©2017 by Insight Health Improvement Ltd

National Objectives

Improvements in diabetic foot care can deliver measurable improvements in patient outcomes and gains in efficiency and productivity, enabling CCGs to meet many key NHS priorities and objectives.

 

The potential for improved diabetic foot care to contribute to the achievement of a large number of core NHS objectives is driven by the following factors: 

  • the high and growing prevalence of diabetes,

  • the frequency of foot problems in this population,

  • the high costs of foot disease (especially if care is sub-optimal),

  • the potential for substantial quality of life gains and financial savings from improved care.

Some examples of ways in which improved diabetic foot care can help CCGs meet key objectives are shown below, but this list is not exhaustive.

STP aide mémoire: Diabetes

The STP aide mémoire: Diabetes from NHS England, Public Health England and Diabetes UK states that 

  • "CCGs should ensure they have a footcare pathway with adequate capacity to enable early referrals of people at risk of diabetic foot disease to foot protection teams and people with active disease to multidisciplinary footcare teams."

How can CCGs demonstrate that they have met this objective?​

Documentation of the diabetic footcare pathway and protocols, plus measurement of time to first expert assessment through the National Diabetes Footcare Audit.

NHS Long Term Plan: Footcare in Diabetes

The NHS Long Term Plan states that 

  • "We will support local health systems to address inequality of access to multidisciplinary footcare teams

and

  • "We will ensure that all hospitals in future provide access to multidisciplinary footcare teams".

NHS RightCare Pathway: Diabetes  

The NHS RIghtCare Pathway for Diabetes identifies a multidisciplinary footcare service and supporting pathway as a core element of an optimal diabetes service.

It states that commissioners should:

  • Develop integrated commissioning models, which will allow for joint commissioning of the full pathway

  • Ensure that all elements of care are available for people with diabetes

  • Work with patients, carers and providers to identify measurable outcomes for which service providers of diabetes care will be held jointly accountable. 

A goal should be shared responsibility and accountability by all providers for the incidence of complications such as amputation. 

NHS Oversight Framework, CCG Metric 3

Emergency admissions for urgent care sensitive conditions

How can high-quality diabetic foot care improve performance against this indicator?

For 4% of emergency admissions for urgent care sensitive conditions, diabetes is given as the primary diagnosis. For a further 17%, falls in those aged 74 or over are given as the cause. Studies indicate that around 1 in 8 falls occurs in a person with diabetes. Diabetic foot disease more than doubles the risk of a fall in diabetes. For 7% of emergency admissions for urgent care sensitive conditions, the primary diagnosis is cellulitis. Diabetic foot disease increases the risk of cellulitis. Timely access to expert care in the community can reduce the prevalence of foot and other complications of diabetes, and reduce emergency admissions for urgent care sensitive conditions.

NHS Oversight Framework, CCG Metric 7

Population use of hospital beds following emergency admission

How can high-quality diabetic foot care improve performance against this indicator?

There are around 700,000 emergency admissions a year in England in people with diabetes, around 1 in 8 of all emergency admissions. That is around 3,500 per CCG. People with diabetes also stay in hospital for longer than people of the same age and deprivation level who do not have diabetes. It is estimated that there are 600,000 more emergency bed days in England each year for people with diabetes than the number that would be expected in people of the same age and deprivation without diabetes. That is approximately 2,800 excess emergency bed days per CCG. Approximately 1 in 8 of these diabetes emergency admissions occurs in someone with a foot problem. Some of these foot problems occur before admission, and some during the hospital stay. People with foot problems stay in hospital around 8 days longer than people who have diabetes but no foot problems. It is likely that improved diabetic foot care, in the community and in hospital could reduce emergency admissions and bed days.

 

NHS Oversight Framework, CCG Metric 13

Injuries from falls in people aged 65 and over

How can high-quality diabetic foot care improve performance against this indicator?

Studies indicate that around 1 in 8 falls occurs in people with diabetes. Diabetic foot disease more than doubles the risk of a fall in a person with diabetes. Reductions in foot ulcer prevalence and amputation risk through high-quality diabetic foot care, including early expert assessment, can reduce the risk of falls in people with diabetes.

NHS Oversight Framework, CCG Metric 17

Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions 

How can high-quality diabetic foot care improve performance against this indicator?

Around 13% of all unplanned admissions for chronic ambulatory sensitive conditions are owing to diabetes complications. Some of these will be primarily for foot disease. In many others, foot problems will be present along with other diabetes complications. Diabetic foot disease also increases the risk of emergency admission for urgent care sensitive conditions, including falls and cellulitis. Diabetes prevalence is 1.5-2 times higher in deprived groups. Timely access to expert care in the community can reduce the prevalence of foot and other complications of diabetes, and reduce unplanned hospitalisations in deprived groups.

NHS Oversight Framework, CCG Metric 58

Reduction in growth in activity in programmes where there exist opportunities to improve outcomes and reduce activity.   

How can improved diabetic foot care contribute to meeting this objective?

This indicator is based on RightCare delivery plans. The key objective of the RightCare programme is to ensure improvements in value for money and allocative efficiency. Intelligence packs identify areas where CCGs need to improve, compared with the ten CCGs most similar to them in population characteristics. As shown above, a multidisciplinary footcare service and supporting pathway are identified in RightCare as a core element of an optimal diabetes service. Diabetic footcare can deliver substantial improvements in value for money and allocative efficiency over relatively short timescales. The average CCG spends around £6 million a year on diabetic foot care. Yet many ulcers are not assessed by experts for up to two months after they develop. The later the expert assessment, the more likely it is that the ulcer will be severe when assessed. More severe ulcers take longer to heal. Reducing the prevalence of severe ulcers by one third would improve patient outcomes substantially, and reduce the cost of ulcer care by around £1 million a year per CCG.