Summary

The project was rolled out from June 2014 and diabetic foot services within Wakefield were redesigned to meet the challenge of reducing amputations and saving limbs. This included establishing a secondary care-based multi-disciplinary team (MDT) clinic Monday to Friday plus the creation of a community-based Diabetes Foot Protection Team (FPT) working across three community sites. The FPT sees all people who are medium risk and above, improving the management of the foot, providing patient education and information, advice and ensuring a prompt referral to the MDT as needed. The project identified that low risk patients could remain in primary care but the medium risk required referral into the FPT. This change in practice has resulted in earlier identification, earlier risk management and has expedited referral.

Results

Since the launch of the service, a total of 148 patients have been referred into the hospital MDT: 131 were new active foot problems, 4 required home visits and 17 were referred onto more appropriate services such as rheumatology, routine podiatry and the FPT. Waiting times have been reduced by four to six weeks and there has been a reduction in the duplication of visits. 550 people with increased or high risk of developing further complication have been referred into the FPT for assessment and the VSN has seen 360. Of the patients referred into the vascular service, 25 plus the seven urgent patients went on to interventions to improve their symptoms. Nine people were diagnosed with peripheral arterial disease in the clinic and all were prescribed best medical treatment including aspirin and statins to prevent secondary disease. The correct treatments can reduce the risk of people with diabetes having a heart attack or stroke.

Challenge

The Diabetes Foot Project was needed to reduce the number of diabetes-related amputations. This would be achieved by preventing new active diabetes foot disease and allowing prompt referral and treatment if any new disease occurred, therefore reducing the risk of further complications and both major or minor amputation.

Objectives

To develop a community-based FPT working across three different locations in Wakefield and ensure that people with diabetes receive a correct foot assessment and risk stratification leading to them being seen by the right person at the right time. To reduce the time required in GP and practice nurse appointments and prevent the development of new foot disease by regular surveillance. To reduce diabetes-related amputations, improve quality of  patient care and cut the number of follow-up appointments by earlier identification and treatment of new foot disease.

Solution

A business case was developed to describe the revised diabetes foot service and the reasons why this was necessary, securing some additional funding in order to develop the FPT and to commission the attendance of an orthotist, on a monthly basis, at the hospital MDT - therefore reducing the length of waiting time for the patients. The diabetes integrated care foot pathway was reviewed to ensure that all people with medium or high risk of complications were referred to the foot protection team and a diabetes foot model was developed to facilitate the flow/pathway between the community podiatrist, the FPT and the MDT following referral into the service. The FPT was established, including a community podiatrist and a community VNS. The FPT enables regular surveillance, treatment and management of those people with medium and high risk of complications. The MDT ensures that all people with diabetes who have a healed foot ulcer are transferred to the FPT for regular review. The FPT also supports a seamless and timely pathway to the MDT and vascular investigations and treatments.

Learnings

It was very difficult to predict the number of referrals the FPT would receive. Data could be collected regarding the number of people with diabetes who had been risk classified as being at increased or high risk of developing complications but it was difficult to determine how many were already being seen by the community podiatry service. The project has highlighted the importance of the FPT to work as an integrated team with the podiatrists and VNS working together providing the assessments and giving their specialist advice.

Evaluation

During the first eight months of the service five people with diabetes and critical limb ischaemia have had prompt referral from the FPT to the vascular service. This has enabled early intervention and the active foot problem has healed therefore preventing the need for amputation. This will be a saving of:

• £11,265 ( if the amputations had  been minor)
• £73,620 ( if the amputations had been major)
• There will also have been savings in bed days if 5 people had spent 10 days in hospital that would potentially be a cost saving of £11,200

If 10% of new ulcers were prevented there would be a cost saving of £19,272.