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New NHS Framework calls for improved care for patients with Diabetic Foot Disease – is it enough?

Posted on May 23, 2016
Archive : May 2016
Category : Blog

This month the NHS has published a new report aiming to improve diabetic patient care by avoiding unnecessary amputations and deaths in those that have Diabetic Foot Disease.

The report aims to ensure that ‘patients with acute Diabetic Foot Disease receive high quality care where ever they present’. In other words, make sure that people with a very high possibility of having an amputation due to their diabetic foot condition get the treatment they need as soon as they are spotted!

With the recently released statement that 135 lower limb amputations per week in England are due to Diabetes, we should be much more aware of the severity of this problem than we have been. This shocking figure was highlighted in an innovative and incredibly powerful way in April by Diabetes UK and AMP shoes. One weekend they set up a pop-up shop with each of the shoes on display representing one of the 135 amputations that would occur within one week. Each shoe was labelled with a name and the age of an amputee. All the ‘shop assistants’ were amputees and ‘customers’ were invited to have their risk of developing Type 2 diabetes assessed whilst in the shop. Something like this not only brings home the severity of the situation but also the fact that it can affect young and old alike.

Key findings

Experts agree that with good diabetes management and expert foot care, 4 out of every 5 of these amputations could be avoided. To make this figure more poignant it is also calculated that about 50% of people who have had an amputation die within 5 years of having the amputation!

The summary of recommendations in this report mostly relate to the care that a person receives after they have been diagnosed with ‘active Diabetic Foot Disease’ ensuring that they are all seen urgently irrespective of their geographical location. It is further recommended that they are given the best care possible to avoid both hospitalisation and any type of amputation. This is of course crucial to help minimise the impact of Diabetic Foot Disease and will ultimately reduce the level of amputations.

But what about prevention?

Having a focus to help deal with the issues of Diabetic Foot Disease, as quickly as possible after diagnosis, is laudable. But the phrase that includes “horses bolting and closing gates” does tend to spring to mind. Where is the strategy for the ‘prevention’ of foot ulcers and Diabetic Foot Disease in the first place? Anything that can help address this will also surely have an impact on the 135 amputations per week, won’t it?

There is no doubt that the care and speed at which a patient with Diabetic Foot Disease is dealt with, is of the upmost importance. The current system needs to be improved and hopefully the findings from this report and the NICE guidelines, that were updated last October, will help to make this happen.

However, if we can work on trying to prevent patients developing Diabetic Foot Disease in the first place, then surely this would reduce the amount of patients developing this condition, wouldn’t it? By doing so it would surely reduce the pressure on the current NHS services, making it easier to handle this smaller number more efficiently.

Cleaning teeth and checking feet

One could almost compare this situation with that of gum disease years ago. There was a big campaign to educate the public on the dangers of not regularly cleaning their teeth. Through education and advertising the aim was to encourage people to clean their teeth twice a day to reduce the chances of them developing gum disease. The campaign illustrated what would happen if you didn’t clean your teeth twice a day and showed pictures of rotting gums and teeth falling out. The fear of this happening and the medical back up behind the campaign, resulted in people forming a habit of brushing their twice a day – becoming part of their daily routine. Now obviously not everyone follows this advice but the majority of people will know that they should be brushing their teeth twice a day.

OK, so cleaning your teeth and checking your feet are completely different activities, I get that. Everyone should clean their teeth daily, but not everyone needs to check their feet daily I hear you say.

Children, from a very early age, are encouraged to look after their teeth and clean them twice daily. A habit is formed quite quickly even though it takes a certain amount of encouragement and reminders from parents. But it quickly becomes part of your morning and evening routine, and isn’t forgotten. It is then done without consciously thinking about it, and even when you are in a rush to leave the house in the morning or go out for an evening. It is just something you do. And feel bad if you don’t do it.

But children from an early age would not be encouraged to check their feet. Why would they? However, they probably subconsciously do check their feet to some extent. We all do. That rubbing sock or small stone in the bottom of your shoe. Those new school shoes that give you a blister, or those new heels (ladies) that you can’t wait to take off half way through the night. We have all done it. And to some extent have then massaged and felt our feet to understand what ‘damage’ we may have done to them.

The difference though, is that people with diabetes can suffer from some form of peripheral neuropathy (a lack of feeling or sensation in their feet). This means that they do not have the ‘luxury’ of pain as people without this condition experience. In other words, that stone in the bottom of their shoe or that rubbing sock will not be felt. Before long this small irritation could become a cut or broken skin and quickly become infected, without the person knowing it has happened. Therefore for people with diabetes establishing a routine to systematically check their feet daily SHOULD be strongly recommended.

Why is this so important?

As Diabetes UK have often quoted – 4 out of 5 of the 135 leg, foot or toe amputations each week are preventable. So why would checking your feet be so important and have any impact on preventing amputations to such an extent?

Let’s use the example of a patient with a neuropathic diabetic foot, who routinely checks their feet every day, and notices a crack or cut on the sole of their foot. They contact their health professional as soon as possible after detection and are seen very quickly (as their records indicate that they have diabetes). The chances of that crack progressing to an ulcer and then becoming an infected ulcer are greatly reduced due to the speed of reaction by the patient to the initial issue.

Now, let’s assume that a similar patient has just been seen by their health professional and had their feet checked, with a follow up appointment booked for 3 months later. Let’s also assume that this patient doesn’t regularly check their own feet, as they feel the check by the health professional is adequate to spot any issues. Let’s also use the above scenario, that a crack or cut has occurred on the sole of their foot. Without regular foot checks by the patient, this could be well on its way to infected ulceration status by the time the health professional sees the patient again. The time taken for this wound to heal will be greatly increased (with all the other issues of immobility of the patient, etc.), if it heals at all. There is now a very good chance that this patient could potentially be on their way to becoming one of the amputation statistic mentioned previously.

Ulcers and amputations are not inevitable

Patients need to be given very clear guidelines on the importance of establishing a daily foot care routine incorporating:

1. A daily foot check using a mirror;

2. A daily foot wash (and careful drying of the feet); followed by

3. Daily moisturising all areas of actual and potential dry skin,

If they follow this advice then the chances of them developing any Diabetic Foot Disease is greatly reduced.

Obviously for newly diagnoses diabetics, there are so many other areas of their health care that initially take priority over foot health. Foot care will likely be mentioned but maybe not reinforced, or not fully absorbed by the patient until later on and sometimes only if there is a problem.

The majority of advice that seems to be given is to “check your feet regularly” but what does that mean? How often is ‘regularly’ – daily, weekly, monthly? What do you look for? How do you do it?

Many diabetics with or without neuropathy know that their foot health is important but until there is a problem they don’t seem to be too concerned about checking them. Feedback from many diabetics we have spoken to is usually (and worryingly) – ‘I haven’t had a problem up until now so I’m sure I’ll be fine’; or ‘If I have a problem then I’ll start to check them’; or ‘I get them checked every 3 months by the nurse so I’m OK….’.

Daily foot checks for diabetics should be like teeth cleaning for everyone – take responsibility for your feet and check them daily, like we do for our teeth. If not you risk losing a toe, a foot or even a whole limb.

Routine is the key

As mentioned earlier, not everyone cleans their teeth twice a day but the majority will know that they should, and most of us just get into a routine and do it without thinking. It should be the same for diabetics and daily foot checks. They should all know that they should be checking their feet daily and understand why this is important. But sadly experience indicates that this is not the case, judging by the blank faces that we come across in discussions with some recently, and not so recently, diagnosed diabetics. It is inevitable that not everyone will follow this advice, but painful ulcers and amputations are not inevitable. The more that the message is reinforced and the more that diabetics are educated in how to look after their feet (and what to look for), then there will be more chance of preventing more of these life paralyzing conditions.

As Chris Askew, CEO at Diabetes UK said “Far from the world of shoe-shopping, a major amputation to a leg or foot can leave someone struggling to get out and about and, even with a prosthetic, faced with a limited choice of footwear. Beyond the psychological impact, amputations cost lives with most people dyingwithin five yearsof having one”.

In summary – prevention is better than cure

This new report is a great step forward in diabetic foot care but there is so much more that can be done to attack this problem from both sides. We need better education and reinforcement of the importance of the simple 3 step daily routine:-

1. Checking your feet daily using a suitable foot mirror so you can see the whole of the bottom of your foot and heel;

2. Wash your feet daily making sure they are properly dried, especially between the toes;

3. Apply a quality and specially developed moisturiser to your feet on a daily basis.

However it is also important for diabetics to understand:

1. How to properly check their feet;

2. What they should be look for; and

3. Who to inform and who to contact if they find anything unusual.

Click here to download the specially developed leaflet: ‘User Guide – What should I be looking for on my feet” for some good information and advice on what to look for.

More education and information will give diabetics the knowledge they need to enable them to take the control back over their foot health, so it needn’t affect their daily life.

The whole adage that prevention is better than cure has never been more poignant.

For a full copy of the NHS report, click here:


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