NDFA Interval Review: July 2014-March 2021

This report has identified important trends in foot care processes and outcomes in England and Wales since the start of the National Diabetes Foot Care Audit (NDFA) in July 2014.

1.1. Key findings

The NDFA has found that the proportion of referrals seen by a specialist foot care team within 13 days has increased from 43% in 2014-15 to 46% in 2020-21 (see Chart 4a). We have also seen a linked reduction in the proportion of ulcers that are severe at first expert assessment (FEA) (from 48% to 43%, Chart 4a) and the subsequent decrease in the proportion of ulcers still active (not healed) at 12 weeks (from 49% to 40%, see Summary chart 1, below). This suggests that the NDFA focus on prompt referral to the specialist team has been effective.

There is still much work to do. Variations in 12 week outcomes persist (Appendix 5.7); there are gaps in service provision, particularly in multi-disciplinary foot care service (MDFS) integration with renal services (Table 1); and it is notable that almost 1 in 5 people (18%) presenting with a severe ulcer are dead or have undergone major amputation within 1 year (Chart 8).

1.2. Recommendations

To help guide service improvement, the NDFA has listed recommendations that aim to further improve foot care provision and outcomes. The NDFA also supports the recommendations in the 2020 Getting It Right First Time (GIRFT) diabetes review (2020), National Institute for Health and Care Excellence (NICE) NG19 guidance and the NHS Long Term Plan (2019). To support foot care services, the NDFA has undertaken Quality Improvement Collaboratives (QIC) with healthcare professionals (HCP) across England and Wales.

Recommendations for healthcare providers and healthcare professionals (HCPs):

Including NHS trusts, local health boards (LHBs) and independent healthcare providers (IHPs); podiatrists, diabetes specialist nurses, diabetes consultants and any HCP that works with people with diabetes.

Recommendation 1: Ensure that HCPs arrange early expert assessment of all new foot ulcer episodes.

Why? The NDFA has shown that faster referral to the specialist foot care service leads to: 1) Fewer severe ulcers (see Chart 2); and 2) Better 12 week outcomes (Chart 3).

Recommendation 2: Ensure that healthcare providers and HCPs review NDFA measures for their organisations, including time to FEA, ulcer severity at FEA and 12 week outcomes.

Why? Internal review of NDFA outcomes will help healthcare providers and HCPs identify gaps in service provision and potential areas for improvement, leading to improved care processes and better outcomes for people with diabetes.

Recommendations for healthcare commissioners:

Including the NHS Commissioning Board, integrated care systems, clinical commissioning groups (CCGs) and LHBs.

Recommendation 3: Ensure that specialist clinical services which care for foot ulcers in diabetes are accessible everywhere.

Why? GIRFT recommendation 11 (2) states that: All trusts should have a dedicated multi-disciplinary footcare service (MDFS) as stated in the NHS Long Term Plan (3) and NICE NG19 (4).

Recommendation 4: Ensure that healthcare providers and HCPs have effective integration between different clinical groups: in the community and with different specialist expertise.

Why? The NDFA has identified a lack of integration between different services: For example, only 33% of healthcare providers confirmed that the MDFS was integrated with renal services and dialysis units (Table 1).

Recommendation 5: Healthcare commissioners should ensure that diabetic foot care training and education is available to all HCPs who provide services to people with diabetes and is available across all healthcare settings and services.

Why? Only 76% of providers confirmed that regular training was provided to ensure that people at increased risk of foot ulceration are both identified and have access to appropriate protective surveillance (Table 1).

Notes: (1) NICE NG19 Recommendation 1.4.2. (2) GIRFT Programme National Specialty Report: Diabetes (2020) Recommendation 11, p.11. (3) NHS Long Term Plan (2019), 3.81. (4) NICE NG19 Recommendation 1.2.1.