Approximately 1% of the NHS budget is spent on active foot disease in diabetes. As up to 80% of these foot problems are largely preventable (Kerr et al, 2019) this is economically unviable and unsustainable, as well unacceptable for patients and healthcare professionals. Early intervention is the answer. The ‘walk-in’ clinic allows access to a member of the multidisciplinary foot team (MDFT) when care is needed, ensuring timely, effective care. Providing opportunities to support care closer to home, without the need for a primary care referral, enables patients to access the most appropriate service at times of crisis.
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To facilitate the implementation of the WIC without additional resource, without causing undue additional pressures on the podiatry service and to achieve the specific objectives, the WIC was initially piloted twice a week on a Tuesday and a Friday within the Podiatry Department’s clinical hub. As the likely demand was largely unknown, the pilot initially invited patients from one locality of Cardiff, comprising a cluster of 10 GP practices, to attend. It ran from 7 December 2018 for eight weeks. It was advertised using various means: in GP surgeries using a flier on their TV screens, via social media, a mailshot to the HCPs in these localities using a new infographic as a poster, and as a hand-out leaflet. The project was also promoted directly to the existing caseload of patients receiving podiatric care. The data for the project was gathered primarily using the NDFA data collection tool. Additional data were also captured manually through a case note review process. Processes within the Podiatry Department were streamlined; a podiatry clinical assistant triaged patients, collected baseline information and provided simple re-dressings, after full assessments and treatment planning by the podiatrist. Feasibility testing during the pilot phase led to the opening of WIC to all GP practices within the Cardiff and Vale boundary in February 2019.
The project followed change management methodology, principally Kotter’s 8-step change model, to ensure there was stakeholder engagement, to manage obstacles to change and enable sustained change. It improved access to HCPs with the appropriate skills to manage this complex patient cohort, with patients receiving timely and seamless care with vascular, orthopaedic, microbiology and diabetes colleagues when needed. The results from the NDFA support this, with significantly more patients self-presenting after the commencement of WIC, suggesting an improvement in patient activation. The numbers of patients waiting longer than three days has reduced from 55.36% to 35.45%, which indicates this type of service provision supports timely access for patients. This prompt access to care has also demonstrated positive improvements to the clinical outcomes of the patients. NDFA data show that the number of patients with persistent ulcerations has reduced, the numbers alive and ulcer free has increased and the number of patients with less severe DFUs has increased, all of which correspond with early intervention. Ensuring appropriate, effective care is available closer to home has meant that many patients have not required hospital admission. Their ‘foot attacks’ have been managed in the community using an MDFT approach, preventing unnecessary burdens on acute hospital sites but facilitating a patient-centred approach. This has also supported a ‘step-down’ approach within the Podiatry Department, which enables appropriate use of resources and skill mix which underpins the prudent principles of healthcare in Wales.
Sustainability and Spread
Within the organisation successional planning has been a key objective to support the All Wales DFU pathway and sustainability of diabetic foot services. Ensuring podiatrists have the appropriate skills and experience to provide this high level of care supports the viability of this model. Taking the project through the NDFA collaborative has permitted country-wide exposure and dissemination through sharing best practice. At a local level, WIC has been embedded into the diabetes healthcare pathways for primary care, ensuring early access at times of crisis for patients. Patient collaboration is key and the patient representative in the DSIG has been crucial to support its adoption. The resources to expand and develop such clinics and enable sustainability will come through improved healing rates and patient activation to access at times of crisis. It is well documented that activated patients use less resources and have better outcomes (Rix & Marrin, 2015). Many patients are concerned about accessing services when needed. The WIC supports their engagement and facilitates access to care when required. There are plans to increase the number of WIC operated during the working week. The introduction of Patient Group Directives (PGDs) will facilitate a ‘one-stop shop’, increasing clinical and cost efficiencies in addition to improving patient experience. Using video consultations will further support patients and HCPs to ensure timely access to care. Further work is planned to engage patients from ‘hard to reach’ groups, such as BAME, through a local organisation, The Mentor Ring. This will ensure there is equity of access for patients from any social background. The results of the project have been shared with colleagues across Wales through the All Wales Diabetic Foot Network. Sharing what has worked well and not so well has provided opportunities to consider further development ideas, such as incorporating technology like apps and telemedicine to enhance current provision. The results of this project support patient activation to reduce the growing economic burden of diabetes on the NHS. Further evaluation of patients’ experience of the WIC is planned, as is the introduction of patient activation and coaching to support a future All Wales work stream, in order to develop a patient foot crisis prevention model.
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