Summary
This partnership was launched to improve diabetes-related health outcomes across Lambeth and Southwark. It consists of patients, who noted inconsistencies in primary foot healthcare, HCPs and commissioners. Aims include providing patients with clear, consistent information about routine and specialist foot care, including self-management and improving the local foot health pathway and resources for patients and providers. Since work began in 2011/12, over 2,900 additional patients received an annual foot check, an increase of 14% by 2013/14.
Results
The partnership defined a diabetes foot health pathway and clarified local services and processes. The pathway was shared with more 120 primary care providers across 93 practices. More than 1,000 patients were received through a referral process implemented in January 2014, accounting for 90 per cent of referrals.
An increase in appropriate referrals saw 10-30% growth, per site, in urgent community clinic activities. More than 2,900 additional patients received a foot check in 2013/ 14, an increase of 14% on 2011/12. Variation in foot checks between best and worst practices narrowed by 30.7%.
More than 200 foot health information packs were distributed at provider events, and resources made available online.
Challenge
Through the Diabetes Modernisation Initiative (DMI), a partnership – Lambeth and Southwark Diabetes Foot Health Group (LSDFHG) – was established, to address the recurrent challenge of diabetes foot health.
People with diabetes and their carers had been unsure of how to self-manage or access specialist care. Primary care providers were unclear about referring into specialist services, and found communication and processes inconsistent.
Specialist services suffered from poor communication, and where they operated across several sites, were unclear about differences in patient case-mix. No formalised arrangement existed between trusts for shared care or transfer to community podiatry.
Commissioners were concerned about the financial implications of current models. All stakeholders suffered from poor communication and a local failure to implement national best practice.
Objectives
There were several objectives. Firstly, to provide people with diabetes with clear, consistent information about foot health and care access. Secondly, to give providers of diabetes-related foot care a defined local foot heath pathway.
Thirdly, the partnership aimed to work closely with commissioners to identify and support changes to resources, and to ensure patients are seen in the most appropriate care setting according to their risk and clinical condition, ideally closer to home in the community.
Finally, it aimed to identify, share and disseminate best practice from each sector to foster mutual learning and ongoing future improvements to the pathway.
Solution
The partnership came up with a multi-pronged solution. Firstly, they wanted to engage stakeholders. This involved giving team members decision-making powers, holding workshops with patients and clinicians, and aligning priorities across organisations. They also analysed foot health activity across all care settings, reviewed risk assessment coding in primary care and identified a lack of alignment. Healed patient caseloads were audited and community podiatry capacity evaluated.
Clear actions and outputs were agreed to meet the objectives and address challenges and a five-month development timeline established.
The partnership developed templates and tools to enhance patients and providers understanding of foot health risk and specialist care, improve communication across settings, and clarify patient referral and transfer processes. They established relationships between organisations, and implemented a plan to share and promote improvements to patients and providers.
Learnings
The partnership benefited from access to the DMI’s active patient forum, which pushed foot health onto the local agenda. Using patient feedback helped identify early barriers in the pathway before they led to poor outcomes.
The importance of being data driven was also evident. The partnership analysed their activity across the system, finding that specialist activity did not align with primary care recording of diabetes foot risk. This underlined that communication from specialist settings and education in primary care needed to be addressed. Data also showed one trust and its community podiatry service that patients with diabetes were not coded systematically and therefore activity was under-reported.
Evaluation
The partnership’s patient foot health risk information leaflets will replace the foot health risk leaflets on the Diabetes UK website for patients/providers. The local diabetes foot health pathway was a simplified tool built on national best practice, with local information. It has won interest from improvement teams working with other patient groups and conditions.
The clinical letter template developed by the partnership could achieve the same results in other hospital and community foot specialist settings by reducing the need for multiple electronic clinical letters. Finally, the partnership itself is one others should consider developing locally with their commissioners – it began as a task-and-finish group to implement rapid improvement, but became a standing group to report on foot health improvements.
