1. Improving foot health: “What does good look like”
DMI Board
13 March 2014
Dr. Jane Doherty, Carol Gayle, Laura Price & Monique Ferdinand
Jane + Laura

2. Contents Background “What does good look like”
Work to date to build improvements
Recommendations to reinforce improvements
Jane

3. Background: Objectives of DMI foot health work
Reduce variation in foot assessments across primary care and increase the number of foot assessments conducted accurately and consistently
Increase patient & provider understanding and confidence in the pathway, with clarity on when and how to refer to specialist podiatry services
Ensure patients are seen in the most appropriate care setting
Understand the capacity of community podiatry service to manage cohorts of patients previously managed in hospital
Jane

4. Background: Foot Health Group Membership
DMI Clinical Leads:
Dr. Carol Gayle
Dr. Jane Doherty
Members & Contributors:
Regular Meetings for Development:
6 meetings in 5 months
Several redesign activities, actions and owners
KCH Diabetes Foot Clinic
GSTT Hospital Foot Clinic
GSTT Community Podiatry
Lambeth & Southwark CCG
Dr. Marcus Simmgen (Diabetes Consultant in Foot Medicine, KCH)
Dr. Prash Vas (Diabetes Consultant in Foot Medicine, KCH)
Maureen Bates (Manager, KCH Diabetes Foot Clinic)
Tejal Patel (Deputy Head, GSTT Dept of Foot Health)
Liza Curtis (Head of GSTT Dept of Foot Health)
Steve Thomas (Diabetes Consultant , GSTT)
Rupert Maher (Head, Lambeth & Southwark community podiatry)
Laura Gearing (Principal Podiatrist, Southwark)
Monica Fisk (Community Podiatrist, Southwark)
Christian Pankhurst (Senior Orthotist, GSTT)
Leah Herridge (Redesign Manager for LTC, Southwark CCG)
Mahroof Kazi (PCC Commissioning Manager, Lambeth CCG)
Linda Drake (Practice Nurse, Southwark CCG)
Bob Skelly (Patient Rep, Southwark CCG)
Jane
Transition meeting from DMI hosted by KCH: February 20, 2014
Agreed terms of reference for Lambeth and Southwark Diabetes Foot Health Group

5. “What does good look like”: Foot assessments in primary care
For 2013/14, we would expect Lambeth and Southwark to be at or above the England average for DM29, a level Lambeth has already achieved
Variation reduced and more practices to be closer to the expected performance for the average achieved in Lambeth and Southwark
Jane
England average was 83.7% in 2011/12 and 85.1% in 2012/13

6. “What does good look like”: Foot Health risk classification
Total Patients on Register
13,109
* Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011)
**Estimates based on actual 2012/13 patient caseload in specialist services within GSTT and KCH hospital clinics, and GSTT community podiatry
Jane

7. “What does good look like”: Foot Health risk classification
Total Patients on Register
13,109
* Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011)
**Estimates based on actual 2012/13 patient caseload in specialist services within GSTT and KCH hospital clinics, and GSTT community podiatry
Jane
Patients with a moderate or high risk classification in primary care to be seen within the community podiatry service caseload, in order to meet best practice outlined by NICE and Diabetes UK

8. Diabetic foot patient pathway for Southwark and Lambeth March 2013
Risk level
Service
What should happen
How to refer
Active
Within 24 hours
King’s Diabetic Foot Clinic
Tel:
Fax
Guy’s Foot Clinic
Tel:
Fax
St Thomas’ Foot Clinic
Tel: Fax:
St George’s Foot Clinic / 0232
Holistic care
Are diabetes & other risk factors well controlled?
Foot ulceration
Foot intact BUT infection
Ischaemic foot + infection
Neuropathic foot + infection
Unexplained foot inflammation ?Charcot
KCH diabetic foot clinic or
GSTT foot health
A&E if out of hours
Tailored intervention by specialist team
Inform GP of intervention
Neuropathic foot + new onset blister / superficial ulceration (up to 48 hours)
Lambeth & Southwark community podiatry (Foot Protection Team)
High
Priority referral
Southwark
Emergency clinics Mon,Wed, Fri
Tel:
Fax:
Community podiatry:
Lambeth
Emergency clinics Mon – Fri:
Tel: /2/3
Community podiatry
Fax /6362
Annual foot check
Test foot sensation
Palpate foot pulse
Inspect for deformity / callus
Check for ulcers
Ask about history of ulcers
Inspect footwear
Ask about pain
Stratify risk and inform patient
Foot intact
Neuropathy or absent pulses
PLUS
Previous ulceration, skin changes or deformity
Tailored intervention by community podiatry (Foot Protection Team)
Referral to specialist hospital team if required
Inform GP of intervention
Lambeth & Southwark community podiatry (Foot Protection Team)
Moderate
Routine referral
Advise patients of their risk level
Responsive to needs of patients
May include more specialised vascular assessment
Specialist advice about footwear and insoles
Arrange follow up care
Inform GP of intervention
Southwark Community Podiatry
Tel
Fax
Lambeth community podiatry
Tel
Fax /6362
Foot intact
Neuropathy or absent pulses
Southwark & Lambeth community podiatry (Foot Protection Team)
At every appointment discuss self management care plan & refer if suitable to self mgnt pathway for options
Low
As required
Advise patients of their risk level Advice and information for emergencies
Discuss self management care plan & self management options. Refer as appropriate.
See self management pathway
Southwark: / 8840
Lambeth:
Foot intact
Normal sensation
Palpable pedal pulses
Primary Care
Diabetic foot patient pathway for Southwark and Lambeth March 2013

9. “What does good look like”: Foot Health risk classification
Total Patients on Register
13,109
* Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011)
**Estimates based on actual 2012/13 patient caseload in specialist services within GSTT and KCH hospital clinics, and GSTT community podiatry
Jane
Patients with a moderate or high risk classification in primary care to be seen within the community podiatry service caseload, in order to meet best practice outlined by NICE and Diabetes UK
With better communication from specialists, coded classification and actual caseload to be closer in number and give better indication of where the capacity should be in the system

10. “What does good look like”: Addressing capacity concerns in community podiatry
Healed patients for over 12 months which meet the agreed guidelines begin to be transferred by April 2014, estimated:
98 for KCH
75 for GSTT
Community podiatry is supported to address the current + projected service capacity deficit (shown here)
Laura

11. Work to date: DMI Foot Health Group improvements
Engage & Analyse
Analysis of community podiatry activity & capacity
Record patients with diabetes in foot settings (esp. GSTT)
Perform audit of healed patients at KCH & GSTT
Ensured proper representation & assigned owners
Baseline foot metrics across settings
Design & Develop
Clinical letter for specialist settings created to improve communications
Foot health & diabetes education resources compiled for practitioners and patients
Self-referral and referral to community podiatry revised + clarified
Transfer process agreed
Guidance for healed foot patients drafted & approved
Laura
Promote & Sustain
Stronger relationships built between foot services & CCGs – Foot group TOR agreed
Foot health improvements communicated to 1° via CCGs ( , EMIS, online)
Foot case study + 1° performance presented at DMI Learning events
Promoted pathway at several primary care PLT & Locality meetings
Foot health promoted at Patient Forum Launch & again in June 2014

12. Recommendations to continue to reinforce and support DMI improvement work
Support the current business case to increase the capacity of community podiatry, and continue to monitor and evaluate the demands on the service
Next Steps:
Monitor and report on transfer activity (high risk)
Referrals from primary care and patients (moderate / high risk)
Audit community caseload to identify if patients could be shifted to primary care
Continue to ensure adequate communication to primary care from specialist settings
Clinical letter reinforced to be used by podiatrists across settings
Foot Health Group to report on usage in 6 months and revise if changes are needed
Promote further touch-points with primary care for support (i.e. learning events)
Jane

13. Recommendations to continue to reinforce and support DMI improvement work
Reinforce the foot health pathway and continue education opportunities for patients and primary care practices
Next Steps:
Local diabetes foot health group to own pathway developed and review annually
CCGs and community podiatry to continue promote foot health & pathway (at least once a year) at primary care and patient events
Continue to foster relationships built between specialist settings in community and hospital (and across trusts), as well as with CCGs and primary care
Diabetes foot health group meets at least three times a year and continues to reinforce DMI work in organisations (next date: June )
CCG and provider organisations support group and efforts to sustain improvements
Jane

14. Recommendations to continue to reinforce and support DMI improvement work
Owner (DMI Board Member / Foot Group Member)
Support the current business case to increase the capacity of community podiatry, and continue to monitor and evaluate the demands on the service
Lambeth CCG (Therese Fletcher / Mahroof Kazi)
Southwark CCG (Leah Herridge)
GSTT Community Services (Amanda Williams / Rupert Maher; Laura Price)
Continue to ensure adequate communication to primary care from specialist settings
KCH diabetes foot clinic (David Hopkins / Carol Gayle; Prash Vas)
GSTT hospital foot clinics (Steve Thomas / Tejal Patel)
Reinforce the foot health pathway and continue education opportunities for patients and primary care practices
Continue to foster relationships built between specialist settings in community and hospital (and across trusts), as well as with CCGs and primary care
Jane

15. What we need from the board:
NOTE the actions completed by the DMI Foot Health Working Group
SUPPORT the further actions required to sustain and reinforce improvements
SUPPORT the Lambeth and Southwark Diabetes Foot Group as a forum for CCGs, GSTT and KCH hospital foot clinics, and GSTT community podiatry services to continue to develop services and reinforce DMI work
Jane