1. Imperial Multidisciplinary Diabetes Foot Service Jonathan Valabhji MD FRCP Consultant Diabetologist, Imperial College Healthcare NHS Trust Adjunct Professor, Imperial College London National Clinical Director for Obesity and Diabetes, NHS England

2. The Role of the Multidisciplinary Team Edmonds ME, Blundell MP, Morris ME, Thomas EM, Cotton LT, Watkins PJ. Improved survival of the diabetic foot: the role of a specialized foot clinic. Q J Med 1986; 60(232):763-771.

3. St Mary’s Multidisciplinary Diabetic Foot Clinic Established 2002 Diabetologist Vascular surgeon Podiatrist Orthotist

4. Mon Tue Wed Thur Fri Sat Sun = Diabetic Podiatry Clinic Week 1 Week 2 Week 3 Week 4

5. Mon Tue Wed Thur Fri Sat Sun = Multidisciplinary Diabetes Foot Clinic Week 1 Week 2 Week 3 Week 4

6. St Mary’s Multidisciplinary Diabetic Foot Clinic 2007 Diabetologist Vascular surgeons Podiatrists Orthotist Microbiologist Radiologist Orthopaedic surgeon Neurologist Diabetes Specialist Nurses

7. Multidisciplinary Foot Clinic : Charcot Infective Mon Tue Wed Thur Fri Sat Sun = Multidisciplinary clinic : Podiatrist, Diabetologist Week 1 Week 2 Week 3 Week 4

8. Secondary / Tertiary Care

9. Community Diabetes Centre Secondary / Tertiary Care Centre Primary Care = Westminster Imperial Diabetes Partnership

10. Amputation incidence per 10,000 subjects with diabetes in Westminster treated at St Mary’s in financial years 2004-2007 compared to 2007-2009 J Valabhji. Reducing Amputations at a multidisciplinary diabetic foot clinic. The Diabetic Foot Journal 2011 14 82-87

11. West London Renal and Transplant Centre

12. Charcot’s neuroarthropathy A disease of bone and joints, characterised by painful or painless bone and joint destruction in limbs that have lost sensory innervation

14. Tibio-talar calcaneal fusion

15. Valabhji J, Oliver N, Samarasinghe D, Mali, T, Gibbs RGJ, Gedroyc WMW Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging Diabet Med 2009; 26:1127-1133. Effectiveness of clinical pathway Predominantly outpatient management Reduction in bed occupancy: 1st 3 years: 84% required admission (median length of stay 16 days) 2nd 3 years: 47% required admission (median length of stay 11 days) Avoidance of any form of amputation in 83% of episodes Major amputation in only 1 episode (2%), minor amputation in 8 episodes (15%)

16. Valabhji J, Oliver N, Samarasinghe D, Mali, T, Gibbs RGJ, Gedroyc WMW Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging Diabet Med 2009; 26:1127-1133. Effectiveness of clinical pathway Predominantly outpatient management Reduction in bed occupancy: 1st 3 years: 84% required admission (median length of stay 16 days) 2nd 3 years: 47% required admission (median length of stay 11 days) Avoidance of any form of amputation in 83% of episodes Major amputation in only 1 episode (2%), minor amputation in 8 episodes (15%)

17. J Valabhji et al. Diabet Med 2010; 27:1304 – 1307 St Mary’s Multidisciplinary Diabetes Foot Service

18. Journey so far NHS PlanHigh Quality Care for All Equity & Excellence Liberating the NHS 2000-2007 Build capacity 2007-2010 Focus on quality 2010-present Deliver better outcomes

19. New Commissioning Roles CCGs (n = 211) Directly commission roles for (£65 billion) secondary care (including non-elective services) community care NHS England Direct commissioning roles for: Primary Care (£13 billion) Specialist Services (£12 billion) Justice Services Armed forces health Local Authorities – Public Health England Direct commissioning roles Physical activity, nutrition, obesity

20. Vascular Surgery Service Reconfiguration and Diabetic Foot Disease Jonathan Valabhji National Clinical Director for Obesity and Diabetes

21. Mon Tue Wed Thur Fri Sat Sun Week 1 Week 2 Week 3 Week 4 Imperial Multidisciplinary Foot Service

22. Publications W Jeffcoate, N Holman, G Rayman, J Valabhji, B Young. The New National Diabetes Footcare Audit of England and Wales. Diabetic Med. 2014 In Press. IF: 2.902. J Valabhji. Foot problems in patients with diabetes and chronic kidney disease. Journal of Renal Care 2012 2012 Feb;38 Suppl 1:99-108. doi: 10.1111/j.1755-6686.2012.00284.x. J Valabhji J, RC Marshall, S Lyons, L Bloomfield, D Hogg, P Rosenfeld, CM Gabriel. Asymmetrical attenuation of vibration sensation in unilateral diabetic Charcot foot neuroarthropathy. Diabetic Medicine 2012 29(9): 1191-1194. IF: 2.902. D.C. Patel, C. Albrecht, D. Pavitt, V. Paul, C. Pourreyron, S.P. Newman, I.F. Godsland, J. Valabhji, and D.G. Johnston. Type 2 diabetes is associated with reduced ATP-binding cassette transporter A1 gene expression, protein and function. PLoS One. 2011; 6(7): e22142. IF: 4.090. J Valabhji. Immunosuppression therapy post-transplantation can be associated with a different clinical phenotype for diabetic charcot foot neuroarthropathy. Diabetes Care 2011 34 e135. IF: 8.087. R. Fikri, C. Bicknell, L. Bloomfield, S. Lyons, D. Samarasinghe, R.G.J. Gibbs, J. Valabhji. Awaiting auto-amputation: a primary management strategy for digital gangrene in diabetic foot disease. Diabetes Care 2011 34 e134. IF: 8.087. J Valabhji. Reducing Amputations at a multidisciplinary diabetic foot clinic. The Diabetic Foot Journal 2011 14 82-87. J Valabhji, RGJ Gibbs, L Bloomfield, S Lyons, D Samarasinghe, P Rosenfeld, CM Gabriel, D Hogg, CD Bicknell. Matching the numerator with an appropriate denominator to demonstrate low amputation incidence associated with a London hospital multidisciplinary diabetic foot clinic. Diabetic Medicine 2010 27 1304-1307. IF: 2.902. Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes Care 2010 33: 2592-2597. IF: 8.087. Thorning C, Gedroyc WMW, Tyler PA, Dick EA, Hui E, Valabhji J. Midfoot and hindfoot bone marrow oedema identified by magnetic resonance imaging in feet of subjects with diabetes and neuropathic ulceration is common but of unknown clinical significance. Diabetes Care 2010 33 1602- 1603. IF: 8.087. J Valabhji, N Oliver, D Samarasinghe, T Mali, RGJ Gibbs, WMW Gedroyc. Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging. Diabetic Medicine 2009; 26: 1127 – 1134. IF: 2.902. MJ Levy, J Valabhji. The diabetic foot. Surgery 2008 26 (1): 25-28.