National Diabetes Foot Care Audit 2018 to 2023

NDFA patient-level information on care processes and outcomes is collected through the NHS England Clinical Audit Platform (CAP) and covers patients in England and Wales with foot ulcers that underwent first expert assessment (FEA) by a specialist foot care service from 14 July 2014 onwards. Data collection began in December 2014.

The Audit also measures the provision of foot care services using the NDA Integrated Specialist Services Survey (ISS survey, abbreviated to ISS), a questionnaire based on National Institute for Health and Care Excellece (NICE) and Getting it Right First Time (GIRFT) recommended structures and systems for delivery of care to people with diabetes. 

2023 ISS data was collected by the NHS England Strategic Data Collection Service (SDCS). The survey was distributed to healthcare providers in England and Wales in October 2023, requesting data on how services were structured as of 1 October 2023. The foot care section of the questionnaire comprised 11 questions on aspects of care delivery which were selected by clinical members of the NDFA Advisory Group.

This report uses ulcer episodes with a date of FEA between 01 April 2018 and 31 March 2023. Results have been split by audit years running from April to March, based on FEA (e.g. 01 April 2018 to 31 March 2019, abbreviated to 2018-19).

In some cases, additional filters were applied during cohort selection, e.g. to ensure an essential data item was available or that sufficient episodes were present.

It is difficult to assess the level of participation in the NDFA, as there is no definitive list of organisations that provide specialist diabetic foot care services in England and Wales.

284 specialist foot care services from 157 healthcare providers have submitted to the Audit between 01 April 2018 and 31 March 2023. The organisation types of the 157 healthcare providers are listed below:

• 106 acute NHS trusts
• 16 non-acute NHS trusts
• 29 independent healthcare providers (IHP)
• 6 Welsh local health boards (LHB)

For context, there were 214 NHS trusts in England at the end of the audit period (31 March 2023), which includes acute, mental health, ambulance, community and care trusts. There were 7 LHBs in Wales. As noted, it is not known how many healthcare providers have specialist diabetic foot care services, so provider participation cannot be accurately calculated.

During the audit period assessed in this report, the mean number of ulcer episodes submitted to the NDFA is 777.4 per healthcare provider (median 575), ranging from 5 to 4,150 with an interquartile range (IQR) of 255 - 1,130. 11.5% of healthcare providers submitted fewer than 100 ulcer episodes to the NDFA. 

74.5% of healthcare providers submitted to all 5 audit years between 2018-19 and 2022-23. On average, healthcare providers submitted in 4.5 of 5 NDFA audit years.

159 providers responded to the 2023 ISS: 147 NHS trust sites, 1 independent sector provider, 1 NHS trust, 10 LHB sites.

For comparison, there were 213 NHS trusts and 7 LHBs in England and Wales on 1 October 2023 (the date of ISS assessment), although some healthcare providers (e.g. mental health or ambulance trusts) would not be expected to contribute to the ISS.

A total of 122,030 ulcer episodes in 106,880 people with diabetes have been registered with the NDFA during the 2018-19 to 2022-23 audit period. Since 2019-20 the number of ulcer episodes has remained relatively stable at around 25,000 per year. There was a slight decrease in ulcer episodes registered in 2022-21, to around 22,000, coinciding with the COVID-19 pandemic. 

Using the annual caseload estimates provided by NDFA submitters in the 2018 NDFA Provider Survey, the NDFA 4th Annual Report estimated 2017-18 case ascertainment to be 20% (slide 14), with a lower percentage in earlier collection years. By 2019-20 the number of patients submitted to the NDFA had risen by 50% since 2017-18, so case ascertainment is estimated to be around 30% in later audit years.

Probable low case ascertainment should be considered when interpreting NDFA findings, with acknowledgement that:

• The patients submitted to the NDFA may not be representative of the entire population of people with diabetic foot ulcers, though there is not presently any evidence to suggest that this is an issue.
• Counts presented in the NDFA are likely to underestimate the true national figure.

Data collected via the CAP and SCDS systems was subject to validation checks on upload, preventing erroneous values from being entered.

HES and PEDW are databases containing details of all admissions, outpatient appointments and accident and emergency (A&E) attendances at NHS hospitals in England (HES) and Wales (PEDW). NDFA patients were linked to hospital admissions data in HES and PEDW, with admissions data available up to 30 September 2023 (HES) and 30 June 2023 (PEDW).

Linkage to Welsh hospital data (PEDW) involved only Welsh patients, derived from the location of the foot care services which had registered the patient's FEA in the NDFA. Therefore, Welsh hospital admissions were only available for people assessed at foot care services in Wales, and any Welsh hospital admissions of people seen by an English foot care service were not included in the audit analyses.

Patients were linked to an NHS England feed of civil registration (mortality) data where the person had an ulcer episode registered in the NDFA with a date of FEA from 01 March 2018 onwards. 

NDFA processes and outcome collection data was extracted from CAP on 25 August 2023. The 2023 ISS survey was open between 09 October and 17 November 2023.

The NDFA report for the period 01 April 2018 to 31 March 2023 was published on 16 May 2024. The time lag to publication was therefore 13 months after the end of the audit period, 9 months after the submission deadline and 6 months after the close of the 2023 ISS survey.

This report is presented in HTML format on the NHS England website. Supplementary materials are published in Excel format. 

In November 2023 a new dashboard was made available to enable interrogation of the data: National Diabetes Audit dashboards

Further information about the audit can be found:

https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-foot-care-audit

This report is the 7th NDFA publication on diabetes related foot disease in England and Wales. All NDFA reports can be found here:

National Diabetes Footcare Audit

The reports all cover multiple years and consequently, data from many of the same patients and ulcer episodes will have been included in earlier reports.

Disclosure control

Disclosure control has been used for numbers derived from patient / ulcer records to reduce the risk of patient identification; numbers 1-7 are shown as 5, while all other numbers are rounded to the nearest 5. Means and percentages have been be calculated using rounded numerators and denominators and are shown to 1 decimal place. The calculated value will not be shown in cases where the denominator is less than or equal to 20.

The most pronounced differences caused by rounding are a result of percentages derived from small denominators (e.g. 20) with small numerators (e.g. 1), with the numerator rounded-up to 5. This scenario is most likely with a low frequency event (e.g. major amputation or 6 month mortality) in a small cohort (e.g. split by organisation).

ISS survey

The ISS survey was first undertaken in 2020 and first used in the NDFA in 2021.

NDA Core collection

The core NDA reports on foot assessments for people with diabetes, but does not cover the process and outcomes information collected in the NDFA. 97.7% of NDFA patients were found in the core NDA demographics table for 2022-23.

Other data sources

The use of other data sources to identify specialist foot care services is limited. In HES/PEDW there is not the specificity of coding necessary to identify specialist foot care services from other diabetes related outpatient clinics or community podiatry services. The National Diabetes Inpatient Safety Audit (NDISA) includes information about foot care services, initiatives and multi-disciplinary foot teams (MDFTs) in hospitals, but is focussed on inpatient care only, not the specialist foot care services of interest to this audit.

Efforts have been made to reduce the burden on participating teams by the inclusion of linked data from other available data sources. By linking NDFA to the core NDA, a reduced number of data items are required from audit participants, and linking to HES, PEDW and ONS mortality data enables further analysis of patient outcomes without increasing the data collection requirements. 

However, it is acknowledged that participation in the audit does involve costs in time and organisation for the providers that participated, and the NDFA continues to look at ways in which this might be reduced in later collection periods.

The NDFA advisory group consists of clinicians, podiatrists, patient representatives, Diabetes UK and analysts from NHS England. The group provides advice on both the analysis and content of the reports as well as the direction and development of the audit. 

NHS England is keen to gain a better understanding of the users of this publication and of their needs. Your feedback is welcome and may be sent to [email protected] (please include 'National Diabetes Foot Care Audit' in the subject line).

Alternatively, you can call our contact centre on 0300 303 5678 or write to NHS England, 7 and 8 Wellington Place, Leeds, West Yorkshire, LS1 4AP.

Patient identifiable information – NHS number – has been collected in order to link information collected by the NDFA to other information about the patients’ diabetes care. Identifiable data is only released by NHS England where the release meets NHS England Information Governance procedures. More information on how NHS England uses patient data as part of the audit can be found in the National Diabetes Audit (England): Transparency Notice and National Diabetes Audit (Wales): Transparency Notice

It is expected that through the audit collection, all organisations will continue to follow existing NHS codes of practice in regard to patient confidentiality, information security management, record management and other legal obligations.

Risk assessment

A risk assessment has been carried out on the audit publication, and disclosure control has been applied. Please see the Coherence and comparability section for further detail.