1. Podiatry Worcestershire
Service redesign

2. Redesign process What is the aim of today’s workshop?
To begin to co-design Podiatry Services in Worcestershire
How will we achieve this?
We will explain what services Podiatry Worcestershire currently offer and where
We will explain the challenges in the current service provision
We will hear what patients and carers say about these services
We will hear what our staff say about these services
We will discuss some other ways of delivering services for us all to think about
Together, we will consider how we could organise things differently, and what we think is needed to make it work

3. About Podiatry in Worcestershire
A community based service that provides services out of clinics and at home.
The service is provided to children and adults registered with a Worcestershire GP.
Provides assessment, diagnosis and treatment of foot and lower limb disorders in those patients seen to be at risk from infection, ulceration or amputation due to an underlying medical condition.
The service is provided in each locality i.e. South Worcestershire, Wyre Forest and Redditch & Bromsgrove, by four individual clinical teams each with a team lead.

4. Services currently offered
Assessment and management of ‘at risk’ Podiatric patients.
Diabetic Foot Risk Assessments for diabetic patients receiving on-going podiatric care.
Provision of specialist wound care tissue viability clinics
General Podiatry clinics for follow up’s and new patient assessments
Specialist assessment and management of Musculoskeletal/Biomechanical foot function related problems e.g. heel pain, lower limb dysfunction
Rapid access for urgent cases e.g. infections, ulcerations.
Nail Surgery, total and partial nail avulsion procedures undertaken for patients aged 12 years and above.
Services are provided in Health Centres as well as Acute and Community Hospital Settings and Domiciliary Visiting of patients is also undertaken subject to meeting criteria.
Close working links with secondary care, Diabetic and Vascular multidisciplinary Clinics
All referrals are triaged on receipt to identify urgent cases and those who may not fit the criteria for care.
These include high risk diabetic patients; patients with vascular disease; patients with connective tissue disorders. This group of patients are particularly ‘at risk’ of tissue breakdown, infection, ulceration gangrene or limb loss. Assessment includes education and empowerment of patients regarding their foot health.
, ulceration management for diabetic, ischaemic patients with poor tissue viability and acute foot pathology.

5. Current venues where Podiatry is being provided
The Princess of Wales Community Hospital, Bromsgrove
Smallwood House, Redditch
Kidderminster Health Centre
Hollywood Medical Practice
Stourport Health Centre
Droitwich Medical Centre
Moor Street clinic
Aconbury East, The Alexandra Hospital, Kidderminster Treatment centre (Diabetes Centre)
Malvern Prospect View
Pershore Community Hospital
Upton Medical Centre
Evesham medical centre
Tenbury Community Hospital
Henwick Holt Medical Centre
Each clinic has different numbers of chairs and we have rooms allocated at certain practices on certain days only.

6. Service Review completed 2016
Gain a better understanding of all the different elements of the podiatry service, its leadership and how it is delivered across all localities.
Identify any inequities within the countywide service
Gain a vision as to how the service could look in the future

7. Service review recommendations
Structure of the service and skill mix
Develop a service specification
Review referral system and referral management
Consider the diabetic foot care pathway
Review the biomechanical service
Review administration service across the county
Review staff support provision
Review service contracts

8. Challenges to current service provision
Managing the number of venues we currently offer effectively
Demand currently outstrips capacity leading to increased waiting times for new patients and follow up’s
The number of patients who require continued input due to high risk factors is increasing
Inequities across the county of treatment provision and waiting times.
Disjointed and disproportionate administrative support
Escalating costs of providing orthotic provision and increasing dressing demands.
Managing many venues is challenging because often the Podiatrist canbe working alone without adminstartive support. If the Podiatrist is sick there is no-one to cover the clinic. During annual leave wound care patients have limited cover. Clinics can become block booked with no capacity for urgent patients. Travelling time takes time away from the Podiatrists clinical time

9. Equality Impact Assessment
Equality Impact Assessment undertaken and reviewed by Equality Advisory group.
Key findings on current service:
There is a need to define what is meant by ‘housebound’
The clinic at Moor Street provides less easy access to people who are disabled
Services need to find more meaningful ways to engage with BME communities as leaflets are often not suitable.
Important to consider the Asian community and the travelling community where there is a higher prevalence of Diabetes, and the homeless community, which currently relies on volunteers
Services need to be aware that some carers may not be able to access appointments at clinics due to caring duties

10. Patient and carer feedback
Feedback obtained by:
Review of compliments, complaints and PALS feedback over the last six months
Attendance at a range of clinics to talk to patients and carers directly
Key Themes:
Staff are caring and once in the service, the treatment is good
Patients and carers saying they want self-care information – they could do some treatments themselves if given the skills, confidence and knowledge
Appointments are reassuring, but not always necessary
Would like more consistency with the staff they do see
Administrative process around making appointments needs to be improved
More patient and carer information – signposting, service information
Clarification around eligibility for home visits
Consistency and equity across the county in terms of service offer/treatments/process to access

11. Staff feedback General Themes included:
The difficulty of managing home visits which take a lot of clinician time
Telephone triage with protected time
Administration restructure to provide equity
Should we be treating the walking well?
Should there be charges for orthotic prescriptions?
Should we stop acupuncture?
Mentorship and rotations for staff

12. Staff feedback Should we stop choose and book? Have students
Regular access to training
Tighter access criteria
Single point of referral
More support to discharge patients
A review of the footcare assistant role
Patient empowerment and education sessions for patients and carers
E-referral

13. The Multidisciplinary Diabetic Footcare Team
New countywide service, from January
Clinical Specialist Podiatrists and Diabetic nurses with access to consultant support
Rapid access to Podiatry fro active foot disease in Diabetic Patients
Single point of referral
1 years funding only for this team from NHS England initially
Ensures compliance with NICE guidelines.

14. Financial considerations
Our redesigned service must be Cash releasing Show active cost avoidance Create capacity CIP/QUIPP- 3% in the next financial year which is £60,000

15. The givens and constraints…
NICE Guidance NG19- Will be covered by the MDFT service for 1 year:
The guideline includes recommendations on:
care within 24 hours
care across all care settings
referral for diabetic foot problems
investigating and managing diabetic foot ulcer, diabetic foot infection and Charcot arthropathy
The Trust uses local policies which must be adhered to for Nail Surgery, Acupuncture, a wound formulary and Tissue Viability

16. Some ideas for us to think about…
Dudley Group NHS Foundation Trust – self referral method, primary and secondary waiting list system for follow up’s
Walsall Health Care NHS Trust
NHS great Glasgow and Clyde- self referral system. Single point of access. Increased emphasis on personal health responsibilities and training patients and carers to manage their own feet.

17. Questions? ?

18. Facilitated group discussion
What elements of the current service do we need to keep/do more of?
How should the Podiatry service for Worcestershire look in the future – structure, services offered, referral process, self-care options?

19. Next steps Two events – 28th November and 1st December
Follow up event on 11th December to share emerging model
New model to be shared with Trust committees and wider, as necessary

20. Thank you!