New framework to improve care for patients with diabetic foot disease published

A new framework to help improve patient care including avoiding unnecessary amputations and deaths in people with diabetic foot disease has been published.

The report, by a host of the main organisations who care for people with diabetic foot disease, aims to make sure patients with acute diabetic foot disease receive high quality care wherever they present.

Foot complications are common in people with diabetes with between five and seven per cent of people with diabetes having a current or previous foot ulceration.

Professor Jonathan Valabhji, NHS England’s National Clinical Director for Diabetes and Obesity, worked with a number of key organisations to produce the report including: the British Orthopaedic Association, the British Orthopaedic Foot and Ankle Society, the Vascular Society, Diabetes UK, the Association of British Clinical Diabetologists, Foot in Diabetes UK; and the British Association of Prosthetists and Orthotists.

“If we can ensure patients with diabetes have the appropriate, high quality care they deserve across the country then we can prevent amputations,” said Professor Valabhji.

“There are several steps we can take to ensure this happens, one of which is to ensure that those presenting with active diabetic foot disease have rapid access to a multidisciplinary diabetic foot service. Higher mortality rates are thought to be related to heart disease and therefore we also need to ensure the all-round health of the patient is cared for, including addressing their overall cardiovascular disease risk.”

Diabetes is the most common cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80 per cent of amputations in people with diabetes.

Around 50 per cent of people die within five years of developing a diabetic foot ulcer.

The framework, for the operational delivery of hospital trust based diabetic foot services, recommends service provision is geared towards meeting patient priorities including:

  • To get better, as quickly as possible, whilst reducing risk of further morbidity.
  • To avoid hospital admission if possible, and certainly admission to a hospital that is distant from home.
  • To avoid major and minor amputation.
  • To be managed speedily, effectively and efficiently with management plans focused on the patient’s individual circumstances and their personal needs.
  • To have their diabetes and other medical conditions well managed at the same time that their foot disease is being assessed and treated.

High mortality after amputation is believed to be associated with cardiovascular disease, and emphasises the importance of good diabetic and cardiovascular risk management.

These are joint recommendations from: British Orthopaedic Association, British Orthopaedic Foot and Ankle Society, Vascular Society, Diabetes UK, Association of British Clinical Diabetologists, Foot in Diabetes UK and the British Association of Prosthetists and Orthotists.

The whole pathway has three areas: foot screening, foot protection for those identified through screening to be at high risk of foot disease, and a multidisciplinary foot care service for those with active diabetic foot disease – all consistent with the new NICE guidance which details the process.

The recommendations say commissioners should make sure all patients with diabetic foot problems have rapid and equal access to services, regardless of location, in order to optimise care and reduce amputation rates.

They describe the key systems, processes and standards needing to be in place to achieve this goal.

The recommendations cover:

  • Commissioning
  • Service design
  • Foot screening
  • Foot protection
  • Multi-disciplinary foot care service
  • Outpatient Management of Acute Diabetic Foot Complications
  • Management of Diabetic Foot Emergencies, including discharge Planning
  • Management of the patient undergoing major amputation
  • Monitoring implementation using the National Diabetes Footcare Audit (NDFA)
  • Training.


  1. Kathy says:

    With the recently released statement that 135 lower limb amputations per week in England are due to Diabetes, we should be much more aware of the severity of this problem than we have been. This shocking figure was highlighted in an innovative and incredibly powerful way in April by Diabetes UK and AMP shoes. One weekend they set up a pop-up shop with each of the shoes on display representing one of the 135 amputations that would occur within one week. Each shoe was labelled with a name and the age of an amputee. All the ‘shop assistants’ were amputees and ‘customers’ were invited to have their risk of developing Type 2 diabetes assessed whilst in the shop. Something like this not only brings home the severity of the situation but also the fact that it can affect young and old alike.

  2. Farber@FootPainRelief says:

    Still prevention is better than cure. If we can disseminate health education of proper foot care to our diabetic clients, development of diabetic foot will be lessened. Thanks for your informative post which I will let my mother read.

  3. Yolanda Woolf says:

    Perhaps NHS England should be looking towards prevention first. Good diabetes control is the key to mitigating complications. Type 1 diabetics have to buy their own insulin (NICE has not approved Tresiba due to cost- this is the only long acting insulin that works for some diabetics. NICE has also denied Type 2 diabetics from testing their blood sugars ) and CGM (this device gives critical, real time data direct to Type 1 and Type 2 patients to learn how to control their diabetes) to maintain good diabetes control. Most GPs’, some nurse specialists and almost all diabetics are unaware of these health enhancing developments) or cannot afford to buy them. Diabetics are expected to manage on their own, on a second rate, short sighted service. You have also forgotten to include the value of orthotists and foot orthoses. As usual, scarece funds will be focused in the wrong place. Podiatry/foot health is very important but only alongside an integrated diabetes health and support service.

  4. Anonymous says:

    I have really been trying hard to encourage our commissioners to take heed of the raft of evidence already available on this topic however this is always met with “we have no more money.” When I point out to them the health economy cost savings from the evidence base already available, they don’t listen either. I do hope this offers something new that commissioners will have to listen? Are there “new” monies or targeted monies avaiiable with this framework?