Fancy footwork: preventing diabetic amputations

In 2007, Dr Richard Paisey was a full-time clinician for Torbay and South Devon NHS Foundation Trust, leading the diabetic foot multidisciplinary team. Despite the team’s hard work, the local rate of major and minor amputations was high: more than three amputations for every 1,000 patients each year, compared with the NHS average for England of 1.1 for every 1,000 patients a year.

The rise in incidence of diabetes has become an increasing burden on the healthcare service. There are four million people in the UK with the condition – about 6% of the population. Roughly one in ten will experience a diabetic foot ulcer at some point in their lives and an ulcer is often a precursor to amputation, with the consequence that about 7,000 people with diabetes are admitted to hospital for amputations every year. The annual cost to the NHS of diabetic footcare problems is approximately £1 billion – or £1 for every £140 the NHS spends.

So why are people with diabetes prone to foot problems? Paisey explains, “The fact of having diabetes means you have a few years of developing numb feet because of a neuropathy. Then, on top of that, you get increased hardening of the arteries – arteriosclerosis sets in in the lower limb arteries. And you’ve got double jeopardy: because you don’t feel it, and the circulation and healing is not so good, you get an ulcer; and if your sugar’s high, the germs like it and it gets worse.” A lack of intervention at the appropriate stage leads, all too often, to amputation.

Investigative work

Paisey set out to see if he could reduce the amputation rate by improving footcare services in South Devon. The big problem, he realised, was that patients were turning up to his clinic when their foot ulcer was already well advanced and there was no choice but to amputate. Earlier diagnosis was crucial. So he and his colleagues began visiting GP practices throughout South Devon to establish why foot ulcers weren’t being diagnosed. Some GPs, they discovered, weren’t examining diabetic patients’ feet during their regular appointments. Often, too, there weren’t enough podiatrists to meet demand. A visit by researchers from the King’s Fund, the healthcare think tank, helped identify another problem, says Paisey. “They said, ‘Your podiatrists are highly skilled people who are wasting their time doing appointments, arranging transport, liaising, writing their own letters. This is ridiculous – you need to have healthcare assistants helping them,’” he explains.

The lack of a joined-up service was hindering effective diagnosis: podiatrists working in the community needed to spend time working in the hospital clinic, so that they could share their insights with surgeons and physicians. The team also found that diabetic patients attending hospital for another reason – for example, having their appendix removed – were not having their feet examined, so clinicians were missing an opportunity to diagnose foot ulcers.

Paisey’s team decided to implement ten changes to footcare services designed to identify problems earlier. These ten new services included administrative support, standardised general-practice foot screening, improved community podiatry staffing, effective care pathways and the introduction of multidisciplinary hospital foot clinics. This meant, says Paisey, that when a patient arrived with tissue loss and poor blood supply, “[it] could all be sorted out really quickly, rather than having them hanging on some waiting list”.

Sterling results

The changes were hugely successful. Over the next eight years, there was a dramatic reduction in the rate of major amputation in South Devon. From more than three amputations for every 1,000 patients, the rate had fallen to 0.4 amputations for every 1,000 patients.

In 2013, when Paisey retired, he was asked to carry on as a footcare lead in the region. He wanted to be able to bring about the improvements in footcare that he had already implemented in South Devon. So, as part of the South West Cardiovascular Network, he carried out a thorough peer review of 15 service providers and their associated GP practices throughout the south-west. He wanted to find out whether the ten key services identified through his earlier research were being offered throughout the region and whether there was a correlation, in 2009–12, between the provision of these services and the amputation rate. The data on amputation rates was compared with regional data for Yorkshire and the Humber sourced from the Hospital Episode Statistics.

The team found that there was indeed a statistically significant correlation: the more key services in place, the lower the amputation rate. In the course of carrying out the reviews, Paisey’s team found a number of service providers that weren’t offering the best preventive care. “Our general practices are fantastic, but if they decide they’re not going to specialise in diabetic feet and have a specialist nurse who majors in it, or a GP who majors in it, that’s up to them,” he says. Some will carry out a patient’s annual review and simply ask the patient about their feet rather than examining them. “This is not a good thing – all doctors know that you make mistakes when you don’t look,” Paisley says.

Another necessary improvement was increasing podiatry capacity. Some clinical commissioning groups were commissioning podiatrists to carry out tasks such as cutting the toenails of older people and helping people with rheumatology who might need special footwear, but that didn’t leave enough capacity to look after diabetic patients with ulcers. Paisey advised commissioners to transfer the more routine work of cutting toenails to healthcare assistants, allowing podiatrists to devote more time to the diabetic patients needing urgent treatment. There was also a need, in some cases, for a referral system that enabled podiatrists to refer patients with infected ulcers quickly to orthopaedic surgeons, so that more intensive evaluation and treatment could be carried out and amputation prevented.

Changes to services

At the end of the peer review, Paisey and his team wrote a report with recommendations to service providers about the improvements that could be made, who should be responsible for the improvements and the timescale for implementation. For example, the team recommended that GPs should be responsible for examining a patient’s feet at a check-up and chasing up patients who didn’t attend appointments. Paisey invited stakeholders to make amendments if they felt he had missed or misunderstood anything but, by and large, he says, they agreed with the recommendations. One of the things he was able to show was that the improvements made economic sense: the money spent on employing more podiatrists was more than recouped in the money saved in reduced amputations.

In 2015, Paisey carried out another review to analyse the impact of the interventions. The major finding, published earlier this year in Diabetic Medicine, was that where the service providers had implemented the ten services, this was “accompanied by a sustained reduction in major diabetesrelated amputation incidence”. In those places where only two or three changes had been put in place – usually for organisational reasons – the amputation rate remained the same, at 1.2 for every 1,000 patients.

Part of the 2015 review involved talking to patients about their experience, to identify areas where the service provision might be failing. One of the findings was that care often wasn’t integrated, so that the district nurse didn’t know what dressings to put on an ulcer, for example, or that it was taking six months, rather than a few weeks, to receive a bespoke shoe for a distorted foot, by which time the foot would be ulcerated. Another problem was that in a rural area, such as the south-west of England, some patients were unable to travel the long distance to a hospital clinic for appointments. Paisey says it’s essential to find ways of bringing secondary care to rural patients, instead of expecting them to make a journey to a hospital.

Future care

The success of the interventions in the south-west demonstrates the value of introducing the ten key services throughout the country. Paisey has already carried out a similar peer review in Nottinghamshire, and an NHS England and Diabetes UK review of diabetes care throughout the country will use Paisey’s framework to investigate footcare provision.

Paisey has also written a methodology for root cause analysis, published by Diabetes UK, that allows health professionals to identify the reasons for high amputation rates in their locality and how to put in preventive measures to reduce them. A National Diabetic Footcare Audit (NDFA), initiated by Professor William Jeffcoate, has been in place since 2015, and collects comprehensive data from service providers about the number of foot ulcers they’ve treated, how quickly they were dealt with and how many healed in 12 weeks. That rich data can be used to identify which areas are doing well and which need to improve. Research is also under way to identify further interventions that can improve outcomes – for example, looking at whether the type of dressing used on an ulcer makes a difference or whether interventional radiology can be used to manage arterial disease and thereby reduce the incidence of neuropathy.

More can be done, however. Paisey would like to see the same kind of standards applied to diabetic footcare that are currently used in conditions such as heart disease, cancer and stroke. He points out that a consultant physician carrying out a ward round and seeing a patient with community-acquired pneumonia would have instant access to the information about the recommended treatment used in the trust for that disease.

“You wouldn’t think of managing [disease] in a hospital without proper guidelines that everybody knew,” he says. “We need that for diabetic foot [ulcers].”