Gill Sykes & Gareth Hicks

What does the ‘future’ hold? Insulin pumps BGL monitoring without taking blood A diabetes vaccine Artificial pancreas Very low calorie diet

We’re at Foot Health The future of foot care in diabetes Screening & Risk Stratification Treatment & advice Correct & Timely Referral

State of the nation 3.2 million people diagnosed with diabetes foot ulcers at any one time 6500 amputations a year In NHS England spent £639-£662 million a year ( £74,000 an hour) Only 50% of patients with diabetes survive 2 years+ 80% of ulcers are preventable Ref: Footcare for people with Diabetes ( Kerr 2012) Putting Feet First, Diabetes UK 2009

Screening in private practice In NICE CG10 and SIGN 116 a foot examination is indicated; Pulses Monofilament & tuning fork test Foot deformity History ( ulcers and/or amputations)

The tools : 10g Monofilament 128 MHz tuning fork Neurothesiometer Rydel-Seiffer tuning fork

Screening The purpose of screening is to award the patient with a foot risk category. Low risk1:500 ulcer risk At risk1:20 ulcer risk High risk 1:2 ulcer risk Leese et al 2006 Foot Risk Awareness & Management Education(FRAME)

Risk categories Active ulceration High risk – previous ulcer/amputation At risk - neuropathy and or vascular impairment with foot deformity Low risk – no neuropathy, no vascular problems or foot deformities

What do I do with this information? Note the risk factor in patients notes, with date & reason Inform the patient Inform GP Screen again in months – low risk Screen again in 3-6 months – at risk Screen again in 1-3 months –high risk (MDT)

Scottish model The Foot Attack is coined for patients needing referral for immediate treatment. In line with this, CPR for feet has been launched CCheck.Examination/assessment PProtectAdvice/footwear/insoles RReferTo Foot protection team

Referring a diabetic foot problem Who is patients’ GP ? Who leads the hospital diabetic foot clinic? What is their phone number? How does the patient get there ? Self ref/GP/direct When you refer – record it ! Gill Sykes is a diabetes specialist podiatrist. With 27 years experience, she takes up the reins....

Clinical Lead Podiatrist Acute Diabetic Care

27 years NHS experience 24 years community Specialising tissue viability Work as part of a multi- disciplinary team Including vascular consultant surgeons, diabetic consultant, tissue viability team, orthotist, specialist physiotherapist. 6 years private practice experience

Calderdale In Calderdale there were 13, 229 diabetics diagnosed in 2013 By 2030 there is predicted 19, 289 diagnosed This is an increase from 8.0% of population to 9.8% (YHPHO, 2013)

Huddersfield In Huddersfield there were 27, 260 diabetics diagnosed in By 2030 there is predicted 38, 262 diagnosed. This is an increase from 8.5% of population to 10.4%. (YHPHO, 2013)

There are two local diabetic foot screening tools within Calderdale and Huddersfield.

Screening Tools Calderdale utilise Podiatry Assistants with competency based training by podiatrists Huddersfield utilise Practice Nursing with competency based training by podiatrists

Benefits of podiatry assistants Competency based Pro -podiatry More thorough assessment i.e. more knowledge of foot pathologies Quicker referral to podiatry Inspection/ advice In Calderdale 2013, 89% of all diabetics in Calderdale were screened (not including DNA’s)

Screening Tool on Systm1 New/ Follow up screening – first appt./ follow up option tick box. Peripheral sensory neuropathy screening – left and right foot 10g monofilament/ normal abnormal. Peripheral arterial screening – right foot left foot both pulses, present, absent. Signal – mono, bi, tri phasic. Lesions/ foot deformity – free text. Diabetic risk category – low, moderate, high, ulcerated. Annual screening plan – Podiatry dept/ GP Practice Treatment plan – referral to podiatry, continue with podiatry, self care/ private care RECALL

NICE guidelines on foot risk The prevention and management of foot problems advises that foot risk should be classified as: at low current risk: normal sensation, palpable pulses at increased risk: neuropathy or absent pulses at high risk: neuropathy or absent pulses plus deformity or skin changes or previous ulcerated foot

SO………….. ‘The postcode lottery of diabetes- related amputations in England is getting worse, according to figures from Diabetes UK’ (Podiatry Now, 2014) ‘Too many people with diabetes not getting a good quality annual foot check or not being informed about their risk status at the end of their check’ (Podiatry Now, 2014)

The figures, based on NHS data, show that overall diabetes-related amputation rate has not improved, with 2.6 thousand lower limb amputations per year with diabetes. The gap between the worst and best performing areas has also got bigger’ (Podiatry Now, 2014).

What we don’t want is this……

Or this………

If in doubt, DO REFER

To pose some questions…..? What will happen to all the low/ medium risk diabetics in the NHS? And staff shortages? And an increase in diabetics? And a growing elderly population? WHAT NOW?

Food for thought.. Some NHS Trusts already have done some of the below…. Discharge low/ medium risk to self management. Training/ competencies for assistant practitioners Involvement of private clinicians, ? partnership working Voluntary sector

Thank You