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Podiatry: Driving value, improving outcomesThe vital role of podiatry in keeping our population active – saving lives and saving limbs

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Podiatry: Driving value, improving outcomes

The College of Podiatry would like to thank the following individuals for their input into this report.

■ Lawrence Ambrose, The College of Podiatry

■ Dr Michael Backhouse, University of Leeds

■ Peter Burbidge, Northern Health and Social Care Trust

■ Allister Campbell, South Eastern Health and Social Care trust

■ Alison Campbell-Smyth, Northern Health and Social Care Trust, Antrim

■ Katie Collins, The College of Podiatry

■ Dr Sarah Curran, Cardiff Metropolitan University

■ Dr Nina Davies, Leeds Community Healthcare NHS Trust

■ Debbie Delves, The College of Podiatry

■ Martin Fox, Pennine Acute Hospitals NHS Trust

■ Tom Kelly, The College of Podiatry

■ Dr Joanne McCardle, Salford Royal NHS Foundation Trust

■ Liz North, The College of Podiatry

■ Stephanie Owen, Queen Elizabeth Hospital Birmingham

■ Sara Petela, PB Consulting

■ Clare Richards, The College of Podiatry

■ Rhiannon Roberts, Podiatry Open Access Service, Aberystwyth

■ Prof Anthony Redmond, Leeds Biomedical Research Centre

■ Adam Thomas, The College of Podiatry

■ Glyn Wallen, The College of Podiatry

■ Frank Webb, Derby Community Health NHS FT

■ Tom Williams, PB Consulting

■ Julie Williams-Nash, The College of Podiatry

■ Alison Wishart, The College of Podiatry

With thanks to services which provided case studies, including:

■ Bronglais Hospital, Aberystwyth, Hwyel Dda University Health Board

■ Cwm Taf University Health Board

■ Leeds Community Podiatry Service, Podiatry Service

■ Northern Health and Social Care Trust, Antrim

■ Pennine Acute Hospitals NHS Trust

■ Podiatry Open Access Service, Aberystwyth

■ Queen Elizabeth Hospital Birmingham

■ Salford Royal Foundation Trust

■ Derby Community Health NHS FT

■ Community Musculoskeletal Assessment and Treatment Service, NHS Wales

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4 Foreword

5 Executive Summary

9 Tackling the diabetes & vascular epidemic: the role of podiatry

17 Improving outcomes in musculoskeletal conditions and rheumatoid arthritis through podiatric interventions

22 The role of podiatry in falls prevention

29 Conculusion

30 Appendix

33 References

Contents

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I am extremely proud to be the President of the College ofPodiatry. The role of membership organisations representinghealthcare professions is absolutely critical to the success of thesystem and the welfare of those who work tirelessly in our NHS.They engage and inform politicians, like me; commissioners; civilservants and other practitioners. This makes for a better systemand more informed politics, which can only be a good thing.

As this timely reports sets out, podiatrists play a significant andutterly necessary role in the system. Indeed, the health and socialcare sectors are facing untold pressure on their funding, and this istaking its toll on community and public health budgets. But when these provider sectors are not able to meet demand, the acute sector picks up the shortfall, whichfurther worsens the financial positions of each trust.

Podiatrists are a cost-effective solution to many of the issuesfacing healthcare providers today. The College has identified threeareas imposing a huge cost burden on our system and sets outways in which the better use of podiatrists could relieve thepressure on the health and care system in each of these areas.Unless tackled properly, diabetes and vascular-relatedcomplications, rheumatological conditions and falls have thepotential to cripple the health service. This is why it is crucial toensure the appropriate and timely use of podiatry.

I commend this report to you, and I encourage you to read it carefully and consider what you can do to improve policy and make use of dedicated and highly-trained podiatrists to save money and help people to live the best lives they possibly can.

The Lord Kennedy of SouthwarkPresident of the College of Podiatry

Foreword

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Podiatrists are trained to diagnose, treat,prevent and rehabilitate complications of thefeet, ankles and lower limbs. They prevent,manage and correct foot problems, relievepain, treat infection and keep people of allages mobile and active. They are the expertsin all aspects of foot and lower limbstructure, function and health.

Podiatrists are uniquely placed, and have thespecialist training, to manage the increasingnumbers of people presenting with foot andlower limb complications resulting from long-term conditions including diabetes,peripheral arterial disease, rheumatoidarthritis and musculoskeletal pain. Thenumber of people diagnosed with these longterm conditions is set to continue due to theincrease in the ageing and obesitydemographics.

With podiatry fully integrated into primarycare, community, acute and independent caresettings, podiatrists are able to manage thesepatients thereby ensuring prevention ofcomplications from these long-termconditions, and reduces the number ofunnecessary referrals made to secondarycare. Podiatrists are able to provide patientswith specialist support by providingscreening, diagnostics and tailored careplans, consequently increasing patient safetyand ensuring access to the right care, closerto home.

Podiatrists provide a vital service tothousands of individuals in the UK every day,and work across the life course fromchildhood right through to elderly andpalliative care. In addition to mangingcomplications and co-morbidities of manylong-term conditions, podiatrists keep peopleactive and mobile. Podiatrists work at thefront line in sports medicine, paediatric care,diabetes, rheumatology, musculoskeletalconditions, peripheral arterial disease, falls

prevention, bone and tendon surgery andessential day to day maintenance of foothealth, enabling mobility across the UK.

The ability of podiatrists to make earlyinterventions within the community canreduce A&E attendances and unnecessaryhospital admissions by facilitating earlydetection and intervention of potentially life-threatening conditions.

This report highlights the role that podiatristsplay in three areas which each have far-reaching consequences across the healthand care system. In each of these areas,podiatrists are often under-utilised, whichmeans an opportunity is being lost to tackleproblems before they escalate, costing thesystem more in staff time and resources, andgreatly impacting on the lives of patients andtheir health outcomes. The potential toimprove public health and achieve theprevention agenda through the better

Executive Summary

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deployment and resourcing of podiatrists isclear and will be highlighted throughout thisreport.

This report covers three key areas in which podiatrists contribute their expertise anddemonstrate their value:

■ Diabetes and vascular disease, specifically foot ulceration and amputation prevention,which costs the NHS around £1 billion per year.

■ Falls prevention, particularly amongst the elderly, which costs the NHS and socialcare around £2.3bn every year, and rising.

■ Musculoskeletal conditions, which consumes around 5 per cent of the NHS budget.

Research undertaken for this report has found that:

■ Early podiatric intervention has the potential to improve mobility and independencein all people who experience foot health problems.

■ Despite the strong recommendation from NICE, a Freedom of Information Request(FOI) carried out in 2017 (with a response rate of 87 per cent) found that 29 per centof CCGs do not commission a foot protection service, and of those that do, onlyaround 7 per cent are not led by a podiatrist.

■ A further FOI undertaken in 2017 revealed that 33 per cent of Trusts who respondeddo not operate a dedicated falls prevention team, and of the 67 per cent that do,only four per cent include a podiatrist in that team.1

■ Podiatrists are under-utilised across the health and care system, avoiding criticalchances to tackle problems before they escalate.

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Diabetes, Peripheral Arterial Disease(PAD) and foot protection services:

■ Podiatrists should be employed incommunity-based PAD assessment andtriage services within each Trust/Board inorder to facilitate early diagnosis andintervention with foot ulceration and severeor critical limb ischaemia, thereby reducingpressure on hospitals and optimisingeffective treatment of these life-shorteningand limb-threatening conditions.

■ In order to reduce regional variation andensure a higher standard of care and betterpatient outcomes, there should be greatercompliance with NICE and SIGNrecommendations that podiatrists shouldlead foot protection services and thatpeople with suspected PAD be offered aNICE-recommended assessment, includingankle brachial pressure index (ABPI) andaccess to structured exercise programmesor vascular teams, as needed.

■ The NHS must invest in long-termdevelopment of podiatrists with the relevantskills and competencies to deliver diabeticfoot care and early diagnosis of PAD. Thisincludes commissioning learningplacements and opportunities toundergraduate and postgraduatepodiatrists.

Musculoskeletal conditions:

■ Every patient newly diagnosed withrheumatoid arthritis should be referred topodiatry services for a lower limbassessment and tailored care package asrequired.

■ As the experts in the diagnosis andtreatment of MSK conditions in the footand lower limb, podiatrists play a major

role in relieving pressure on primary andsecondary care settings and supportingpeople to manage their condition so thatthey can recover faster and stay in workand/or return to work earlier.

■ Women should not be forced to wear highheeled shoes in the workplace as part of auniform. This requirement should bebanned from all workplace policies.

Falls prevention:

■ All falls prevention teams should include apodiatrist, or have access to a podiatrist.This should be reflected in relevant NICEand SIGN guidance.

■ Anyone over the age of 65 who has a fallshould have a lower limb assessmentcarried out by a podiatrist. This should bereflected in relevant NICE and SIGNguidance.

■ Standardised education and signpostingmust be provided to patients deemed atrisk of falling on how to reduce their riskof falling, including information on howthey can access podiatry services.

Recommendations for government and the NHS:

■ Government should publicly recognise theunique contribution and role of podiatry insupporting the early intervention andprevention agendas.

■ In order to standardise access to podiatryservices across the country, the NHSacross the four nations should mandatedata collection relating to thecommissioning on the podiatry workforceand services.

This report makes recommendations for action in each ofthese areas, as well as recommendations for government.

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■ Government and the NHS should takeaction to facilitate a wider implementationof NICE and SIGN guidance.

Best practice is not about reinventing thewheel – it is about accepting an unforeseenshortfall and adopting good ideas. This reportsets out the simple measures that couldmake the difference in three areas thatimpose a huge cost burden on the NHSacross the UK.

“I am delighted to see this timely report. As we set outin the NHS England document, ‘Allied HealthProfessions into Action’, Allied Health Professionals(AHPs) have a unique contribution to make to theprevention, rehabilitation and return to work agendas.

“I am very proud to represent podiatrists, along withother AHPs. And to promote how podiatrists enablebetter health for the population and support people tobe pain free, active, and remain in work.

“This report sets out recommendations forcommissioners and healthcare leaders which can save money and improve outcomes, often simplythrough the better deployment of existing podiatryservices. It is an excellent example of the contributionAHPs can make to system leadership.”

- Suzanne Rastrick, Chief Allied Health Professions Officer, NHS England

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The scale of the problem and its significance

Five million people in the UK are at high risk ofdeveloping Type 2 diabetes.2 The dramaticincrease in the number of people with diabetesalso means that the number of individuals withdiabetes-related complications, such as footulcers or lower limb amputations, is alsoincreasing dramatically. Foot ulcers andamputation are associated with high levels ofmortality and are linked to peripheral arterialdisease (PAD) and neuropathy (nerve damage).

People with diabetes are around 23 timesmore likely to have a toe, foot or lower limbamputation than those without diabetes.3 Themortality rate of patients with diabetic footulcers is worryingly high. Mortality rates forthose with diabetic foot ulcers and those whohave undergone amputations are greater thanfor those with breast or prostate cancer, withone study suggesting suggesting mortalityrates are as high as 44 per cent within 5 years.4

Tackling the diabetes & vascular epidemic: the role of podiatry

People withdiabetes are around

23times morelikely to have a toe, foot orlower limbamputation than thosewithoutdiabetes.

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It is estimated that around 60,000 to 75,000people with diabetes in England have a footulcer at any given time.5 Every week over 135toe, foot or lower limb amputations arecarried out on people with diabetes, butaround 80 per cent of these could beprevented6. Amputation rates in the devolvednations are equally concerning; for exampleaccording to the Scottish Diabetes Survey2016, 1,705 (0.7 per cent) of those with Type2 diabetes had a major lower limbamputation.7

In addition to the negative impact on qualityof life for those with diabetes-relatedcomplications, there is a serious financialimpact. The financial cost of ulceration andamputation in England was estimated at£972mil to £1.13bn in 2014-15. Thisaccounts for £1 in every £140 the NHS spends.8 In Wales diabetes accountsfor 10 per cent of the annual NHS Walesbudget.9

The estimated costs associated with a majoramputation are not confined to healthcare,but also span social care and welfare as theimpact of amputation on an individual’sability to undertake meaningful employmentand live a life free from social care is limited. The number of diabetes related amputationsin England increased by 16 per cent between2009-12 and 2012-1510. This is likely tocontinue to increase, both in absolute termsand as a proportion of total NHS spending,unless there is a significant increase in earlydetection of people at risk of diabetic footulceration. Diabetes prevalence is alsoincreasing across the UK as a whole; forexample, if current trends continue it is

estimated that 300,000 people in Wales willhave Diabetes by 2025.11

What should be done?

Effective use of podiatry is crucial to tacklingthe rise of diabetes-related complications,which devastate lives and use a significantamount of NHS resources. Podiatry is aregulated profession, with a highly trainedand skilled workforce with unparalleledexperience in delivering care to patients withvascular and diabetic foot problems.

The NICE guideline NG19 recognises thisexpertise and recommends that ‘The footprotection service should be led by a podiatristwith specialist training in diabetic footproblems’.12 Podiatrists are uniquely trainedto diagnose and treat potentially life-alteringfoot problems, including soft tissue and boneinfections, fractures, dislocations, anddiabetic ulcerations. Podiatrists work acrosscare settings thereby facilitating seamlesscare for patients and ensuring theappropriate flow of patients betweencommunity and acute settings.

Utilising podiatry in a community setting todiagnose and triage patients with footconditions has been demonstrated to reducepressure on hospitals through interventionsin the community and avoid costlyunnecessary outpatient referrals. It has alsoled to the reduction in excessive prescribingof antibiotics by primary care clinicians whodo not have specialist training in diabetic footconditions, a key priority for governments.This further supports the objective of the

The financial cost ofulceration accounts for £1 in every £140the NHS spends

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NHS in promoting improved health through educationand providing care closer to home for patients.

Despite the strong recommendation from NICE, aFreedom of Information Request carried out in 2017 (witha response rate of 87 per cent) found that 29 per cent ofCCGs do not commission a foot protection service, andof those that do, around 7 per cent are not led by apodiatrist. A greater effort must be made to ensure thatall CCGs adhere to this guidance, which is designed tosupport the reduction in regional variation in foot caredelivery and outcomes.

NICE recommends that all Trusts/Boards have amultidisciplinary footcare service in order to provideintensive and co-ordinated services for the aggressivetreatment of patients with diabetic foot problems,including those with foot infections, ischaemia (poorcirculation) and severe deformity. The Diabetic Foot Clinicat King’s College Hospital is a centre of excellence whichenables this patient cohort rapid access to specialisedexpertise. The team includes diabetologists, podiatrists,nurses, orthotists, physiotherapists, dermatologists,radiologists and orthopaedic, plastic and vascularsurgeons who work closely together, within the focus ofan outpatient Diabetic Foot Clinic. Despite this, almost athird of hospital sites are not compliant with thisrecommendation and do not have a multidisciplinaryfootcare service.13 This must be corrected given theevidence which shows that these services can treatpatients successfully and reduce major amputation inpatients.14

The 2016 National Diabetes Footcare Audit revealed thatjust 62 per cent of CCGs provide training for routinediabetic foot examinations.15 Without regular training ofpractitioners involved in the delivery of diabetic footcare,consistent standards in delivery of care will not beachieved across the UK. The recent diabetestransformation funding, which prioritises diabeteseducation, recognises the vital importance of this,however this education should not rely on small pocketsof funding on an irregular basis in order to achieve long-lasting change.

of CCGs do not commission a foot protectionservice

of CCGs provide training for routine diabetic footexamination

29%

62%

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Case Study:Salford lower limb vascular assessment and triage service Salford Royal Foundation Trust

Background: Before this service wascommissioned, people in Salford with lowerlimb vascular concerns had to travel toCentral Manchester Foundation Trust for anassessment from the vascular surgery team.The vast majority did not need surgery andwere discharged to primary care. GPs werepaying a secondary care outpatient tariff forpatients who did not need a secondary careservice.

Objective: Reducing hospital referrals forlower limb vascular conditions by providingpodiatry-led assessments in the community.This supports the vision of the Five YearForward View in providing care closer tohome.

How the service was established: A businesscase was developed to provide assessmentand support for patients with symptomaticPAD for 2 hours a week over a 3-month period.This funded a full-time Band 7 podiatrist anda 0.5 whole time equivalent Band 2administration assistant. The podiatrist’swork plan included seven clinical sessionsseeing a total of 21 patients, two trainingsessions and one admin session per week.

The service was given an estimated time toimplement of 4-12 months.

How the service runs: The assessmentservice operates in a local health centre tomake it accessible to the local population,and clinics are run five days a week with some

evening and Saturday slots. Referrals aremade by GPs using Choose and Book, andmay also come from the general podiatry andtissue viability service. Patients receive apatient information leaflet explaining aboutthe service and what to expect from theappointment.

Each patient has a full non-invasive vascularassessment, which takes around 45 minutes.After the assessment a tailored managementplan is agreed, including recommendations toGPs for drug therapy, and referrals to smokingcessation and structured exercise therapy asnecessary. The podiatrist can also referpatients directly to vascular surgery ifappropriate.

What has the impact been?

Savings delivered: Net annual savings of£62,700 in 2015/16 for a population of239,000 were made; equivalent to £26,200per 100,000 people.

The savings were from avoiding 489unnecessary outpatient referrals (281vascular services, 208 diabetic footscreenings) costing £234 each. The runningcost of the service is £51,733, which funds aBand 7 podiatrist independent prescriber anda part-time Band 2 administrative assistant.

Quality outcomes delivered: The patientexperience improves significantly becausecare is given quicker and closer to home.There is also evidence that safety is improveddue to faster diagnosis of life-threateningconditions in a small number of cases,including suspected aneurysms.

Net annual savings of

£62,700in 2015/16

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Case Study:High Risk Foot Protection TeamWhitworth and Buxton Diabetes Clinic

Objective: To move the treatment of complexdiabetic foot cases closer to the community, toprevent unnecessary bed days, and to provideindividual care whilst reducing pressure onhospitals.

How the service was established: Historically,complex diabetic foot patients were seen atStepping Hill Hospital in Stockport – 21 milesaway. A High Risk Foot Protection Team wasestablished and led by the podiatric surgeryteam which specialises in treating complexpatients.

How the service runs: The service canappropriately assess, diagnose and treatcomplex diabetic foot complications in acommunity setting and in a timely manner toreduce the need for a costly referral to theacute sector. The clinic is able to treat softtissue and bone infections, fractures,dislocations, and diabetic ulcerations. It usesthe vast experience of the podiatric surgeryteam to treat day cases swiftly and effectively.

Patients can access the service throughattendance at minor injuries or through theirGP surgery. Referrals come from GPs,community podiatrists, diabetes specialistnurses and consultants at Chesterfield RoyalHospital. The service can administer theappropriate antibiotics or operate almostimmediately – including local antibiotics,avoiding systemic antibiotic use – avoiding anescalation of the problem or admission tohospital.


The service has been extremely successful,both in patient satisfaction and cost savings. Anastonishing 98 per cent of respondents saidthey would be ‘extremely likely’ to recommendthe service to family and friends.

In a study period between 2015 and 2017, theservice has treated around 88 new patientseach year, each often requiring numerousfollow-up treatments.

The service has avoided about 38 admissionsto hospital each year through immediatetreatment. This was achieved in some casesthrough the expert packing of ulcers withlocally administered antibiotics, often enablingthe early discontinuation of systemicantibiotics. In other cases, patients weretreated for bone infections which, if admitted,would often have involved a period in hospitalon IV antibiotics. Some patients were treatedfor cellulitis in the foot and leg which would,upon admission, have also often resulted in IVantibiotics.

The service has avoided about 38admissions to hospital

each year throughimmediate treatment

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Case Study:

Podiatry Open Access ServiceBronglais Hospital, Aberystwyth

Objective: To address the needs of patientswith an emergency foot problem in acommunity setting to reduce unnecessary A&Eattendance.

How the service was established: This openaccess service began as a once weekly clinicfor patients to attend in an emergencysituation, for example those presenting with anew foot ulcer, cellulitis, or a foot infection. Itwas soon established that many patients whoattended A&E with similar problems did notalways receive the most appropriate treatmentin this setting.

How the service runs: The clinics are run fromthe outpatients department within the acutetrust, with referrals accepted from primarycare or self-referrals. The emergency openaccess clinic is not designed to provide generalpodiatry treatment, but deals with emergencycases which, if not treated, would escalate torequire hospital admission. The purpose andscope of the clinic is communicated to GPsurgeries and patients so that correct referralsare made.

Typical presentations are chilblains, in-growingtoenails, new ulcerations, osteomyelitis,necrosis and sometimes Charcotneuroarthropathy. GPs refer complicatedpatients to this clinic for guidance ontreatment plans, vascular assessments, off-loading, and tissue viability.

The open access clinic is open three days aweek, but this is set to be increased to four.Currently weekend cover is not provided.


Occasionally, patients will need to be admittedfor treatment for sepsis, but overall, mostpatients are kept within the communitysetting, reducing the pressure and financialburden on hospitals. This service has now beenadopted throughout the Health Board at allmain hospital sites.

A recent case was seen in open access wherea patient presented with a very painful footfollowing a period of increased exercise. Hehad a diabetic foot ulcer, and the symptomsmay have been mis-diagnosed as cellulitis oran infection. Ordinarily, the patient would havebeen admitted for intravenous antibiotics oroffered home intravenous antibiotics with theacute response team. Due to the medicalhistory of the patient, it soon transpired thatthis was not an acute cellulitis, but asuspected Charcot neuroarthropathy. Thepatient was quickly given an air boot andreferred for an urgent MRI scan. The patientwas assessed by an experienced podiatristwho works very closely with the endocrinologyconsultant. An appropriate management planwas discussed with both the consultant andthe patient, which prevented the need for thispatient to attend A&E.

An A&E visit, admission and two treatments fora patient believed to have an infection wouldhave cost around £5,600. This cost wasavoided, as was the cost of misdiagnosis,which would have led to a worsened conditionand greater cost of treatment.

£5,600per patient cost avoided

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Case Study:Manchester Leg Circulation ServicePennine Acute Hospitals NHS Trust

Background: Podiatrists, Nurses and Doctors inManchester were regularly tackling theconsequences of late diagnosis and under-management of PAD, resulting in avoidableamputations and vascular related deaths. Thissituation existed in parallel to the issue of highnumbers of inappropriate or unnecessaryreferrals of people with suspected PAD tohospital vascular teams. Many of these referralsdid not need to be seen by the Vascular Team.Resources that could be best used on peoplewith severe or deteriorating arterial disease werebeing wasted.

Objective: A radical change in the traditionalPAD paradigm was needed and earlyidentification, detection and management ofPAD therefore was deemed essential inManchester and was the main reason why thiscommunity service redesign was commissioned.

The Manchester Leg Circulation Service was firstcommissioned in 2009 under the clinicalleadership of Consultant Podiatrist LouiseStuart MBE, to help address these key limb andlife threatening problems in the local population.The service has since redesigned itself to meetthe NICE Guidance on PAD (GC 147) and thesubsequent NICE Quality Standard (QS 52).

How the service runs: At the heart of the serviceredesign is the Integrated Care Pathway for PAD,which has been developed using best evidenceand with consultation involving all local vascularstakeholders, including Podiatrists, Nurses,Surgeons, managers and commissioners. It hasbeen published in Podiatry and Nursing journalsand included in regional and national PAD-related documents as an example of bestpractice.

Education sessions were delivered to all keystakeholders on identifying PAD better and anintegrated care pathway was developed to improve patient safety and ensure seamlesscare delivery between organisations.

The two vascular-trained clinicians (vascularpodiatrist and vascular nurse specialist) carrymobile vascular diagnostic equipment andprovide specialist assessment, clinical diagnosis/ exclusion of PAD and facilitate treatmentoptions, ranging from; discussing diagnosis andprognosis, prescribing cardiovascularmedicines, referring patients to supervisedexercise programmes, support with quittingsmoking / losing weight and timely vascularsurgeon appointments for those who need one.


This service model demonstrates animprovement in earlier identification of PAD andthat 80 per cent of people with PAD can now bemanaged successfully in the community. Byensuring that only the appropriate severity ofPAD is referred on for surgical opinion, vascularout-patient clinics now have more capacity tosee their urgent patients in a timely way. With anoverall 30 per cent referral cost saving, it hascreated a ‘win – win’ situation for all keystakeholders involved.

In the first three years, over 2000 people hadbeen referred by the service with suspected PADand more than 700 of them then had a PADdiagnosis confirmed and have since beenoptimally managed, mostly under the care oftheir GP. Additionally, by introducing a 30second abdominal aorta pulse check, the LegCirculation Service identified fifteen patientswho had undiagnosed abdominal aorticaneurysms, with three of those patientsrequiring urgent surgical repair and theremaining twelve being placed on our Trust’ssurveillance programme. This simple, lifesavingearly detection initiative has resulted in aNursing Times Award (2015).

NICE (2012), the All-Party Parliamentary Groupfor PAD (2014) and the recent STAMP (STopAMPutations) initiative by NHS England (2015)on critical limb ischaemia, have all recognisedand endorsed the Leg Circulation Service’sservice model and Integrated Care Pathway,linking it to the Clinical Guideline and Reportlaunches, as an example of best practice.

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Recommendations for action

Podiatrists should be employed incommunity-based PAD assessment andtriage services within each Trust/Board inorder to facilitate early diagnosis andintervention with PAD and critical limbischaemia, thereby reducing pressure onhospitals and optimising effective treatmentof these life and limb-threatening issues.

In order to reduce regional variation andensure a higher standards of care and betterpatient outcomes, there should be greatercompliance with NICE and SIGNrecommendations that podiatrists shouldlead foot protection services and that peoplewith suspected PAD be offered a NICE-recommended assessment, including anklebrachial pressure index (ABPI) and access tostructured exercise programmes or vascularteams, as needed.

The NHS must invest in long-termdevelopment of podiatrists with the relevantskills and competencies to deliver diabeticfoot care and early diagnosis of PAD. Thisincludes commissioning learningplacements and opportunities toundergraduate and postgraduate podiatrists.

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Every day in the UK over 21 per cent of the populationconsult a GP about musculoskeletal (MSK) pain.16 Theimpact of rheumatoid arthritis (RA) on both quality oflife and the functioning of health services across theUK is considerable. A European study found that theimpact of RA on quality of life is severe, having almostthe lowest quality of life score of the chronicdiseases.17 The economic cost of sick leave anddisability-related benefits relating to RA alone is£1.8bn.19

The total cost of treating a patient with RA every singleyear is estimated to be around €16,500 in the UK.20

European estimates suggested the cost of treating the400,000 people in the UK with RA is around €6.6bnevery single year, or £6bn.21 This represents around 1in every 20 pounds spent in the NHS every single year.

RA places a huge burden on thee health service; andeffective management of it at an early stage is

Improving outcomes in musculoskeletalconditions and rheumatoid arthritis through podiatric interventions


The economic costof sick leave anddisability-relatedbenefits relating to rheumatoidarthritis alone is

£1.8bn

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absolutely critical. Around 90 per cent ofpeople with RA were found to have a footpathology,22 and around 56 per cent of RApatients will experience foot pain at sometime during their disease,23 but a 2004 reportfound that only 40 per cent had access tofoot care services.24 A study at RochdaleInfirmary found that the majority of patientsattending the rheumatology outpatientdepartment had footwear unsuitable for useby somebody with rheumatoid arthritis.25

As the experts in the diagnosis and treatmentof MSK conditions in the foot and lower limb,podiatrists play a major role in relievingpressure on primary and secondary caresettings and supporting people to managetheir condition so that they can recover fasterand stay in work and/or return to workearlier.26


All of the available research suggeststreatment of RA and other musculoskeletalconditions should begin as soon as possibleto delay the progress of the disease,including through the use of disease-modifying anti-rheumatic drugs (DMARDs) ifappropriate, but the cost of drugs in thetreatment of rheumatoid arthritis makes uponly 7 per cent of the total medical spend.27

Management and monitoring forms the vastmajority of RA treatment costs.

Podiatrists are a crucial part of the treatmentof those with RA. A 2007 study from the USAshowed that after nurses and doctors,

podiatrists were the medical professionalsmost often seen by patients with RA.28 Theyare absolutely critical in the treatment ofrheumatoid complications, and serviceproviders in the UK should recognise thatsignificance.

The appropriate application of podiatrytreatment in the care pathway candemonstrably have excellent implications forthe prognosis of RA patients. A study of theuse of foot orthoses by those with RA foundthat, ‘after 30 months, the intervention hadthe greatest clinical effect on foot disability,reducing this by 30.8 per cent from thebaseline value. Foot pain was reduced by 19.1per cent’.29 A study by Marike van der Leedenfurther showed that if people with RA do notget insoles early, they have worse outcomes.30

NICE clinical guideline [CG79] on‘Rheumatoid arthritis in adults:management’ reflects this, recommendingthat ‘All people with RA and foot problemsshould have access to a podiatrist forassessment and periodic review of their foothealth needs’.31 It goes on to state that‘Functional insoles and therapeutic footwearshould be available for all people with RA ifindicated’.32 SIGN guidance also recommendsthat all people with rheumatoid arthritisshould have access to foot health services.33

Despite this, only half of all rheumatologydepartments report basic foot care servicesfor their patients and less than 1 in 10 haveformal care pathways or mechanisms forreferral to foot health services.34 A further UKstudy on the prevalence, impact and care offoot problems in people with RA, published in

The financial cost of treatingpatients with rheumatoid arthritisis equivalent to £1 in every £20the NHS spends each year

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October 2017, found that the provision ofeffective, timely and targeted care remains apressing need.35

It is crucial to ensure thatCCGs/Trusts/Boards adopt therecommendations within NICE and SIGNguidance in order to ensure that all patients,no matter where they live in the UK, receivethe same standard of care. It is alsoimportant that healthcare commissionersinterpret ‘periodic review’ in the appropriateway to prevent the unnecessary escalation ofa condition or related problems. In this caseit is important that patients with RA shouldhave an annual assessment by a podiatrist toensure rheumatic foot health problems donot escalate.

The wider use of podiatric assessment andtreatment at an early stage of treatmentwould improve the patient’s prospects of

returning to work and would go some way toreducing the £1.8bn economic cost ofabsence from work due to RA, as well asdramatically improving quality of life.However, only around 67 per cent of thosereporting rheumatic foot pain in a wide-ranging study had ever seen a podiatrist,and only 61 per cent had been prescribedinsoles.36 If services were fully compliantwith NICE guidance CG7937, this numberwould be substantially higher.

Where potential problems arise, early accessto podiatry services is crucial, as trainedpodiatrists are best able to recognise andappropriately refer disease flare and arthriticcomplications. Podiatrists are also bestplaced to assess and monitor peripheralvascular and neurological diseases, whichhave been shown to save money by avoidingunnecessary referrals to Acute Vascular Unitswhen lower limb pain arises.38

of those reportingrheumatic foot pain in awide-ranging study hadever seen a podiatrist

67%

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Background: In May 2012 the WelshGovernment Orthopaedic Innovation andDelivery Board advised the introduction of aClinical Musculoskeletal Assessment andTreatment Service (CMATS) in all healthboards across Wales. The service wasdeveloped to provide a “single point ofaccess” from primary care referring intosecondary care for musculoskeletalconditions. Whilst the underlying principles ofthe service are not new having beingestablished in England for 10+ years, itdemonstrates the introduction of interfacemusculoskeletal clinics and services, andmirrors national musculoskeletal pathwaysthat are supported by the NHS Wales NationalOrthopaedic Delivery Framework. Examplesare provided here from two NHS WalesUniversity Health Boards (UHB) – Hywel Ddaand Cwm Taf.

Objective: Focused on improving patientaccess and streamlining care for patients withmusculoskeletal conditions though specialistmusculoskeletal assessment, advice andmanagement, a reduction in waiting times forconsultant specialists and improvedconversion rates for surgery. CMATS can referon to all secondary care specialists includingorthopaedics, rheumatology, neurosurgeryand pain services.

How the service was established: CMATS isa multidisciplinary team that consists ofadvanced physiotherapists and podiatristswith specialised skills in the area of MSK,clinical specialist nurses, and administratorcoordinators. The team has the ability toorder investigations such as x-rays, MagneticResonance Imaging (MRIs) and taking bloods,as well as undertaking injection therapy. Theteam is also supported by pain managementprograms, and lifestyle services that includethe management of obesity. During the earlyphases of the service, all GP practices werecontacted and face-to-face presentations onthe function of CMATS were given, along with

information on the referral process sent to allGPs and practice managers.

How the service runs: The service runs withall GP practices able to refer patients, alongwith referrals from primary carephysiotherapy, podiatry, secondary careorthopaedic/rheumatology consultants and,accident and emergency to CMATS for triage(stage 1). A face-to-face CMATS assessment,diagnostic and management appointment isprovided with option of referral to secondaryreferral if required (i.e. rheumatology,orthopaedics) (stage 2). In addition, theCMATS team can also refer patients intopathways such as the National ExerciseReferral Scheme and services based on coretherapy.


All referrals are triaged within 5 days with allpatients seen within an 8 week target. Asnapshot of database information from eachuniversity health board is provided below:

Hywel Dda UHB: Of the face-to-face contactsat CMATS podiatry clinics only 17 per cent ofpatients were referred to orthopaedics, with47 per cent followed-up with core podiatry,and 19 per cent at CMATS podiatry. From allof CMATS data, 65 per cent of the 73 percent of patients referred from CMATS toorthopaedics were listed for surgery. Thisshows a high conversion rate and suggestsappropriate referral behaviour by the CMATSteam. It is also noted that 43 per cent ofpatients were triaged off secondary care painlists and transferred onto CMATS without theneed for consultant input. Prior to theintroduction of CMATS orthopaedic waitinglists had been steadily increasing, a trendwhich has now reversed.

Cwm Taf UHB: In 2016-2017, 47 per cent ofpatients were redirected away fromorthopaedic service with 46 per cent

Case Study:Community Musculoskeletal Assessment and Treatment Service (CMATS), NHS Wales

21


Recommendations

Every patient newly diagnosed withrheumatoid arthritis should be referred topodiatry services for early examination aswell as podiatric and orthotic treatment asrequired.

Patients with rheumatoid arthritis shouldhave an annual assessment by a podiatristto ensure rheumatic foot health problemsdo not escalate.

A joined up approach to MSK supportsindividuals to adopt lifestyle changes,which can support the management andtreatment of their condition. This supportspatient wellbeing and relieves pressure onsecondary care services, such as radiologyand surgery.

requiring face-to-face contactby the CMATS team (n = 4344out of n = 9423). From face-to-face appointments, 7 per centof patients were referred forsecondary orthopaedic care,whilst 35 per cent were referredon to core therapy services. 56per cent of patients wereprovided with advice anddischarged. The auditconversion rates to surgeryfrom CMATS face-to-facecontact is 76 per cent.

Service user experience showsa 94 per cent good-excellentsatisfaction with 88 per cent ofpatients stating they are happyto be assessed by an advancedclinician. An online survey forGPs also showed that 54.55 percent of GPs were satisfied and27.27 per cent were verysatisfied.

All referrals are triaged within

5 dayswith all patients seen within an

8 weektarget

22



Falls can cause serious harm and injury, includingbruises, hip fractures, or head traumas.39 Fallsand subsequent fragility fractures are associatedwith substantial disability, pain, reduced qualityof life and even death. Falls can impair the abilityto live independently and can result in admissionto hospital, and premature admissions toresidential care. Half of those who sustain a hipfracture never regain their former level of functionand one in five dies within three months.

Falls are common following a stroke. Thelikelihood of having a fall significantly increasesafter the first fall.

Public Health Wales found that about a third ofall people aged over 65 fall each year, with higherrates among those over 75.40 Hospital EpisodeStatistics data show that falls accounted for438,009 admissions to hospital in 2014-15 inEngland, an increase of 3.8 per cent from 2013-

The role of podiatry in falls prevention

Hospital Episode Statistics data show that falls accounted for

438,009 admissions to hospital in2014-15 in England, anincrease of 3.8 per centfrom 2013-14 (421,848)

Figure 1: The fall cycle

23


Fall

Fear of falling again

Reducedactivity

Reducedmuscle

strength &balance

Increased risk of falling

14 (421,848).41 Patients aged 65 or overaccounted for the majority of admissionsfor falls at 64.5 per cent.

Evidence shows that podiatric interventionimproves balance in older adults.Treatment can improve function duringgait if pain is reduced, exerciseprogrammes can improve strength andflexibility, and appropriate footwear fittedwith orthotic devices can provide externalsupport and improved function.

The cost of falls to the NHS is huge. Anindividual hip fracture can result inhospital admission costs of £5,744 perpatient and an ambulance callout of£230.42 It is estimated that the cost offalls to the NHS is £2.3 billion a year andthere are also significant costs for socialcare services.43 Preventing falls, therefore,would not only reduce a financial burdenfor healthcare services, but wouldindisputably improve the lives of thosewho would otherwise suffer seriouscomplications from one or more falls.


Falls are not an inevitable consequence ofold age. Many falls and fractures can beprevented by well organised services andorganisations working in partnership.Podiatrists play a crucial role in fallprevention; including promoting foothealth, patient education, healthpromotion, rehabilitation and mobility.44

This includes assessing and reducingdisabling foot pain and the fear of walking,helping to increase mobility and range ofmotion of the foot, falls screening andfootwear and self-care advice.

Foot pathology and inappropriate footwearhave been shown to increase anindividual’s risk of falls. It is essentialthat patients identified as being at highrisk for falling, or with a history of falls,undergo an assessment of their foot

An individual hip fracture can result in hospital admission costs of

£5,744per patient and an ambulance callout of

£230

24


conditions and footwear and that appropriate measures aretaken to address these factors.45 A study found that in onecohort of patients admitted to hospital, 86 per cent ofinpatients wore footwear that was likely to increase theirrisk of falls.46

The NICE pathway ‘Falls in older people overview’ specifiesthe patient journey in both the acute setting (preventingfalls during a hospital stay for those aged 50-64 deemedhigh risk of falling and for the over 65s) and the communitysetting (preventing falls in the community for over 65s).47

Podiatrists are equipped to play a key role in falls preventionin both the community and acute settings. The NationalService Framework for Older People have called for healthimprovement plans to reduce this burden48 and NICEsuggests screening all patients over 65 years for falls risk.49

Healthcare providers should facilitate an assessmentcarried out by a podiatrist for anyone over the age of 65who has had a fall.

A challenge faced by the podiatry profession is the lack ofdata collected by Trusts on the input and impact ofpodiatry in the delivery of various services, which is oftenused as a justification for the lack of investment inpodiatry expertise. However, a study of ‘Podiatryinvolvement in multidisciplinary falls prevention clinics’from Australia found that all clinic managers consideredpodiatry to be important in falls prevention.50 This issupported by a UK study which found that a multifacetedpodiatric intervention programme was associated with a36 per cent reduction in the rate of falls in communitydwelling older people with disabling foot pain.51 Given thesignificant costs associated with a fall, it is evident thatfalls prevention is a key area where savings can be madeand patient outcomes can be improved.

In addition to treating foot conditions podiatrists have a keyrole in education and advice on inappropriate footwearwhich can contribute to poor balance and an increased riskof falling.52 Education and signposting on how to reducefalls risks for patients are critical, particularly for patientsdeemed at high risk of falling. This should includeinformation on how they can access podiatry services withinthe community. A scheme to exchange ill-fitting slippershelped to reduce falls among older people by 60 per cent.53

Despite the proven benefits of podiatry in falls prevention,a series of Freedom of Information requests undertaken in2017 revealed the low proportion of areas operatingdedicated falls prevention teams.

A UK study found that amultifacetedpodiatricinterventionprogramme was associatedwith a

36%reduction in therate of falls incommunitydwelling olderpeople withdisabling footpain

25


It is unacceptable to have such avariation in access to podiatryexpertise and care within fallsprevention teams. All fallsprevention teams should includea podiatrist, or at the very leasthave access to a podiatrist. Thisshould be reflected in all NICE,SIGN and other relevant guidanceand be adopted by healthcarehealthcare providers across theUK.

England:33 per cent of Trustssaid they do notoperate a dedicatedfalls prevention team.Of those that do, onlyfour per cent include apodiatrist.

Wales:25 per cent of Boardsdo not operate fallsprevention teams, andonly two out of the fivewhich do include apodiatrist.

Scotland:42 per cent of Trustswhich responded saidthey do not operate fallsprevention teams, andof the seven Trusts thatdo, only one has a teamincluding a podiatrist.

Northern Ireland:25 per cent of Trustsresponding said they do operate a dedicatedfalls prevention team,but none of those teams include apodiatrist.

33%

42%

25%

25%

26


Case Study:Falls…empowering communities to bemobile, independent and safe Cwm Taf University Health Board (UHB)

Background: Every year in Wales 230,000and 460,000 older individuals fall, with78,000 attending an accident and emergencyunit in Wales, costing the NHS £98 million.Whilst the cost is significant, there are humancost implications following a fall. These relateto a fear of falling again, loss of confidence,anxiety, reduced activity, isolation andloneliness and impact on social interaction.The reasons for a fall are multifactorial andcan happen spontaneously in some cases.Evidence suggests that a multi-faceted footcare programme can reduce the number offalls by 36 per cent. Key approaches to thisreduction may involve strengthening exercisesof the foot and ankle, wearing appropriatefootwear and foot orthoses.54

What was the objective? For podiatry to playa key role in the delivery of a multi-facetedfoot care programme, which reduces thenumber of falls.

What action was taken? Within Cwm TafUniversity Health Board (UHB) from 03-03-2016 – 03-03-2017, the podiatry andorthotics department were involved in 42,030face-to-face contact appointments. Theseappointment slots focus on effective andjudicious assessment and Making EveryContact Count (MECC). Whilst ‘hands-on’management is provided, the team focus onfoot health education, falls prevention advice,footwear advice/provision, foot orthosesempowering patients to understand chronic

disease and its effect, and what can be done to minimise the risks, which is critical. Equal importance is offered by signposting patients to the National ExerciseReferral Scheme, Stop Smoking Sensationand/or at home if a risk of a fall is identified(with the service focused on minimisingindividuals not being admitted to hospital).

This multifaceted approach directs care andsupport for patients to be mobile and safe ina community setting. Within Cwm Taf, themusculoskeletal lead is a member of the fallsgroup and has close links with the signposting referrals.


Using a recent Cwm Taf censusepidemiological data has been used to outlinea cost benefit analysis of the podiatry servicewhich shows:

■ Falls per year cost £98,000,000 and£78,000 to attend accident andemergency, with each fall costing £1256;

■ A third of individuals aged age 65+ will fall= 40,800 = 13,600 x £1,256 =£17,081,600;

■ Half of individuals aged 80+ will fall =13,300 = 6650 x £1256 = £8,352,400;

■ TOTAL = £25,434,000;

■ If podiatry reduces falls by 36 per cent (asper Spink et al., 2008), podiatry reducesthe cost of falls by £9,156,240.

If podiatry reduces falls by 36 per cent, podiatryreduces the cost of falls by

£9,156,240

27


Case Study:Leeds Community Podiatry Service, PodiatryService

What was the objective: To provide goal based,podiatric care to children in their localcommunity.

How was the service was established? Leeds’Paediatric Podiatry Service was establishedover 15 years ago, to meet the demand andcomplexities of the care required for children.The number of children living in Leeds was139,024 in the 2011 census which is 18.5 percent of the total population of 751,485. Theservice is led by a clinical lead, specialising inpaediatrics and staffed by podiatrists with aspecial interest in paediatrics.

How does the service run? The service providesassessment for children up to the age of 18.Children can access the service though a healthcare professional or as a self-referral. Referralsare made for a variety of reasons includingpain, being unable to take part in sport anddevelopmental concerns associated withstructure and function.

The service can appropriately assess andprovide measurable, goal based care. Theclinics are involved in the treatment of painfuland functional concerns associated with, forexample, tarsal coalitions, juvenile idiopathicarthritis and musculoskeletal pain. Otherpresentations are complicated, with movementand or behavioural issues such asdevelopmental coordination disorder or delay,genetic anomalies, those on the autisticspectrum and sensory processing disorders.


The service measures the outcome of carebased on the World Health Organisation’sInternational Classification of Function andDisability and focuses on a child’s level ofimpairment, ability to perform activities,participation and well-being. The outcomesestablish that podiatry is able to help childrenwith a range of health challenges. For themajority of children, the service is able to helpindependent of other services and for a widerange of presentations.

The outcome measure domains reflect thatchildren’s lower limb presentations are nothomogeneous in that not all can be improvedand some may maintain whilst some maydeteriorate independent of intervention.

The service is able to improve 71 per cent ofchildren’s impairments and activities andmaintain 21 per cent; this aspect includesmanagement of structure, body function andpain. The service is able to improve children’sparticipation levels by 50 per cent and maintain43 per cent; this includes them attendingschool, taking part in family activities andplaying sports. The service is able to helpimprove 65 per cent of children’s well-beingand maintain 21 per cent; this includes distresslevels, embarrassment of a condition andparental or family worry.

The service works closely with themultidisciplinary team to help achieveimproved outcomes for the approximate 10 percent of children who are challenged inparticular domains. This includes the supportof occupational therapists, paediatricians,child and adolescent mental health service,orthopaedics, rheumatology and pain teams.

The service is able to improve of children’simpairments71%

28


Recommendation for action

All falls prevention teams should include apodiatrist, or have access to a podiatrist.This should be reflected in relevant NICEand SIGN guidance.

Anyone over the age of 65 who has a fallshould have a foot check carried out by a

podiatrist. This should be reflected in relevantNICE and SIGN guidance.

Education and signposting must be providedto patients deemed at risk of falling on howto reduce their risk of falling, includinginformation on how they can access podiatryservices within the community.

Case Study;Awareness Raising - Sloppy SlipperExchange EventNorthern Health and Social Care Trust(NHSCT), Northern Ireland

What problem was identified? Between April1st 2010-March 31st 2011, 2883 peopleattended an A&E department within theNHSCT due to a fall. Within the same timeperiod, 740 people over the age of 65 wereadmitted to hospital as in-patients with afracture. Of those fractures, 431 werefractured necks of femurs. Currently it isestimated, that within one year of surgery, forrepair of a fractured neck of femur, a quarterof people will die. A hip fracture is all toooften the final destination of a 30-yearjourney fuelled by decreasing bone strengthand increasing falls risks.

What was the set objective? Sloppy slipperexchanges are not a new idea. Health Trustsand councils all over the UK have held manyprevious events differing in size and design,but all with a common goal; to remove sloppyslippers from people at risk of falling, andreplace them with a safe secure fitted pair.The event also aimed to increase people’sawareness of falls risk factors, and provideadvice regarding simple actions that can betaken to help prevent falls and improve bonehealth.

What action was taken? The event wasattended by over 200 people. The running time of the event was from 10am – 2pm, withthe first eager attendants arriving at 9.25pm.Evaluation of the event was carried outfollowing the event through face-to-face andtelephone interviews.


■ 83 per cent of those people who acceptedthe slippers felt that they were safer andmore secure than the slippers that theyhad been wearing.

■ Of the 54 people contacted, just two percent had experienced a fall since the event,although the faller stated that slipperswere not a contributing factor to the fall.

■ 71 per cent of people said that they feltmore confident mobilising in their homeand 67 per cent reported a reduced fear offalling in their home.

■ 100 per cent of respondents, even thosewho did not like and do not wear theslippers, indicated that they are now moreaware of the dangers of inadequatefootwear as a result of the event.

of people said that they felt moreconfident mobilising in their home 71%

29


In the course of producing this report, theCollege of Podiatry has spoken to thoseworking in services in all four nations thatmake up the United Kingdom. The value ofpodiatry is evident across the length andbreadth of the country, and the commonstrengths across national boundaries andcommissioning systems are clear for all tosee.

This report demonstrates the uniquecontribution podiatrists make in three areasposing a threat to the financial standing ofour National Health Service. But podiatristsdo not simply work in our single-payer system– they also fill gaps in our social care servicesand relieve the pressure on local authorities.The work they do - whether funded by theindividual, the local authority or the localNHS commissioners – prevents extremelycostly unnecessary admissions, improves lifein old age, and provides a very personalservice encompassing routine clinicalvigilance, company for the lonely and ahuman face and company for the lone.

There is only so much that can be achievedthrough efficiency savings. Commissionersmust now look outside the box and carefullyconsider how to make use of resourcesoutside the conventional and generalhospital-based care.

Podiatrists work seamlessly across the healthand social care system and provideinterventions in the community to preventconditions from escalating and becoming agreater cost burden on the system.

This report makes a number of practical andachievable recommendations about howthose with potential or current foot conditionscan be supported to achieve better healthand outcomes. In not making better use oftheir existing resources, healthcare leadersare missing an opportunity to save money,improve patient outcomes around savinglimbs, lives and keeping people active, aswell as making our health and social caresystem ready for the challenges of thecoming decades.

Conclusion

30


A number of Freedom of InformationRequests (FOIs) were sent to Trusts, ClinicalCommissioning Groups (CCGs), HealthBoards and Health and Social Care Trusts.

The following FOI questions were sent toTrusts:

■ How many falls prevention teams doesyour Trust operate?

■ How many of these falls prevention teamsinclude a podiatrist? Please state thenumber of podiatrists employed withineach falls prevention team.

■ How many of these falls prevention teamsare led by a podiatrist?

■ If the trust does not operate any fallsprevention teams, please provide a reasonfor this.

■ How many patients have been diagnosedwith rheumatoid arthritis conditions inyour Trust in: (a) 2012/13, (b) 2013/14,(c) 2014/15, (d) 2015/16

■ How many of those patients were referredto podiatry services following theirrheumatological diagnoses in (i) 2012/13,(ii) 2013/14, (iii) 2014/15, (iv) 2015/16

■ Does your Trust operate a foot protectionservice, as recommended by NICEguideline NG19 on ‘Diabetic footproblems: prevention and management’?

■ If the answer to Q1 is yes, please state thenumber of podiatrists and orthotistsemployed within this service.

■ If the answer to Q1 is yes, is this serviceled by a podiatrist with specialist trainingin diabetic foot problems, asrecommended by NICE guideline NG19 on‘Diabetic foot problems: prevention andmanagement’?

■ If the answer to Q1 is no, please provide areason for this.

The following FOI questions were sent toCCGs:

■ Does your CCG commission a footprotection service, as recommended byNICE guideline NG19 on ‘Diabetic foot problems: prevention andmanagement’?

■ If the answer to Q1 is yes, please state thenumber of podiatrists and orthotistsemployed within this service.

■ If the answer to Q1 is yes, is this serviceled by a podiatrist with specialist trainingin diabetic foot problems, asrecommended by NICE guideline NG19 on‘Diabetic foot problems: prevention andmanagement’?

■ If the answer to Q1 is no, please provide areason for this.

Appendix – Data Collation

31


■ The services of how many podiatrists werecommissioned in each of the followingfiscal years 1) 2013-14; 2) 2014-15; 3)2015-16; 4) Budgeted for 2016-17; all in(i) Working Time Equivalent and (ii)Headcount format

■ What was/is the total amount spent onpodiatric services by your CCG in each ofthe following fiscal years 1) 2013-14; 2)2014-15; 3) 2015-16; 4) Budgeted for2016-17?

■ Do you have any plans to increase yourpodiatric services?

■ How many referrals were made from NHSservices to private podiatric services ineach of the following fiscal years 1) 2013-14; 2) 2014-15; 3) 2015-16; 4) Budgetedfor 2016-17, and how much did thesereferrals cost the CCG in each such year?

A summary of responses is provided here.

Spending: A review of CCG spending onpodiatrists was conducted. Of the 207 CCGsin existence, it was possible to determine theamount spent on podiatrists in all or some ofthe years stated below in 105 CCGs, around51 per cent of CCGs. The total spent onpodiatrists as stated by the 105 CCGs in thefollowing years was reported as:

Workforce:

■ 29 per cent of CCGs do not commission afoot protection service, and of those thatdo, around 7 per cent are not led by apodiatrist.

■ 33 per cent of Trusts who responded donot operate a dedicated falls preventionteam, and of the 67 per cent that do, onlyfour per cent include a podiatrist in thatteam.

2013/14 2014/15 2015/16 2016/17

£97,323,932.02 £107,488,435.53 £108,847,023.06 £106,434,054.83

32

Wales – falls prevention

8/8 Boards responded6/8 Boards have falls prevention teams2/6 Boards have at least one podiatrist inthemNone have teams led by podiatrists

Scotland – falls prevention

12/14 Boards responded5/12 Boards have no falls prevention teams1/7 Boards have a podiatrist in the teamNo teams are led by a podiatrist

Northern Ireland – falls prevention

4/5 Trusts responded3/4 Trusts have falls prevention teamsNone include a podiatrist

Appendix – Devolved Nations FOI responsesummary

PAGE 32


33


1 See Appendix – Data Collection.

2 State of the Nation 2016: Time to take control of diabetes, Diabetes UK, pg.5. Also:https://www.diabetes.org.uk/professionals/position-statements-reports/statistics

3 “Diabetic Foot Care in England: An Economic Study”, Marion Kerr, Insight Health Economics, January 2017.

4 Ibid.

5 Ibid.

6 Armstrong DG, Wrobel J, Robbin JM. Guest editorial: Are diabetes-related wounds and amputations worse than cancer?International Wound Journal. 2007; 4(4):286-287

7 Scottish Diabetes Survey 2016, NHS Scotland, 2016. Link:http://www.diabetesinscotland.org.uk/Publications/Scottish%20Diabetes%20Survey%202016.pdf

8 Kerr, M., 2017.

9 Diabetes in Wales, Diabetes UK. Link: https://www.diabetes.org.uk/in_your_area/wales/diabetes-in-wales

10 Kerr, M., 2017, p. 27.

11 Diabetes in Wales, Diabetes UK. Link: https://www.diabetes.org.uk/in_your_area/wales/diabetes-in-wales

12 “NICE guideline NG19, Diabetic foot problems: prevention and management”, National Institute for Health and CareExcellence, January 2016.

13 Kerr, M., 2017, p.26.

14 “The benefits of working together in diabetic foot care for the vulnerable patient”, Michael Edmonds, State of the Art Lecture,2015, pg.33.

15 “National Diabetes Foot Care Audit Report 2014-2016”, NHS Digital, 7 March 2017, pg.20. Link:http://www.hqip.org.uk/public/cms/253/625/19/731/NDFA_2017_Report_PPT_Format_Final%20to%20HQIP.pdf?realName=vbKPm8.pdf&v=0

16 Arthritis Research UK. National Primary Care Centre, Keele University (2009), Musculoskeletal Matters.

17 “The Burden of Rheumatoid Arthritis and Access to Treatment: health burden and costs.”, Lundkvist, J., Kastang, F., Kobelt,G., The European Journal of Health Economics, vol. 8, 2008, p. S51, Link: https://www.jstor.org/stable/pdf/27823145.pdf.

18 Ibid, p. S50.

19 “NHS ‘Takes Too Long to Diagnose and Treat Rheumatoid Arthritis.’” Mayor, Susan., British Medical Journal, vol. 339, no.7713, 2009, p. 126., Link: www.jstor.org/stable/25672109.

20 Lundkvist, J., Kastang, F., Kobelt, G., 2008, p. S55.

21 Ibid, p. S57.

22 “The foot in chronic arthritis: a continuing problem”. Kerry MR, Holt GM, Stockley I., Foot 1994; 4: 201–3.

23 “Foot pain in rheumatoid arthritis prevalence, risk factors and management: an epidemiological study”, Simon Otter et al.,Clinical Rheumatology, 2009, p 261.

24 “Meeting the challenge for foot health in rheumatic diseases.” Williams, A.E. and A.P. Bowden., Foot, 2004. 14(3): pp. 154-158.

25 “Meeting the challenge for foot health in rheumatic diseases.” Williams, A.E. and A.P. Bowden., Foot, 2004. 14(3): p. 155.

References

34


26 ‘Changes in ankle range of motion and muscle strength in habitual wearers of high-heeled shoes’, Kim et al., PubMed,2013. Link: https://www.ncbi.nlm.nih.gov/pubmed/23520300

27 Lundkvist, J., Kastang, F., Kobelt, G., 2008, p. S57.

28 “The Complexity of Care for Patients with Rheumatoid Arthritis: Metrics for Better Understanding Chronic Disease Care,Kahn, Katherine L., et al. Medical Care, vol. 45, no. 1, 2007, pp. 55–65., Link: www.jstor.org/stable/40221375.

29 “A randomized controlled trial of foot orthoses in rheumatoid arthritis.”, James Woodburn, Sharon Barker and Philip SHelliwell, The Journal of Rheumatology, vol. 29, no. 7, 2002, p. 1381.

30 Prevalence and course of forefoot impairments and walking disability in the first eight years of rheumatoid arthritis, Marikevan der Leeden et al., PubMed, 2008.

31 Rheumatoid arthritis in adults: management, NICE clinical guidance [CG79], December 2015. Link:https://www.nice.org.uk/guidance/cg79/chapter/Recommendations

32 Ibid.

33 Scottish Intercollegiate Guidelines Network (2011) Management of early rheumatoid arthritis, A national clinical guideline.Link: http://www.sign.ac.uk/pdf/sign123.pdf

34 “Provision of foot health services in the UK”, Redmond et al., Rheumatology (Oxford, England), 2006.

35 “Prevalence, impact and care of foot problems in people with rheumatoid arthritis: results from a United Kingdom basedcross-sectional survey”, Wilson et al., Journal of Foot and Ankle Research, October 2017. Link:https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-017-0229-y

36 “Foot pain in rheumatoid arthritis prevalence, risk factors and management: an epidemiological study”, Simon Otter et al.,Clinical Rheumatology, 2009, p 262.

37 Rheumatoid arthritis in adults: management, NICE Clinical guideline [CG79], February 2009.

38 “A PAD service led by nurses and podiatrists”, Martin Fox, Nursing Times, 26th October 2012, 108: 44, 18-20. Link:https://www.nursingtimes.net/clinical-archive/cardiology/a-pad-service-led-by-nurses-and-podiatrists/5051070.article

39 “Falls factsheet”, World Health Organisation, September 2016. Link: http://www.who.int/mediacentre/factsheets/fs344/en/

40 Falls Prevention, Public Health Wales. Link: http://www.wales.nhs.uk/sitesplus/888/page/83453

41 http://content.digital.nhs.uk/catalogue/PUB19124/hosp-epis-stat-admi-summ-rep-2014-15-rep.pdf

42 “Falls: assessment and prevention of falls in older people”, NICE Costing Statement, June 2013, pg.7. Link:https://www.nice.org.uk/guidance/cg161/resources/costing-statement-190029853

43 “Falls in older people: assessing risk and prevention”, NICE Clinical guideline [CG161], June 2013.

44 “The role of the podiatrist in falls prevention”, Olga Frankowski, December 2010. Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032153/

45 Foot Pathology and Inappropriate Footwear as Risk Factors for Falls in a Subacute Aged-Care Hospital Rebecca L. Jessup,MPH, BPod, Original Articles, 2007.

46 Ibid.

47 “Falls in older people review”, NICE pathway, NICE, 2014, pg.2. Link: https://pathways.nice.org.uk/pathways/preventing-falls-in-older-people/preventing-falls-in-older-people-overview.pdf

48 Department of Health (DH). National Service Framework for Older People. London: DH; 2001

49 NICE Guidance in Falls “The assessment and prevention of falls in older people” Clinical Guideline 21, Nov 2004. and ClinicalGuideline 161 June 2013. Link: www.nice.org.uk/CG161NICEguideline

50 “Podiatry involvement in multidisciplinary falls prevention clinics in Australia”, Menz HB, Hill KD, Journal of the AmericanPodiatric Medical Association, 2007.

35


51 “Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling footpain: randomised controlled trial”, Spink, Menz, Fotoohabadi, Wee, Landorf, Hill, Lord, British Medical Journal, Volume 343,July 2011.

52 Hatton AL, Rome K, Dixon J, Martin DJ, McKeon PO. Footwear interventions: a review of their sensorimotor and mechanicaleffects on balance performance and gait in older adults. J Am Podiatr Med Assoc 2013;103:516–33. 10.7547/1030516.

53 See ‘CASE STUDY: Awareness Raising – Sloppy Slipper Exchange Event.

The College of PodiatryQuartz House207 Providence SquareMill StreetLondon SE1 2EW

Tel: 020 7234 8620Email: [email protected]

Published: December 2017 Last updated: December 2017

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