1. Improving foot health proposal DMI Programme Board 19 th July 2013 Dr Carol Gayle and Monique Ferdinand

2. 19 July 2013 2 Foot health – DMI programme board 2 Contents Our objectives Work done to date Conclusions from analysis What we want to deliver and timescales Measures of success Risks and constraints

3. 19 July 2013 3 Foot health – DMI programme board 3 Objectives of DMI foot health work Reduce variation in foot assessments across primary care Increase patient and 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 Ensure capability and capacity of community podiatry service to manage cohorts of patients previously managed in secondary care

4. 19 July 2013 4 Foot health – DMI programme board 4 Work done to date 1.L & S diabetes foot care pathway Created for 1° care clinicians to clarify when and where to refer patients 2.Primary care education events Two events in Jan 2013 Aimed to improve recognition of foot health problems, launch pathway, provide practical support from podiatrists 3.Data collection and analysis Used to inform next steps for improving foot health Has been difficult to obtain, gaps in recording, unclear coding

5. Foot intact Normal sensation Palpable pedal pulses Foot intact Neuropathy or absent pulses Foot intact Neuropathy or absent pulses PLUS Previous ulceration, skin changes or deformity High Moderate Low Lambeth & Southwark community podiatry (Foot Protection Team) Southwark & Lambeth community podiatry (Foot Protection Team) Primary Care Risk levelServiceHow to refer Neuropathic foot + new onset blister / superficial ulceration (up to 48 hours) KCH diabetic foot clinic or GSTT foot health A&E if out of hours Lambeth & Southwark community podiatry (Foot Protection Team) What should happen Advise patients of their risk level Advice and information for emergencies Discuss self management care plan & self management options. Refer as appropriate. 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 See self management pathway Southwark: 020 3049 8863 / 8840 Lambeth: 020 8655 7842 Southwark Community Podiatry Tel 020 3049 7900 Fax 020 3049 7901 Lambeth community podiatry Tel 0203 049 4040 Fax 0203 049 6361/6362 Southwark Emergency clinics Mon,Wed, Fri Tel: 020 3049 7900 Fax: 020 3049 7901 Community podiatry:020 3049 7900 Lambeth Emergency clinics Mon – Fri: Tel: 0203 049 4001/2/3 Community podiatry 0203 049 4040 Fax 0203 049 6361/6362 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 Diabetic foot patient pathway for Southwark and Lambeth March 2013 Tailored intervention by community podiatry (Foot Protection Team) Referral to specialist hospital team if required Inform GP of intervention Tailored intervention by specialist team Inform GP of intervention King’s Diabetic Foot Clinic Tel: 020 3299 3223 Fax 020 3 299 4536 Guy’s Foot Clinic Tel: 0207188 2449 Fax 020 7188 2450 St Thomas’ Foot Clinic Tel: 020 7188 1983 Fax: 020 7188 1991 St George’s Foot Clinic 0208 725 1429 / 0232 Within 24 hours Priority referral Routine referral As required Holistic care Are diabetes & other risk factors well controlled? At every appointment discuss self management care plan & refer if suitable to self mgnt pathway for options Active Foot ulceration Foot intact BUT infection Ischaemic foot + infection Neuropathic foot + infection Unexplained foot inflammation ? Charcot

6. 19 July 2013 6 Foot health – DMI programme board 6 Conclusions from analysis – foot assessments in primary care Foot checks recorded in primary care have increased in the last year, although the variation across GP practices is still wide LambethSouthwarkEngland average 2011/12 83.7% (11,512) 81.5% (9,762) 83.6% 2012/13 85.6% (12,761) 84.4% (11,058) QOF – DM29: percentage of patients receiving a foot check – values without exceptions Practice level variation: 2011/12  21.7% to 94.2% 2012/13  44.4% to 96.8% Although this variation has narrowed in 2012/13, there are still some practices with low levels of foot checks being recorded

7. 19 July 2013 7 Foot health – DMI programme board 7 Conclusions from analysis – community podiatry Referrals from specialist podiatry teams in secondary care to community podiatry are known to be low (none seen in audit performed) Source of referral most commonly from GP or Self Audit of 50 patients in community podiatry in Jan 2012 (25 from each borough) Reasons for referral Highest number of referrals were for nail care (up to three reasons were allowed) Eight per cent were referred for a foot check

8. 19 July 2013 8 Foot health – DMI programme board 8 Conclusions from analysis – hospital podiatry services There are potential cohorts of patients managed by KCH and GSTT podiatry teams who could be transferred to community podiatry KCH exploring if those who are high risk but stable needing ongoing surveillance could be managed within community podiatry There would be a need to conduct a similar exercise within GSTT KCH to conduct audit of f/up healed patients GSTT: audit of 42 L&S diabetic patients seen by podiatry in January 2012 KCH diabetic foot clinic: Patient level data for 2011/12 and being analysed for 2012/13 GSTT podiatry: The caseload includes inpatients at GSTT, as well as outpatients at St. Thomas. Difficulty in coding patients. GSTT diabetic foot clinic: Patient level data obtained for 2011/12, analysis not yet reviewed by clinical lead.

9. 19 July 2013 9 Foot health – DMI programme board 9 Conclusions from analysis – primary care risk stratification compared to activity along pathway Mismatch between perceived levels of demand determined by primary care risk assessments and actual activity levels in specialist community and secondary podiatry services in 2011/12 analysis Risk levelGP assessed riskPatient count by service Low17,033 (81.48%) Moderate3,118 (14.92%) 5,432 community podiatry unique patients High616 (2.95%) Active136 (0.65%) 577 KCH diabetic foot clinic + 1013 GSTT (estimated) Total20,903 (100%) Not clear why discrepancy exists. Possibilities include: Inaccurate / inappropriate risk stratification in 1°care Breakdown in communication re: patient information and activity across pathway Lack of confidence in managing low, moderate, high risk in community and 1°care settings Elements of clinical podiatry service are not provided in 1°care, i.e. nail cutting

10. 19 July 2013 10 Foot health – DMI programme board 10 Proposed deliverables and activities 1.Identify cohort of patients from secondary care who could be managed in other appropriate settings, such as community podiatry services Determine guidance / criteria for patients to be discharged Understand pathway required Seek appropriate approvals Understand capacity of community podiatry 2.Embed foot health improvements in primary care initiatives of the DMI Use DMI primary care initiatives Target practices who are performing fewer

11. 19 July 2013 11 Foot health – DMI programme board 11 Proposed deliverables and activities II 3.Improve communication for providers and for patients with diabetes who require foot care through tools, guidance and decision aids Further development of existing templates Revisit methods to collect and share diabetes and foot health patient information 4.Determine an appropriate “shared care” arrangements (secondary & community care) Agreement about what care means in each setting Ensure clarity of pathway across providers 5.Promote and embed foot health pathway alongside development / distribution of legacy phase outputs Promote / develop methods to improve patient experience Make available outputs from DMI work in accessible/known location

12. 19 July 2013 12 Foot health – DMI programme board 12 Activities that are out-of-scope 1.Tertiary or super-specialist services Likely to be in scope of the Changing Diabetes @KHP programme Work already underway at KHP to reconfigure integrated vascular services 2.Improvement plans for Community Podiatry services Initiatives in place to reduce wait-times, improve processes around home visits and reduce variation between service provision in S & L Currently reviewing capacity, and will align with DMI work 3.Addressing nail care services in S & L Community podiatry to begin initiative to understand the capability of services provided by AgeUK (i.e. training required) Will provide insight regarding the appropriate setting for those who have diabetes and cannot manage their nail care

13. 19 July 2013 13 Foot health – DMI programme board 13 Approach and Timescales

14. 19 July 2013 14 Foot health – DMI programme board 14 Measures of Success How to Measure: Review QoF data EMIS reports from CCGs DMI improvement plans / reward scheme outcomes Activity data from secondary and community podiatry Assess primary care providers knowledge of pathway (i.e. survey at learning event) Audit of reason for referral from primary care to community podiatry and secondary care Review patient experience survey results from specialist services Number of shared learning touchpoints and meetings between community podiatry and secondary care Reduced variation in foot assessments across primary care Greater number of risk assessments recorded accurately & appears closer to activity Increased understanding of pathway and when to refer to specialist Patients seen in most appropriate care setting (i.e. shift of activity experienced) Improved patient experience of specialist podiatry services Community podiatry manages cohorts of patients previously managed in secondary

15. 19 July 2013 15 Foot health – DMI programme board 15 Constraints & Risks 1.Unable to fully understand patient activity and case mix within GSTT podiatry services and GSTT diabetic foot clinic 2.Community podiatry does not have the capacity to manage more patients from secondary care 3.Secondary care specialists hesitant to transfer patients or unsure of capability of community services

16. 19 July 2013 16 Foot health – DMI programme board 16 What we need from the board: NOTE the objectives, route to success, time constraints and critical timescales SUPPORT the proposal, and; ACKNOWLEDGE & ADVISE on constraints and risks