Ian Reilly BSc, MSc, FCPodS, Cert MHS, DMS

Consultant Podiatric SurgeonNorthamptonshire Foundation NHS Trust

Show how the extension of podiatric practice into surgery has finally been properly recognised and how this has allowed the podiatry profession to fully realise its potential in managing biomechanical disorders of the lower limb

1. Scope of Practice

2. Titles

3. Strategies

4. Pharmacology

Qualified from Northern College in 1988 District Chiropodist 1993 – 2000

Podiatric Surgeon since 1996 Senior Lecturer in Podiatry 2000/02

Employed full time in Podiatric Surgery since 2002

Consultancy in 2004 www.podsurgeon.co.uk

The foot and associated structures

Chiropody – treatment of the (hand and) foot Podiatry or podiatric medicine is a branch of

medicine devoted to the study of diagnosis, medical and surgical treatment of disorders of the foot, ankle, and lower extremity

The term podiatry came into use in the early 20th century in the United States and is now used worldwide

▪ https://en.wikipedia.org/wiki/Podiatry

The first formalised courses in local anaesthesia were run in 1969/70

These courses lacked the formal sanction of the professional body as they were run in breach of the terms of the Chiropodists Board (1968)

▪ Borthwick, AM. Occupational imperialism at work: the case of podiatric surgery. British Journal of Podiatry. 2001 4, (3), 70 - 79

Training from US (of A) podiatrists

Nail, skin and digital surgery

Biomechanics – building on the simple insole therapy used to date

▪ Initially in private practice only (no access to NHS theatres or funding)

Nail pathology

Soft tissue masses

Toe deformities

Metatarsalgia

Hallux valgus

Hallux rigidus

Heel pain

Flat foot surgery

Ankle surgery

In the wake of GP fund–holding in the early 1990s and the emphasis on quasi markets in healthcare, podiatric surgery became an accessible, cost effective and clinically effective option (NHS recognition) Several podiatrists practicing foot surgery were

appointed to consultant level positions in the NHS▪ Borthwick, AM. Challenging Medicine: The case of

podiatric surgery. Work, Employment and Society. 2000. 14(2), 369–383

“The Department of Health thinks podiatric surgeons are wonderful because they are quick to train, cheap, and take patients off orthopaedic waiting lists”

Hawkes, N. ‘Consultants’ treading on doctors’ toes. The Times. London. Monday 30th August. 2004: 15.

HCPC Register - BSc(Hons) (3 years) Post basic experience (Diploma 2 years/MSc

3 years) Theory of Surgery - Anatomy and Physiology,

Pharmacology, Medicine, Diagnostic Imaging, Podiatry

Podiatric Surgery Trainee Part 1 - written exam: surgical principles Part 2 (2/3 years) – practical examination/viva

voce▪ FCPodS (HCPC annotation)

Registrar – Cert of Completion: CCPST (3 years)

Consultant Podiatric Surgeon

Recognition

Moves by the profession of medicine to contest the practice of invasive foot surgery by podiatrists in the UK have more recently re-focused on the legitimacy of the use of the title “ podiatric surgeon”

▪ Borthwick AM, Boyce RA, Nancarrow SA. Symbolic power and professional titles: the case of “podiatric surgeon”. Health Sociology Review. 2015.

The medical profession has argued that, because the public naturally assumes that those undertaking surgery are medically qualified, it is, therefore, clear that podiatrists who adopt titles such as “ consultant podiatric surgeon” will mislead patients

Menz, H., et al. ’Foot’ and ‘surgeon’: A tale of two definitions. Journal of Foot and Ankle Research. 2010. 3(30).

“…the public automatically assumes that anybody with this title is not only a doctor, but an extremely well-qualified one…without exception they are astonished when they find these people have no medical qualifications”.

British Orthopaedic Trainees Association

“pseudoscientists pretending to have all kinds of qualifications and quoting authorities all over the shop… a consultant podiatric surgeon is just a chiropodist who has decided to charge a bit more” Goldacre, B. (2004). It’s all in a title. The Guardian.

London. September 16th, 2004

The term “ surgeon” is legally restricted to the medically trained under the UK’ s Medical Act (1983), and a holding out clause extended to those implying they are so qualified,

It is less clear that pre-fixing the term with another identifier, such as “ podiatric”

▪ Borthwick AM, Boyce RA, Nancarrow SA. Symbolic power and professional titles: the case of “podiatric surgeon”. Health Sociology Review. 2015.

WHAT was our strategy?Where are we now?

Where do we want to be??

How will we get there???

▪ (What way is best?)

Training

Access to local anesthesia

Radiology

Drugs

Theatre access

“I saw dentistry as our role model. Once you could give an injection to do a procedure, like the dentists, you were in a class of your own. And ... I could see a need for it in chiropody...the fact that you would be knowledgeable and skilled enough to use a local anaesthetic and perform some surgery, even if you didn't do it that often, immediately put chiropody on a par dentistry. It also enabled chiropodists to do something that patients weren't able to do for themselves.”

Medicines Committee of the Society of Chiropodists and Podiatrists

And the Croydon Group/Podiatry Association

As an example of evolving practice

Supplementary Orders allowed CPSM Registered Chiropodists to access to obtain and administer - in the course of there professional practice - POMs containing:

Bupivacaine hydrochloride

Lignocaine hydrochloride

Mepivacaine hydrochloride

Prilocaine hydrochloride

… if they hold a certificate of competence in the use of analgesics (LA cert)

The (then) Chiropodists' Board and the SaCaP negotiated with the Medicines Committee an enhanced list of POMs for access, sale or supply by appropriately qualified State Registered Chiropodists The Medicines (Pharmacy and General Sale

Exemption) Amendment Order 1998

- Ibuprofen (400mg - amount sufficient for 3 days treatment)

- Co-dydramol (10/500 tablets - amount sufficient for 3 days treatment

- Amorolfine hydrochloride cream up to 0.25% w/w

- Amorolfine hydrochloride lacquer up to 5% by w/v

- Topical hydrocortisone up to 1% by w/w- Bupivacaine HCl with adrenaline - Lignocaine HCl with adrenaline

In 1998 a report on the Supply and Administration of Medicines under Group Protocols was published Patient Group Directions (PGDs) are written

instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment▪ The Report recommended that the legal position should be

clarified, and in August 2000 the relevant medicines legislation was amended

A prescriber review (Crown, 1999) sought to review the prescriber/access criteria in the UK It considered existing prescribers and potential

‘new’ prescribers and was initiated as a review of nurse prescriber pilots (and to lesser extent use of POMs by emergency paramedics)

Types of prescriber were recommended:

- Independent prescriber - unlimited access to the full range (or restricted range) of POMs

- Dependent (now supplementary) prescriber - may prescribe only if patient has received the medication previously from a RMP

- Non-prescriber - not able to prescribe

- Certain Podiatric sub-groups had a strong case for increased access (enter Dr Shipman)

Amendments to the Prescription Only Medicines Order and NHS Regulations to permit supplementary prescribing by nurses and pharmacists to come into effect on 4 April 2003; and Podiatrists, Physiotherapists and Radiographers from 2005

MHRA Date: 28 Oct 2005 Ref: MLX331 Subject: PROPOSALS FOR AMENDMENTS TO THE RANGE OF

MEDICINES WHICH CAN BE SOLD, SUPPLIED OR ADMINISTERED BY

PODIATRISTS

We are writing to consult you, in accordance with section 129(6) of the Medicines Act 1968, on proposals to amend the range of medicines which can be sold, supplied or administered by registered podiatrists…

Further meetings took place in April and May 2006…

Made 19th October 2006

Laid before Parliament 26th October 2006

Coming into force 17th November 2006

Adrenaline (Epinephrine)

Injection Administer

Registered Podiatrists only. Must

hold certificate of competence in

the use of analgesics.

Levobupivacaine Hydrochloride Administer As above

Methylprednisolone Administer As above

Ropivacaine Hydrochloride Administer As above

Plus 3 ANTIBIOTICS

Independent prescribing is defined as: Independent prescribing by an appropriate practitioner (e.g. doctor, dentist, nurse or pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing of medicines Consultation on proposals to introduce independent

prescribing by podiatrists, 15 September 2011

Scope of practiceTitlesStrategyPharmacology

Any questions?info@podsurgeon.co.uk