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Potential for Improvement

Findings of the National Diabetes Footcare Audit (NDFA)

England and Wales, 2014-21

The NDFA gathers data from diabetes foot services around the country about care structures, processes and outcomes. Its findings reveal deficiencies in care in many parts of the country.

Many people wait several weeks for expert assessment of foot ulcers. Patients who wait the longest are more likely to have severe ulcers, and are less likely to be healed at 12 weeks. 

Having a severe ulcer at first expert assessment triples the likelihood of a foot disease-related hospital admission.*

*NDFA report 2014-18

NICE recommends that people who present with active foot disease should be referred for expert assessment within 1 working day, for triage within 1 further day.

For many people in England and Wales, two or more weeks pass between first presentation to a healthcare professional and first expert assessment. In 2020-21, time to first expert assessment was at least two months for 1 in 18 patients.

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Delayed expert assessment increases the likelihood of a severe ulcer. In 2020-21, 43% of all ulcers reported to NDFA were severe, but 57% were severe in cases  where first expert assessment occurred at least 2 months after first presentation.

Severe ulcers are less likely to be healed at 12 weeks, and people who wait the longest for expert assessment are the least likely to be healed. ​Between 2014 and 2021, 50% of ulcers that had expert assessment within 2 days were healed 12 weeks later. Where there was a delay of more than 2 months before expert assessment, the 12-week healing rate after that assessment was 35%.

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The likelihood of a foot disease related hospital admission within 6 months is more than tripled if an ulcer is severe at first expert assessment. There is one foot disease hospital admission within 6 months for every 2.4 severe ulcers. The mean length of stay for these admissions is 16 days.*

*NDFA report 2014-18

The likelihood of major amputation is more than quadrupled if an ulcer is severe at first expert assessment. In 2020-21, 2.7% of people with severe ulcers had a major amputation within 6 months of expert assessment.

Major amputations within 6 months, 2020-21.png

If the prevalence of severe diabetic foot ulcers were reduced by a third, the average ICS would save around £4.7 million a year.

Professor William Jeffcoate is Chair of the NDFA Advisory Group.

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