| Diabetic Foot,
The, Winter, 2005 by Alistair McInnes
I had the privilege and pleasure of
speaking at the first diabetic foot seminar to be held in
Nicosia, Cyprus, on 12 November 2005. The conference was
organised by the Cyprus Society of Chiropodists and Podiatrists,
the Cyprus Diabetic Association and the Cyprus Association for
the Study of Diabetes. I was also asked to lead a discussion on
the future for diabetic foot services on the island in light of
the development of the National Plan for Diabetes and the
Cypriot Government's proposal to create a new national
healthcare system. There are a number of complex issues
regarding diabetes foot services on the island and the UK model
of care is regarded by many healthcare professionals as a 'gold
standard' for them to emulate in the future.
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Following on from the conference--which took place on World
Diabetes Day (14 November) and focused on the threat of
amputation and diabetic foot disease--I had the opportunity to
visit a number of booths that had been set up throughout
Nicosia, where healthcare practitioners and members of the
Cyprus Diabetic Association were drawing attention to the
increasing prevalence of diabetes in Cyprus (5.1% in 2003 and
rising; http://www.eatlas.idf.org/prevalence [accessed
21.11.2005]). The enthusiasm and dedication demonstrated by all
those involved was most impressive and I wish them well for the
future.
Diabetic foot services in the UK
My experience in Cyprus led me to consider the future for
diabetic foot services in the UK, where wide disparities remain
in health outcomes throughout the country and between different
socioeconomic groups (Department of Health [DoH], 2005c).
However, when the aforementioned UK 'gold standard' model of
care is adopted (that is, when fully resourced, appropriately
organised and fully trained dedicated multidisciplinary foot
care teams are available), there is no doubt that the burden of
morbidity and mortality that manifests as diabetic foot disease
can be significantly reduced (Bakker, 2005).
With the UK Government's requirement for increased legislation
to reform the NHS (DoH, 2000), some proposed changes may pose a
threat to the future provision of diabetic foot services. One of
the major concerns arises from the document Commissioning a
patient-led NHS (DoH, 2005b). With the anticipated merging of
primary care trusts (PCTs) to form larger PCTs and a separation
of the commissioning from the provider function, there is a
worry that devolved practice-based commissioning may lead to a
fragmentation of diabetic foot services. The political drive
appears to comprise the provision of local services by the
primary care sector and a diminution of services provided from
the hospital sector.
Optimum diabetes services result from integration of all
providers (despite organisational boundaries), with better
health outcomes and a reduction in health inequalities (DoH,
2005c). It would be a terrible irony--given the potential
benefits of Agenda for Change (DoH, 2005a) and the Knowledge and
Skills Framework (DoH, 2004) to the NHS workforce and
patients--to see a dismantling of the multidisciplinary diabetes
foot team that I believe operates best in the hospital setting.
Patients with diabetic foot disease present with multiple
pathologies and often require urgent and prompt attention from
many hospital services that the multidisciplinary team may
access immediately. If this service is diminished in any way, to
quote Dr Mike Edmonds (Consultant Physician, King's College
Hospital Diabetic Foot Clinic, London), from the 2nd Annual
Diabetic Foot Journal Lecture, in October,
'it would be nothing short of a
betrayal of our patients.'
The new commissioning arrangements have to be carefully managed
to preserve good practice and desirable outcomes of care.
Perhaps the fears that many healthcare practitioners have
expressed will be assuaged by the fact that the National Service
Framework for diabetes (DoH, 2003) and the National Institute
for Health and Clinical Excellence (NICE; formerly National
Institute for Clinical Excellence) guidelines (NICE, 2004) will
inform the commissioners and preserve the hospital-based
multidisciplinary foot care team. In addition, the National
Diabetes Support Team will provide backing for online diabetes
services via local diabetes networks; 87% of PCTs are now part
of a whole-system diabetes network or community (Diabetes UK,
2004).
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There are many examples of recent innovative excellent practice
in the management of diabetes (DoH, 2005c), and there is no
doubt in my mind that there is a requirement to expand the
diabetic foot services in the community setting so that
appropriate seamless care can be provided in the most
cost-effective and clinically effective fashion. The
commissioners have a very challenging and complex task ahead.
It is perhaps gratifying to hear that Patricia Hewitt, the
Secretary of State for Health, say from the House of Commons on
25 October that
'community staff employed by PCTs will
continue to be employed by PCTs
unless and until the PCT decides otherwise, following full
public
consultation' (UK Parliament, 2005).
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