This redesign of the diabetes foot pathway in North East Essex resulted in a NICE-compliant pathway and required no additional funding. In fact, it saved funds which were reinvested into the service to increase vascular, orthopaedic and orthotic time. The service began in 2014 with a fixed budget of £2 million with no additional funding in the five-year contract period. The new, redesigned service saw reduced waiting time, with patients seen and assessed by competent staff with appropriate referrals to specialist clinics which have the capacity to provide a high standard of service.
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A disruptive approach stopped the tradition of specialists reviewing all patients that were referred, thereby letting go of patients that had been in the system for many years, encouraging self care and developing other healthcare professionals to assess, monitor and maintain foot health, thereby reducing demand on specialist services. Initial investigations found there was no lead or co-ordination across the pathway, despite one team working across the MDT and community clinics. Due to demand on clinics, podiatrists were not free to provide training to Primary Care or Community staff, which led to late and inappropriate referrals. A review of other areas found that large or well-known centres have multiple MDT-type clinics accepting any patients which are referred. However, due to our fixed budget, we had to build a sustainable service for the growing diabetes population and at the same time put measures into place to prevent complications and identify early signs of complications, which would be reviewed promptly by the most appropriate healthcare professional. This new service was based on the successful NEEDS diabetes model of a clinically led service, complex patients reviewed by the specialists and Primary, Community and support services are supported and trained by the specialists to provide a high standard of care ensuring patients are monitored and referred to a specialist in an appropriate, timely manner.
The review of the service commenced in September 2015, changes commenced in April 2016 with full implementation with an evaluation of changes by end of March 2017. The review involved interviews with all staff within the service. Outcomes were shared with the steering group that had been set up to support the redesign, the management teams and the CCG. A vision paper was then developed with all organisations agreeing to work collaboratively to implement the changes:
- Steering group with project management support set up, monthly meetings took place with individual actions outside of the meeting
- Clinic criteria developed for each area - MDT and community clinics based on NICE risk criteria
- Lead Consultant and podiatrist named for pathway
- Information cards for patients with their risk score and advice re hot foot or concerns
- Training delivered for AGEUK for toenail cutting
- New scheduling of clinics allowing for adequate new referrals and reducing follow-up appointments
- DSN & Podiatry joint clinics set up within the community
- All low-risk patients discharged back to the care of their practice
- Moderate-risk patients given appropriate education and follow-up appointments depending on their need.
85.1% of patients at high-risk of foot problems are being referred to podiatry (up from 27.9% in 2014) - an extra 615 patients. Individual patient reviews resulted in 20% reduction of community clinic appointments releasing podiatrists to implement foot care and risk assessment training across primary and community care. There was a fall in the DNA rate from 10% to 5.5% as we found that previously patients had accessed private help while waiting for the NHS appointments. Reduction in wait times were achieved, meeting and exceeding NICE 2016 criteria of ‘urgent’ triaged within one working day, ‘high risk’ at 1-2 weeks, ‘moderate risk’ within 6-8 weeks and ‘low risk’ (biomechanics) at 12-18 weeks. Financial savings were achieved through reduction of appointments within the MDT foot clinic and the reduction of activity within community podiatry resulted in a reduction of £100,000 in the subcontract value to ACE. This money has been reinvested.
Sustainability and Spread
Training within primary and community care will be ongoing, thus resulting in appropriate referrals which are timely and therefore will have an impact on prevention and healing times. Patients have more time in their appointments for education, increasing the ability to self care. All parties across different organisations acknowledged that the service required a radical change and supported the developments in line with NICE. Other areas would need this open and honest approach so improvements can be made. Community provider ACE followed the same principles for its general podiatry clinics and have had the same reduction in waiting times and demands in service.
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