COMMENTARY

Is Diabetic Footcare in the UK Still a 'Cinderella' Service?

Prof William Jeffcoate

Disclosures

March 12, 2019

I'm William Jeffcoate. I'm a diabetologist based in Nottingham, and I'm also clinical lead of the National Diabetes Foot Care Audit of England and Wales.

What's the situation for diabetic foot problems in England and Wales?

We've got the background problem of foot ulcers and diabetes, which is a major problem and one which has been traditionally, perhaps, neglected by people, health care professionals. But we know it obviously causes tremendous suffering to the people who've got a foot ulcer, whether or not they go on to amputation, which is always the major threat.

But it also is enormously expensive. And people don't think of diabetic foot ulcers as being a major health care issue. And yet, care of diabetic foot ulcers we know costs at least a billion pounds each year to the NHS. That's just about 1% of the total NHS budget, so it is an enormous problem, we know that.

Are diabetic problems uniform across England and Wales?

We don't have a simple answer to that. But what I can tell you is what we know isn't uniform.

If you look at the numbers of amputations done where someone loses not [just] a toe but loses part of their leg; that's called a major amputation. If we look at the major amputations that are done throughout England, it varies eightfold depending on which bit of England you live in.

Now, one of the factors that we know will determine how many people have amputations is race.

And yet that figure I just gave you, the eightfold is corrected for race, for ethnicity. And so there is something going on which is leading to a tremendous discrepancy in the outcomes of management.

Do you have insights into why that might be?

There are data which show that the structure of care is ever so important. Twenty years or so ago, two centres in the UK, one in Middlesborough, one in Ipswich, changed the way that they cared for diabetic foot ulcers such that they integrated well with general practice; they set up referral pathways to make sure that people were given an expert assessment in the shortest possible time.

What they actually showed, in both groups and at the same time independently, was that the number of cases of major amputation that occurred in their area dropped from something like 3.5 per 1000 people with diabetes per year to something 0.7. So an enormous drop in the incidence of amputation, just by changing the way people worked. No new great investment, no new staff, but just the structure of care. So there's a very strong pointer to something which might be underlying the variation which we know exists throughout England.

Have you been able to draw any best practice learning points from those changes?

Indeed, people have been looking at it, but in particular, NICE [National Institute for Health and Care Excellence] guidance. So NICE, of course, is guidance. It's not an instruction but it's guidance to clinicians and to those who commission clinical activity that such services should be available to someone. And so there's guidance for cancer treatment or whatever. If we're talking about guidance for foot ulcers, it's quite clear, NICE guidance is quite clear that people should be promptly referred for an expert assessment.

One factor which might be contributing to the variation is actually variable compliance with NICE guidance.

One of the questions the National Diabetes Foot Care Audit asked over the last 4 years was directed at those who are commissioning foot care services.

Fewer than 50% of those who replied said that they actually were complying with all aspects of NICE guidance in terms of provision of, for instance, an urgent referral pathway.

And so the evidence we have is that the compliance with guidance is patchy and could easily be contributing to the variation which we know exists in the incidence of amputation.

Do we know the reasons for non-compliance? Is it money?

I don't know. Those who are commissioning care are obviously trying to balance their budgets against what services they provide and they are under pressures from all sides. Whatever the problems are, the result is that in this particular field, NICE guidance is irregularly being followed.

Does an amputation always mean something has gone wrong in a person's diabetic foot care?

I'm not sure we've actually got the evidence to say that so far. What the audit has been looking at is simple factors such as time that elapses between the time that the person with the foot problem first goes to see a professional, any professional, and the time that they have a first expert assessment. And then linking that time to the severity of the ulcer when first seen. And there is a direct link, a highly statistically significant link, between the time that elapses between first assessment and how bad the foot ulcer is.

There is also a link betweenthe time and the severity and the outcome.

We looked at different outcomes, we've looked at whether they're healed at 3 months, whether they get admitted to a hospital, whether they have an amputation. So all of those factors linked in with these basic aspects of care structure.

Is the risk of diabetic problems underestimated?

I think traditionally, and I'm not talking really about the current day and age, traditionally, diabetic foot ulcers have been neglected. Diabetes traditionally was neglected, though that's changed in the last 15 years or so. And it's been obviously now headline news across the world.

Nevertheless, within diabetes, of all the various complications, people think of renal failure, they think of loss of sight. But actually the foot ulcer is the one that's actually been a bit of a Cinderella sub-category of complications of diabetes. People don't like it. They don't like feet. They don't like feet with ulcers.

And again, historically, this has meant that people haven't been trained in how they ought to be managed.

And when they're not trained, they will tend to delegate somebody else, who also hasn’t been.

There is a lack of interest, professional interest, I think, in the causes of the problem and the ways in which different types of foot ulcers need to be managed. It is a very complex subject because the different types of ulcers, and the same ulcer, can change at different times. Sometimes it's infected, sometimes it's not infected.

So the complexity has also been a factor that has limited the capacity to do scientific research into what's the best treatment that should be done. So for all of those reasons, from what I could call the yuck factor, or perhaps I should say, that sort of basic unattractiveness of the problem, to the lack of adequate scientific basis for clinical practice - I think they all contribute to the problem that we have and that is reflected in variation and outcome across the country.

Is it hard to get health professionals interested in diabetic foot problems?

I think no. I think any healthcare professional, once they perceive the problem, is only too keen to have information. Now they should resolve it. That information might just be a telephone number of who they should ring up in order to get the best advice in the area at the earliest possible time.

Is there a role for technology to help monitoring and treatment?

There is a role, all sorts of roles, all sorts of ways of measuring things. And of course, there's quite a lot of research going on at the moment into ways in which you can assess the status of the wound, either using direct measures, or else using measures which monitor centrally. All sorts of ways, all of them are important.

But I think actually, the crux is the much more basic one of the structure of healthcare. If I had a new diabetic foot ulcer, I'd really want the people looking after me to comply with NICE guidance. And that is to make sure that I saw someone who is an expert in the field, and who worked as part of a multidisciplinary team, which I think is also important, so that they could call in other people: vascular surgeon, orthopaedic surgeon, microbiologists, whoever else is needed.

I think I think the bottom line is the same one. I think it's as simple as aspects of the structure of care which are probably making the greatest contribution to variation, and if only we can pinpoint them precisely and try and get services available soon, evenly across the country, then we will see the degree of variation actually declining.

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