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

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

3. Rationale 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

4. Foot care Briefing & basic data
Diabetes Footcare Briefing available at:
networks/cardiovascular/resources/

5. National Picture

6. CCG
Major Amputations per 1,000 diabetic patients
April March 2013
April 2009 – March 2012
England
0.9
NHS Ashford CCG
1.6 (26)
1.3(21)
NHS Canterbury & Coastal CCG
0.8 (24)
0.8 (22)
NHS South Kent Coast CCG
1.4 (44)
1.4 (43)
NHS Thanet CCG
1.4 (31)
1.6 (36)
NHS Swale CCG
0.9 (15)
1.1 (18)
NHS Medway CCG
0.8 (37)
NHS Dartford, Gravesham & Swanley CCG
0.7 (25)
0.8 (26)
NHS West Kent CG
0.8 (44)
North West Surrey CCG
1.3 (57)
1.2 (48)
Surrey Downs CCG
0.8 (27)
0.7 (22)
Surrey Heath CCG
0.5 (6)
North East Hampshire & Fareham CCG
0.5 (12)
0.7 (17)
Guildford & Waverley CCG
0.8 (18)
0.7 (16)
East Surrey CCG
0.8 (15)
Horsham & Mid Sussex CCG
0.8 (20)
0.6 (11)
Crawley CCG
0.5 (9)
Coastal West Sussex CCG
1.0 (71)
Brighton and Hove CCG
1.0 (31)
0.9 (27)
High Weald, Lewes & Havens CCG
0.4 (8)
0.5 (10)
Hastings & Rother CCG
1.6 (42)
0.9 (24)
Eastbourne, Hailsham & Seaford CCG
1.7 (43)
South East Coast Total
589
568
In the South East Coast region there were 88 (21 major and 67 minor) more amputations between than in the period,

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

8. Foot Care MDTs
Blue members are core MDT has determined by the NDIA
All 14 services said they had a foot care MDT (compared to NDIA – national?)
Member
MDT Member
Non Member but access
No access
No Response
Vascular Surgeon 8 6
Diabetologist 12 2
Specialist Podiatrist 14
DSN 5 1
Tissue Viability 4
Interventional Radiologist 9
Orthopaedic Surgeon 3 11
Microbiologist
Orthotist
Only2 met NDIA criteria

9. SEC compared to NDA: sites without a MDFT (criteria for NDA)
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. MDT Pathways & Guidelines
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

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

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

15. Urgent Access
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

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

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. National Foot Care Audit
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

22. Key aspect of care: Off-loading
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

23. HCP & Patient Education
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

24. FOOT PROTECTION TEAM
Permission to Defer?

25. Integrated Data Sharing – Bigger than us
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

26. Levers for Change
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

27. Get in touch South East Strategic Clinical Networks www.secscn.nhs.uk