The Ealing Experience and Vision for the Future: Dr Sanjeev Mehta, Consultant Diabetologist, Ealing Hospital NHS Trust Dr Sanjeev Mehta Consultant in Diabetes and Endocrinology Ealing Hospital NHS Trust Integrated Care Organisation Incorporating the Community Services of Brent, Ealing, and Harrow 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Overview My background Diabetic foot care in Ealing in 2010 Progress over the past 3 ¾ years Challenges ahead Questions 19 April 2017 London Foot Network Meeting

London Foot Network Meeting My background London Graduate Specialist Registrar, Diabetes and Endocrinology, NW Thames Rotation Locum Consultant in Diabetes and Endocrinology, Central Middlesex Hospital, June – December 2009 Consultant in Diabetes and Endocrinology, Ealing Hospital, January 2010 to date 19 April 2017 London Foot Network Meeting

Lower limb amputations in diabetic patients in Ealing, 2009/10 19 April 2017 London Foot Network Meeting

Diabetic Foot Service – Ealing Hospital 2009/10 Recently established diabetic foot clinic (Consultant Diabetologist and podiatrist with input from Tissue Viability Nurse) 50 new referrals seen in the previous 12 months Vascular surgery clinic run in parallel Twice monthly diabetic foot Multidisciplinary Team (MDT) meetings (Diabetologist, Interventional Radiologist, Vascular Surgeon, Orthopaedic surgeon, Podiatrists, Tissue Viability Nurse) No antibiotic guidelines in place for management of diabetic foot infections 19 April 2017 London Foot Network Meeting

Antibiotics – consensus statement 19 April 2017 London Foot Network Meeting

Antibiotic guidelines Spring 2010 – Trust antibiotic guidelines written (by myself and the Associate Specialist in microbiology) Spring 2010 – Microbiologists start attending diabetic foot MDT meetings January 2011 – Locum Consultant in Infectious Diseases appointed – starts attending diabetic foot MDT meetings Autumn 2011 – out-patient antibiotic service established for patients who need long term iv antibiotics (eg for MRSA osteomyelitis) January 2013 – first revision of Trust antibiotic guidelines 19 April 2017 London Foot Network Meeting

Access to clinic and increasing capacity Simple, mainly “tick-box” referral form developed Referral by post, e-mail or fax Early referral encouraged Specialist registrars encouraged to come down to clinic and see patients under my supervision Last year ~150 new referrals seen Podiatrists now do a daily clinic in the hospital – dedicated slots available to review in-patients 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Teaching and Training Healthcare professionals Diabetic foot MDT meetings Diabetic foot clinic Education courses and talks for General Practitioners and Practice Nurses (e.g Warwick certificate in Diabetes Care) E-star events Hospital Grand Rounds Junior Doctor (including CMT and GPVTS) teaching Diabetic foot study day Patients Structured Education Courses (eg “Right Start”) Regular podiatry input and reinforcement of key messages “Lets talk about diabetes” initiative 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Other initiatives Summer 2011 – In-patient Integrated Care Pathway developed September 2011 – Focus on foot care at Diabetes Team “Away Day” December 2011 – Diabetic Foot Study Day – free to all staff in Ealing Integrated Care Organisation 2012 – Formalisation of our Foot Protection Team Participation in the London Diabetic Foot Network Involvement in the amputation root cause analysis audit Involvement in the KCH Charcot PTH study 19 April 2017 London Foot Network Meeting

Diabetic Foot Disease Profile Data available for every CCG in England on the National Diabetes Information Service website www.diabetes-ndis.org Examines the scale of inpatient care of people with diabetes who are admitted to hospital for a range of footcare conditions Data compiled from Hospital Episode Statistics and covers episodes of hospital care over the preceding 3 years, including: Total episodes of inpatient care for diabetic foot disease Total nights in hospital due to diabetic foot disease Episodes of care when an amputation is performed in those with diabetes 19 April 2017 London Foot Network Meeting

Diabetic Foot Disease Profile – Ealing PCT 19 April 2017 London Foot Network Meeting

Diabetic Foot Disease Profile – Ealing CCG 19 April 2017 London Foot Network Meeting

Diabetic Foot Disease Profile – Ealing CCG 19 April 2017 London Foot Network Meeting

Diabetic foot Disease Profile – Ealing CCG 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Where are we now? 41% reduction in amputations over 2 years since Diabetic Foot Disease profiles first published Total amputations (major & minor) currently half the average for all CCGs in England Major and minor amputation rates both significantly below the average for all CCGs in England Episodes of care in hospital and numbers of days in hospital for diabetic foot care significantly below the average for all CCGs in England 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Challenges ahead Centralisation of vascular (and renal) services Potential for fragmentation of care Need for clear pathways and means of communication Shaping a Healthier Future Lack of an integrated “Diabetes Budget” Reaching and treating the most vulnerable patients Demand management Reducing in-patient length of stay Prevention of hospital acquired foot ulcers Casting 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Lessons learnt Try and do the basics well Many heads are better than one! Audit your amputations (and learn from this) Know and use your audit / outcome data Education, education, education! Beware of complacency 19 April 2017 London Foot Network Meeting

London Foot Network Meeting Acknowledgements All members of the multidisciplinary foot care team, Ealing Hospital NHS Trust Community Podiatrists and the foot protection team, Ealing Integrated Care Organisation Dr Jonathan Valabhji Dr Wing May Kong Professor Michael Edmonds Miss Stella Vig and the London Foot Network 19 April 2017 London Foot Network Meeting

Thank you for your attention Questions? 19 April 2017 London Foot Network Meeting