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DIABETES FOOT CAREARE SERVICES IN ENGLAND AND WALES PUTTING YOUR FEET FIRST A summary report about the quality of foot care for people with diabetes
Based on findings from National Diabetes Footcare Audit (NDFA) 2014ndash15 in England and Wales
2
Contents
The first National Diabetes Foot Care Audit (NDFA) report was published in March 2016 The NDFA provides a picture of the care provided to people with diabetes who are treated for foot ulcers
The reportrsquos findings come from information collected by foot care clinics in England and Wales for the period 14 July 2014 to 10 April 2015129 foot care clinics provided data for the NDFA
The NDFA is commissioned by Healthcare Quality and Improvement Partnership (HQIP)
NHS Digital (previously known as the Health and Social Care Information Centre) manages the NDFA working closely with Diabetes UK Clinical teams across England and Wales also provide support
This report summarises some of the key findings from the 2014ndash15 NDFA
Background
BACKGROUND 2
What is the National Diabetes Foot Care Audit (NDFA) 3
Why do we audit foot care for people with diabetes 3
About this summary report 4
THE NDFA FINDINGS 6
Foot ulcer characteristics 7
Foot ulcers 12 weeks after first assessment 11
Key findings 12
Improving diabetes foot care for people with diabetes 13
bull Recommendations for health care professionals 13
bull Recommendations for people with diabetes 15
FURTHER INFORMATION 17
How the NDFA collects information 17
Where to go for more information 18
Explanation of words used in this report 19
Contact 20
3
What is the NDFAThe NDFA is a national clinical audit (or survey) about the care of people with diabetes who develop a foot ulcer
Specifically the NDFA looks at
bull whether people with a diabetic foot ulcer had their annual foot check
bull how severe ulcers are when people are first seen by the specialist foot care team
bull what factors have the biggest effects on healing and recovery
Foot care services collect information for the audit all year-round A report is produced each year which looks at the data from the previous year
Information is only collected from people who give their permission for the use of their personal data in this way
You can read more about the audit methods and data collection on page 17
Why do we audit foot care for people with diabetes
The National Institute for Health and Care Excellence (NICE) produces the guidelines for the treatment of diabetic foot problems All diabetes foot care services should follow these guidelines so that people with diabetes receive the best possible foot care
The NDFA looks at whether the foot care provided meets these guidelines The audit looks at whether people with diabetes who are at risk of foot ulcers are referred to a specialist for assessment The audit also checks whether people with diabetes who develop foot ulcers get care and treatment at the right time and from the right people
The reason why the NDFA collects this information and produce a report is to highlight where diabetes foot care is good and show where care needs to improve
The findings from the NDFA are sent to all foot care services Healthcare managers and staff are asked to look at areas where their care can be improved and to develop plans to improve these services Future reports will measure whether those plans have made a difference
The full audit findings are publicly available ndash you can find them on the NHS Digital website
4
About this summary report
This report summarises some of the key findings of the NDFA report for 2014ndash15 It is a document for everyone ndash people with diabetes healthcare professionals health service managers and anyone interested in diabetes foot care
Before writing this summary report Diabetes UK talked to people with diabetes to find out what NDFA information they wanted to see and how to present the findings
In this report we explain
bull the relevant national guidelines about good quality foot care for people with diabetes
bull some of the key findings from the 2014ndash15 NDFA
bull recommendations for improvements to diabetes foot care
This report does not cover all the findings from the NDFA report If you would like to read the full report you can download it from NHS Digital website
At the back of the report we have listed contact details for organisations There is also a list explaining some of the words and terms used in this report
5
Looking after your feet ndash what care to expectIt is very important to take good care of your feet because having diabetes puts you at risk of foot problems Although foot ulcers can be very serious they usually respond well to treatment Poor circulation and severe infection may delay or prevent healing The NICE guidelines which should be followed by all healthcare professionals are summarised below
Annual foot checkEveryone with diabetes should have their feet checked by a qualified healthcare professional once a year During the foot check appointment your healthcare professional should explain how to look after your feet and talk with you about your risk of developing foot problems in the future If you are found to be at increased risk you should be referred to a Foot Protection Service t o be assessed by a specialist
Diabetes UK provides a useful leaflet about what to expect at your annual foot check
Treatment for diabetic foot problemsDiabetic foot ulcers
If you have a diabetic foot ulcer it is important to be seen by a foot care specialist as soon as possible The healthcare professional should check the size and depth of the ulcer and look for signs of infection or other problems The treatment will depend on how severe the ulcer is where it is and what you would prefer The treatment will almost always include dressings and pressure relief
Diabetic foot infection
If your healthcare professional thinks you have a foot infection and you have a wound on your foot a small sample may be sent for testing You should be offered antibiotics
Charcot arthropathy
Charcot arthropathy occurs in some people who lose feeling in their feet The bones in the foot can become weak and lead to dislocations fractures and changes in the shape of the foot or ankle The treatment for Charcot foot usually involves having a plaster cast fitted
ReferralIf any doctor or nurse thinks you may have an active diabetic foot problem they should refer you to a specialist foot care service within one working day The specialist foot care service should then triage the referral within another working day
Early referral and treatment is really important as it can prevent diabetic foot problems becoming worse
ANNUALCHECK
6
Information was collected from 5015 people who had treatment for a foot ulcer between 14 July 2014 and 10 April 2015 However the number of foot ulcers recorded was 5215 because a number of people had two or more new foot ulcers during the period
The NDFA looked at whether people with diabetes who were treated for a foot ulcer were different from other people with diabetes To do this the NDFA compared the characteristics of people included in the NDFA with people with diabetes who are included in the audit of all people with diabetes (called the National Diabetes Audit)1
Annual foot checkNICE guidelines recommend that all people with diabetes receive a foot risk assessment once a year People who have been assessed as being moderate or high risk of developing diabetic foot problems should be seen more often by a foot care service
The audit checks whether people who have a foot ulcer are less likely to have had a foot check than those who didnrsquot have a foot ulcer In fact the NDFA found that people with a diabetic foot ulcer were just as likely to have had an annual foot check as other people with diabetes2 (85 in both groups)
The table across shows some of the differences between the wider population of people with diabetes and people with a foot ulcer
The NDFA findings
1 The National Diabetes Audit (NDA) collects information on whether people with diabetes in England and Wales receive their annual diabetes checks and are meeting the treatment targets This includes all people with diabetes
2 The information for lsquoother people with diabetesrsquo comes from the National Diabetes Audit ndash see footnote above
Type 1
Type 2
HbA1c 58mmolmol (75) or less
Male
Female
Average age
Average number of years with diabetes
Live in most deprived areas
White ethnicity
13
87
70
30
26
91
9
44
23
56
9
64
61
67
70
15
6444
All people with diabetes (from NDA)NDFA
Characteristics of people with a diabetic foot ulcer compared to all people with diabetes
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
2
Contents
The first National Diabetes Foot Care Audit (NDFA) report was published in March 2016 The NDFA provides a picture of the care provided to people with diabetes who are treated for foot ulcers
The reportrsquos findings come from information collected by foot care clinics in England and Wales for the period 14 July 2014 to 10 April 2015129 foot care clinics provided data for the NDFA
The NDFA is commissioned by Healthcare Quality and Improvement Partnership (HQIP)
NHS Digital (previously known as the Health and Social Care Information Centre) manages the NDFA working closely with Diabetes UK Clinical teams across England and Wales also provide support
This report summarises some of the key findings from the 2014ndash15 NDFA
Background
BACKGROUND 2
What is the National Diabetes Foot Care Audit (NDFA) 3
Why do we audit foot care for people with diabetes 3
About this summary report 4
THE NDFA FINDINGS 6
Foot ulcer characteristics 7
Foot ulcers 12 weeks after first assessment 11
Key findings 12
Improving diabetes foot care for people with diabetes 13
bull Recommendations for health care professionals 13
bull Recommendations for people with diabetes 15
FURTHER INFORMATION 17
How the NDFA collects information 17
Where to go for more information 18
Explanation of words used in this report 19
Contact 20
3
What is the NDFAThe NDFA is a national clinical audit (or survey) about the care of people with diabetes who develop a foot ulcer
Specifically the NDFA looks at
bull whether people with a diabetic foot ulcer had their annual foot check
bull how severe ulcers are when people are first seen by the specialist foot care team
bull what factors have the biggest effects on healing and recovery
Foot care services collect information for the audit all year-round A report is produced each year which looks at the data from the previous year
Information is only collected from people who give their permission for the use of their personal data in this way
You can read more about the audit methods and data collection on page 17
Why do we audit foot care for people with diabetes
The National Institute for Health and Care Excellence (NICE) produces the guidelines for the treatment of diabetic foot problems All diabetes foot care services should follow these guidelines so that people with diabetes receive the best possible foot care
The NDFA looks at whether the foot care provided meets these guidelines The audit looks at whether people with diabetes who are at risk of foot ulcers are referred to a specialist for assessment The audit also checks whether people with diabetes who develop foot ulcers get care and treatment at the right time and from the right people
The reason why the NDFA collects this information and produce a report is to highlight where diabetes foot care is good and show where care needs to improve
The findings from the NDFA are sent to all foot care services Healthcare managers and staff are asked to look at areas where their care can be improved and to develop plans to improve these services Future reports will measure whether those plans have made a difference
The full audit findings are publicly available ndash you can find them on the NHS Digital website
4
About this summary report
This report summarises some of the key findings of the NDFA report for 2014ndash15 It is a document for everyone ndash people with diabetes healthcare professionals health service managers and anyone interested in diabetes foot care
Before writing this summary report Diabetes UK talked to people with diabetes to find out what NDFA information they wanted to see and how to present the findings
In this report we explain
bull the relevant national guidelines about good quality foot care for people with diabetes
bull some of the key findings from the 2014ndash15 NDFA
bull recommendations for improvements to diabetes foot care
This report does not cover all the findings from the NDFA report If you would like to read the full report you can download it from NHS Digital website
At the back of the report we have listed contact details for organisations There is also a list explaining some of the words and terms used in this report
5
Looking after your feet ndash what care to expectIt is very important to take good care of your feet because having diabetes puts you at risk of foot problems Although foot ulcers can be very serious they usually respond well to treatment Poor circulation and severe infection may delay or prevent healing The NICE guidelines which should be followed by all healthcare professionals are summarised below
Annual foot checkEveryone with diabetes should have their feet checked by a qualified healthcare professional once a year During the foot check appointment your healthcare professional should explain how to look after your feet and talk with you about your risk of developing foot problems in the future If you are found to be at increased risk you should be referred to a Foot Protection Service t o be assessed by a specialist
Diabetes UK provides a useful leaflet about what to expect at your annual foot check
Treatment for diabetic foot problemsDiabetic foot ulcers
If you have a diabetic foot ulcer it is important to be seen by a foot care specialist as soon as possible The healthcare professional should check the size and depth of the ulcer and look for signs of infection or other problems The treatment will depend on how severe the ulcer is where it is and what you would prefer The treatment will almost always include dressings and pressure relief
Diabetic foot infection
If your healthcare professional thinks you have a foot infection and you have a wound on your foot a small sample may be sent for testing You should be offered antibiotics
Charcot arthropathy
Charcot arthropathy occurs in some people who lose feeling in their feet The bones in the foot can become weak and lead to dislocations fractures and changes in the shape of the foot or ankle The treatment for Charcot foot usually involves having a plaster cast fitted
ReferralIf any doctor or nurse thinks you may have an active diabetic foot problem they should refer you to a specialist foot care service within one working day The specialist foot care service should then triage the referral within another working day
Early referral and treatment is really important as it can prevent diabetic foot problems becoming worse
ANNUALCHECK
6
Information was collected from 5015 people who had treatment for a foot ulcer between 14 July 2014 and 10 April 2015 However the number of foot ulcers recorded was 5215 because a number of people had two or more new foot ulcers during the period
The NDFA looked at whether people with diabetes who were treated for a foot ulcer were different from other people with diabetes To do this the NDFA compared the characteristics of people included in the NDFA with people with diabetes who are included in the audit of all people with diabetes (called the National Diabetes Audit)1
Annual foot checkNICE guidelines recommend that all people with diabetes receive a foot risk assessment once a year People who have been assessed as being moderate or high risk of developing diabetic foot problems should be seen more often by a foot care service
The audit checks whether people who have a foot ulcer are less likely to have had a foot check than those who didnrsquot have a foot ulcer In fact the NDFA found that people with a diabetic foot ulcer were just as likely to have had an annual foot check as other people with diabetes2 (85 in both groups)
The table across shows some of the differences between the wider population of people with diabetes and people with a foot ulcer
The NDFA findings
1 The National Diabetes Audit (NDA) collects information on whether people with diabetes in England and Wales receive their annual diabetes checks and are meeting the treatment targets This includes all people with diabetes
2 The information for lsquoother people with diabetesrsquo comes from the National Diabetes Audit ndash see footnote above
Type 1
Type 2
HbA1c 58mmolmol (75) or less
Male
Female
Average age
Average number of years with diabetes
Live in most deprived areas
White ethnicity
13
87
70
30
26
91
9
44
23
56
9
64
61
67
70
15
6444
All people with diabetes (from NDA)NDFA
Characteristics of people with a diabetic foot ulcer compared to all people with diabetes
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
3
What is the NDFAThe NDFA is a national clinical audit (or survey) about the care of people with diabetes who develop a foot ulcer
Specifically the NDFA looks at
bull whether people with a diabetic foot ulcer had their annual foot check
bull how severe ulcers are when people are first seen by the specialist foot care team
bull what factors have the biggest effects on healing and recovery
Foot care services collect information for the audit all year-round A report is produced each year which looks at the data from the previous year
Information is only collected from people who give their permission for the use of their personal data in this way
You can read more about the audit methods and data collection on page 17
Why do we audit foot care for people with diabetes
The National Institute for Health and Care Excellence (NICE) produces the guidelines for the treatment of diabetic foot problems All diabetes foot care services should follow these guidelines so that people with diabetes receive the best possible foot care
The NDFA looks at whether the foot care provided meets these guidelines The audit looks at whether people with diabetes who are at risk of foot ulcers are referred to a specialist for assessment The audit also checks whether people with diabetes who develop foot ulcers get care and treatment at the right time and from the right people
The reason why the NDFA collects this information and produce a report is to highlight where diabetes foot care is good and show where care needs to improve
The findings from the NDFA are sent to all foot care services Healthcare managers and staff are asked to look at areas where their care can be improved and to develop plans to improve these services Future reports will measure whether those plans have made a difference
The full audit findings are publicly available ndash you can find them on the NHS Digital website
4
About this summary report
This report summarises some of the key findings of the NDFA report for 2014ndash15 It is a document for everyone ndash people with diabetes healthcare professionals health service managers and anyone interested in diabetes foot care
Before writing this summary report Diabetes UK talked to people with diabetes to find out what NDFA information they wanted to see and how to present the findings
In this report we explain
bull the relevant national guidelines about good quality foot care for people with diabetes
bull some of the key findings from the 2014ndash15 NDFA
bull recommendations for improvements to diabetes foot care
This report does not cover all the findings from the NDFA report If you would like to read the full report you can download it from NHS Digital website
At the back of the report we have listed contact details for organisations There is also a list explaining some of the words and terms used in this report
5
Looking after your feet ndash what care to expectIt is very important to take good care of your feet because having diabetes puts you at risk of foot problems Although foot ulcers can be very serious they usually respond well to treatment Poor circulation and severe infection may delay or prevent healing The NICE guidelines which should be followed by all healthcare professionals are summarised below
Annual foot checkEveryone with diabetes should have their feet checked by a qualified healthcare professional once a year During the foot check appointment your healthcare professional should explain how to look after your feet and talk with you about your risk of developing foot problems in the future If you are found to be at increased risk you should be referred to a Foot Protection Service t o be assessed by a specialist
Diabetes UK provides a useful leaflet about what to expect at your annual foot check
Treatment for diabetic foot problemsDiabetic foot ulcers
If you have a diabetic foot ulcer it is important to be seen by a foot care specialist as soon as possible The healthcare professional should check the size and depth of the ulcer and look for signs of infection or other problems The treatment will depend on how severe the ulcer is where it is and what you would prefer The treatment will almost always include dressings and pressure relief
Diabetic foot infection
If your healthcare professional thinks you have a foot infection and you have a wound on your foot a small sample may be sent for testing You should be offered antibiotics
Charcot arthropathy
Charcot arthropathy occurs in some people who lose feeling in their feet The bones in the foot can become weak and lead to dislocations fractures and changes in the shape of the foot or ankle The treatment for Charcot foot usually involves having a plaster cast fitted
ReferralIf any doctor or nurse thinks you may have an active diabetic foot problem they should refer you to a specialist foot care service within one working day The specialist foot care service should then triage the referral within another working day
Early referral and treatment is really important as it can prevent diabetic foot problems becoming worse
ANNUALCHECK
6
Information was collected from 5015 people who had treatment for a foot ulcer between 14 July 2014 and 10 April 2015 However the number of foot ulcers recorded was 5215 because a number of people had two or more new foot ulcers during the period
The NDFA looked at whether people with diabetes who were treated for a foot ulcer were different from other people with diabetes To do this the NDFA compared the characteristics of people included in the NDFA with people with diabetes who are included in the audit of all people with diabetes (called the National Diabetes Audit)1
Annual foot checkNICE guidelines recommend that all people with diabetes receive a foot risk assessment once a year People who have been assessed as being moderate or high risk of developing diabetic foot problems should be seen more often by a foot care service
The audit checks whether people who have a foot ulcer are less likely to have had a foot check than those who didnrsquot have a foot ulcer In fact the NDFA found that people with a diabetic foot ulcer were just as likely to have had an annual foot check as other people with diabetes2 (85 in both groups)
The table across shows some of the differences between the wider population of people with diabetes and people with a foot ulcer
The NDFA findings
1 The National Diabetes Audit (NDA) collects information on whether people with diabetes in England and Wales receive their annual diabetes checks and are meeting the treatment targets This includes all people with diabetes
2 The information for lsquoother people with diabetesrsquo comes from the National Diabetes Audit ndash see footnote above
Type 1
Type 2
HbA1c 58mmolmol (75) or less
Male
Female
Average age
Average number of years with diabetes
Live in most deprived areas
White ethnicity
13
87
70
30
26
91
9
44
23
56
9
64
61
67
70
15
6444
All people with diabetes (from NDA)NDFA
Characteristics of people with a diabetic foot ulcer compared to all people with diabetes
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
4
About this summary report
This report summarises some of the key findings of the NDFA report for 2014ndash15 It is a document for everyone ndash people with diabetes healthcare professionals health service managers and anyone interested in diabetes foot care
Before writing this summary report Diabetes UK talked to people with diabetes to find out what NDFA information they wanted to see and how to present the findings
In this report we explain
bull the relevant national guidelines about good quality foot care for people with diabetes
bull some of the key findings from the 2014ndash15 NDFA
bull recommendations for improvements to diabetes foot care
This report does not cover all the findings from the NDFA report If you would like to read the full report you can download it from NHS Digital website
At the back of the report we have listed contact details for organisations There is also a list explaining some of the words and terms used in this report
5
Looking after your feet ndash what care to expectIt is very important to take good care of your feet because having diabetes puts you at risk of foot problems Although foot ulcers can be very serious they usually respond well to treatment Poor circulation and severe infection may delay or prevent healing The NICE guidelines which should be followed by all healthcare professionals are summarised below
Annual foot checkEveryone with diabetes should have their feet checked by a qualified healthcare professional once a year During the foot check appointment your healthcare professional should explain how to look after your feet and talk with you about your risk of developing foot problems in the future If you are found to be at increased risk you should be referred to a Foot Protection Service t o be assessed by a specialist
Diabetes UK provides a useful leaflet about what to expect at your annual foot check
Treatment for diabetic foot problemsDiabetic foot ulcers
If you have a diabetic foot ulcer it is important to be seen by a foot care specialist as soon as possible The healthcare professional should check the size and depth of the ulcer and look for signs of infection or other problems The treatment will depend on how severe the ulcer is where it is and what you would prefer The treatment will almost always include dressings and pressure relief
Diabetic foot infection
If your healthcare professional thinks you have a foot infection and you have a wound on your foot a small sample may be sent for testing You should be offered antibiotics
Charcot arthropathy
Charcot arthropathy occurs in some people who lose feeling in their feet The bones in the foot can become weak and lead to dislocations fractures and changes in the shape of the foot or ankle The treatment for Charcot foot usually involves having a plaster cast fitted
ReferralIf any doctor or nurse thinks you may have an active diabetic foot problem they should refer you to a specialist foot care service within one working day The specialist foot care service should then triage the referral within another working day
Early referral and treatment is really important as it can prevent diabetic foot problems becoming worse
ANNUALCHECK
6
Information was collected from 5015 people who had treatment for a foot ulcer between 14 July 2014 and 10 April 2015 However the number of foot ulcers recorded was 5215 because a number of people had two or more new foot ulcers during the period
The NDFA looked at whether people with diabetes who were treated for a foot ulcer were different from other people with diabetes To do this the NDFA compared the characteristics of people included in the NDFA with people with diabetes who are included in the audit of all people with diabetes (called the National Diabetes Audit)1
Annual foot checkNICE guidelines recommend that all people with diabetes receive a foot risk assessment once a year People who have been assessed as being moderate or high risk of developing diabetic foot problems should be seen more often by a foot care service
The audit checks whether people who have a foot ulcer are less likely to have had a foot check than those who didnrsquot have a foot ulcer In fact the NDFA found that people with a diabetic foot ulcer were just as likely to have had an annual foot check as other people with diabetes2 (85 in both groups)
The table across shows some of the differences between the wider population of people with diabetes and people with a foot ulcer
The NDFA findings
1 The National Diabetes Audit (NDA) collects information on whether people with diabetes in England and Wales receive their annual diabetes checks and are meeting the treatment targets This includes all people with diabetes
2 The information for lsquoother people with diabetesrsquo comes from the National Diabetes Audit ndash see footnote above
Type 1
Type 2
HbA1c 58mmolmol (75) or less
Male
Female
Average age
Average number of years with diabetes
Live in most deprived areas
White ethnicity
13
87
70
30
26
91
9
44
23
56
9
64
61
67
70
15
6444
All people with diabetes (from NDA)NDFA
Characteristics of people with a diabetic foot ulcer compared to all people with diabetes
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
5
Looking after your feet ndash what care to expectIt is very important to take good care of your feet because having diabetes puts you at risk of foot problems Although foot ulcers can be very serious they usually respond well to treatment Poor circulation and severe infection may delay or prevent healing The NICE guidelines which should be followed by all healthcare professionals are summarised below
Annual foot checkEveryone with diabetes should have their feet checked by a qualified healthcare professional once a year During the foot check appointment your healthcare professional should explain how to look after your feet and talk with you about your risk of developing foot problems in the future If you are found to be at increased risk you should be referred to a Foot Protection Service t o be assessed by a specialist
Diabetes UK provides a useful leaflet about what to expect at your annual foot check
Treatment for diabetic foot problemsDiabetic foot ulcers
If you have a diabetic foot ulcer it is important to be seen by a foot care specialist as soon as possible The healthcare professional should check the size and depth of the ulcer and look for signs of infection or other problems The treatment will depend on how severe the ulcer is where it is and what you would prefer The treatment will almost always include dressings and pressure relief
Diabetic foot infection
If your healthcare professional thinks you have a foot infection and you have a wound on your foot a small sample may be sent for testing You should be offered antibiotics
Charcot arthropathy
Charcot arthropathy occurs in some people who lose feeling in their feet The bones in the foot can become weak and lead to dislocations fractures and changes in the shape of the foot or ankle The treatment for Charcot foot usually involves having a plaster cast fitted
ReferralIf any doctor or nurse thinks you may have an active diabetic foot problem they should refer you to a specialist foot care service within one working day The specialist foot care service should then triage the referral within another working day
Early referral and treatment is really important as it can prevent diabetic foot problems becoming worse
ANNUALCHECK
6
Information was collected from 5015 people who had treatment for a foot ulcer between 14 July 2014 and 10 April 2015 However the number of foot ulcers recorded was 5215 because a number of people had two or more new foot ulcers during the period
The NDFA looked at whether people with diabetes who were treated for a foot ulcer were different from other people with diabetes To do this the NDFA compared the characteristics of people included in the NDFA with people with diabetes who are included in the audit of all people with diabetes (called the National Diabetes Audit)1
Annual foot checkNICE guidelines recommend that all people with diabetes receive a foot risk assessment once a year People who have been assessed as being moderate or high risk of developing diabetic foot problems should be seen more often by a foot care service
The audit checks whether people who have a foot ulcer are less likely to have had a foot check than those who didnrsquot have a foot ulcer In fact the NDFA found that people with a diabetic foot ulcer were just as likely to have had an annual foot check as other people with diabetes2 (85 in both groups)
The table across shows some of the differences between the wider population of people with diabetes and people with a foot ulcer
The NDFA findings
1 The National Diabetes Audit (NDA) collects information on whether people with diabetes in England and Wales receive their annual diabetes checks and are meeting the treatment targets This includes all people with diabetes
2 The information for lsquoother people with diabetesrsquo comes from the National Diabetes Audit ndash see footnote above
Type 1
Type 2
HbA1c 58mmolmol (75) or less
Male
Female
Average age
Average number of years with diabetes
Live in most deprived areas
White ethnicity
13
87
70
30
26
91
9
44
23
56
9
64
61
67
70
15
6444
All people with diabetes (from NDA)NDFA
Characteristics of people with a diabetic foot ulcer compared to all people with diabetes
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
6
Information was collected from 5015 people who had treatment for a foot ulcer between 14 July 2014 and 10 April 2015 However the number of foot ulcers recorded was 5215 because a number of people had two or more new foot ulcers during the period
The NDFA looked at whether people with diabetes who were treated for a foot ulcer were different from other people with diabetes To do this the NDFA compared the characteristics of people included in the NDFA with people with diabetes who are included in the audit of all people with diabetes (called the National Diabetes Audit)1
Annual foot checkNICE guidelines recommend that all people with diabetes receive a foot risk assessment once a year People who have been assessed as being moderate or high risk of developing diabetic foot problems should be seen more often by a foot care service
The audit checks whether people who have a foot ulcer are less likely to have had a foot check than those who didnrsquot have a foot ulcer In fact the NDFA found that people with a diabetic foot ulcer were just as likely to have had an annual foot check as other people with diabetes2 (85 in both groups)
The table across shows some of the differences between the wider population of people with diabetes and people with a foot ulcer
The NDFA findings
1 The National Diabetes Audit (NDA) collects information on whether people with diabetes in England and Wales receive their annual diabetes checks and are meeting the treatment targets This includes all people with diabetes
2 The information for lsquoother people with diabetesrsquo comes from the National Diabetes Audit ndash see footnote above
Type 1
Type 2
HbA1c 58mmolmol (75) or less
Male
Female
Average age
Average number of years with diabetes
Live in most deprived areas
White ethnicity
13
87
70
30
26
91
9
44
23
56
9
64
61
67
70
15
6444
All people with diabetes (from NDA)NDFA
Characteristics of people with a diabetic foot ulcer compared to all people with diabetes
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
7
Foot ulcer characteristics
About 1 in 10 people with diabetes in the audit had more than one ulcer at the one time The majority (89) had one ulcer Approximately 1 in 20 (54) people had Charcot foot disease
The audit found that the majority of people (more than 80) who had an ulcer also had loss of sensation (neuropathy)
People with diabetes with foot ulcers
more than one ulcer at the one time
Charcot foot disease
Loss of sensation
ABOUT
ABOUT
MORE THAN
1 in 10
1 in 20
8 in 10
What is a foot ulcerA foot ulcer often starts as a small break in the skin which does not heal It may start small but can get bigger quickly
It can start from something as small as a blister that forms because you didnrsquot feel your shoe rubbing a small cut or wound from standing on a sharp object You may not have felt the pain because you have lost sensation in your feet
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
8
How long did it take to get an assessment by a multi-disciplinary foot team The NICE guidelines recommend that people with diabetes who have an active foot problem should be referred to a specialist team within one working day and be triaged within two working days Some people with diabetes go to their GP or another healthcare professional such as in AampE Some people self-refer straight to the specialist foot care team especially if they have been seen by them previously
People with diabetes were asked how long it took from first seeing any healthcare professional to getting a first assessment by a specialist foot care team The table below shows that almost a third (29) of people self-referred Only a minority (14) were seen within two days
Time from first appointment with healthcare professional to being assessed by specialist foot care team
2 days or less
Between 3 and 13 days
Between 14 days and 2 months
More than 2 months
Self-referral
14
29
20
8
of peopleTime to referral
29
If self-referring patients are excluded two in five (39) were not seen until two weeks after they first saw a healthcare professional about their ulcer
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
9
Time to first assessment and foot ulcer severity The audit found that two-thirds of people with diabetes who self-referred had less severe ulcers If the taken time to be seen by the specialist team was longer they were more likely to have a severe ulcer
How severe were the ulcersWhen ulcers are assessed by a healthcare professional a scoring system is used to assess how severe the ulcer is This scoring system used for the NDFA is called SINBAD See the box below for more detail
Explanation of SINBAD score
Site ndash where is the ulcer
I schaemia ndash problems with blood circulation due to damaged blood vessels This can cause damage to the skin tissue
N europathy ndash damage to the nerves that results in a loss of sensation
B acterial infection ndash whether or not there is an infection in the ulcer
Area ndash the size and shape of the ulcer
Depth ndash how deep the wound is
In the SINBAD system an ulcer can be scored between 0 (least severe) to 6 (most severe)
Definition of ulcer severity
bull Less severe ulcer = SINBAD score of less than 3
bull Severe ulcer = SINBAD score of 3 or more
Time to referral and severe ulcers
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
34
49
49
53
60
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
10
Was the length of time to first assessment linked to healingPeople with diabetes who self-referred were more likely have healed ulcers at the 12 week follow-up
No foot ulcer Foot ulcer still present
5149
Foot ulcers 12 weeks after first assessment
The audit collected information about foot ulcers 12 weeks after the first assessment by the specialist foot care team
How many people were ulcer free at 12 weeksData wasnrsquot available for 421 of the 5215 ulcer cases included in the audit And 119 people had died before the 12 week follow-up took place The infographic below summarises the status of the ulcer for the remaining 4675 people at the 12 week follow-up
Healed ulcers at 12 week follow-up
Self-referred
2 days or less
3ndash13 days
14 days ndash 2 months
2 months or more
56
49
50
43
34
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
11
Variation between foot care servicesThe NDFA showed that there were differences in foot ulcer healing rates between foot care services The average healing rate at the 12 week follow-up was 60 for less severe ulcers and 35 for severe ulcers
It is important to be cautious about making direct comparisons between different services There are a number of reasons for this
bull This first NDFA does not cover all areas of England and Wales
bull There were big differences in the number of ulcer cases submitted by each service which makes it difficult to make comparisons
bull The differences will be a result of steps taken at every stage of the footcare pathway and not just the care provided at the services who participated in the audit For example the care provided at a GP practice may affect ulcer healing
Despite this the findings suggest that some services have better healing rates than others
Was the severity of the ulcer linked to healingPeople with diabetes who had more severe ulcers were almost twice as likely to still have an ulcer at the 12 week follow-up
Variation for severe ulcers
Less severe ulcers Severe ulcers
36
24
49 467260
Healed ulcers at 12 week follow-up Variation for less severe ulcers
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
12
Key findings
The longer the delay between first visit to a health care professional and first assessment by a foot care specialist the more likely that foot ulcers were severe
Half of all people with diabetes were ulcer free 12 weeks after their first assessment with a foot care specialist
Patients who had more severe ulcers at the first assessment were almost twice as likely not be ulcer free after 12 weeks
People who self-referred and those who were seen within 2 weeks of first assessment had higher rates of ulcer healing than those seen later
Key findings
DELAY
12 WEEKS
12 WEEKS
2 WEEKS
SEVERE
SELF-REFERRED
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
13
The NDFA findings highlight areas of healthcare that can give people with diabetes the best chance of recovery from a foot ulcer
Recommendations for people with diabetes
Improving foot care for people with diabetes
Donrsquot smoke and keep blood pressure
and cholesterol on target
Make sure you get all the annual
checks you need
Keep blood glucose levels
on target
If you have had a foot problem or your annual foot check
shows you are at increased risk of foot problems you need
advice from a specialist at a Foot Protection Service
Seek professional advice as soon as you notice any problems
with your feet
Glucose
measurem
ents
See Diabetes UK leaflet
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
14
Recommendations for people with diabetes
Keep blood glucose levels on target You have less chance of getting nerve damage in your feet if your blood glucose levels stay on target
Donrsquot smoke and keep blood pressure and cholesterol on target You have less chance of getting poor circulation in the feet
Make sure you get all the annual checks you need ndash itrsquos your right to have them These include
bull foot checks
bull eye screening
bull kidney tests
If you have had a foot problem or your annual foot check shows you are at increased risk of foot problems you should be referred for expert assessment by a member of a Foot Protection Service It is really important to attend these check-ups to improve the chance of healing and to prevent any further problems
Seek professional advice as soon as you notice any problems with your feet
Glucose
measurem
ents
People with diabetes can find out more about the guidelines for diabetic foot care on the NICE website
More information about looking after your feet can be found on Diabetes UK website including information on how to get involved in improving foot care services ndash Diabetes UKrsquos Putting Feet First Campaign
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
15
Recommendations for clinicians in General Practice and primary care
Recommendations for clinicians involved in the provision of specialist foot care services
Be aware of Foot Protection and
Multidisciplinary Foot Care Services
and referral pathways
Take part in the NDFA
Review the NDFA findings
Refer immediately for expert assessment if person is at risk
of ulceration or has a new problem
Provide a good quality foot check
If active foot disease refer immediately to
Multidisciplinary Foot Care Service
Choose an area for
improvement
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
16
Recommendations for clinicians involved in the provision of specialist foot care services
Take part in the NDFA
Foot care services can help make future years of the audit more comprehensive if every specialist service participates The more foot care services that contribute to the audit the greater influence the NDFA will have on foot care programmes for people with diabetes
Review the NDFA findings
All foot care services should look at the full national and regional findings at httpdigitalnhsukfootcare
This will help pinpoint where treatment and care for people with diabetes who develop foot ulcers is producing good results and where there is a need for improvement or new approaches Putting these new approaches into practices will lead to improved outcomes for people with diabetes
Choose an area for improvement
Recommendations for clinicians in General Practice and primary care
Be aware of the Foot Protection and Multidisciplinary Foot Care Services and referral pathways
Refer immediately for expert assessment if a person is at risk of ulceration or has a new problem
If active foot disease refer immediately to Multidisciplinary Foot Care Service
Provide a good quality foot check
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
17
How the NDFA collects informationThe National Diabetes Footcare Audit (NDFA) collects data all year-round from services that treat foot ulcers in England and Wales
321 People with diabetes attending a clinic get a leaflet explaining what the audit is about They have the choice of agreeing or refusing to have their information included in the NDFA Only if they agree is their information used
Doctors nurses or podiatrists running diabetes foot clinics collect information on people with diabetes who develop foot ulcers or suspected Charcot foot This only includes information that is normally collected and recorded as part of foot care notes For example information about the severity of the ulcer and whether the ulcer is healed at the 12 week follow-up appointment
A full list of the information collected for the audit is available on the NDFA website
Foot care services collect information for the NDFA on a continuous basis Each year there is a deadline for foot care services to send the information they have collected for the NDFA All the information from England and Wales goes to NHS Digital using a secure website NHS Digital analyse all the data and include it in a national report They also publish reports on the NHS Digital website
Further information
Why have you received this information leaflet
Your foot care clinic is taking part in an important project to check that people with diabetes are being provided with good care The NDFA project collects information about the care that people receive for their foot ulcers
The information that is collected will help your clinic know if they need to improve their foot care service
Why do you need to know about this
We would like to use information about the care that all patients receive from all foot care clinics in England and Wales so that we get a full picture of diabetes foot care This will involve collecting some information about the care that you have received for your foot ulcer
A member of the team will ask you for your permission to include information about your care in this important project
What information about you is collected
As you probably know all people with diabetes should have their feet checked at the GP practice or diabetes clinic If problems occur you may need to go to a specialist clinic and may even need to be admitted to hospital
We would like to know what foot care is like across all these different services That means we need to look at information about your care from all of the health services you have seen To do this we need to use your NHS number (everyone has a unique number which is used by the NHS) and your date of birth Your NHS number and date of birth will allow us to look at the care you have received from all services ndash your GP foot clinic and hospital We need your permission to use your information
For full details of what information is collected please ask the person who gave you this leaflet or contact the NDFA project team
National Diabetes Foot Care Audit (NDFA)
ImportantPatient
Infor mation
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
18
Healthcare Quality Improvement Partnership (HQIP)To learn more about clinical audits ndash and patient involvement in national clinical audits
Patient Advice and Liaison Service (PALS)For questions about local health services or an enquiry about health matters contact PALS at wwwnhsuk
Community Health Councils (CHC) in Wales For help and advice about NHS Services in Wales wwwwalesnhsuksiteplus899home
NHS Choices (England)NHS Choices provides information about your health including finding and using NHS Services in England
NHS Wales NHS Wales provides information about your health including finding and using NHS Services in Wales
The National Diabetes Footcare Audit (NDFA)Information about the NDFA and copies of the full reports are available on the Health and Social Care Information Centrersquos website httpdigitalnhsukfootcare
Diabetes UKFor more information about diabetes including living with diabetes go to wwwdiabetesorgukGuide-to-diabetes or call Diabetes UKrsquos Helpline on 0345 123 2399 for advice and support
For information about getting involved in making a difference to diabetes treatment and care go to wwwdiabetesorgukGet_involvedDiabetes-Voices
To find out more about Diabetes UKrsquos activities in your area go to wwwdiabetesorgukIn_Your_Area
National Institute for Health and Care Excellence (NICE) guidelinesFor information about how NICE develops guidelines wwwniceorguk
For guidelines about diabetic foot problems NICE Guidelines NG19
Where to go for more information
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
19
Explanation of words used in this booklet
AuditA way of gathering information and measuring local NHS organisationsrsquo performance and quality of care against national guidelines from which come recommendations for improvements
Blood glucoseBlood glucose is the main sugar the body makes from the food we eat Glucose travels in the bloodstream providing energy to all the bodyrsquos living cells However the cells cannot use glucose without the help of insulin
DiabetesDiabetes is the shortened name for the health condition called diabetes mellitus Diabetes happens when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin
Foot Protection ServiceThe foot protection service is usually based outside the hospital for example in a health centre or GP clinic The foot protection service specialises in providing foot care for people with diabetes preventing diabetic foot problems and dealing with foot problems that donrsquot need to be treated in hospital
The foot protection service should be led by a podiatrist with special training in dealing with diabetic foot problems
HbA1c testThe HbA1c (pronounced H B A one C) test uses a blood sample to measure a personrsquos average blood glucose level over the previous two to three months The result is given in mmolmol or as a percentage
Multidisplicinary Foot Care Service
The multidisciplinary foot care service is usually based at a hospital It specialises in treating more severe diabetic foot problems
The terms lsquomultidisciplinaryrsquo means that the foot care service is made up of different kinds of healthcare professionals who work together to deliver care The diabetes multidisciplinary service should include diabetologists (consultants who specialise in diabetes) podiatrists and diabetes nurse specialists as well as other healthcare professionals with expertise in treating and managing diabetic foot problems
National Institute for Health and Care Excellence (NICE) NICE is the independent regulatory body providing national guidance to the NHS on new and existing medicines treatment and care
SINBADSINBAD is the name given to a system for measuring how severe an ulcer is SINBAD stands for Site Ischaemia Neuropathy Bacterial Infection Area and Depth See p8 for further information
TriageTriage is the process of deciding on the urgency and type of treatment that a patient needs based on their symptoms and the severity of their condition
Type 1 diabetesType 1 diabetes develops when the body permanently destroys its own insulin-producing cells When this happens a person needs regular insulin given either by injection or an insulin pump
Type 2 diabetesA condition in which the body either makes too little insulin or cannot use the insulin it produces to turn blood glucose into energy Diet and exercise is often enough to control a Type 2 diabetes condition but some people also need diabetes medication or insulin
UlcerAn ulcer is the term used for a break in the skin which does not heal rapidly as expected
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
20
We welcome your views on how we can improve this report
Please contact Laura FargherDiabetes UKThe Boultings Winwick StWarringtonWA2 7TTTelephone 020 7424 1013Email laurafargherdiabetesorguk
CONTACT
