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The British Journal of Diabetes & Vascular

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 DOI: 10.1177/1474651411407389

2011 11: 69British Journal of Diabetes & Vascular DiseaseGraham P Leese, Duncan Stang, John A Mcknight and Scottish Diabetes Foot Action Group

A national strategic approach to diabetic foot disease in Scotland: changing a culture  

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Abstract

A diabetes foot action plan was introduced to Scotland in 2006. This has included developing a foot-screening programme with foot risk stratifica-

tion. Currently 140,000 people (61% of all patients with diabetes) have undergone foot risk stratification, with 69% categorised as low risk, 20% as moderate risk and 11% as being at high risk of foot ulceration. This has helped support the introduction of needs-related care pathways. Schemes to support community-based podia-trists and strengthen links and referral pathways to spe-cialist foot services have been introduced. Identifying key competencies for podiatrists and orthotists working for patients with diabetes has underpinned the development of a competency framework for each profession. Nationally agreed and utilised patient education leaflets and staff education programmes, including online training pro-grammes have been introduced. Surveys of multidisci-plinary foot services, have shown amongst other things, a low level of consultant involvement in such clinics (58% of Health Boards). Overall, national data indicated that across Scotland in 2009 the prevalence of foot ulceration was 2.5% in December 2010 and amputation was 0.5% in 2009, the latter having declined from 0.8% in 2003.Br J Diabetes Vasc Dis 2011;11:69-73.

Key words: amputation, antibiotic, competency, diabetes, foot, ulcer, screening

IntroductionDocuments such as the Scottish Diabetes Action Plan (2006), updated in 2010,1 the SIGN and NICE guidelines on diabetic foot care

in type 2 diabetes2,3 and the diabetes in-patient document4 have all tried to identify what standards of care patients with diabetic foot problems should expect. Although developing guidelines can be testing, their implementation is a much greater challenge. The SDFAG has the responsibility to deliver the Action Plan across Scotland.

The national approach has been to identify the risk of foot ulceration for each individual patient. The level of risk would then determine the prioritisation of specialist healthcare they receive. All patients should receive access to appropriate infor-mation and information should be shared between all healthcare professionals involved in the care of that patient. In addition all patients need rapid access to emergency foot care services when required. How has this strategy been implemented in Scotland?

Foot screening and risk stratificationTraditionally, feet are examined annually by looking for foot ulcers and other problems which need immediate attention. An assessment of foot pulses and neuropathy is made but consideration of future ulceration risk is often minimal and opportunities to prevent ulceration are frequently missed. Within Scotland a cultural change is being attempted to move away from the concept of foot examination towards a concept of foot risk stratification. Risk stratification includes examining pulses and nerve function, but also includes other predictors of foot ulceration such as previous ulceration,5 foot deformity, ability to self care and presence of callus being integrated into

A national strategic approach to diabetic foot disease in Scotland: changing a cultureGRAHAM P LEESE1, DUNCAN STANG2, JOHN A MCKNIGHT3

On behalf of the Scottish Diabetes Foot Action Group

© The Author(s), 2011. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1474651411407389 69

1University of Dundee, Dundee, UK.2 National Diabetes Foot Co-ordinator in Scotland, Scottish Government, Edinburgh, UK.

3Western General Hospital, University of Edinburgh, Edinburgh, UK.

Correspondence to: Professor Graham LeeseWard 1 and 2, Ninewells Hospital, Dundee, DD19SY, UK.Tel: +44 (0)1382 633882; Fax: +44 (0)1382 425509E-mail: graham.leese@nhs.net

Abbreviations and acronyms

GP general practitioner

IDSA Infectious Diseases Society of America

IT information technology

IWGDF International Working Group for the Diabetic Foot

MDFC multi-disciplinary foot clinic

MRSA multidrug -resistant Staphylococcus aureus

NES NHS Education for Scotland

NHS National Health Service

NICE National Institute for Health and Clinical Excellence

SCI-DC Scottish Care Information –Diabetes Collaboration

SDG Scottish Diabetes Group

SDFAG Scottish Diabetes Foot Action Group

SIGN Scottish Intercollegiate Guidelines Network

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a foot risk score. Patients are then categorised as having a low, moderate or high risk of ulceration, or having active ulceration. The SIGN guideline advocated the use of the Scottish foot risk score2 which was validated in a study of 3,526 patients.6 Individuals identified at high risk had an 83-fold increased risk of subsequent foot ulceration, with a six-fold increase for mod-erate risk patients.6 Patients at low risk had a 99.7% (95% confidence interval: 99.6–99.8%) chance of remaining ‘ulcer free’ after 2.4 years follow-up, indicating that ‘low risk’ was genuinely low risk.6 Using these simple clinical criteria, patients at high risk were also less likely to have an ulcer that healed,7 more likely to undergo amputation and more likely to die than low risk patients.6 Other similar risk stratification pathways have been used in the US including the IWGDF system that categorises patients into three tiers of ulceration risk.8,9 It calcu-lates risk after assessing presence of neuropathy, absent pulses, previous ulceration and foot deformities. The Seattle group have also developed a foot risk score using a number of risk factors integrated using a validated complex algorithm.10,11

One advantage of the Scottish foot risk score is that it is recorded on electronic patient records that are shared on a national patient electronic diabetes register (SCI-Diabetes) which is accessible by the specialist, general practitioner, podiatrist, practice nurse, orthotist and diabetes specialist nurse. The sys-tem has been adopted for national use, and the level of risk has been linked to recommended care pathways. Patients identified as being at low risk of foot ulceration are educated to self-care, but also educated about when and how to seek emergency care. Patients with moderate or high-risk feet receive podiatry sup-port, with a level of expertise dependent on their need. It is recommended that patients with active foot ulceration should be seen within the setting of a multidisciplinary foot clinic.

The most recent audit (December 2010) indicates that 61% of the diabetes population in Scotland have had a risk stratifi-cation performed, representing a total of 143,492 patients. Overall 69% were categorised as low risk, 20% moderate risk and 11% high risk, with 2.5% having an active ulcer.

National patient and staff educational informationIn general patients value being offered a consistent educational message from different healthcare professionals. Not all health-care professionals within a geographical area, or between dif-ferent areas will necessarily agree on the key information. Thus, widespread consultation, integration and adaptation of a num-ber of currently existing information sheets was required to achieve seven nationally agreed leaflets. These include leaflets for patients categorised as low, moderate and high risk of ulceration after screening, a holiday foot leaflet, footwear advice, Charcot feet and advice for patients with ulceration (figure 1). The Plain English campaign reviewed the leaflets and the leaflets have been translated into six different languages.

In addition there is a nationally agreed training booklet and DVD for staff undertaking risk stratification. All this information is readily available electronically on DVD and online through SCI-DC (Scottish diabetes register). An online training module has been developed by the University of Edinburgh, with the flexibility to meet the needs of healthcare professionals from a variety of backgrounds and prior knowledge.

The foot risk stratification scheme (see above) has been summarised within a ‘traffic lights’ schema, where green repre-sents low risk, amber represents moderate risk and red repre-sents high risk (figure 2). This educational approach is presented as posters which have been widely distributed and is conceptu-ally useful for staff and patients.

Specialist diabetes foot servicesIn the knowledge that MDFCs can reduce the rates of amputa-tion,12,13 it was necessary to identify the provision of specific MDFCs across Scotland. Each NHS board in Scotland should have a MDFC, where resources and geography allow, to pro-vide comprehensive treatment or management for diabetes patients with active foot disease.12-14 But what is the definition of a MDFC? Within Scotland a consensus definition has been reached. The service provision of a MDFC may be provided in a different way in remote and rural areas.

To provide a MDFC the following health professionals should be present at every multidisciplinary clinical session:

• highly specialist diabetes podiatrist • consultant diabetologist (session resourced and included in

job plan)• orthotist with competence in diabetes should be co-located

with the main diabetes foot clinic, such that the podiatrist and orthotist can see patients together if needed.

This team should have rapid access to pressure relieving devices including total contact casts and prefabricated walkers.15-17

Figure 1. National patient leaflets

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The following should be available on site:

• diabetes specialist nurse• dietician experienced in diabetes.

There should be available access to

• radiology within 24 hours• named vascular surgeon• named orthopaedic surgeon• immediate in-patient admission• microbiology and appropriate antibiotics• a range of pressure relief devices.

In remote and rural areas specific clinics may not be practical and the model needs to be adapted to develop a ‘virtual’ service using modern IT links and communication systems such as video links.

The survey identified that all 14 health board areas, but not all hospitals, had access to a podiatrist with an interest in dia-betes. A dedicated session for a consultant within a job plan (i.e. paid protected time) was evident in only 58% of health

board areas and the percentage of hospitals with a dedicated consultant session was much lower. Only 42% of health boards had a dedicated orthotist as defined above.

Antibiotic guidelinesThe SDG approached the Scottish Infectious Disease Society and together developed a consensus document for recommended antibiotics in different situations. There is a need to use narrower spectrum, better targeted antibiotics as empirical choices before laboratory sensitivities are returned, in an attempt to reduce the risks associated with increased prevalence of MRSA and Clostridium difficle. A national guideline in Scotland is possible because, in general, bacterial sensitivities are similar across the country, and likely infecting organisms tend to be Staphylococcus aureus and Streptococcus pyogenes. The IDSA/IWGDF classifica-tion of foot infections18 was used to structure the guidance into a published externally peer-reviewed guideline.19

Development of local foot networks There is clear evidence that the MDFCs are effective at reducing amputations.12,13 Cardiovascular deaths can be reduced by

Figure 2. Foot risk assessment and traffic light schema with suggested patient pathways related to risk

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promoting the treatment of cardiovascular risk factors in foot ulcer patients,20 and such care is often best delivered in a MDFC. However, it is important that the MDFC is easily accessed and that the referral routes out of, as well as in to the MDFC are clear so that the MDFC has the capacity to respond in a timely fashion to patients in need. Creating links between the specialist centre and the community are key in helping to facilitate this timely flow of patients into and out of specialist and community services to avoid referral delays21 and maintain the overall efficiency of the service. Creating ‘link podiatrists’ in the community with an interest in diabetes, supported by a training podiatrist even with a only a modest amount of time e.g. 1 day per 500,000 population, has been used to help sup-port the training and professional development of these ‘link’ community podiatrists. This includes:

(a) one-to-one sessions with the podiatrist in the community, possibly supervising difficult cases;

(b) backfill to allow the podiatrist to attend the MDFC which allows sharing of knowledge and networking, and

(c) more formal educational sessions.

Link podiatrists within such a network feel supported and more confident and able to deal with diabetic foot problems.22,23

Further support mechanisms being developed include ensuring that services operating outside of standard working times, such as accident and emergency departments, GP out of hours services and possibly NHS direct/NHS 24 have contact telephone numbers they can give patients to contact the foot-care teams the following day.

Competency framework in podiatry and orthoticsIt is widely acknowledged that diabetes foot care is complex and there is a requirement for the attainment of set levels of quality and consistency in its delivery. Currently, in the NHS, a number of podiatrists and other health professionals are already working at varying levels of competencies. These range from basic dia-betes experience to extended scope practitioner levels. However, there continues to be no clearly defined clinical competency framework for those individuals working with the diabetic foot and these skills are attained through a variety of routes. This is leading to inconsistent clinical practice throughout the UK. Although there is a wide range of educational routes for gaining theoretical knowledge of the diabetes foot, defined clinical exposure and experiential opportunities are often lacking. This identifiable gap requires a structured approach to attaining clinical skills that are underpinned by educational components.

This has been recognised in Scotland and ‘The Scottish Diabetes Foot Action Group’ supported the formation of a subgroup that would begin to identify and standardise the specialist skills required in the management of the diabetic foot. This led to the inception of the ‘Scottish Diabetes Foot Workforce Development Group’ that has wide group represen-tation from podiatrists, consultants, managers, NES, Skills for Health and educational providers.

This competency framework aims to address the gaps and establish standards of professional competence for practice in diabetes foot care. It has been produced in collaboration with ‘Skills for Health’ and sets of competencies and dimensions (Level 2–8) have been developed. The framework stretches both ends of the skill levels required for diabetes foot care and management.

The main objective of the framework is to ensure there are competent health professionals available with the appropriate skills at the appropriate time in a patient’s journey. The frame-work was informed by the national minimum skills framework for commissioning of footcare services for people with diabe-tes24 and it will provide clear guidance for individuals and man-agers in planning career pathways. It also has the potential to assist in workforce planning and inform diabetes foot service developments of the future. The majority of the competencies are generic with some podiatry profession specific elements. However, the infrastructure of the document can be transfer-able to any profession working with in the diabetes foot arena. This is already being achieved by orthotists and they are cur-rently adapting this podiatry framework to reflect their profes-sional role.

Practical outcomesNationwide screening to risk stratify for ulcer development has resulted in over 60% of all patients with diabetes in Scotland having been categorised with a foot risk score already. The Scottish experience has helped inform and influence the intro-duction of foot risk stratification into the Quality and Outcomes Framework that supports and funds General Practice. The change in culture towards foot risk stratification has begun. Risk stratification allows different healthcare pathways to be established for different risk levels, and allows healthcare pro-fessionals with the most specialised skills to be targeted towards those in greatest need. As a result, the professional skill sets available to the health service can be used in the most effective and efficient ways depending on local needs.

This is, however, just an initial step. Effective referral path-ways, with close communication between those delivering general and specialist foot services, and breaking down the barriers between the two to allow fast and efficient referrals in both directions is required. This requires ongoing support for key staff workers, especially those who work in community, who often work in relative professional isolation. In addition high quality specialist services, when required, should be readily available, with the full complement of the necessary multi- disciplinary team. Our review of services indicates that these aspects need further development within Scotland.

Whilst acknowledging these development needs, it is note-worthy that key nationwide data are available on foot care. Over 90% of people with diabetes have had a foot examina-tion in the last 15 months, over 60% have undergone a foot risk stratification recorded electronically at sometime, and the prevalence of foot ulcers is currently 2.5%. Amputation preva-lence rates have declined according to the Scottish Diabetes

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Survey from 0.8% in 2003 to 0.5% in 2009.25 This all shows significant progress towards improving foot outcomes for patients with diabetes in Scotland, although the mountain is only partially climbed!

AcknowledgementsWe are grateful to the Scottish Government for providing a grant for this work to proceed, and to the Scottish Diabetes Foot Action Group for supporting and guiding the work.

DeclarationThe authors have no conflict of interest. Duncan Stang has been funded by the Scottish Government to undertake a sec-ondment as National Co-ordinator.

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3. National Institute for Health and Clinical Excellence (NICE). NICE guid-ance on type-2 diabetes: foot care. London, NICE, 2004. www.nice.org.uk/nicemedia/live/10934/29242/29242.pdf (accessed December 2010).

4. National Institute for Health and Clinical Excellence (NICE). Diabetic foot problems. In Patient Management of Diabetic Foot Problems. March. London, NICE, 2011. www.nice.org.uk/nicemedia/live/13416/ 53556/53556.pdf (accessed March 2011).

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8. International Diabetes Federation. International concensus on the dia-betic foot. Five cornerstones, identification of the foot at risk. 2007. www.iwgdf.org/index.php?option=com_content&task=view&id=39&Itemid=60 (accessed February 2009).

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12. Edmonds ME, Blundell MP, Morris ME et al. Improved survival of the diabetic foot: the role of a specialized foot clinic. Q J Med 1986;60: 763-71.

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15. Laing PW, Cogley DI, Klenerman L. Neuropathic foot ulceration treated by total contact casts. J Bone Joint Surg Br 1992;74:133-6.

16. Myerson M, Papa J, Eaton K, Wilson K. The total-contact cast for man-agement of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am 1992;74:261-9.

17. Armstrong DG, Lavery LA, Wu S, Boulton AJM. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: A randomized controlled trial. Diabetes Care 2005;28:551-4.

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Key messages

● In Scotland 61% of patients with diabetes have undergone foot risk stratification

● 11% are at high risk, 20% at moderate risk and69% at low risk of foot ulceration

● The point prevalence of foot ulcers was 2.5%● The point prevalence for amputation was 0.5%● Only 58% of health boards have dedicated consultant

time for a diabetes foot clinic● Only 42% of health boards have dedicated orthotist

time for a diabetes foot clinic

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