1. Atlas of variation R B Paisey, SW CCG advisory group 04/05/2014
Excuses or challenges!
Age
Ethnicity
Legacy effect
Rural population
Lack of detail

2. Evolution and the diabetic foot
Increasing numbers
Fashion victims

3. The problem in profile R B Paisey, SW CCG advisory group 04/05/2014

4. Why speed is of the essence R B Paisey, SW CCG advisory group 04/05/2014
Vascular disease and outcome
Reference Rate of Healing of Neuropathic Ulcers of the Foot in Diabetes
and Its Relationship to Ulcer Duration and Ulcer Area.
Ince, Game and Jeffcoate. Diabetes Care 2006

5. Profile Torbay total ulcer and amputation rates 2005-2013

6. They all have admin, clerical and IT help
The diabetic foot Other Audits R B Paisey, SW CCG advisory group 14/07/2014
1. Williams MV, Drinkwater KJ. Radiotherapy in England in 2007: modelled demand and audited activity. Clin. Oncol. R. Coll. Radiol. G. B. 2009;21:575–90.
2. Cloud G, Hoffman A, Rudd A, Intercollegiate Stroke Working Party. National sentinel stroke audit Clin. Med. Lond. Engl. 2013;13:444–8.
3. Birkhead JS, Walker L, Pearson M, Weston C, Cunningham AD, Rickards AF, et al. Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP). Heart Br. Card. Soc. 2004;90:1004–9.
4. Sweeney AB, Flora HS, Chaloner EJ, Buckland J, Morrice C, Barker SGE. Integrated care pathways for vascular surgery: an analysis of the first 18 months. Postgrad. Med. J. 2002;78:175–7.
They all have admin, clerical and IT help

7. The first peer review visits (NHS Diabetes) 2011 to 2013
Team involved
Host team
Zoli Zambo Shelina Jetha Richard Paisey Graham Bruce Alex Harrington Matthew Cichero Rob McCarthy Angie Abbott
Foot review patients Multidisciplinary team in action Podiatry leads Commissioners Nursing support staff Admin team

8. 10 visits as NHS Diabetes

9. Amputation rates according to services available 2011
centre
Data base
MDT
Orthotics
In clinics
Pod lead for foot service
Com pod >1/1000
Diabetic populn 1 + 2 3 - 4 5
+/- 6 7 8 9 10

10. Measuring within area variation R B Paisey, SW CCG advisory group 04/05/2014
All amputations/1000 persons with diabetes per 5 years per practice

11. Clustering within areas R B Paisey, SW CCG advisory group 04/05/2014

12. Integrating with the patient and carers

13. Prompt treatment matters-the patient’s narrative
Major lower limb amputation
Resolution of ulcers
Male age 61 T2DM 5 years
Good family support
Great toe ulcer
Low dose antibiotics in community 6 weeks
Not healing, referral to MDT
Osteomyelitis in tibia
AKA
Male age 84 T2DM 10 years
Living alone
Bilateral heel ulcers
MDT in 5 days
Offloading and intense antibiotics
Complete healing
No surgery required

14. NHS England peer reviews Thanks to
Margaret Bamford, Michelle Roe NHS Diabetes
Duncan Browne, SW regional diabetes lead
SW Region:
podiatrists (Alex Harrington)
vascular surgeons
foot and ankle specialists
diabetologists
Orthotists
DUK
Persons living with diabetes
Commissioners

15. NHS England lead for quality improvement Two diabetes leads
Peer review team
NHS England lead for quality improvement
Two diabetes leads
Two podiatry leads
Vascular surgeon
Orthopaedic surgeon

16. What constitutes an effective MDT?
Enough space for parallel working
Two podiatrists with rotation in from community
Orthotist contract
Diabetologist job plan
Vascular surgeon job plan
Orthopaedic/podiatric surgeon job plan
Access to microbiology/tissue viability/diabetes nursing
Access point for referral

17. The foot protection team R B Paisey, SW CCG advisory group 04/05/2014
Practice nurse annual review and education for low risk patients
7.2 podiatrists/100,000 populace (all podiatry)
Skill mix-band 5 for high risk patients band 6 for ulcer treatment
Liaison with district nurse, care homes, practice
Link and rotation in to MDT with clear point of contact
Ref Health Committee Written evidence from the Society of Chiropodists and Podiatrists (PEX 21) 2013

18. Heterogeneity of diabetic foot care services
CCG
General
Practice
Patient
and carer
NHS Trust Hospital
Social enterprise
Nursing and residential homes

19. Advanced information R B Paisey, SW CCG advisory group 04/05/2014
To be obtained by CAG review team
a) Population served by CCG
b) Percentage with diabetes
c) Five year minor and major amputation rates/1000 diabetic persons in each practice
d) What is the compliance in practices with the 9 care processes for diabetes annual review?
Supplied by CCG,MDT,Community Pod
a) Location, frequency and regular attendees at MDT
b) Locations, skill mix and frequency of community diabetes podiatry clinics
c) Rotation scheme between community and MDT podiatry
d) Access to diabetic foot care pathways
e) Root cause analysis of amputations
f) Services commissioned and delivered for low, medium and high foot risk diabetic persons
g) Are there regular training programmes for primary and secondary care staff in diabetes foot care?

20. Peer review timetable Time Venue Purpose Participants from locality
Review team member
Documentation
Meeting room
Introductions
CCG, Trust Board, review team, diabetes foot care
leads in podiatry and diabetes
All
Written notes
Aims and structure of review
MDT area
(clinic in progress if
necessary)
Assessment of clinic space,
frequency, staffing and
integration with community and wards
Podiatrist, diabetes lead, vascular surgeon,
orthopaedic surgeon, orthotist, clerical support staff
Diabetes specialist, podiatrist and surgeon
Use data collection form
Interview room
Interviews with patients
4 patients two healed two amputees
NHS England lead and second podiatrist
Use national audit form
Quiet room
Review of 4 of 10 sets of patient notes
Admin staff member for clinic
Second diabetologist
Coffee break
none
Highlight list of important issues
Discussion of access to diabetes foot care general practice-community podiatry –MDT and back
GP, CCG, community podiatry, diabetes, vascular surgery leads for diabetes foot care and orthotist
Lunch
Outline of recommendations
None
Feedback to local team

21. Thanks for listening

22. Ulcer Classification SINBAD
Site
Ischemia
Neuropathy
Bacterial infection
ulcer Area
ulcer Depth
Ulcers scored 0(neg) or 1(pos) for each characteristic
Sum of scores (0-6) = overall grade.

23. Best practice Patient centred continuity of care
Integration with general practice
Podiatry based
With audit of all ulcers
Clarity in commissioning
Research HEELS and future studies

25. Delivery of Care Prevention of foot disease
Hospital acquired heel ulceration