London Diabetic Foot Network ‘Striving Towards Reduction in Variation & Implementation of an Integrated Foot Care Pa

1. London Diabetic Foot Network‘Striving Towards Reduction in Variation & Implementation of an Integrated Foot Care Pathway for London’

2. London Diabetes Foot Care Network June 2010: Proposal to NHS Diabetes Stakeholder Meeting September 2010 London Diabetic Foot Network Meeting Feb 2011 London DFN Meeting Feb 2012 LDFN September 2012 and Jan 2013

3. Vision for London Diabetic Foot Network • To reduce variation in diabetic foot care through communication, shared learning and implementation of integrated pathways by 2014

4. Aims to implement a Clinical Network Establish • Local Diabetic Foot Networks and Champions – self-governing • A London Steering Group for DF disease • An Advisory Champion Group • A Directory of Services • A Research Network • A Patient Access Group

5. Aims to implement a Clinical Network • Local Diabetic Foot Networks and Champions – self-governing – Variable implementation: No teeth! • A London Steering Group for DF disease – Clinical Advisory Group for Diabetes – SCN • An Advisory Champion Group – Voice into the DSCN and DUK • A Directory of Services: Richard Leigh/DUK • A Research Network: Association with the AHSN • A Patient Access Group: Mike Edmonds, Christian Pankhurst and DUK • Standard approach to diabetic foot care • Root cause analysis of major and minor amputations

6. Challenges? • Align to the visions and objectives of partner organisations • Three key deliverable objectives • What teeth do you wish to gain? • Meetings twice a year? • Formalise cluster leads and strategies? • Partnership with CLAG

7. Q and AWorkshop • Further opportunities

8. Setting up a Diabetic Foot Registry • Research proposal on behalf of the London Diabetic Foot Care Network

9. Current problems • Varied assessments by multiple individuals • Lack of unified descriptors for DFU 3. Poor data collection on diabetic foot complications

10. Research Proposal‘The role of using 3D imaging technology Improving Outcomes in Diabetic Foot Care’

11. Why this technology is needed? 3D Imaging allows: • Repeated accurate measurements of wounds enabling trajectories of wound healing and prediction of time to heal. • A central database and development of a registry and research resource. • Photographic evidence for patient involvement with diabetic foot management plans.

12. Describe the patient group and healthcare setting • Among people with diabetes, foot complications are common. • 2.5 per cent of patients with diabetes, approximately 59,000 people, are estimated to have a foot ulcer at any given time. • Diabetic foot disease accounts for 20% of the total cost of diabetes care in the UK. • Research to be undertaken within Acute and Community Settings within the Foot Care Networks.

13. Why is this research important to the NHS • Service improvement: Diabetic foot ulcers can lead to amputation. 50% of people who have a major amputation die within two years; many of these amputations could be avoided with the right care. • Cost savings: NHS spends £650 million dealing with foot ulcers and amputations caused by diabetes. • Currently the numbers of amputations are rising from 5,700 in 2009/10 to over 6,000 in 2010/11. • Projected to be 7,000 by 2014/15 if urgent action is not taken to reduce these. . • .

14. Proposal • To utiilse 3D imaging technology as a Telehealth tool across boundaries allowing development of: 1. Diabetic Foot Registry 2. Tracking of wound healing 3. Enabling timely discharge to the correct care setting 4. Enabling patients to be involved in their care 5. Prediction and time setting for wound care management 6. Reduction of amputation rate by improved wound care management

15. Benefits of Study 1) What are the benefits in terms of reduced uncertainty? • Allow an understanding of real-time outcomes for patients with diabetic foot complications ► (population-based) • Assessment of cost-effectiveness to the NHS ► targeting of services ► methodological gains through performing the assessment. 2) How long before benefits could be realised, bearing in mind time take to perform the assessment and affect a change in practice? • Data collection for one year and then application of learning over the following 18 months. A number of benefits maybe realised once the device is implemented into normal clinical practice.

16. Benefits of Study 3) Would the assessment offer value for money? Yes as this will impact on diabetic foot care. 4) How important is an early assessment? Very important as potential usage across interfaces allowing an integrated management plan for high risk patients. 5) Other factors including policy considerations, prevalence of the condition and social/ethical concerns. No overt concerns.

17. Going forward • NHS Supply Chain Support for the proposal • Will supply the hardware • Steering Group: Professor Homer, Natasha Patel and Gerry Rayman • London wide (plus other key centres) • First meeting Dec 2013

18. North East • Cluster wide service restructuring is taking place • Cluster wide directory of services almost completed, any corrections to be emailed to James Gotts – james.gotts@bartshealth.nhs.uk • Access: New patient open access variable • Email and share access and education protocols with everyone across the North East • Diabetic Foot training for primary care - Zabeer Rashid and Abi Green will lead on this • Latha Hapugoda will take Waltham Forest foot data to CCG board and WF Diabetes Network meeting

19. North West 1. Directory of service almost complete • 8 PCT areas represented and commissioning • Integrated care needed: Flows of money: disparate groups • Bundles of care vs piecemeal or provider driven with single access to funding • Active commissioning lobbying needed for the pathway with detail to allow this to be an easy process • Find the GP Commissioning Champion for cluster – Dr Raquel Delgado ?? 2. Renal Disease: • Renal patients fast tracked into the hub but where are post discharge providers to ensure collaborative approach 3. Vascular • As above: Plan patient pathway so that patients are discharged to responsible appropriate provider 4. To be followed up by Trusha, Wing May and Gaytree.

20. North Central • Have had cluster wide meetings – Richard Leigh is leading • Directory of Service and mapping process almost complete • Plan follow-up cluster meetings • CCGs: Need to be able to influence in terms of commissioning as a group • Local sector guidelines and process map as a care pathway plan to allow signposting as well as a timeframe with contact details • Single sheet: for circulation and back to meeting in September 2013 • Natalie will pull together a single sheet flow diagram

21. South West • DOS discussed at length, there are some variations • Gaps identified and actions for change • Hotline to be unified • Competency for FPT need to be named and single sector without will be supported to enable • Competency framework for podiatry • Foot education program for patients • Stakeholder meeting: 13th June Diabetes Week • Patient Education meeting to be confirmed

22. South East 1. Concern re vascular centralisation: delays into central hub and sub optimum discharge. Pathway into the hub maybe erratic and sporadic • Feedback to Andy Mitchell 2. Research re access to services: Prevalence study of ulcers, pressure sores within a cluster within a time frame: September presentation snapshot audit 3. Screening: Assurance re screening and education 4. Assurance of services: Vascular podiatrist high-risk non-ulcerated foot 5. Mental health problems prevalent in cluster population and increase risk to compliance and long-term health 6. Antibiotics: national problem and local guidelines exist but working towards a community policy

23. Service Users • Patient leaflets: Agreed to be done 1st June • Health Watch Right information at the right time • Structure and governance locally • Assurance from the Health and Well Being Board • Diabetes Voices involvement • Quality of service from the patient’s side: • GP Education? • How to speak up when care is not good enough?

24. Next Steps • Foot care mapping • Commissioning presentation • Cluster feedback importantly and sharing of best practice • Patients in cluster meetings • Next meeting Sept 19th • Commissioning document to go to NHS Commissioning Board via Andy Mitchell and Stephen Thomas

25. The Foot Attack Centre Prevention and Risk Stratification Immediate local access to foot protection/multidisciplinary team and 48 hour access target for endovascular and surgical treatment

26. London Diabetic Foot Network ‘success and challenges for the future’

27. What have we learnt • Excellent Champions already exist • Horizontal leadership and ownership works well • Create headspace for all! • Funding stream • Umbrella organisation • Partnerships essential • Next meeting funded but where do we go from there?

28. Foot Attacks can kill! Stop the Foot Attack!