Gill Sykes & Gareth Hicks

What does the ‘future’ hold?

Insulin pumps BGL monitoring without taking bloodA diabetes vaccineArtificial pancreasVery low calorie diet

We’re at Foot HealthThe future of foot care in diabetes

Screening & Risk StratificationTreatment & adviceCorrect & Timely Referral

State of the nation3.2 million people diagnosed with diabetes61000 foot ulcers at any one time6500 amputations a yearIn 2010-11 NHS England spent £639-£662

million a year ( £74,000 an hour)Only 50% of patients with diabetes survive 2

years+80% of ulcers are preventable Ref: Footcare for people with Diabetes ( Kerr 2012) Putting Feet First , Diabetes UK 2009

Screening in private practice In NICE CG10 and SIGN 116 a foot

examination is indicated;

PulsesMonofilament & tuning fork testFoot deformityHistory ( ulcers and/or amputations)

The tools :10g Monofilament

128 MHz tuning forkNeurothesiometerRydel-Seiffer tuning

fork

Screening The purpose of screening is to award the

patient with a foot risk category.

Low risk 1:500 ulcer riskAt risk 1:20 ulcer riskHigh risk 1:2 ulcer risk

Leese et al 2006

Foot Risk Awareness & Management Education(FRAME) www.diabetesframe.org

Risk categoriesActive ulceration High risk – previous ulcer/amputation

At risk - neuropathy and or vascular impairment with foot deformity

Low risk – no neuropathy, no vascular problems or foot deformities

What do I do with this information?Note the risk factor in patients notes, with

date & reasonInform the patientInform GPScreen again in 12 -15 months – low riskScreen again in 3-6 months – at riskScreen again in 1-3 months –high risk (MDT)

Scottish modelThe Foot Attack is coined for patients

needing referral for immediate treatment.In line with this , CPR for feet has been

launchedC Check . Examination/assessmentP Protect Advice/footwear/insolesR Refer To Foot protection team

Referring a diabetic foot problemWho is patients’ GP ?

Who leads the hospital diabetic foot clinic?What is their phone number?How does the patient get there ? Self

ref/GP/directWhen you refer – record it !

Gill Sykes is a diabetes specialist podiatrist. With 27 years experience, she takes up the reins....

Clinical Lead Podiatrist Acute Diabetic Care

27 years NHS experience24 years communitySpecialising tissue viabilityWork as part of a multi- disciplinary teamIncluding vascular consultant surgeons,

diabetic consultant, tissue viability team, orthotist, specialist physiotherapist.

6 years private practice experience

CalderdaleIn Calderdale there were 13, 229 diabetics

diagnosed in 2013By 2030 there is predicted 19, 289 diagnosedThis is an increase from 8.0% of population to

9.8%(YHPHO, 2013)

HuddersfieldIn Huddersfield there were 27, 260 diabetics

diagnosed in 2013.By 2030 there is predicted 38, 262

diagnosed.This is an increase from 8.5% of population to

10.4%.(YHPHO, 2013)

There are two local diabetic foot screening tools within

Calderdale and Huddersfield.

Screening ToolsCalderdale utilise Podiatry Assistants with

competency based training by podiatrists

Huddersfield utilise Practice Nursing with competency based training by podiatrists

Benefits of podiatry assistants

Competency basedPro -podiatryMore thorough assessment i.e. more

knowledge of foot pathologiesQuicker referral to podiatryInspection/ adviceIn Calderdale 2013, 89% of all diabetics in

Calderdale were screened (not including DNA’s)

Screening Tool on Systm1 New/ Follow up screening – first

appt./ follow up option tick box. Peripheral sensory neuropathy

screening – left and right foot 10g monofilament/ normal abnormal.

Peripheral arterial screening – right foot left foot both pulses, present, absent. Signal – mono, bi, tri phasic.

Lesions/ foot deformity – free text. Diabetic risk category – low,

moderate, high , ulcerated. Annual screening plan – Podiatry

dept/ GP Practice Treatment plan – referral to podiatry,

continue with podiatry, self care/ private care

RECALL

NICE guidelines on foot risk The prevention and management of foot

problems advises that foot risk should be classified as:

at low current risk: normal sensation, palpable pulses

at increased risk: neuropathy or absent pulses

at high risk: neuropathy or absent pulses plus deformity or skin changes or previous ulcerated foot

SO…………..‘The postcode lottery of diabetes- related

amputations in England is getting worse, according to figures from Diabetes UK’ (Podiatry Now, 2014)

‘Too many people with diabetes not getting a good quality annual foot check or not being informed about their risk status at the end of their check’ (Podiatry Now, 2014)

The figures, based on NHS data, show that overall diabetes-related amputation rate has not improved, with 2.6 thousand lower limb amputations per year with diabetes. The gap between the worst and best performing areas has also got bigger’ (Podiatry Now, 2014).

What we don’t want is this……

Or this………

If in doubt, DO REFER

To pose some questions…..?What will happen to all the low/ medium risk

diabetics in the NHS?And staff shortages?And an increase in diabetics?And a growing elderly population?

WHAT NOW?

Food for thought..Some NHS Trusts already have done some of

the below….Discharge low/ medium risk to self

management.Training/ competencies for assistant

practitionersInvolvement of private clinicians, ?

partnership workingVoluntary sector

Thank You