Feet On The Street

Providing NHS Podiatry Services to Rough Sleepers in Central

London

Healthy Feet for All!

Alison Gardiner BSc MChS HCPC RegSpecialist Podiatrist for Homeless and Vulnerable PeopleCentral London Community Healthcare.

Group Task

• It’s difficult to look after your feet on the street! What challenges would you encounter ?

• What foot problems might you be more likely to develop?

Foot Facts• The foot contains 26

bones, 100 ligaments, 33 joints & 20 muscles

• The average person walks 4 miles every day

• Feet produce an eggcup full of sweat every day…

Some common foot conditions...

Corns and calluses (plantar, interdigital , dorsal)

Toe deformitiesClawed, hammer, mallet, overriding, burrowing,polydactyly, syndactyly

Verruca

Bunion

Fungal skin infection

Fungal nail infection

Cracked heels

Infected ingrowing toenail

Flat Feet

High arched feet

Trench FootAdvise to air feet, leather shoes, change socks

Blisters

Less common foot conditions Malignant melanoma and tuberculosis

Diabetes and Feet• 3.6 million diagnosed cases in the UK but many

more undiagnosed

• Black and ethnic minority groups higher rates

• Social exclusion/ deprivation/ mental health problems/learning difficulties higher rates

• Most common cause of amputation of the lower limb in the UK

• 150 amputations every week in UK

Diabetes can cause• Peripheral neuropathy (numb

feet)• Peripheral vascular disease

(poor circulation)• Ulceration, infection, gangrene

and amputation

This can be prevented by• Good diabetic control• Diabetic foot health education• Yearly diabetic neurovascular foot assessment by

nurse, gp, podiatrist• Quick access to podiatry/healthcare for any

problems

Diabetic foot ulcers

May be painless if feet are numb

Central London Community Health Care

Homeless Podiatry Service

• Alongside nurse led CLCH Homeless Health Team provision

• Easy access. Drop in• 5 sessions a week in homeless day centres• Good links with specialist pods in mainstream• Westminster and Hammersmith & Fulham• Hostel visits for housebound• Foot health promotion/screening in day

centres/hostels• Training for hostel/day centre staff• Promote access of vulnerable people to mainstream

service. Training for pods in mental health, working with interpreters etc. Undergraduate placements and teaching University of East London

• NEW! Vulnerable SOP (Standard Operating Procedure)

Why are homeless peopleso prone to foot problems?

• Alcohol. Peripheral neuropathy, increased risk of diabetes and osteoporosis, poor immunity, assault, accidents. Wernicke Korsakoff Syndrome

• Drugs. Infection of injection sites, thrombosis, HIV, chaotic lifestyle

• Sleeping on buses/benches. Peripheral dependent oedema

• Asylum seekers. Conditions rarely seen in UK. Polio, TB, leprosy, rickets, polydactyly, untreated talipes(club foot), industrial/agricultural accidents, torture

• Carrying heavy bags• Increased risk of diabetes & diabetic complications.

• Finance. Lack of money for shoes, socks and clippers, cheap shoes man made materials. Pulling off nails, sharing clippers.

• Not removing shoes/socks at night. Fear of theft, self neglect, need move quickly, constantly ‘on the go’. Trench foot. Fungal infection, blisters

• Self treating due to lack of podiatry access with blades, knives, acid based corn plasters. Ulceration. Infection and scarring

• Smoking• Sharing showers. Verrucae• Walking long distances. Stress. No choice! Blisters,

biomechanical problems

• Mental health issues resulting in self neglect. Difficulty engaging with workers.

• Difficulty in maintaining good hygiene. Scabies, infections (fungal, bacterial and viral)

• Exposure to elements. Cold/wet/heat• Poor nutrition. Poor healing and infection• Difficulty accessing healthcare and podiatry

• Banned from services due to behavior• Perceived or actual insensitive treatment by

medical staff / receptionists• Embarrassment• Language barriers• Illiteracy• No glasses• No internet access• Maslow’s Hierarchy of Need

CASE STUDIES

CLCHHomeless Podiatry Service

• 39 year old male

• Alcoholic, multiple drug user

• Fracture left leg at 24, no physio, led to clawed toes & plantar corn

• Self treated corn with razor blade

• Infection & hospitalisation

• Corn removed, advice, physio/orthopaedic/podiatric surgery referral, orthopaedic shoes, insoles?

• 50 year old Asian male

• NIDDM, peripheral neuropathy, heart disease

• Neuropathic foot ulcer, Charcot foot . MRSA infection

• Dressings, deflective padding, swabs, specialist advice, post op sandals.

• Now under specialist diabetic podiatry team and housed.

• Foot healed

• 50 year old black male

• Mycotic thick toenails could not cut

• Intravenous drug user now on methadone

• Now stable on methadone in hostel

• Nails later treated with Terbinafine tablets. Now able to self care

• Alcoholic male 55

• Poor memory

• Shoes and socks not removed for 8 months

• Trench foot got worse when in hostel! Refused to go into hospital for IV antibiotics

• Recently deceased-pneumonia

• Male 63• Frequent hostel

evictions. Revolving door prison/street/hostel

• Alcoholic, Wernicke-Korsakoff Syndrome, epilepsy. PVD, heavy smoker

• Fracture right ankle age 15, not set at time!!!! Walks on side of foot

• Infected ulcer right foot. Trench foot

• Not able to attend appointments or follow advice due to Korsakoff’s. Never took off shoes/socks. Not suitable for surgery. Ulcer dressing and redistributive padding. Antibiotics. Orthopaedic shoe referral difficult. Now in a home

• Elderly male• Diabetic, schizophrenia• Slept rough in Hyde

Park many years • MDT work with Joint

Homeless Team and nurse from Great Chapel Street

• Shoes/socks never removed

• Very flexible podiatry• Leg ulcers with

maggots• Hospitalised• Now in a home

TAKE HOME MESSAGES!• THINK FEET. What could be going on in my

clients shoes?

• Be DIABETES AWARE. Is my diabetic client getting annual neurovascular foot checks? If you are a nurse consider updating skills to perform a diabetic foot assessment and give diabetic foot care advice, ensure access to the necessary testing equipment.

• Provide SUPPORT FOR SELF CARE AND PREVENTION– socks, shoes, nail clippers, bathing

Contact Details

Alison Gardiner

Specialist Podiatrist for Homeless and

Vulnerable People

Central London Community Healthcare

Alison.gardiner@clch.nhs.uk

Tel: 07789777498

Useful links

• Society of Chiropodists and Podiatrists (Common foot problems) http://www.scpod.org/foot-health/common-foot-problems/

• Diabetes UK https://www.diabetes.org.uk/Guide-to-diabetes/Complications/Feet/Taking-care-of-your-feet/

• CLCH Podiatry Service (Mainstream) www.clch.nhs.uk/services/podiatry-(foot-health)