetic patient at both arterial and non-arterial

centres.

The Diabetes Clinical Network Foot

Care Subgroup The Diabetes Clinical Network Foot Care Subgroup is providing the following support:

• The foot care subgroup (network) has been established for 3 years and has

agreed strategic actions.

• A third diabetes foot care survey to identify gaps in the MDFT services across

Kent, Surrey and Sussex. The services are benchmarked against NICE

guidelines (CG19)

• Ongoing support for all of the MDFT services which are registered for the

national foot ulcer audit. The audit will identify severity and stage of the foot

ulcer at the time the member of the MDFT assesses the patient, the time taken

from first referral to the MDFT, and the outcomes at 12 weeks. The initial report

has provided important information for all services. (The National Diabetes Foot

Care Audit Report 2014-2015 (HSCIC 2016))

• Ongoing support for the reconfiguration of vascular services. The South East

Coast Strategic Clinical Network has been working with the Sussex Vascular

Network and the Kent and Medway Specialist Vascular Services to align

diabetes foot care across Kent, Surrey and Sussex.

• The development of a guidance document for commissioners: NHS South East

Coast: Clinical Senate: Strategic Clinical Networks: Diabetes Foot Services-

Guidance for commissioners: sample service specification.

• Have offered workshops to facilitate development of service specifications with

CCGs and NHS Providers across the Network.

• Facilitating shared best practice following gaps analysis from the foot care

services survey to help develop NICE compliant services across Kent, Surrey

and Sussex.

• Sharing of best practice to develop agreed guidelines and protocols which have

been identified from the survey.

• Explore the feasibility of RCA (Root, Cause, Analysis for major amputations)

• Facilitate discussions on provision of structured foot health education

programmes

• Ongoing national foot ulcer audit

Recommended Action for CCGs

It is recommended that CCGs:

• Support the implementation of the foot care NICE Guidance (NG19 2015)

• Consider the development and configuration of the local dedicated foot care

MDT

• To use contracting levers to ensure that all diabetic patients have a foot check

in hospital

(Diabetes UK ‘Putting Feet First’ campaign supporting this initiative)

• To support the development of local foot protection teams/services and

MDFT/services. (NICE rec)

• To ensure that all patients are treated in accordance with NICE Quality Standards 11 and 12. 11-People with diabetes with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services, and the MD foot care service is informed;

• 12- people with diabetes with an active foot problem that is not limb-threatening or life-threatening are referred to the MDT foot care service or foot protection service within 1 working day and triaged within 1 working day

• Support robust protocols and clear local pathways (NICE recommendation)

• Regular review of treatment and patient outcomes (NICE recommendation)

• To review the SCN gap analysis and develop action plans to address the gaps

• To support local participation in the National foot care audit to provide valuable

information re: structures and processes.

• To participate in the Foot care subgroup meetings.

Additional Reading and Resources

• Diabetes UK: 6 Steps to improving diabetes foot care:

file:///C:/Users/Kitt/AppData/Local/Microsoft/Windows/INetCache/Content.Outl

ook/X30GYF8Q/0769A_Putting%20Feet%20First%204%20sider_A4_digital%

20PDF_July04_HC.%20FINAL.pdf

• The Joint Societies guidance on operational delivery of MDT foot care

https://www.diabetes.org.uk/About_us/What-we-say/Specialist-care-for-

children-and-adults-and-complications/Operational-Delivery-of-the-Multi-

Disciplinary-Care-Pathway-for-Diabetic-Foot-Problems/

• National Foot Care Audit

http://www.hscic.gov.uk/media/20604/National-Diabetes-Foot-Care-Audit-

NDFA---2014-2015-Report/pdf/nati-diab-foot-care-audit-14-15-rep.pdf

• Putting Feet First HCP Pathway

https://shop.diabetes.org.uk/usr/downloads/0792A_Putting%20Feet%20First

%20Pathway%20Update_A3_To%20Print.pdf

Conclusion

The South East Clinical Network is determined to support commissioners and

providers of diabetes foot care to eliminate variation in the services and support the

Clinical Commissioning Groups to fully commission the integrated foot pathways which

include the Multi -Disciplinary Foot Service and the Foot Protection Service, the

essential components of the service. (NICE CG19)

Appendix APPENDIX 1

TABLE OF RESULTS FROM DIABETES FOOT CARE SERVICES OF NHS SOUTH EAST COAST

NETWORK

5. Please indicate the professionals involved with the MDT 2015

Members of the MDT 2015

Access No access

Members of the MDT 2016

Access No access

Vascular Surgeon

7 9 1 9 2 2

Diabetologist 12 4 1 12 1

Specialist Podiatrist

13 3 1 13 (1 no response)

Interventional Radiologist

1 9 6 1 7 3 (2 no responses)

Orthopaedic Surgeon

2 11 2 4 4 3 (2 no response)

Tissue Viability Nurse

4 10 4 3 8 1 (1 no response)

Microbiologist 2 14 1 4 8 (1 no response)

Orthotist 4 11 2 2 8 2 (1 no response)

Diabetes Specialist Nurse

9 6 3 6 6

(1 no response)

Question number 2014

2015

2016

yes no uncertain yes

no

uncertain Yes no uncertain

4. Is there a dedicated MDFT in your organisation?

14 0 10 5 11 3

5.6.8.9 (see separate section)

7. Is there a dedicated foot protection team in your organisation?

8 4 1 7 8 1 6 8

10. Is there a named clinical lead of the MDFT?

10 3 10 5 1 10 2 1 (1 no response)

11. (named leads)

12. Is there a named clinical lead for the FPT?

Not asked in 2014

3 10 2 6 6 2

13. (Named leads of FPT)

1 (no response)

14. Are FPT patients provided with named contact and telephone no?

Not asked in 2014

1 15 5 4 3 ( 2no response)

15. Is there a central phone no. for the MDFT?

Not asked on 2014

9 7 8 6

16. Is there a central phone no for the FPT?

Not asked in 2014

3 13 5 6 (3 no response)

17. Is there a published referral form that HCPs can use to directly refer to the MDFT?

Not asked in 2014

9 6 1 10 3 1

18. Is there a published pathway agreed for referral of patients with active foot ulcer across primary and secondary care?

8 2 3 9 7 8 5 1

19(.detail re: above)

20. Are all patients with an active foot ulcer who are referred to the MDFT seen within 24 hours?

2 11 3 12 1 3 10 (1 no response)

21.(detail re: above)

22. Is there a published pathway for the prevention, early detection and management of diabetic foot disease?

6 2 5 7 6 3 6 5 3

23. Are there published guidelines for the prevention, early detection and management of DF disease?

5 2 6 6 6 4 8 3 3

24. Are those guidelines the same as used in community settings?

Not asked in 2014

6 6 1

25. Are risk assessed patients reviewed at regular intervals (NICE compliant)?

9 2 1 7 4 4 11 2 1

26. Are all hospital inpatients with an active ulcer discharged back to the MDT/FPT?

5 8 9 6 5 6 3

27.(details re: above)

28. Do all patients with diabetes admitted to hospital have a foot examination recorded?

3 8 3 1 9 5 2 6 6

29. Is there a podiatry service available for

14 1 1 14 1 1 13 1

hospital inpatients with diabetes?

30.(details re above)

31. Are there sub-24 hours vascular services available for patients with diabetes and critical limb ischaemia?

9 2 3 9 2 6 13 1

32. Are there agreed published guidelines for both primary and secondary care regarding access to vascular services?

1 9 4 5 7 5 8 3 3

33. Is there access to a plaster technician/similar for total contact casting or similar device?

12 1 0 13 3 1 13 1

34. Is there access to an orthotist for the provision of specialist footwear?

11 2 16 1 14

35. Is there an agreed published protocol for antibiotic treatment for infected foot ulcers?

8 3 2

9 5 3 11 1 1 (1 no response)

36. Is there an agreed published protocol for wound dressings?

1 8 4 6 9 2 4 8 2

37. Is there an agreed structured, tailored diabetes education programme including foot care for all patients?

7 5 1 8 6 3 5 5

4

38.Is there a dedicated session for the treatment of painful neuropathy

12 1 14 3 1 10 3

39. Is there an agreed standard ulcer classification used by the MDFT?

5 6 6 3 10 1

40.Is there an agreement to take part in the Foot Audit (SINBAD system July 2014)

13 13 1 2

41. Is there an agreed electronic database that all members of the MDFT can access?

1 10 2 3 9 4 4 9 1

42. Can appropriate HCP in primary care access the electronic database?

0 8 2 3 11 1

43. Will funding be made available in 2014/5 for all members of the MDT to access CPD in diabetes care?

4 1 8 3 2 11 3 2 9

2016 Only

Does your MDFT have regular audit/clinical governance meetings?

Yes 2 No 12 Uncertain

APPENDIX 2

Data from Public Health England. Diabetes footcare activity profiles. July 2015

The areas in red show the CCGs that have above national average number of amputations.

CCG Major Amputations per 1,000 diabetic patients April 2009 – March 2012

Major Amputations per 1,000 diabetic patients April 2010- March 2013

Major Amputations per 1,000 diabetic patients April 2011 – March 2014

Major Amputations per 1,000 diabetic patients April 2012 – March 2015

England 0.9 0.9 0.8 0.8

NHS Ashford CCG 1.3(21) 1.6 (26) 1.3(22) 0.9 (16)

NHS Canterbury & Coastal CCG

0.8 (22) 0.8 (24) 1.0(29) 0.9 (28)

NHS South Kent Coast CCG

1.4 (43) 1.4 (44) 1.0 (34) 1.0 (34)

NHS Thanet CCG 1.6 (36) 1.4 (31) 1.2 (29) 1.3 (31)

NHS Swale CCG 1.1 (18) 0.9 (15) 1.0 (17) 0.8 (15)

NHS Medway CCG

0.8 (37) 0.8 (37) 0.8 (34) 0.7 (34)

NHS Dartford, Gravesham & Swanley CCG

0.8 (26) 0.7 (25) 0.6 (23) 0.6 (22)

NHS West Kent CG

0.8 (44) 0.8 (44) 0.7 (41) 0.8 (46)

North West Surrey CCG

1.2 (48) 1.3 (57) 1.3 (57) 1.1 (53)

Surrey Downs CCG

0.7 (22) 0.8 (27) 0.7 (22) 0.6 (19)

Surrey Heath CCG 0.5 (6) 0.5 (6) 0.7 (8) 0.8 (9)

North East Hampshire & Fareham CCG

0.7 (17) 0.5 (12) 0.5 (13) 0.5 (15)

Guildford & Waverley CCG

0.7 (16) 0.8 (18) 0.8(17) 1.0 (22)

East Surrey CCG 0.8 (15) 0.8 (15) 1.0 (19) 0.8 (17)

Horsham & Mid Sussex CCG

0.6 (11) 0.8 (20) 0.6 (15) 0.8 (21)

Crawley CCG 0.6 (11) 0.5 (9) 0.5 (9) 0.9 (17)

Coastal West Sussex CCG

1.0 (71) 1.0 (71) 0.9 (71) 1.0 (79)

Brighton and Hove CCG

0.9 (27) 1.0 (31) 1.0 (32) 0.9 (29)

High Weald, Lewes & Havens CCG

0.5 (10) 0.4 (8) 0.6 (12) 0.6 (14)

Hastings & Rother CCG

0.9 (24) 1.6 (42) 1.0 (27) 0.9 (27)

Eastbourne, Hailsham & Seaford CCG

1.7 (43) 0.9 (27) 1.7 (47) 1.1 (33)

South East Coast Total

568 589 578 0.9 (581)

The areas in red show the CCGs that have above national average number of amputations.

CCG Minor amputations Annual rate per 1000 adults with diabetes – 1st April 2011 to 31st March 2014

Minor amputations Annual rate per 1000 adults with diabetes – 1st April 2012 to 31st March 2015

England 1.8 1.8

NHS Ashford CCG 1.4 (25) 1.6 (29)

NHS Canterbury & Coastal CCG 1.8 (55) 2.1 (64)

NHS South Kent Coast CCG 1.6 (51) 2.0 (67)

NHS Thanet CCG 2.7 (65) 2.5% (61)

NHS Swale CCG 2.1 (36) 2.5 (45)

NHS Medway CCG 1.3 (56) 1.4 (66)

NHS Dartford, Gravesham & Swanley CCG

2.4 (84) 2.0 (73)

NHS West Kent CCG 3.1 (183) 3.0 (185)

North West Surrey CCG 2.7 (121) 2.6 (120)

Surrey Downs CCG 1.2 (38) 1.4 (48)

Surrey Heath CCG 1.6 (18) 1.7 (20)

North East Hampshire & Fareham CCG

1.5 (39) 2.1 (57)

Guildford & Waverley CCG 2.1 (46) 2.0 (45)

East Surrey CCG 2.6 (51) 2.3 (48)

Horsham & Mid Sussex CCG 1.5 (39) 2.0 (57)

Crawley CCG 1.4 (25) 1.4 (26)

Coastal West Sussex CCG 1.9 (143) 2.1 (163)

Brighton and Hove CCG 2.1 (66) 1.8 (58)

High Weald, Lewes & Havens CCG

2.3 (49) 1.8 (39)

Hastings & Rother CCG 2.4 (68) 2.4 (69)

Eastbourne, Hailsham & Seaford CCG

2.7 (76) 2.9 (84)

South East Coast Total 2.02 (1334) 2.08 (1424)

CCG value significantly higher than England average of 1.8

APPENDIX 3 - Foot Surveillance

SCN CCG Code CCG

Participation

Foot Surveillance - T1

Foot Surveillance - T2

South East SCN 09J

NHS Dartford, Gravesham and Swanley CCG

5.9% (2/34) 83.30% 82.40%

South East SCN 99J NHS West Kent CCG

37.7 (23/61) 69.80% 87.10%

South East SCN 10D NHS Swale CCG

84.2% (16/19) 73.30% 84.00%

South East SCN 09G NHS Coastal West Sussex CCG

96.2% (40/43) 70.40% 86.30%

South East SCN 09W NHS Medway CCG

39.3% (22/56) 65.20% 85.90%

South East SCN 09D NHS Brighton and Hove CCG

88.9% (40/45) 68.30% 84.20%

South East SCN 99H NHS Surrey Downs CCG

97% (32/33) 66.20% 81.30%

South East SCN 09E

NHS Canterbury and Coastal CCG

4.8% (1/21) 80.60% 89.10%

South East SCN 09X

NHS Horsham and Mid Sussex CCG

60.9% (14/23) 70.20% 89.00%

South East SCN 10E NHS Thanet CCG

30% (6/20) 64.00% 88.80%

South East SCN 09P NHS Hastings and Rother CCG

66.7% (20/30) 76.70% 88.70%

South East SCN 09F

NHS Eastbourne, Hailsham and Seaford CCG

71.4% (15/21) 69.50% 83.50%

South East SCN 09H NHS Crawley CCG

84.5% (11/13) 70.00% 85.40%

South East SCN 10A NHS South Kent Coast CCG

3.3% (1/30) 80.50% 88.70%

South East SCN 09C NHS Ashford CCG

14.3% (2/14) 67.40% 84.90%

South East SCN 09Y NHS North West Surrey CCG

9.5% (4/42) 67.40% 88.70%

South East SCN 09N

NHS Guildford and Waverley CCG

33.3% (7/21) 72.90% 89.20%

South East SCN 99K

NHS High Weald Lewes Havens CCG

100% (21/21) 65.60% 86.10%

South East SCN 09L NHS East Surrey CCG

27.8% (5/18) 78.50% 89.70%

South East SCN 10C NHS Surrey Heath CCG

88.9% (8/9) 70.20% 84.10%

Wessex SCN 99M

NHS North East Hampshire and Farnham CCG

70.8% (17/24) 75.70% 87.20%

England 73.40% 87.20%