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

2. Why we conducted survey Purpose of survey Different models Background

3. 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 Rationale

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

5. National Picture

6. CCG Major Amputations per 1,000 diabetic patients April 2010- March 2013 Major Amputations per 1,000 diabetic patients April 2009 – March 2012 England0.9 NHS Ashford CCG1.6 (26)1.3(21) NHS Canterbury & Coastal CCG0.8 (24)0.8 (22) NHS South Kent Coast CCG1.4 (44)1.4 (43) NHS Thanet CCG1.4 (31)1.6 (36) NHS Swale CCG0.9 (15)1.1 (18) NHS Medway CCG0.8 (37) NHS Dartford, Gravesham & Swanley CCG 0.7 (25)0.8 (26) NHS West Kent CG0.8 (44) North West Surrey CCG1.3 (57)1.2 (48) Surrey Downs CCG0.8 (27)0.7 (22) Surrey Heath CCG0.5 (6) North East Hampshire & Fareham CCG 0.5 (12)0.7 (17) Guildford & Waverley CCG0.8 (18)0.7 (16) East Surrey CCG0.8 (15) Horsham & Mid Sussex CCG0.8 (20)0.6 (11) Crawley CCG0.5 (9)0.6 (11) Coastal West Sussex CCG1.0 (71) Brighton and Hove CCG1.0 (31)0.9 (27) High Weald, Lewes & Havens CCG0.4 (8)0.5 (10) Hastings & Rother CCG1.6 (42)0.9 (24) Eastbourne, Hailsham & Seaford CCG 0.9 (27)1.7 (43) South East Coast Total589568 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

7. We received: 20 number of surveys (thank you) We believe there are 14 foot care services across the patch: 1.East Kent Hospitals NHS Foundation Trust & Kent Community Trust 2.Maidstone & Tunbridge Wells NHS Hospitals Trust & Kent Community Trust 3.Medway Community Trust 4.Dartford & Gravesham NHS Hospital Trust 5.Surrey & Sussex NHS Healthcare Foundation Trust (East Surrey Hospital Site) & Community First Trust 6.Epsom & St Heiler NHS Hospital Trust & Central Surrey Community Trust 7.Ashford & St Peters Hospitals NHS Foundation Trust & North West Surrey Virgin Care 8.Royal Surrey Hospital NHS Foundation Trust 9.East Sussex Healthcare Trust & East Sussex Community Trust 10.Brighton & Sussex University Hospital Trust (Royal Sussex County Hospital) & Sussex Community Trust 11.Brighton & Sussex University Hospital Trust (Princess Royal Hospital) & Sussex Community Trust 12.Western Sussex Hospitals NHS Foundation Trust (Worthing Hospital) & Sussex Community Trust 13.Western Sussex Hospitals NHS Foundation Trust (St Richards Hospital )& Sussex Community Trust 14.Frimley Park NHS Hospital & Virgin Care Results

8. All 14 services said they had a foot care MDT (compared to NDIA – national?) Foot Care MDTs MemberMDT Member Non Member but accessNo accessNo Response Vascular Surgeon860 Diabetologist1220 Specialist Podiatrist1400 DSN581 Tissue Viability554 Interventional Radiologist0941 Orthopaedic Surgeon3110 Microbiologist491 Orthotist3551 Blue members are core MDT has determined by the NDIA Only2 met NDIA criteria

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

10. National goals for Diabetes Foot Care Services

11. 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

12. 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 MDT Pathways & Guidelines

13. 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? Are all patients with an active foot ulcer who are referred to the MDT seen within 24 hours

14. SEC compared to NDA: input from MDFT within 24 hours

15. 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 Urgent Access

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

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

18. 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?

19. SEC compared with NDA SEC 2014 21.4%

20. 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)

21. 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 National Foot Care Audit

22. 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 Key aspect of care: Off-loading

23. 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 HCP & Patient Education

24. FOOT PROTECTION TEAM Permission to Defer?

25. 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 Integrated Data Sharing – Bigger than us

26. 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 Levers for Change

27. South East Strategic Clinical Networks www.secscn.nhs.uk england.secscns@nhs.net Get in touch