Since April 2017, NHS England and NHS Improvement has made £105 million of diabetes transformation funding available to improve treatment and care for the 2.8 million adults and children diagnosed with Type 1 or Type 2 diabetes across England.
For Dartford, Gravesham and Swanley Clinical Commissioning Group (CCG) and King’s Health Partners, this funding facilitated the establishment of a diabetes multi-disciplinary foot care team (MDFT) located at Darent Valley Hospital in Dartford. The new service commenced in November 2017.
The podiatry service at Darent Valley Hospital already provided foot care for diabetes patients with active foot disease, but not as a fully-fledged MDFT. There was a single podiatrist working alongside diabetes and vascular clinics, and the local vascular surgeon undertook some minor amputations and day cases locally. However, patients had to attend St. Thomas’ Hospital in London for vascular interventions and major amputations. This resulted in lengthy journey times and inconvenience for local patients who would often experience inpatient stays and ongoing outpatient care in London. Also, local minor amputation rates were higher than other areas of the vascular network and the England average.
Local clinicians worked with King’s Health Partners and the CCG to develop and submit a diabetes transformation funding bid for a local MDFT. The aims of the project were to:
- improve patient outcomes and experience
- reduce hospital admissions for patients with active foot disease
- reduce amputation rates for patients with active foot disease
- provide care closer to home
What the CCG and King’s Health Partners did
In April 2017, funding of £205,000 was approved which meant that adequate funding was available for all components of the MDFT. The subsequent year’s (Year 2) funding was £255,000 which tapered to £178,500 the following year (Year 3).
Clear governance processes were put in place including a local steering group with clinical input and remote project management support provided by the Health Innovation Network.
Agreement was reached for the necessary component parts of the MDFT:
- Additional B7 and B6 Podiatrists (to be recruited)
- 1 PA for Consultant Diabetologist (from existing consultant establishment)
- 1 PA for Consultant Vascular Surgeon (via the Vascular Network)
- Clinical Nurse Specialist Vascular Nurse (via the Vascular Network)
- Clinical psychologist (external provider)
- Orthotics (existing co-located service)
- Access to Consultant Microbiologist
- Administrative support (introduced in 2019)
Significant clinical leadership was provided by the Principal Podiatrist who was passionate about establishing a successful service. Similarly, the local Consultant Diabetologists and Vascular Surgeon were very involved in its establishment.
The resulting culture was one of fully engaged and committed clinical and project management parties, ensuring both a team approach and a patient-centred model. Psychology support was also available at all MDFT clinics provided by an independent provider.
Once recruitment of personnel had been finalised and equipment ordered and in place, the service launched in November 2017. It sees severe diabetes foot complications focusing on:
- Acute Charcot
The clinical pathway for the service was amended to reflect the new model and enhanced links developed with the community podiatry service. The MDFT service leads interfaced with primary and community care healthcare professionals to increase awareness of the service, clarifying referral arrangements and providing training and education on diabetes foot care.
From November 2017, a weekly outpatient MDFT clinic was established and in December 2018 an additional fortnightly clinic commenced, combined with additional vascular consultant commitment, both for the service and local vascular day case activity.
NICE guidance on triaging of referrals was adhered to. Outside of the weekly clinics, referred patients were triaged and, if necessary, seen by a MDFT podiatrist and additional consultant input could be requested if this was required prior to the next formal clinic. Inappropriate referrals would be referred to the local community podiatry service.
The service also sees inpatients with diabetes foot complications that are referred by the wards with a MDFT inpatient ward round taking place on outpatient clinic days at the end of the MDFT clinic. The ward rounds have podiatrist and consultant input. At other times, referred inpatients are seen by a MDFT podiatrist or MDFT Vascular Clinical Nurse Specialist (consultant input can also be accessed following such assessments). Otherwise, MDFT Podiatrists undertake regular foot assessment ward rounds to identify inpatients with active foot disease and provide assessment, treatment and advice to ward staff. At the end of quarter 3 2019/20, 90% of inpatients were seen within 24 hours of referral.
Intended clinical outcomes of the service were:
- increased provision of training and education for health care professionals
- education for patients with diabetes, including family and carers
- appropriate pathways in place ensuring treatment in a timely manner
- improved MDT approach across all services and all tiers
- improved referral of patients in a timely manner
- reduced complications (amputations and ulceration)
- improved access to specialist services for treatment of acute foot presentation
- cardiovascular screening and interventions for patients with ulcers can reduce mortality
- improvements in wider diabetes management (e.g. HBA1c levels)
- identification and treatment of diabetes inpatients with active foot disease as per NICE guidelines
From the planning and the commencement of the service, it was clear that there is a need to undertake a comprehensive training and education programme for both healthcare professionals and patients. This has included formal clinical training, but also raising awareness of the MDFT service and advice on how and when to refer/present.
Patients received 1:1 training and advice at each clinic appointment and the service has undertaken awareness sessions in primary care for patients and their relatives/carers.
For healthcare professionals – including primary care, community services and secondary care – this has included formal training on diabetes foot assessments / treatment as well as awareness sessions about the MDFT service.
We were able to measure the success of the MDFT by:
1. Numbers of new outpatient attendances
- Numbers of new patients continue to rise.
- Patients are referred to step down clinics and community podiatry services as soon as possible to assist with managing service capacity.
2. Number of inpatient referrals
- Inpatient referrals have risen considerably.
- Inpatients are also identified through foot assessment ward rounds undertaken by podiatrists.
3. Number inpatient referrals seen within 24 hours
- The number of inpatients seen within 24 hours has risen continually.
- At the end of quarter 3 in 2019/20, 90% of inpatients were seen within 24 hours of referral.
4. Reductions in inpatient admissions
- Following the first full year of the service in 2018/19, the number of diabetes foot-related inpatient admissions started to fall at local and tertiary sites.
5. Reduction in length of stay
- Following the first full year of the service in 2018/19, the length of stay of inpatients with diabetes foot complications started to fall at local and tertiary sites.
6. Reduction in occupied bed days
- Following the first full year of the service in 2018/19, the occupied bed days of inpatients with diabetes foot complications started to fall at local and tertiary sites.
7. Monitoring number of major and minor amputations
- The trend in terms and number and costs of amputations has been increasing year on year but, following the first full year of the service in 2018/19, we have seen a downturn in this trend.
8. Financial costs and changes
- These changes resulted in a reduction in costs associated with diabetes foot patients in secondary care within the first full year of the MDFT service in 2018/19.
- In terms of inpatient costs associated with active foot disease, it is estimated that following the first full year of the MDFT service there was a cost reduction of approximately £190,000. This figure will be supplemented by corresponding cost reductions in primary and community care.
- It is anticipated that costs will continue to reduce in subsequent financial years.
9. Impact on wider diabetes management
- Audits show that attendance at MDFT services has also led to improvements in patients’ wider diabetes management (e.g. HBa1C levels).
10. Friends and Family test
- The service continues to achieve excellent Friends and Family survey results.
- 100% recommendations were noted.
- Patients are clearly benefiting from services closer to home.
- Education and training for health care professionals and patients.
- Recruitment of podiatrists has proved very difficult with the service only being fully staffed since November 2019.
- Clinic space has been limited and a bid to upgrade another clinic room has only recently been successful – additional clinic rooms often have to be found and negotiated on clinic days.
- Weekend working has been difficult to implement due to the difficulty recruiting permanent podiatrists and not having other MDFTs nearby to pool resources.
- The working relationship with the tertiary sector, although clinically excellent, needs to adapt as more complex cases are managed locally requiring increased levels of communication and an increased focus on repatriation.
- The RCA processes continue to evolve. The piloted RCA template has proved difficult to populate fully and does not always provide the qualitative patient information that would be useful. A review is required as to how to record the patient journey experience and the focus / forum as to how the RCA outcomes should be reviewed and lessons learnt implemented.
Key lessons learnt
- Strong clinical leadership is essential.
- Good systems to monitor performance and the return on investment are needed.
- Be prepared to evolve and adapt the service model.
- The size and scope of the training and education agenda should not be underestimated – there is an ongoing need to raise awareness of diabetes foot care with healthcare professionals in all settings as well as patients and their relatives / carers.
- We have experience a continued need for project management once the service is mainstreamed.
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