Health CommitteeWritten evidence from the Society of Chiropodists and Podiatrists (LTC 44)

Executive Summary

The Society of Chiropodists and Podiatrists, the professional body and trade union which represents over 10,000 Chiropodists and Podiatrists, wishes to respond to your invitation to submit evidence to its inquiry into the management of long term conditions.

The Society of Chiropodists and Podiatrists is well placed to comment on the treatment of long term care as it is, or should be, an integral part of the care pathway relating to the treatment of a number of long term conditions. These range from Diabetes to Peripheral Arterial Disease and Rheumatoid Arthritis. Moreover its members, whether employed by the NHS or in private practice, work in a range of settings—community and acute.

The Society found that the current mix of service responsibilities does not always serve the patient best nor are services sufficiently well organised so that community and acute services are well integrated. For example those with diabetes often lack the availability of a multidisciplinary footcare team (MDFT) as only 45.5% of hospital sites currently have one. In terms of evidenced best practice each MDFT should be linked to a Foot Protection Team working in both the community and the acute sector. This lack of provision is despite clear and accepted research showing that the integration of these sectors generates better patient outcomes and saves money (up to £34 million a year). The submission includes examples of effective integrated provision.

Similarly, people with Peripheral Arterial Disease are often not diagnosed in the early stage of disease progression- an early diagnosis could be made by a Podiatrist. The 10 year mortality for those with Peripheral Arterial Disease, at approximately 50%, is worse than those for other serious conditions such as breast cancer. However better assessment, diagnosis and management through the provision of community Podiatry and other services would lead to a reduced mortality rate and lead to more appropriate referrals to vascular clinics.

Similarly, despite NICE noting that all people with Rheumatoid Arthritis should have access to foot health services, only half of all rheumatology departments report basic foot health services for their patients and less than one in 10 have formal care pathways or mechanisms for referral to foot health services. Better integrated NHS primary and acute care, including the provision of foot orthoses (insoles) which have the potential to prevent major functional and structural foot problems, would result in earlier diagnosis and better treatment resulting in estimated productivity gains to the economy of £31 million from reduced sick leave and lost employment.

The revised NHS Constitution’s first guiding principle declares that the NHS has a duty to promote equality through the services it provides. The Society of Chiropodists and Podiatrists therefore urges that full foot health services provision be extended throughout England rather than the current rolling back and cutting of services. Foot health services have a large part to play in improving the quality of life and longevity of an ageing population with long term conditions through their ability to diagnose and treat foot conditions, make timely onward referrals and via the delivery of health promotion advice to prevent symptoms. Despite providing guidance to commissioners, for example on best practice on “Putting Feet First in Diabetes Care” for the attention of CCGs and Health & Wellbeing Boards, the Society fears that the new NHS may lead to fragmentation and not better practice in treating those with long term conditions.

Diabetes

1. Currently 2.9 million people (4%) in the UK have been diagnosed with diabetes. It is estimated that a further 850,000 are either undiagnosed or have no confirmed diagnosis.1 Epidemiologists estimate that this figure will have increased to 5 million by 2025 and to 10% of the whole population by 2032.2

2. The prevention and management of foot disease in people with diabetes is an essential component of every commissioned diabetes pathway. The challenge for the NHS is to ensure these services are in place and therefore reduce the incidence of amputation.

3. 5–7%, (130,000–180,000) of people with diabetes will experience a foot ulcer at some stage in their lives.3 At any single time there will be over 60,000 people in England with a foot ulcer. Evidence shows foot complications account for more hospital admissions than any other complication of diabetes; 500,000 hospital bed nights are taken up by foot complications per year. Moreover the mortality rate for people with diabetic foot ulcers is third only to pancreatic and lung cancers at five years.4

4. The National Diabetes Inpatient Audit (2012) found that 9.3% of patients had a foot complication on admission, of which 53.3% had input from a multidisciplinary foot team within 24 hours. The audit found that 1.6% of patients developed a foot lesion during their admission which was reduced from 2.2% in 2010.5

5. The current number of amputations is rising from 5,700 in 2009–10 to over 6,000 in 2010–11. It is reported that given the increasing incidence of diabetes there will be over 7,000 amputations performed on people with diabetes in England by 2014/15, unless urgent action is taken.6

6. There is currently a high variability in incidence of lower limb amputation, both minor and major, evident across commissioning organisations. For minor amputations the variation is tenfold- from 0.3 per thousand adults to 3.5, with an average of 1.4 per thousand. For major amputations the range is from 0 to 1.8 per thousand, with an average of 0.7 per thousand adults.7

7. Jeffcoate et al (2012) concluded that the 10-fold variation in amputation rates between commissioning organisations in England related largely to the structure of available specialist services.8 It has also been widely reported, and accepted by Department of Health Ministers, that 80% of amputations are preventable.9

8. NICE clinical guideline 10 (2004) set out a footcare management plan in order to reduce the risk of problems occurring in those with diabetes.10 Similarly Diabetes UK11 put forward four simple steps to reducing amputations:

All people with diabetes should have annual foot checks, be told and understand their risk score, and know how to look after their own feet.

People in all areas should have swift access to Foot Protection or Multidisciplinary Foot Care Teams, which have been shown to significantly reduce levels of risk.

People with diabetes who go into hospital, for whatever reason, should have their feet checked on admission and throughout their stay.

Healthcare professionals need a greater understanding of the importance of diabetic footcare.

9. NHS Diabetes and Diabetes UK commissioned the landmark publication, Footcare for People with Diabetes: The Economic Case for Change.12 It has calculated that the total expenditure within the NHS on diabetic foot care in 2011 was between £573 and £686 million. This does not include the economic impact from disability payments, reduced tax revenues and re-housing.

10. Clear clinical evidence was provided that showed the importance of diagnostic tests, early referral to specialist care, the use of multidisciplinary teams and cardiovascular screening, all of which can reduce amputation and mortality rates. NICE guidance Clinical Guideline 11913 backs this up by stating in its list of key priorities that “ongoing care of an individual with an ulcerated foot should be undertaken without delay by a multidisciplinary foot care team.”

11. Evidence was cited for a multidisciplinary foot care team (MDFT) approach for inpatients with diabetes in Southampton which led to a reduction in the length of inpatient stays from 50 days to 18 days. Not only were patient outcomes improved but annual savings to the NHS of £888,979 were generated. In another example, at The James Cook Hospital in Middlesbrough, a MDFT generated annual savings of £249,459. Likewise an 11 year study at Ipswich Hospital found that the incidence of major amputation per 10,000 people with diabetes fell by 82% following the introduction of an inpatient MDFT. The incidence of minor amputation per 10,000 people with diabetes fell by 21%.

12. By standardising best practice multidisciplinary team working throughout the UK the NHS could make net savings and reduce the number of amputations. Marion Kerr estimated, for example, that if there were a 50% reduction in amputations by 2018, the savings generated are calculated as £42 million over the five year period from 2013.14 Meanwhile the National Audit Office has estimated that a reduction of late referrals to specialist foot teams by 50% could save at least £34 million each year through the reduction of amputations.15

13. The Society of Chiropodists and Podiatrists has long had an on-going concern about whether the issue of amputations, and consequent mortality, receives the level of public attention it warrants given that the mortality rates for people with diabetic foot ulcers and those having amputations are greater than those with breast or prostate cancer.16 By prioritising best practice in long term conditions, as well as meeting the Nicholson Challenge, there is an ideal opportunity to right this wrong. To do so would also be in line with two of the five outcomes for the NHS identified within the “Mandate for NHS England: preventing people from dying prematurely and enhancing quality of life for people with long term conditions”.17 Foot health services are struggling to manage current demand and the predicted increase in the prevalence of diabetes will lead to overload- consequently a workforce review is urgently required.

Peripheral Arterial Disease

14. Peripheral Arterial Disease (PAD) is common in the UK population in those aged 55 or over, but is often not diagnosed until it is moderate or severe. Outcomes have been poor, with substantial cardiovascular mortality and morbidity and, to a lesser degree, chronic lower limb wounds and amputation.18

15. PAD has recently been included in NICE guidance (2012)19 and Quality and Outcomes Framework indicators.20

16. Fox (2013)21 postulated that with better assessment, diagnosis and management of PAD in community services, there could be fewer, but more appropriate referrals to vascular clinics. This could in turn free up surgical appointment slots to allow rapid access for people with critical limb ischaemia, thus unlocking improvement at no significant additional cost.

17. PAD’s 10 year mortality, at approximately 50%, is worse than those for other serious conditions such as breast cancer and malignant melanoma of the foot. This may be due to a lack of early diagnosis and effective clinical management.22

18. As up to 50% of those with PAD are asymptomatic it is important that those with risk factors are screened early to enable lifestyle changes to take place, thus enabling a reduction in hospital admissions, amputations and premature death; and improvements in quality of life and life expectancy. Podiatrists are able to diagnose PAD and enable onward vascular referral.

Rheumatoid Arthritis

19. Rheumatoid Arthritis is a chronic inflammatory joint disorder that affects approximately 580,000 people in England, which suggests that over 690,000 people in the UK live with the condition.23 Females are up to four times more likely to develop the condition than men. Up to 90% of people with Rheumatoid Arthritis have some form of disease related foot involvement. Long standing inflammation leads to structural deformity and soft tissue lesions, which in turn generates areas of pressure that may result in foot ulceration.

20. NICE (2009)24 and Scottish Intercollegiate Guidelines Network (2011)25 concurred that all people with Rheumatoid Arthritis should have access to foot health services. Yet only half of all rheumatology departments report basic foot care services for their patients and less than 1 in 10 have formal care pathways or mechanisms for referral to foot care services.26

21. The National Audit Office’s report, Integration Across Government,27 stated that better integrated NHS primary and acute care would result in earlier diagnosis and treatment of patients with the Rheumatoid Arthritis, ultimately resulting in productivity gains to the economy of £31 million from reduced sick leave and lost employment.

22. The Podiatry Rheumatic Care Association28 recommended that early intervention through the provision of foot orthoses (insoles) has the potential to prevent major functional and structural foot problems providing joint mobility is still good. They cited studies which demonstrated that through the intervention of foot orthoses, a sustained effect is had on the foot structure and stability of the joints of the foot, thus reducing pain and improving mobility.

23. There is potential to prevent major functional and structural foot problems by providing foot orthoses early on in the disease process. However, because foot changes have the potential to occur within two years of disease onset it is essential that patients are referred for assessment of foot function as early as possible following diagnosis. Similarly NICE guidance29 recommended that functional insoles and therapeutic footwear should be available for all people with rheumatoid arthritis if indicated.

9 May 2013