Greater Glasgow & Clyde Diabetes Managed
Clinical Network and Podiatry Services Review:
Expectation of Footcare for Persons with
Diabetes
Version 5: 16th May 2012
Created by: Brian Kennon, Chair of GG&C Diabetes MCN Foot sub-group
Reviewed by: David Wylie, Podiatry Services Manager & Professional Lead
Alison Rodgers, GG&C Diabetes Project Co-ordinator
Gail Beaton, Podiatry Manager
Gillian Harkin, Lead Clinical Podiatrist - Diabetes
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Greater Glasgow & Clyde Diabetes MCN & Podiatry review:
Expectation of care for persons with diabetes
Introduction
Diabetes foot disease is associated with significant morbidity and mortality
(1,2). There is good evidence that multi-disciplinary foot teams can improve
the outcome of patients with active foot disease and also that foot screening
can be effective in identifying an individuals’ risk of developing a foot ulcer.
Subjects at low risk have a 99.6% chance of remaining free from ulceration at
1.7 years of follow up. (3)
SIGN 116: Diabetes Management Guideline advocates that: ‘All patients with
diabetes should be screened to assess their risk of developing a foot ulcer’
(4). There is also the recommendation that the result of a foot screening
should be entered onto an online screening tool, such as SCI-DC. This
provides accurate, automatic risk stratification and a recommended
management plan, including patient information (appendix 1). An additional
benefit in using an automated system is that previous studies have shown that
failure to use such a scoring system often results in inaccurate risk
stratification which may in turn be prone to medico-legal challenge.
Diabetes foot care is also a key priority for the Scottish Government and the
Diabetes Action plan from 2010 highlights that:
 Within the previous 15 months 80% of people with diabetes should have
an allocated foot risk score which should be electronically communicated
to all health care professionals involved in the care of the patient.
 All patients with low risk feet should have access to education for selfmanagement of foot care. This should be supported by the national foot
care leaflets.
 National foot care leaflets should be available to all patients depending on
their risk score
 IT links are required to allow transfer of foot related information between
the national diabetes database and the main GP systems
The aim of this document is to outline the future direction of diabetes foot care
services within Greater Glasgow & Clyde, ensuring a process of care in line
with the Scottish Governments ‘Quality Strategy’, namely a patient-centred,
efficient, effective, equitable, safe and timely service. This work expands on
the previous GG&C Podiatry Vision 2014 document previously circulated.
.
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Expectation of Care (see appendix 2)
At diagnosis:
1. all persons with diabetes will receive a standardised package of education
from podiatry services as to optimal foot care. This may be individual or group
sessions dependent on patient need/wishes.
2. all persons with diabetes will receive foot screening from an appropriately
trained health care professional in which their individual risk score will be
calculated. This will dictate future care as detailed below and will be recorded
on SCI-DC.
3. all persons with diabetes will receive a national patient information leaflet
appropriate to their risk score. This will include details of whom to contact if
any concerns or in the event of an emergency.
Persons stratified as Low risk
1. all persons with diabetes at low risk will receive annual foot screening from
an appropriately trained non-podiatry health care professional. For persons
with type 1 and type 2 diabetes this will be the responsibility of secondary and
primary care teams respectively.
2. all persons with diabetes will have their foot screening recorded on SCI-DC
to allow automatic risk stratification. If there is any change to their risk score
the care plan will be amended accordingly as detailed below.
3. all persons at low risk will be advised to seek immediate review should they
develop any problems with their feet and also provided with appropriate
contact information
4. all persons at low risk who develop non-urgent podiatric problems i.e.
verrucca etc should be given contact details for podiatry services so they can
be reviewed in a timely manner.
Persons stratified as Moderate risk
1. all persons with diabetes at moderate risk will receive a minimum of one
foot assessment per year by podiatry services. This will be recorded on SCIDC. Individualised care plans will then be developed dependent on the
persons need. If there is any change to their risk stratification the care plan
will be amended accordingly.
2. all persons at moderate risk will be advised to seek immediate review
should they develop any problems with their feet and also given appropriate
contact information.
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Persons stratified as High risk
1. all persons with diabetes at high risk will receive a minimum of one foot
assessment per year by podiatry services. This will be recorded on SCI-DC.
Individualised care plans will then be developed dependent on the persons
need. If there is any change to their risk stratification the care plan will be
amended accordingly.
2. all persons at high risk will be advised to seek immediate review should
they develop any problems with their feet and also given appropriate contact
information.
3. all persons at high risk, in which a podiatric need is identified, should have
pre-planned follow up. There should be short return dates of 2 – 12 weeks
dependent on need.
Persons with Active foot disease
1. all persons with diabetes and active foot disease will be referred to a multidisciplinary foot service at presentation. Such persons should be deemed as
an emergency and referred as such.
2. all persons with diabetes and active foot disease will be reviewed by the
multi-disciplinary foot service in a timely manner. The GG&C national target is
set at one working day. This will be dependent on patient availability and often
transport issues. The management of active foot disease will often involve
shared care between community based specialist diabetes podiatry services
and a multi-disciplinary foot service.
3. all persons discharged from the multi-disciplinary foot service will have preplanned follow up with community based podiatry services.
Points to Consider
1. all persons with diabetes who are attending podiatry for any reason should
have up to date risk stratification. If screening is not up to date i.e. within the
last 12 months, this should be done ‘opportunistically’ at that visit and
recorded on SCI-Diabetes. Further management will be dependent on their
risk stratification as detailed above.
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Proposed Implementation Plan
1. Initial proposals circulated to the GG&C Diabetes MCN Foot sub-group
for additional comments 10th March 2012
2. Agreed proposal submitted to the GG&C MCN Steering Group for
further review 12th March 2012
3. Once agreed the proposal will be circulated around primary and
secondary care diabetes services May 2012
4. From the 1st April 2012 the focus of podiatry services will be to ensure
staff and patient teaching and training as well as the assessment and
management of ‘at risk’ subjects.
5. From the 1st October 2012 podiatry services will no longer routinely
screen persons previously stratified as ‘low risk’. The focus will
continue to be to support non-podiatry staff and concentrate resource
improving the care of persons ‘at risk’.
Specific Considerations
Nursing home and domiciliary care
1. all persons with diabetes in nursing/care homes or are housebound should
have annual foot risk stratification. This should be recorded on SCIDiabetes
2. all persons with diabetes in nursing/care homes or are housebound should
have an individualised care plan dependent on risk stratification and an
individual’s circumstances.
Comment: this is currently an unmet need. Further collaborative work will be
required with other MCN sub-groups to ensure this area is addressed. This
will include training for care home staff as well as other initiatives to ensure
appropriate specialist review.
Minority Ethnic Groups
1. all health care professionals involved in foot screening will ensure persons
with diabetes receive the appropriately translated national risk specific foot
leaflet.
Comment: the foot sub-group will work collaboratively with other MCN subgroups to try and ensure maximum engagement from minority ethnic
groups.
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Persons on Renal Dialysis
1. all persons with diabetes on renal dialysis should have annual foot risk
stratification. This should be recorded on SCI-DC.
2. all persons with diabetes on renal dialysis should have an
individualised care plan dependent on risk stratification and an
individuals circumstances.
Comment: patients on renal dialysis should be under the care of secondary
care diabetes team. They are often high risk subjects and therefore likely
to need extensive podiatric input. Due to the frequency of hospital visits
required for dialysis there is a risk that annual foot risk stratification will be
overlooked hence the reason for consideration in specific high risk groups.
Challenges & Proposed Solutions
1. Foot risk screening training for Health Care Professionals
Solution: All staff encouraged to complete the national online training
resource F.R.A.M.E. (www.diabetesframe.org). Local podiatry services to
support staff training to ensure non-podiatry resource can complete
screening of ‘low risk’ subjects.
2. Formation and roll out of a quality assured standardised footcare
education package for newly diagnosed patients
Solution: Podiatry and diabetes services will develop a quality assured
standardised generic patient education footcare resource for all patients at
diagnosis. An appointment system for group or one-to-one sessions will be
arranged as per patient need/preference.
3. Limited podiatry resource to ensure that ‘at diagnosis’ patients will be
reviewed by a podiatrist.
Comment: There has been ongoing debate regarding the potential benefit
of patients seeing a podiatry services ‘at diagnosis’. It is felt this contact
allows a valuable interaction early in the disease and helps enforce good
practice. There are practical considerations as to the resource required to
introduce this as an expectation of care.
Solution: In keeping with point 2 there may be an opportunity to devise
group sessions ‘at diagnosis’ that would incorporate structured education
as well as screening by podiatry services. This would ensure appropriate
risk stratification ‘at diagnosis’ and then risk specific follow up as per
standard algorithms. The majority of patients will then require only one visit
for education and screening and those at risk can have additional podiatry
assessment at that time point or at a later date depending on resource.
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IT solution for access to SCI-DC (system will change to SCI-diabetes Aug
2012)
Solution: On going work nationally to allow seamless access from GP
systems to SCI-diabetes. As an interim measure a hyperlink has been
provided from the GG&C LES diabetes template page. There is also the
possibility of including SCI-DC within an individual clinicians’ universal
login set up.
4. Population of podiatry sessions for the review of moderate and high
risk patients
Solution: SCI-DC (diabetes) will be used to identify all moderate and high
risk subjects within a practice and existing community based systems will
populate podiatry sessions.
5. Generic podiatry review incorporates (if required) foot risk stratification
to ensure screening has been performed within the last 12 months
Solution: As detailed in ‘Points to Consider’ podiatry staff will ensure that
all persons with diabetes attending generic podiatry review have had foot
screening performed within the last 12 months. If this hasn’t been done it
will be performed at that visit. There is ongoing review as to the resource
that will be required to ensure this expectation of care can be realised.
6. Timely podiatry review of subjects with acute clinical need.
Solution: Primary care teams have highlighted that in some areas there
are problems accessing podiatry in a timely manner. It is envisaged that
restructuring of diabetes foot care provision will improve access to those
subjects at greatest clinical risk/need. All patients with active foot disease
(as detailed above) should be immediately referred to the multi-disciplinary
foot service. Those with specific podiatric need should be reviewed in a
timely manner.
8. Awareness amongst staff in primary and secondary care that all
persons with diabetes and active foot disease require immediate referral to
a MDFC
Solution: Ongoing education across primary and secondary care to ensure
all persons are referred immediately. Further work with the pan-GG&C
Emergency Medicine governance group & NHS 24 to ensure that all
patients presenting as an emergency have contact details for the MDFC
so that they can be reviewed at the earliest possible time point.
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Future Developments
1. Development of Multi-disciplinary ‘high risk’ community based clinics
The ultimate aim if to offer subjects stratified as ‘high risk’ review by a
community multi-disciplinary team involving podiatry, diabetes and orthotic
input. At present there is no community based orthotic resource however
pilot sites will be used across GG&C to establish if this will be a cost
effective model for diabetes foot care. This high risk clinic is targeted
primarily at patients who are assessed as being high risk but have not yet
developed active foot disease or attended MDFC in the acute setting.
2. Structured education for persons with active foot disease or stratified as
high risk
There is ongoing work locally to devise a structured education package for
those persons with active foot disease or deemed at greatest risk. The aim
of such an initiative is to improve patient engagement with their own foot
care which in turn may hopefully improve diabetes related foot outcomes
such as reduction in amputations and improved ulcer healing times.
3. Expectations of footcare for in-patients with diabetes
The provision of footcare for in-patients with diabetes has been highlighted
as an area of significant risk. National initiatives have been created to try
and address this issue. Three sites in GG&C, namely the Southern
General, Victoria infirmary and Western Infirmary, are ThinkGlucose pilot
sites and the foot outcomes that will be assessed is the frequency of foot
checks and the development and referral of active foot problems. The
MCN foot group will aim to prioritise in-patients diabetes foot care in future
workstreams.
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References
1. Boulton A, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global
burden of diabetic foot disease. Lancet 2005; 366(9498): 1719-24.
2. Tentolouris N, Al-Sabbagh S, Walker MG, Boulton AJ, Jude EB. Mortality in
diabetic and non-diabetic patients after amputations performed from 1990 to
1995: A 5-year follow-up study. Diabetes Care 2004; 27: 1598–1604
3. Leese GP, Reid F, Green V, McAlpine R, Cunningham S, Emslie-Smith A,
Morris AD, McMurray B, Connacher A
Stratification of foot ulcer risk in
patients with diabetes a population-based study Int J Clin Prac 2006 60: 541545
4. SIGN Guideline 116: Management of Diabetes 2010 Available at
http://www.sign.ac.uk/pdf/sign116.pdf
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Appendix 1: Diabetes Foot Risk Stratification & Care Pathway
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Appendix 2: Expectation of Care
New diagnosis of diabetes
Foot screening & risk stratification
by HCP (national information)
Low Risk
Moderate Risk
High Risk
Annual
screening by
appropriately
trained HCP
(If change in
risk score or
concerns refer
podiatry)
Assessment &
care by
podiatry
Assessment &
care by
podiatry
Active foot
disease
Active foot
disease
High risk MDT
•Podiatry
•DSN
•Orthotics
Active foot
disease
Standardised
education by
podiatry
Active Disease
Multidisciplinary
foot clinic
•Podiatry
•Diabetologist
•DSN
•Orthotics
•Radiology
•Vascular
•Orthopaedics
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