Diabetes – the future

1. Diabetes – the future Gill Sykes & Gareth Hicks

2. What does the ‘future’ hold? • Insulin pumps • BGL monitoring without taking blood • A diabetes vaccine • Artificial pancreas • Very low calorie diet

3. We’re at Foot Health • The future of foot care in diabetes • Screening & Risk Stratification • Treatment & advice • Correct & Timely Referral

4. State of the nation • 3.2 million people diagnosed with diabetes • 61000 foot ulcers at any one time • 6500 amputations a year • In 2010-11 NHS England spent £639-£662 million a year ( £74,000 an hour) • Only 50% of patients with diabetes survive 2 years+ • 80% of ulcers are preventable • Ref: Footcare for people with Diabetes ( Kerr 2012) • Putting Feet First , Diabetes UK 2009

5. Screening in private practice • In NICE CG10 and SIGN 116 a foot examination is indicated; • Pulses • Monofilament & tuning fork test • Foot deformity • History ( ulcers and/or amputations)

6. The tools : • 10g Monofilament • 128 MHz tuning fork • Neurothesiometer • Rydel-Seiffer tuning fork

7. Screening • The purpose of screening is to award the patient with a foot risk category. • Low risk 1:500 ulcer risk • At risk 1:20 ulcer risk • High risk 1:2 ulcer risk Leese et al 2006 • Foot Risk Awareness & Management Education(FRAME) www.diabetesframe.org

8. Risk categories • Active ulceration • High risk – previous ulcer/amputation • At risk - neuropathy and or vascular impairment with foot deformity • Low risk – no neuropathy, no vascular problems or foot deformities

9. What do I do with this information? • Note the risk factor in patients notes, with date & reason • Inform the patient • Inform GP • Screen again in 12 -15 months – low risk • Screen again in 3-6 months – at risk • Screen again in 1-3 months –high risk (MDT)

10. Scottish model • The Foot Attack is coined for patients needing referral for immediate treatment. • In line with this , CPR for feet has been launched • C Check . Examination/assessment • P Protect Advice/footwear/insoles • R Refer To Foot protection team

11. Referring a diabetic foot problem • Who is patients’ GP ? • Who leads the hospital diabetic foot clinic? • What is their phone number? • How does the patient get there ? Self ref/GP/direct • When you refer – record it ! • Gill Sykes is a diabetes specialist podiatrist. With 27 years experience, she takes up the reins....

12. Gill Sykes Clinical Lead Podiatrist Acute Diabetic Care

13. 27 years NHS experience • 24 years community • Specialising tissue viability • Work as part of a multi- disciplinary team • Including vascular consultant surgeons, diabetic consultant, tissue viability team, orthotist, specialist physiotherapist. • 6 years private practice experience

14. Calderdale • In Calderdale there were 13, 229 diabetics diagnosed in 2013 • By 2030 there is predicted 19, 289 diagnosed • This is an increase from 8.0% of population to 9.8% (YHPHO, 2013)

15. Huddersfield • In Huddersfield there were 27, 260 diabetics diagnosed in 2013. • By 2030 there is predicted 38, 262 diagnosed. • This is an increase from 8.5% of population to 10.4%. (YHPHO, 2013)

16. There are two local diabetic foot screening tools within Calderdale and Huddersfield.

17. Screening Tools • Calderdale utilise Podiatry Assistants with competency based training by podiatrists • Huddersfield utilise Practice Nursing with competency based training by podiatrists

18. Benefits of podiatry assistants • Competency based • Pro -podiatry • More thorough assessment i.e. more knowledge of foot pathologies • Quicker referral to podiatry • Inspection/ advice • In Calderdale 2013, 89% of all diabetics in Calderdale were screened (not including DNA’s)

19. Screening Tool on Systm1 New/ Follow up screening – first appt./ follow up option tick box. Peripheral sensory neuropathy screening – left and right foot 10g monofilament/ normal abnormal. Peripheral arterial screening – right foot left foot both pulses, present, absent. Signal – mono, bi, tri phasic. Lesions/ foot deformity – free text. Diabetic risk category – low, moderate, high , ulcerated. Annual screening plan – Podiatry dept/ GP Practice Treatment plan – referral to podiatry, continue with podiatry, self care/ private care RECALL

20. NICE guidelines on foot risk The prevention and management of foot problems advises that foot risk should be classified as: • at low current risk: normal sensation, palpable pulses • at increased risk: neuropathy or absent pulses • at high risk: neuropathy or absent pulses plus deformity or skin changes or previous ulcerated foot

21. SO………….. ‘The postcode lottery of diabetes- related amputations in England is getting worse, according to figures from Diabetes UK’ (Podiatry Now, 2014) ‘Too many people with diabetes not getting a good quality annual foot check or not being informed about their risk status at the end of their check’ (Podiatry Now, 2014)

22. The figures, based on NHS data, show that overall diabetes-related amputation rate has not improved, with 2.6 thousand lower limb amputations per year with diabetes. The gap between the worst and best performing areas has also got bigger’ (Podiatry Now, 2014).

23. What we don’t want is this……

27. Or this………

29. If in doubt, DO REFER

30. To pose some questions…..? • What will happen to all the low/ medium risk diabetics in the NHS? • And staff shortages? • And an increase in diabetics? • And a growing elderly population? • WHAT NOW?

31. Food for thought.. Some NHS Trusts already have done some of the below…. • Discharge low/ medium risk to self management. • Training/ competencies for assistant practitioners • Involvement of private clinicians, ? partnership working • Voluntary sector

32. Thank You