Podiatry Worcestershire Service redesign

Redesign process What is the aim of today’s workshop? To begin to co-design Podiatry Services in Worcestershire How will we achieve this? We will explain what services Podiatry Worcestershire currently offer and where We will explain the challenges in the current service provision We will hear what patients and carers say about these services We will hear what our staff say about these services We will discuss some other ways of delivering services for us all to think about Together, we will consider how we could organise things differently, and what we think is needed to make it work

About Podiatry in Worcestershire A community based service that provides services out of clinics and at home. The service is provided to children and adults registered with a Worcestershire GP. Provides assessment, diagnosis and treatment of foot and lower limb disorders in those patients seen to be at risk from infection, ulceration or amputation due to an underlying medical condition. The service is provided in each locality i.e. South Worcestershire, Wyre Forest and Redditch & Bromsgrove, by four individual clinical teams each with a team lead.

Services currently offered Assessment and management of ‘at risk’ Podiatric patients. Diabetic Foot Risk Assessments for diabetic patients receiving on-going podiatric care. Provision of specialist wound care tissue viability clinics General Podiatry clinics for follow up’s and new patient assessments Specialist assessment and management of Musculoskeletal/Biomechanical foot function related problems e.g. heel pain, lower limb dysfunction Rapid access for urgent cases e.g. infections, ulcerations. Nail Surgery, total and partial nail avulsion procedures undertaken for patients aged 12 years and above. Services are provided in Health Centres as well as Acute and Community Hospital Settings and Domiciliary Visiting of patients is also undertaken subject to meeting criteria. Close working links with secondary care, Diabetic and Vascular multidisciplinary Clinics All referrals are triaged on receipt to identify urgent cases and those who may not fit the criteria for care. These include high risk diabetic patients; patients with vascular disease; patients with connective tissue disorders. This group of patients are particularly ‘at risk’ of tissue breakdown, infection, ulceration gangrene or limb loss. Assessment includes education and empowerment of patients regarding their foot health. , ulceration management for diabetic, ischaemic patients with poor tissue viability and acute foot pathology.

Current venues where Podiatry is being provided The Princess of Wales Community Hospital, Bromsgrove Smallwood House, Redditch Kidderminster Health Centre Hollywood Medical Practice Stourport Health Centre Droitwich Medical Centre Moor Street clinic Aconbury East, The Alexandra Hospital, Kidderminster Treatment centre (Diabetes Centre) Malvern Prospect View Pershore Community Hospital Upton Medical Centre Evesham medical centre Tenbury Community Hospital Henwick Holt Medical Centre Each clinic has different numbers of chairs and we have rooms allocated at certain practices on certain days only.

Service Review completed 2016 Gain a better understanding of all the different elements of the podiatry service, its leadership and how it is delivered across all localities. Identify any inequities within the countywide service Gain a vision as to how the service could look in the future

Service review recommendations Structure of the service and skill mix Develop a service specification Review referral system and referral management Consider the diabetic foot care pathway Review the biomechanical service Review administration service across the county Review staff support provision Review service contracts

Challenges to current service provision Managing the number of venues we currently offer effectively Demand currently outstrips capacity leading to increased waiting times for new patients and follow up’s The number of patients who require continued input due to high risk factors is increasing Inequities across the county of treatment provision and waiting times. Disjointed and disproportionate administrative support Escalating costs of providing orthotic provision and increasing dressing demands. Managing many venues is challenging because often the Podiatrist canbe working alone without adminstartive support. If the Podiatrist is sick there is no-one to cover the clinic. During annual leave wound care patients have limited cover. Clinics can become block booked with no capacity for urgent patients. Travelling time takes time away from the Podiatrists clinical time

Equality Impact Assessment Equality Impact Assessment undertaken and reviewed by Equality Advisory group. Key findings on current service: There is a need to define what is meant by ‘housebound’ The clinic at Moor Street provides less easy access to people who are disabled Services need to find more meaningful ways to engage with BME communities as leaflets are often not suitable. Important to consider the Asian community and the travelling community where there is a higher prevalence of Diabetes, and the homeless community, which currently relies on volunteers Services need to be aware that some carers may not be able to access appointments at clinics due to caring duties

Patient and carer feedback Feedback obtained by: Review of compliments, complaints and PALS feedback over the last six months Attendance at a range of clinics to talk to patients and carers directly Key Themes: Staff are caring and once in the service, the treatment is good Patients and carers saying they want self-care information – they could do some treatments themselves if given the skills, confidence and knowledge Appointments are reassuring, but not always necessary Would like more consistency with the staff they do see Administrative process around making appointments needs to be improved More patient and carer information – signposting, service information Clarification around eligibility for home visits Consistency and equity across the county in terms of service offer/treatments/process to access

Staff feedback General Themes included: The difficulty of managing home visits which take a lot of clinician time Telephone triage with protected time Administration restructure to provide equity Should we be treating the walking well? Should there be charges for orthotic prescriptions? Should we stop acupuncture? Mentorship and rotations for staff

Staff feedback Should we stop choose and book? Have students Regular access to training Tighter access criteria Single point of referral More support to discharge patients A review of the footcare assistant role Patient empowerment and education sessions for patients and carers E-referral

The Multidisciplinary Diabetic Footcare Team New countywide service, from January Clinical Specialist Podiatrists and Diabetic nurses with access to consultant support Rapid access to Podiatry fro active foot disease in Diabetic Patients Single point of referral 1 years funding only for this team from NHS England initially Ensures compliance with NICE guidelines.

Financial considerations Our redesigned service must be Cash releasing Show active cost avoidance Create capacity CIP/QUIPP- 3% in the next financial year which is £60,000

The givens and constraints… NICE Guidance NG19- Will be covered by the MDFT service for 1 year: The guideline includes recommendations on: care within 24 hours care across all care settings referral for diabetic foot problems investigating and managing diabetic foot ulcer, diabetic foot infection and Charcot arthropathy The Trust uses local policies which must be adhered to for Nail Surgery, Acupuncture, a wound formulary and Tissue Viability

Some ideas for us to think about… Dudley Group NHS Foundation Trust – self referral method, primary and secondary waiting list system for follow up’s Walsall Health Care NHS Trust NHS great Glasgow and Clyde- self referral system. Single point of access. Increased emphasis on personal health responsibilities and training patients and carers to manage their own feet.

Questions? ?

Facilitated group discussion What elements of the current service do we need to keep/do more of? How should the Podiatry service for Worcestershire look in the future – structure, services offered, referral process, self-care options?

Next steps Two events – 28th November and 1st December Follow up event on 11th December to share emerging model New model to be shared with Trust committees and wider, as necessary

Thank you!