Summary
The initiative was to create a comprehensive foot screening education programme that utilises both traditional and innovative training methods for primary care across the Integrated Care System (ICS) (Suffolk and North East Essex). In order to enable accurate diabetic foot risk categorisation and appropriate referral based on the integrated care foot pathway, standardised virtual training sessions with clear objectives, utilising live polling systems, unique immersive 360 video and live facilitated sessions with a specialist podiatrist were developed. This ensured that the skills of staff undertaking diabetic foot screening were embedded in primary care, despite COVID-19 restrictions.
Innovation
Delays in presentation to specialist foot care have been linked to reduced healing rates and increased risk of amputation. The ICS had multiple foot pathways, but they were face-to-face only and not effective in primary care. The team reviewed the options, including what worked nationally, such as virtual DAFNE. The plan was to: provide a first-class foot screening education programme using traditional and innovative training methods; devise standardised, virtual training sessions with clear objectives, utilising live polling systems, immersive 360 video and live sessions with a specialist podiatrist; disseminate knowledge of the ICS-wide integrated foot care pathway, ensuring skills were embedded in primary care, plus offer a range of training options. The aim was to provide consistency, improve the quality and accuracy of foot screening, embed awareness of the pathway for people with diabetes, plus improve the National Diabetes Foot Care Audit interval. Staff at 90 GP practices were given equal access to the training, to deliver consistent foot screening in line with national guidelines.
Equality, Diversity and Variation
The engagement of specialist podiatrists, consultants, DSNs and management across the ICS allowed all input into developing the pathway and training plan. As face-to-face training was often poorly attended, remote training opportunities were a priority during the pandemic. Collaborative working ensured training was consistent and equitable. The MDT reviewed and modified the script and storyboard for a 360⁰ foot check video to ensure that the content was engaging, relevant and understandable for HCPs from different educational backgrounds. A suite of education options was developed for different levels of knowledge and experience. Staff could select the training most suited to them. Opportunities, such as shadowing specialist foot services, were available and all had access to the video and other resources. Deprivation varies across geographical areas and the training was mandated as equal for all. All in primary care could access the training, regardless of time, distance from training site, affordability of travelling for face-to-face training and additional learning needs. Teaching plans were written by the training development team for each type of training session and the same resources were utilised across the ICS. During COVID-19, virtual training delivery increased. Face-to-face training was only delivered when deemed safe. The integrated foot care pathway and education programme were advertised to all primary care practices and consultant diabetologists advocated the importance of attending training.
Results
This project was initially financed by East of England transformation funds. However the plan was to ensure the project would be sustainable in future with minimal costs. The video – produced in collaboration with the University of Essex, which paid for it – is not region- or care pathway-specific and free to other areas. The only ongoing costs are clinician time in delivering training, minimal stationary costs and occasional room hire. Adding virtual training minimised costs. Between November 2021 and July 2022, 340 HCPs received foot training across North East Essex and Suffolk, despite pandemic challenges. North East Essex saw the greatest uptake (n=146), followed by East Suffolk and Ipswich (n=138) and then West Suffolk (n=56). The split was fairly equal between face-to-face (54%) and virtual (46%) training. The majority of attendees were practice nurses (56%) and HCAs (28%). However, eight other designations attended (16%). Other specialist staff, such as pharmacists, paramedics and minor injury staff, also attended. A small number of practices did not engage with the programme. North East Essex had the most GP practices with three or more people trained. This diabetes service is outcome-focused, with strong primary care links and financial incentives for practice engagement in delivering key services to diabetes patients. It also has a significantly higher rate of diabetes diagnosis, which could drive greater attendance at training. The ‘did not attend’ (DNA) rate for face-to-face training sessions was low (8%) and was nearly half that of virtual sessions (15%). The new pathway is embedded with an audit of 50 records in Suffolk revealing that no low-risk patients were referred, saving at least £50 on every inappropriate referral. Datix incident reports around late presentation to foot services have halved since training began.
User Feedback
Anonymised feedback was sought. The 360⁰ video was found to be clear and understandable and viewers felt more confident in undertaking foot screening. The project team was thrilled with the feedback received from the training initiative. The training programme was adapted over time. It was suggested that patients also needed educating on foot disease and when and how to seek emergency foot care. This led to the development of animated patient education videos and an ICS-approved information leaflet.
Dissemination and Sustainability
There was emphasis on making both the integrated foot care pathway and training programme as user-friendly as possible. This project was delivered ICS-wide, but many of the resources were designed to be used free of charge across the UK. Links to the resources have been circulated to the East of England Podiatry leads and an article has been written for a UK-wide diabetes publication. Virtual training is financially astute and enables training to reach a wider and larger audience. A rolling education programme continues, with face-to-face and virtual options to cater for differing learning styles and needs. The programme will be modified, at low cost, for community nursing teams and residential home staff. Free animated videos about foot care are being produced for people with diabetes, which will be disseminated widely
