Kent, Surrey & Sussex Foot Care Survey Abigail Kitt & Alistair McInnes

Background Why we conducted survey Purpose of survey Different models

Rationale The purpose of the survey was to: Establish the structures of the MDFTs across the Kent, Surrey and Sussex SCN Identify any ‘gaps’ in the service Compare results with the National Diabetes Audit Share good practice Identify ways forward to improve the services and reduce amputations

Foot care Briefing & basic data Diabetes Footcare Briefing available at: http://www.secscn.nhs.uk/our- networks/cardiovascular/resources/

National Picture

CCG Major Amputations per 1,000 diabetic patients April 2010- March 2013 April 2009 – March 2012 England 0.9 NHS Ashford CCG 1.6 (26) 1.3(21) NHS Canterbury & Coastal CCG 0.8 (24) 0.8 (22) NHS South Kent Coast CCG 1.4 (44) 1.4 (43) NHS Thanet CCG 1.4 (31) 1.6 (36) NHS Swale CCG 0.9 (15) 1.1 (18) NHS Medway CCG 0.8 (37) NHS Dartford, Gravesham & Swanley CCG 0.7 (25) 0.8 (26) NHS West Kent CG 0.8 (44) North West Surrey CCG 1.3 (57) 1.2 (48) Surrey Downs CCG 0.8 (27) 0.7 (22) Surrey Heath CCG 0.5 (6) North East Hampshire & Fareham CCG 0.5 (12) 0.7 (17) Guildford & Waverley CCG 0.8 (18) 0.7 (16) East Surrey CCG 0.8 (15) Horsham & Mid Sussex CCG 0.8 (20) 0.6 (11) Crawley CCG 0.5 (9) Coastal West Sussex CCG 1.0 (71) Brighton and Hove CCG 1.0 (31) 0.9 (27) High Weald, Lewes & Havens CCG 0.4 (8) 0.5 (10) Hastings & Rother CCG 1.6 (42) 0.9 (24) Eastbourne, Hailsham & Seaford CCG 1.7 (43) South East Coast Total 589 568 In the South East Coast region there were 88 (21 major and 67 minor) more amputations between 2010-13 than in the period, 2009-12

Results We received: 20 number of surveys (thank you) We believe there are 14 foot care services across the patch: East Kent Hospitals NHS Foundation Trust & Kent Community Trust Maidstone & Tunbridge Wells NHS Hospitals Trust & Kent Community Trust Medway Community Trust Dartford & Gravesham NHS Hospital Trust Surrey & Sussex NHS Healthcare Foundation Trust (East Surrey Hospital Site) & Community First Trust Epsom & St Heiler NHS Hospital Trust & Central Surrey Community Trust Ashford & St Peters Hospitals NHS Foundation Trust & North West Surrey Virgin Care Royal Surrey Hospital NHS Foundation Trust East Sussex Healthcare Trust & East Sussex Community Trust Brighton & Sussex University Hospital Trust (Royal Sussex County Hospital) & Sussex Community Trust Brighton & Sussex University Hospital Trust (Princess Royal Hospital) & Sussex Community Trust Western Sussex Hospitals NHS Foundation Trust (Worthing Hospital) & Sussex Community Trust Western Sussex Hospitals NHS Foundation Trust (St Richards Hospital )& Sussex Community Trust Frimley Park NHS Hospital & Virgin Care

Foot Care MDTs Blue members are core MDT has determined by the NDIA All 14 services said they had a foot care MDT (compared to NDIA – national?) Member MDT Member Non Member but access No access No Response Vascular Surgeon 8 6 Diabetologist 12 2 Specialist Podiatrist 14 DSN 5 1 Tissue Viability 4 Interventional Radiologist 9 Orthopaedic Surgeon 3 11 Microbiologist Orthotist Only2 met NDIA criteria

SEC compared to NDA: sites without a MDFT (criteria for NDA) 2014 69.2%

National goals for Diabetes Foot Care Services

The Quality of the MDT 10 of the 13 have a named MDT Clinical Lead. May be misunderstanding of transparency of named lead clinician across secondary/primary care

MDT Pathways & Guidelines Question 11: Is there a published pathway agreed with the Trust for the referral of patients with an active foot ulcer for across primary and secondary care: 8 Yes 3 No 3 Unsure Question 13: Is there a published pathway agreed with the Trust for the Prevention, early detection & management of diabetic foot disease: 6 Yes 3 No 5 Unsure Question 14: Are there published guidelines (NICE compliant) for the prevention, early detection and management of diabetic foot disease used in both outpatient and community settings & Question 15: Are these outpatient guidelines the same as those used in community settings? 5 Yes 2 No 7 Unsure

Are all patients with an active foot ulcer who are referred to the MDT seen within 24 hours 3 Yes 11 No Of the 3 that said “Yes” they said this happened more than 50% of the time. Question: Should we invite the 2 services that are achieving to share how this is achieved and discuss what are the main blocks and potential ways forward to over come this?

SEC compared to NDA: input from MDFT within 24 hours

Urgent Access Question 20: Are there sub-24 hour vascular services available for patients with diabetes and critical limb ischaemia? 9 Yes 2 No 3 Unsure Question 21: Are there agreed published guidelines for both primary and secondary care regarding access to vascular services? 1Yes 9 No 4 Unsure

Inpatient Podiatry Question 19: Is there a podiatry service available for hospital in-patients with diabetes? EVEYONE has some level of inpatient podiatry support – Yippeeeeeeeeee

SEC compared to NDA: Inpatient podiatry service SEC SCN 2014 100% * *criteria

BUT Question 18: Do all patients with diabetes admitted to hospital have a foot examination recorded (documented in patient notes)? 3 Yes, 8 No, 3 Unsure Suggests that limited screening & prevention – i.e. hospital inpatient safety is at risk?

SEC compared with NDA SEC 2014 21.4%

Hospital inpatient safety Numbers appear small. Probably due to reporting on pressure ulcers? Clearly an issue in Scotland where they have funding to implement CPR (Check, Protect & Refer)

National Foot Care Audit Question 28: Is there an agreed standardised ulcer classification system published and used by the MDT for all patients presenting with an active foot ulcer? 5 Yes, 9 No Question 29: Has the specialist podiatrist agreed to take part in the national foot ulcer audit (using the SINBAD system) commencing in July 2014? Please circle below All YES!!!!!!! – Well done

Key aspect of care: Off-loading Question 22: Is there access to a plaster technician/similar for total contact casting or similar device? 13 Yes, 1 No Question 23: Is there access to an orthotist for the provision of specialist footwear? 12 Yes, 2 No

HCP & Patient Education Question 26 Is there an agreed structured, tailored diabetes education programme including foot care offered to all patients with diabetes? 7 Yes, 6 No, 1 Unsure Question 32 Will funding be made available in 2014/15 for all members of the MDT to access continuing education in diabetes care? 4 Yes, 1 No, 9 Unsure

FOOT PROTECTION TEAM Permission to Defer?

Integrated Data Sharing – Bigger than us Question 30 Is there an agreed electronic diabetes database that all members of the MDT can access? 2 Yes, 10 No, 2 Unsure Question 31 Can appropriate HCPs in primary care access the diabetes database? 0 Yes, 9 No, 3 Unsure

Levers for Change Domain 2 of the NHS Outcomes Framework focuses on “Complications associated with diabetes including emergency diabetic ketoacidosis and lower limb amputation” (Domain 2: 2.8) This supports NICE Diabetes Quality Standards, specifically Statement 10: “People with diabetes at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance (CG10 & CG119) and Statement 11: “People with diabetes with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours”. In response to this all 12 of the national Cardiovascular Strategic Clinical Networks, have agreed with their diabetes clinical advisory groups to prioritise improving diabetic limb amputation rates. In the UK we spend £600m - £700m per annum (£125m on amputations, £213 on inpatient ulceration care, £324m on primary, community, outpatients and A&E care) on diabetic foot ulcers or amputations. (Marion Kerr). As diabetes prevalence increases so exponentially does the number of amputations. It is expected that 7,000 patients with diabetes will have an amputation by 2014/15. Vascular Reconfiguration

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