Summary

Reduction of lower limb amputations as a result of diabetes has been a main priority of the South West (SW) Cardiovascular (CV) Strategic Clinical Network (SCN). National statistics have highlighted high lower extremity amputation rates in diabetes (LEAD) in South West England. Improvements in care processes in other parts of England with similar ethnicity and rurality have resulted in sustained reduction in the LEAD. A standardised Peer Review of foot care services for diabetes patients across all 14 acute trusts and 11 Clinical Commissioning Groups (CCGs) within the South West SWSCN has evolved over four years. Its aim was to understand the variation in practice, establish compliance with NICE standards, identify and share good practice and make recommendations for change and improvement. Provisional data shows a significant reduction in the number of major amputations across the South West in 2015.

Results

122 sets of notes were audited concerning patients with diabetes-related foot problems in the preceding 12 months. Summary data sheets with description of problem, neuropathy, vascular status and co-morbidity were found in 20 sets of notes. Electronic access to community podiatry notes by the MDT, and vice versa was only achieved in a minority of centres. There were excellent examples across the region of good GP practice annual review protocols and patient education - but these were not practised throughout the region, nor co-ordinated within many CCG areas. Commissioning processes had not addressed details of staffing levels or skill mix in community podiatry services. Hospital podiatry was often at full stretch with much time spent on non-clinical tasks. Some Trusts were not compliant with NICE guidance to provide a full MDT weekly. Job plans did not include diabetic foot MDT work in many cases. Information sharing is only slowly being developed. Following the peer reviews many CCGs have established working groups for diabetes to deliver the action plans:

• 10 areas have started to plan education for primary care staff
• 8 have increased podiatry staffing
• 6 have consolidated or started MDTs
• 6 rotate podiatrists between community and MDT
• 5 have job planning for MDT team
• 8 have rationalised information trails.

Provisional data for 2015 shows 178 major amputations coded across the South West compared to an average of 251 in the preceding three years suggesting that the peer reviews have had a signifi cant impact.

Challenge

The population of South West (SW) England is of more than 90% white British ethnicity with good longevity and a legacy effect of retirement to much of the area. These characteristics are associated with high prevalence and incidence of diabetic neuropathy and its consequences. Currently 6% of the population in the SW are living with diabetes which amounts to 169,444 persons and the numbers are increasing due to obesity and an ageing population. 768 amputations took place in the SW as a result of diabetic complications over the last year with amputation twice as likely for patients in the region as in London - it is estimated 80% of amputations are potentially avoidable. The commissioning of the care pathway is fragmented.

Objectives

To reduce major and minor lower extremity amputation rates in the SWSCN footprint to below the average of demographically similar areas in England by 2018. To deliver a peer review programme involving local clinicians expert in their fi eld to review the care pathway for diabetic patients at risk of a foot amputation across all CCGs.

Solution

Definitive peer review visits were undertaken during an eight month period from October 2014 to April 2015 to each district general hospital in the region. The review team comprised a consultant diabetologist, a NHS Diabetes representative, and two podiatrists. Reviews centred on the Multi-Disciplinary Team (MDT) hospital clinic and a report was developed with local providers to endorse good practice and to support plans for service improvement. A formal review process included the following: a governance process to define terms of reference; preliminary information from the CCG and Trust detailing the provision of key services and variation in amputation rates; and a set timetable with one hour initial discussion with all reviewers and providers.

Learnings

The Foot Peer review was a useful mechanism to engage clinicians and commissioners to identify issues within their own locality and to unite in addressing these problems. It was also an excellent vehicle to identify, share and promote best practice. There was good co-operation and engagement from both CCGs and providers of services and in total 120 clinicians took part.

Evaluation

Evaluation of the first round of peer reviews identified the need for a more systematic approach the process. By utilising a small team for all the visits, the first review team had been consistent but by involving a wider group of clinical experts in the second round it helped to encourage a wider review of the total pathway. The reviews benefited from strong clinical leadership by a consultant diabetologist but it would have been beneficial to have had greater involvement from GPs as part of the review teams. Practice nurses gave invaluable insights to the primary care part of the care pathway which is key in ensuring timely access to the right care.