Patients with Diabetes Foot Care Commissioning Guidance and Sample Service Specification

Patients with Diabetes Foot Care Commissioning Guidance and Sample Service Specification Author: Abigail Kitt Email: england.secscns@nhs.net Web: www.secscn.nhs.uk Page 1

Version Date Details/provenance/comments Author Sent to 0.1 19/5/15 Sent to Liz for formatting Abigail Kitt Liz Wigzell 0.2 20/5/15 Document into template Liz Wigzell Abigail Kitt 0.3 31/7/15 Sent to David Lipscomb for comment Abigail Kitt David Lipscomb/Jackie Huddleston 0.4 26/8/15 Incorporating Jackie Huddleston comments and further formatting for final review Jackie Huddleston Abigail Kitt 0.5 27/8/15 Further amendments made Abigail Kitt SCN website and all CCGs Table of contents Introduction... Error! Bookmark not defined. Diabetes in England... Error! Bookmark not defined. Diabetes Community Health Profile across SE CVD SCN... Error! Bookmark not defined. Diabetes Foot Disease... Error! Bookmark not defined. Diabetes Foot Disease across the South East... Error! Bookmark not defined. Major amputations across the SE CVD SCN... Error! Bookmark not defined. Rationale for revised commissioning... 7 Expected numbers of patients for the service... 7 Commissioning the integrated pathway... 9 Sample Service Specification... 11 Purpose, role and service population... 11 Main aims of service... 11 Scope of service... 12 Identification and referral... 12 Risk stratification... 13 Service delivery... 14 Foot Protection Team/Service... 15 Page 2

Staff and competencies... 17 Patient education... 19 Quality Standards and Activity Indicators... 21 Continual service improvement... 21 Service pathway... 22 References... 24 Page 3

Introduction Page 4

Introduction This Commissioning Guidance has been developed by the South East Strategic Clinical Network Diabetes Foot Care Subgroup to provide support to commissioners with reviewing, specifying, commissioning and monitoring diabetic foot care services. The sample service specification contained within this document provides guidance only on what could be within a contracted service specification and is based on national best practice guidance. Diabetes in England Diabetes is an increasingly urgent health issue and from 1996, the number of people living with diabetes has more than doubled with an estimated UK average of 6% of the population diagnosed with diabetes. General practices register the number of people with diabetes as part of the Quality and Outcomes Framework (QOF) and prevalence figures show that 2.7 million people in England had been diagnosed with diabetes in 2013. Diabetes Community Health Profile in the South East Cardiovascular Strategic Clinical Network In 2011/12 there were just under 200,000 people aged 17 and over diagnosed with diabetes in South East Coast Strategic Clinical Network (QOF). The prevalence of diagnosed diabetes in the SE SCN is 5.4%-lower than cross England (5.8%). Diabetes Foot Disease In England an estimated 5-7% of people with diabetes are thought to have current or past foot ulceration. Other estimates suggest that around 61,000 people with diabetes are thought to have foot ulcers at any given time. Only two thirds of diabetic foot ulcers heal without surgery and up to 28% may result in amputation. Recurrence rates for foot ulcers remain high with an estimated 70% developing a new ulcer within a 5 year period. Around 6000 people with diabetes have leg, foot or toe amputations each year in England which equates to over 120 amputations each week. Ulcers and amputations impact hugely on quality of life and high mortality. Following primary ulceration, 5 year mortality rates have been estimated to be 42-44% and following amputation, they are estimated to be 68-79%. The mortality associated with diabetic lower extremity amputation is higher than the most common cancers in terms of 5 year survival. Other significant factors include low self-esteem and high levels of depression. Diabetic foot disease is also a strong indicator for cardiovascular health risk. The NHS expenditure on diabetic foot disease is equivalent to approximately 1 in every 175 spent by the NHS in England. Total expenditure on healthcare related to foot ulceration and amputation in diabetes in 2010-2011 in England is estimated at 580.5 million. Page 5

Diabetes Foot Disease across the South East Page 6

Diabetes Foot Disease across the South East The picture across the South East reflects the impact that diabetes foot disease has on the nation. The expenditure for lower extremity amputations (excluding ulcers, rehabilitation and social care costs) cost the NHS in the South East over 4 million in the year 2013/14. (Figures based on Kerr M 2014). There remains a significant variation in amputation rates across Kent & Medway, Surrey and Sussex with the rest of England. There is a strong body of evidence (Kerr M 2014) that suggests that up to 80% are preventable through improved awareness among people with diabetes about their risk status and the actions to take, in addition to access to good quality structured care. Major amputations across the SE CVD SCN Data from Public Health England: Diabetes footcare activity profiles (July 2015) CCG Major Amputations per 1,000 diabetic patients April 2010- March 2013 Major Amputations per 1,000 diabetic patients April 2009 March 2012 Major Amputations per 1,000 diabetic patients April 2011 March 2014 England Average 0.9 0.9 0.8 NHS Ashford CCG 1.6 (26) 1.3(21) 1.3(22) NHS Canterbury & 0.8 (24) 0.8 (22) 1.0(29) Coastal CCG NHS South Kent 1.4 (44) 1.4 (43) 1.0 (34) Coast CCG NHS Thanet CCG 1.4 (31) 1.6 (36) 1.2 (29) NHS Swale CCG 0.9 (15) 1.1 (18) 1.0 (17) NHS Medway 0.8 (37) 0.8 (37) 0.8 (34) CCG NHS Dartford, 0.7 (25) 0.8 (26) 0.6 (23) Gravesham & Swanley CCG NHS West Kent 0.8 (44) 0.8 (44) 0.7 (41) CG North West Surrey 1.3 (57) 1.2 (48) 1.3 (57) CCG Surrey Downs 0.8 (27) 0.7 (22) 0.7 (22) CCG Surrey Heath CCG 0.5 (6) 0.5 (6) 0.7 (8) North East 0.5 (12) 0.7 (17) 0.5 (13) Hampshire & Fareham CCG Guildford & 0.8 (18) 0.7 (16) 0.8(17) Waverley CCG East Surrey CCG 0.8 (15) 0.8 (15) 1.0 (19) Horsham & Mid Sussex CCG 0.8 (20) 0.6 (11) 0.6 (15) Page 7

Crawley CCG 0.5 (9) 0.6 (11) 0.5 (9) Coastal West 1.0 (71) 1.0 (71) 0.9 (71) Sussex CCG Brighton and Hove 1.0 (31) 0.9 (27) 1.0 (32) CCG High Weald, 0.4 (8) 0.5 (10) 0.6 (12) Lewes & Havens CCG Hastings & Rother 1.6 (42) 0.9 (24) 1.0 (27) CCG Eastbourne, Hailsham & Seaford CCG 0.9 (27) 1.7 (43) 1.7 (47) South East Total 589 568 578 The areas in red show the CCGs that have above national average number of amputations Rationale for revised commissioning Commissioners need to commission the integrated diabetes foot care services pathway in accordance with the aims of the Five Year Forward View (NHS England 2014) which calls for: Networks of care-not just organisations Out-of-hospital care becomes a much larger part of what the NHS does Services being integrated around the patient Introducing and evaluating new care models to establish which produce the best experience for patients and the best value for money To also consider the Quality Statements 10 and 11 (Diabetes in adults quality standard NICE 2011) and the CCG Outcome Indicators Set, Domain 2.2.8 (Health and Social Care Information Centre 2015). Commissioners are required to identify both potential gaps in current service provision and projected need e.g. the anticipated number of patients who will require the service. Expected number of patients for the service Page 8

Table 1 has been based on estimates from the NICE Commissioning Guide for Diabetes Foot Care services (2006). From the Diabetes Prevalence Model for England (National Diabetes Information Service) the data for estimates of people aged 16 or older who have diabetes (diagnosed and undiagnosed) is available from the CCGs. Example: The resident population for 2012 for NHS Eastbourne, Hailsham and Seaford CCG demonstrated a resident population of people with diabetes to be 12,352. Using table 1 estimates, the following table 2 below shows approximate number of appointments required by a diabetes foot care service in the Eastbourne, Hailsham and Seaford CCG based on NICE guidelines. Table 2 Risk level Number of diabetes Frequency of Number of patients review appointments appts per annum Low risk 7411 1 7411 Increased risk 3273 4 13092 High risk 1235 12 14820 Likely to require emergency foot care 432?? This document is in line with the NHS England diabetes sample service specification (NICE 2014), the Commissioning Diabetes Foot Care Services (NHS Diabetes 2011) and the Foot care services for people with diabetes: Commissioning Guide (NICE CG10 NHS 2006). Best practice published by NICE will inform this sample service specification throughout. The sample service specification aims to deliver equity of access to foot care for people with diabetes. This will be achieved by the provision of the integrated foot care pathway that spans across primary, community and secondary services. This will ensure that the care required will be provided by the most appropriate and competent staff no matter the severity, urgency or progression of their disease. The sample service specification details the following services of an effective foot care pathway in an integrated model across primary, community and secondary sectors: Prevention of active disease of the foot in those at increased risk Treatment of active disease of the foot Management of the person whose foot disease has been treated The members of the Foot Protection team/service and the Multidisciplinary Foot Care Team/ Service will be detailed together with the competencies required to deliver care for people at all levels of risk of active foot disease. In addition, examples of key performance indicators to measure the impact and outcomes of the service will be provided. (see Activity Indicators, Quality Standards and Performance Management on page 12) The provider must ensure ease of access, clarity of operational hours and named clinical lead, contact number and location for diabetes foot care services. Page 9

Commissioning the integrated pathway It is anticipated that all elements of care will be available to ensure equity of access for patients. The pathways of care must ensure prompt and effective transition of care across health care organisations. The publication in 2011 of new QOF indicators for general practice, NICE guidelines CG 119 and the NICE Quality Standard 10 completes the picture for the minimum expectations for people with diabetes. (Putting Feet First Diabetes UK 2012) The delivery of the integrated pathway is based on a multidisciplinary approach which operates across primary care, community and acute hospital services. Commissioning by Clinical Commissioning Groups must be characterised by whole service provision * thus avoiding fragmentation of the service which leads to inefficiencies and ineffectiveness. *Vascular services, which are a specialist commissioning function, will be reconfigured across Kent, Surrey and Sussex in order to improve service delivery and outcomes. Vascular Provider networks will be organised into designated arterial centres and linked non-arterial centres. The arterial centres will provide arterial surgery and complex endovascular procedures and the non-arterial centres of the network will provide assessment and diagnosis of peripheral arterial disease together with day case endovascular procedures ( The Vascular Society of Great Britain and Ireland 2015). There may be different arrangements in vascular networks across the SCN. At the time of publication, the Vascular provider networks are drafting out guidelines for the management of diabetic patients. *It is vital that diabetic foot care in the vascular network is organised to enable equal access to vascular expertise for the diabetic patient at both the arterial centre and non-arterial centres. There need to be agreed protocols for the safe and efficient transfer of patients between the network hospitals. Delays due to bed shortages for transfers between centres must be avoided. Commissioners will be required to work with patients, carers and providers to identify measurable outcomes for which service providers will be held jointly accountable. Page 10

Sample Service Specification Page 11

Sample Service Specification Purpose, role and service population The purpose of the sample service specification is to outline the foot care that people with diabetes should receive at any point along the integrated care pathway and ensure equity of access to that care. The diabetes foot service should be available to any service user with a diagnosis of diabetes. Main aims of the service To provide an integrated service which complies with national service standards. The service aims to comply with the domains of the NHS Outcomes Framework. Domain 1 - Preventing people from dying prematurely Domain 2 - Enhancing quality of life for people with long-term conditions Domain 3 - Helping people to recover from episodes of ill-health or following injury Domain 4 - Ensuring people have a positive experience of care Domain 5 - Treating and caring for people in safe environment and protecting them from avoidable harm Scope of the service The primary objectives in managing diabetic foot problems are to: prevent complications to reduce morbidity and mortality; provide best possible treatment; promote rehabilitation; improve quality of life and further prevention of foot problems which involves managing medical and surgical problems. The service will provide equity of access to all people with diabetes. The service will respond to age, culture, disability and gender sensitive issues in line with local service guidance The desired outcomes for the diabetes foot service will be provided across all health sectors: Provide opportunities for all patients to access structured foot health education Prevent or delay peripheral neuropathy, peripheral arterial disease, deformity, foot ulcers, infection, gangrene and limb loss from amputation Provide opportunities for all health care professionals who come into contact with people with diabetes to acquire the necessary competencies to identify and manage people according to their risk of developing foot problems and refer appropriately to other agencies Ensure all patients with diabetes receive equitable foot care and management based on their needs Provide access to rehabilitation and physiotherapy services to improve mobility and independence Provide a pathway for the regular monitoring and management of diabetic foot disease Page 12

Provide a pathway for new active or deteriorating foot disease within 24 hours Reduce recurrence of ulcers in those who have had previous episodes of ulceration Identification and referral The provider will: Act as the main care provider and coordinator for patients with or without diabetic foot disease and will refer patients into the appropriate services when local criteria are met. Provide an initial risk assessment to be used by the provider to triage referrals directly into services where patients are experiencing issues which meet the locally defined criteria. The provider will be both the generalist and specialist provider for patients with diabetic foot disease. Patients with complications related to diabetic foot disease will be referred to other community and/or specialist services when local criteria are met. It is vitally important to ensure that timely referrals to specialist care are made for those patients with foot ulceration that require urgent medical attention. Continued support for the patient will be required after medical episode has been resolved. Referrals will be accepted from appropriately trained HCPs (local policy may differ here, e.g. self-referral, nursing homes, care homes, people who are housebound, GP referral only) Criteria for referral: diagnosed with diabetes. Risk Stratification The care to be provided as outlined in this sample specification is dependent on risk, progression and severity of the patient s condition. Based on a risk assessment, the appropriate care and who should be involved with that care is outlined. Referral and transfer of care will be integral to ensure care for patients is appropriate as their risk of foot complications increases or decreases. Risk assessment, compliant with NICE guidelines, should be carried out by a suitably trained health care professional. The outcome of an annual foot screening assessment by clinicians will facilitate and govern risk stratified foot care. Assessment of foot risk is based on history (previous amputation, amputation) and simple clinical examination (deformity, peripheral sensation and foot pulses). Patients will be stratified into the following categories based on the risk assessment: Low risk-normal sensation and palpable foot pulses Increased risk-neuropathy or absent pulses or other risk factor High risk-neuropathy or absent pulses plus deformity or skin changes or previous ulcer Active foot lesion/ulcer-ulcer, blister, break in skin; inflammation or swelling of any part of the foot; any sign of infection or systemic sepsis; unexplained pain in the foot; fractures or dislocation; gangrene of part or all of foot Based on a risk assessment, the patient will be directed, referred and delivered care by a suitably qualified health care professional member of the multidisciplinary foot care team or foot protection team/service. Page 13

Service Delivery The following section details the patient pathway and care to be delivered to patients by the provider, dependent on risk of developing foot complications within set time frames. Diabetic foot care should be delivered as defined by NICE guidelines CG10 and CG119 to all patients. Diabetic foot review-regular review The provider should: Ensure regular (at least annual) visual inspection of patient s feet, assessment of foot sensation and palpation of foot pulses by trained personnel in line with NICE guidance CG10. Classify foot risk Encourage self-monitoring and inspection of feet by patients. Provide appropriate education and support for all health care professionals providing the service. Care of patients who are currently at low risk-regular review (normal sensation, palpable pulses) The provider should: Agree a management plan in line with NICE Guidance CG10 including foot care education with each patient depending on their clinical need and consider diabetes control and modifiable cardiovascular risk factors as appropriate (Putting Feet First Diabetes UK 2012) Develop and arrange patient education programme that is patient-centred for self care of foot disease which includes when to seek help. Arrange re-assessment for risk factors for foot ulceration on a regular (at least annually) basis in either primary care or through the service. Clarify emergency access to care if the patient s risk rating changes. Provide education and support for all health care professionals providing the service. Care of patients at increased risk-3-6 monthly review (neuropathy or absent pulses or other risk factor) The provider should ensure that care of patients with increased risk should be delivered by a team of health professionals who have specialist expertise in the assessment and management of disease in the foot in diabetes in line with NICE Guidance CG10. At each 3-6 monthly review, the provider should: Inspect patient s feet Review need for vascular assessment Evaluate footwear Enhance foot care education Consider joint/integrated diabetes control and modifiable cardiovascular risk factors and refer as appropriate Ensure assessment and appropriate treatment of neuropathic pain including optimising glycaemic control and neuropathic analgesics. Care of patients at high risk-1-3 monthly review (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) Page 14

The provider should ensure that care of patients at high risk should be delivered by a team of health professionals (Foot Protection Team/Service*), who have specialist expertise in the assessment and management of disease of the foot in diabetes in line with NICE Guidance CG10. At each 1-3 monthly review the provider should: Inspect patient s feet Review need for vascular assessment Ensure special arrangement for access to a suitably qualified team or health care professional for those people with disabilities or immobility. Consider joint/integrated diabetes control and modifiable cardiovascular risk factors and refer as appropriate Ensure assessment and appropriate treatment of neuropathic pain including optimising glycaemic control and neuropathic analgesics. Evaluate provision and provide appropriate intensified foot care education, specialist footwear and insoles, and skin and nail care. Foot Protection Team/Service The aim of a Foot Protection Service is to prevent first and further ulceration, hospital admission and reduce the risk of lower extremity amputation in people with diabetes who are classified at increased risk. This service will introduce or review a treatment/management plan, based on individual needs and formed in partnership with the person with diabetes. Patients with active or ulcerated feet should have care offered and provided within 24 hours. Providers should ensure that on clinical presentation of active foot disease, the following care should be provided to patients in line with NICE guidelines CG10: Initial assessment within 4 hours Investigation of suspected diabetic foot infection Debridement, dressings and off-loading Assessment of suspected critical limb ischaemia. A suitable named health care professional should be accountable for the overall care of the patient and for ensuring that healthcare professionals provide timely care. The named health care professional should refer a patient to a multidisciplinary foot care service within 24 hours of the initial examination of the patient s feet. Transfer for the responsibility of care to a named member of the MDFT/service is expected if a diabetic foot problem is the dominant clinical factor for inpatient care. Foot Care Emergencies-Care provided within 24 hours Providers should ensure that on presentation with a foot emergency, the following care should be provided to patients in line with NICE Guidance CG119: Investigate and treat vascular insufficiency* Initiate and supervise wound management Use dressings and debridement as indicated; Use systemic antibiotic therapy for cellulitis or bone infection as indicated Orthotics, casts and specialist footwear Try to achieve optimal glucose levels and control of risk factors for cardiovascular disease. Page 15

With the anticipated reconfiguration of vascular services, it is vital that diabetic foot care in the vascular networks is organised to enable equal access to vascular expertise for the diabetic patient at both the arterial centre and the non-arterial centres (Recommendations of the Vascular Society of Great Britain and Ireland.) Rapid response to foot ulcer requiring urgent medical attention It is vital that those patients with a foot ulcer that requires urgent medical attention is seen and treated within 24 hours by a member of the multidisciplinary diabetes foot care service. (NICE Quality Statement 10). The MDFT requires a named clinical lead to take responsibility for the patient and co-ordinate the management plan accordingly. Hours of Operation Every diabetes foot care service across the SCN should have clearly stated operational hours and clearly stated arrangements for weekends and bank holidays. In addition the location for the MDFT should be clearly stated. The named clinical lead and dedicated phone line availability need to be clearly stated for both the MDFT/Service and the FPT/service. Staff and competencies The service, which includes Primary care, the Foot Protection Service and the Multidisciplinary Foot Care Service should ensure that all appropriate health care professionals involved with the diabetes foot care service have the competencies in line with NICE Guidance CG10, TRIEPod-UK and the Putting Feet First: national minimum skills framework.(2011) Annual and regular reviews and service users classified at low risk The HCP(s) delivering a regular or annual review or care to a patient at low risk should have the competencies required for annual foot screening which normally occurs in primary care. The training should be evidence-based and quality assurance mechanisms in place on an annual basis. The FPT/service and/or the MDFT/Service members should be involved with the delivery of training. The HCP requires the competencies to: Identify the presence of sensory neuropathy Identify when the arterial supply to the foot is reduced Identify deformities of the foot that may put it at risk Identify other factors that may put the foot at risk (e.g. poor foot health behaviours) Discuss with the patient their individual level of risk and agree plans for future surveillance and supported self-management Initiate appropriate referrals and transfer for expert review of those with increased risk Advise on action to be taken in the event of a new ulcer/lesion Advise on the use of footwear that will reduce the risk of a new ulcer/lesion Advise on other aspects of foot care that will reduce the risk for a new ulcer/lesion Arrangement for Continuing Professional Development should be specified and agreed with the provider. Members of the FPT/Service and/or the MDFT/Service should be involved with CPD both in delivery and active participation. The training needs to be offered to other organisations who care for people with diabetes (Nursing homes, residential homes, community podiatry and others). Page 16

In addition there will need to be arrangements in place for appropriate induction for new staff and planned development training. Increased or high risk The role of the FPT/Service or MDFT/Service that provides annual and regular reviews and provides care to service users at increased or high risk includes the following competencies: Specialist surveillance of people at risk (including hospitalised inpatients) Education of other health care professionals in routine examination and risk identification and stratification. Close liaison with specialist foot care multi-disciplinary teams Management of selected cases of foot disease in the community Sharing care with specialist foot care multi-disciplinary teams of selected cases of foot disease Sharing long-term management with other health care professionals of people with successfully treated disease Discussion and agreement of plans to support the service user in managing their condition The team/service providing this care should be contactable by telephone, fax or email and their identity and contact details should be readily available to other health care professionals working in the community. Care of people with foot care emergencies and active foot ulcer Providers should ensure that care of patients with foot care emergencies and active ulceration should be delivered by a specialist multidisciplinary tam of health professionals. Specialist multidisciplinary teams should comprise of specialists with relevant complementary skills who work together or in close communication with each other. The team must include, or have ready access to, members of the following: Medical: diabetologists Surgical: vascular, orthopaedic and plastic surgeons Urgent inpatient facilities Antibiotic administration Other medical staff including microbiologists Diagnostic and interventional radiologists Podiatrists and surgical podiatrists Diabetes specialist nurses Nurses with training in dressing of diabetic foot wounds Plaster room technicians Orthotists Pharmacists Physiotherapists The specialist multidisciplinary team should be able to provide the following services: Consultation concerning the prevention or management of active foot disease Supervising the management of selected cases with active foot disease of both inpatients and outpatients and patients in the community where necessary Coordinating care and education of foot disease in diabetes. Page 17

Patient Education Education is an essential element in the empowerment of people with diabetes. Foot care should be considered an important part of self-care in people with diabetes, and as much part of a self-care routine as blood glucose control. Patient education and information needs to be tailored to meet each individual s needs. Different levels of education, care and support will be required by people with diabetes. (NICE CG10 2014) A person with diabetes should expect to be offered information about the following: What they can expect in terms of care* Self-care and self-monitoring When and where to seek advice -Details of the health care professional (HCP) to contact if an individual feels their condition has changed and they need advice before their next routine appointment -Details of an alternative (out-of-hours) contact if an emergency arises (such as a new ulcer) and the usual contact professional is not available. The possible consequences of neglecting the feet Management of symptoms (e.g. pain) Other information about foot care and other aspects of diabetes should be offered as needed (NICE CG10 2014) Useful documents include: What care to expect at your annual foot check (Diabetes UK) Ten steps to healthy feet (Diabetes UK) The Touch the Toes Test (Diabetes UK) Equipment There need to be arrangements in place for upgrade and maintenance of relevant equipment and facilities. In the delivery of care there must be prompt access to microbiological services and advice; prompt access to either non-arterial or arterial centres for imaging and vascular services and advice; close liaison with orthotic services for orthotics and specialist footwear and off-loading devices; prompt access for casting requirements. Transfer of care criteria This model of care (Putting Feet First Diabetes UK) is reliant on the seamless integration of generalist and specialist services. To achieve this it will be essential that patient records are integrated and wherever possible shared or owned by the person with diabetes-and the two elements have good communication mechanisms to allow for continuity of care. Integration can be further supported by formal arrangements for specialists to support generalists through: Telephone direct number e.g. dedicated times for taking calls for advice. For older frail people with diabetes, there should be arrangements in place for coordination between health and social care services. Transport services should also be made available as required. The provider must ensure ease of access, clarity of operational hours and named clinical lead, contact number and location for diabetes foot care services Page 18

Quality Standards, and Activity Indicators Page 19

Quality Standards and Activity Indicators The provider is required to deliver care according to the standards for clinical practice set by NICE. The service is required to deliver the outcomes for diabetes as determined by the NHS Outcomes Framework. The following indicators should be considered and monitored by commissioners to ensure safe, high quality care is provided. (CCG relevant outcome indicators included and QS 10 and 11 NICE) Activity Indicator Description Threshold Source Foot screening Transfer of care Proportion of patients with diabetes who have received foot screening and have been risk classified within the last 15 months No. of patients discharged from the MDFT QOF data Internal Key Performance Indicators Incidence No. of new episodes of foot disease Internal and National Diabetes Foot Audit Incidence No. of new cases of foot disease arising in in-patients with diabetes cared for hospitals, nursing and care homes National Diabetes Foot Audit GP database Number of hospital admissions for diabetic foot problems Internal/National Diabetes Audit No. of bed days for Diabetes foot disease Proportion of patients with active foot disease were seen by a member of MDFT within 24 hours Internal Data from outpatients and data from inpatients Proportion of patients where foot ulcer was the primary reason for hospital admission Proportion of patients admitted to hospital with diabetes who had a foot examination within 24 hours of admission Proportion of patients who have had an LEA and been discharged back to a foot protection programme National Audit Internal Internal Diabetes Page 20

Number of patients who have presented with a new presentation of active Charcot foot Outcomes Patient Feedback on satisfaction, experience and health status Internal Internal Outcomes Incidence of ulcer healing by a fixed time, or time to healing Being ulcer free at 12 months Internal Internal Quality Standards Foot examinations Management Plan Ulceration Amputation Wait time Treatment Percentage of patients with diabetes with a record of a foot examination and risk classification Percentage of patients who have a record of an agreed management plan (including foot health education) in the previous 15 months Percentage of patients with recorded diabetes with feet at high risk of ulceration Percentage of patients with recorded diabetes with a new ulcer in the previous 12 months Percentage of patients with recorded diabetes with a new below ankle amputation in the previous 12 months Percentage of patients with recorded diabetes with a new above ankle amputation in the previous 12 months Percentage of patients assessed by team within 12 weeks of first presentation to a Health Professional Percentage of patients assessed by team within 24 weeks of first presentation to a Health Professional Percentage of patients with active ulcer 12 weeks after presentation Percentage of patients with active ulcer after 24 weeks after presentation QOF and National Diabetes Audit NICE Audit criteria NICE Audit criteria/ QOF NICE Audit Criteria NICE Audit Criteria NICE Audit Criteria National Diabetes Foot Audit (NDFA) NDFA NDFA NDFA Page 21

Mortality Percentage of patients alive 12 weeks after presentation Percentage of patients alive after 24 weeks after presentation NDFA NDFA Additional outcome measures may be considered. Currently Quality of Life indicators are not included in the National Diabetes Audit. However other patient centred resources may be considered. The LTC6 (longterm conditions) questionnaire considers the healthcare that has been provide over the last 12 months. It considers the experience of the patients, the care that they have experienced and the support provided to provide their own self-care. (LTC6 Questionnaire The Health Foundation NHS) Continual Service Improvement Providers are expected to have an internal quality assurance and risk management process that assures the commissioners of its ability to manage the risks of running the service. The service will identify a method of agreeing measurements for continuous improvement of the service being offered and work to ensure unmet need is identified and brought to the attention of the commissioner. Providers should: Ensure that appropriate failsafe mechanisms are included across the whole pathway Review and risk assess the service. Set out date and a mechanism for review. Work with the Commissioner and Quality Assurance Teams to develop, implement, and maintain appropriate risk reduction measures Ensure that mechanisms are in place to regularly audit implementation of risk reduction measure and report critical incidents Ensure that appropriate links are made with internal governance arrangements, such as risk registers Ensure that routine staff training and development is undertaken with the key involvement of the Foot Protection team/service and the Multidisciplinary Foot Care team/service Providers should participate fully in any local of National Quality Assurance processes and respond in timely manner to any recommendations made. This will include the submission to QA teams and commissioners of: Data and reports from external quality assurance schemes Minimum data sets Self-assessment questionnaires/tools and associated evidence Audits or data relating to nationally agreed internal quality assurance processes Where national recommendations and acceptable/achievable standards are not currently fully implemented, the provider will be expected to indicate in service plans what changes and improvements will be made over the course of the contract period. The provider should develop a continual service improvement plan (CSIP) in line with the performance indicators and the results of internal and external quality assurance checks. The CSIP will respond and any performance issues highlighted by the commissioners, having regard to any concerns raised via any service user feedback. The CSIP will contain action plans with defined timescales and responsibilities, and will be agreed with the commissioners. Page 22

SERVICE PATHWAY Urgent referral MDFT Admit deep infection ACTIVE DISEASE Admit vascular compromise Admit acute Charcot Investigations and Imaging Antibiotics offloading 1-3 monthly review FPT/Service HIGH RISK Podiatry Agree self management plan Vascular assessment Special arrangements for disability Diabetes control and modifiable cardiovascular risk factors Treatment of neuropathic pain Specialist footwear and orthotics 3-6 monthly review by FPT/Service INCREASED RISK Podiatry Agree self management plan Vascular assessment Neuropathy assessment Evaluate footwear Diabetes control and modifiable cardiovascular risk factors Annual Foot screen by Primary Care LOW RISK Risk factor identification Inspect footwear Education Page 23

References Page 24

References 1. FIVE YEAR FORWARD VIEW-NHS ENGLAND www.england.nhs.uk/wp-content/uploads/2014/10/fyfvweb.pdf 2. Diabetes in adults quality standard NICE (2011) 3. CCG outcome indicator set. Health and Social Care Information Centre (2015) 4. NHS England diabetes sample service specification NICE (2014) 5. Commissioning Diabetes Foot Care Services NHS Diabetes (2014) 6. Foot Care Service for people with diabetes: commissioning guide NICE CG 10 NHS (2006) 7. NICE CG119: www.nice.org.uk/nicemedia/live/1346/53558/53558.pdf 8. NICE CG10:www.nice.org.uk/CG10 9. NHS Commissioning Diabetes Foot Care service Specification. NHS Community Assembly (2014) 10. The Provision of services for Patients with Vascular Disease. The Vascular Society of Great Britain and Ireland (2015) 11. The APPG Report on Vascular Disease (2014) 12. Diabetes UK Putting Feet First Integrated Care Pathway (2012) 13. Diabetes UK Fast track for a foot attack : reducing amputations (2013) 14. National Minimum Skills Framework:www.diabetes.org.uk/Documens/Professionals/Education%20&%20skills/NMSF-2011 15. Podiatry competency framework for integrated diabetic foot care: a user d guide. McCardle J.,Chdwick,P.,Leese G.,McInnes A., Stang D.,Stuart L and Young M. (2012) SB Communications Group, London UK 16. The LTC6 Questionnaire. The Health Foundation NHS. Key Documents 1. NICE CG119 Diabetic foot problems-inpatient management of diabetic foot problems 2. NICE CG10 Type 2 Diabetes-Foot Care 3. NHS Diabetes: Commissioning Diabetes Foot Care Services Diabetes Service Specification (2014)- NHS Commissioning Assembly 4. The Provision of Services for Patients with Vascular Disease 2014. The Vascular Society of Great Britain and Ireland 5. The APPG Report on Vascular Disease (2014) 6. Putting Feet First: Fast track for a foot attack: reducing amputations 2013 (Diabetes UK) 7. Service for people with diabetes with a diabetic foot: NHS London Strategic Clinical Networks Page 25