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Diabetes Care 1989;12:24, 31. 2.
The LEA Study Group.
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Diabet Med 1995;12:14, 18. 3.
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National Service Framework (2001) on Standards. http://www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCareTopics/Diabetes/fslen. 4.
Fletton JA, Perkins J, Jaap AJ, et al.
Is community chiropodial/podiatric care appropriately targeted at the ‘at-risk’ diabetic foot?
Foot 1995;5:176, 179. 5.
Fletton JA, Robinson IM, Tooke JE.
Community chiropodial podiatric care and the ‘at risk’ diabetic foot: a case for professional updating?
J Br Podiatr Med 1996;51:4. 6.
Donohoe ME, Fletton JA, Hook A, et al.
Improving foot care for people with diabetes mellitus , randomized controlled trial of an integrated care approach.
Diabet Med 2000;17:581, 587. 7. http://www.rdehospital.nhs.uk/diabetes/home.htm.
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10 The Diabetic Foot in Primary Care: A UK Perspective Roger Gadsby
INTRODUCTION Traditionally, most people with diabetes in the United Kingdom had their care supervised by hospital doctors, but there was no organised system of care for those who did not attend hospital clinics.
In the 1970s, a few systems of ‘shared care’ between hospital clinics and general practitioners (GPs) were developed, and by the 1980s a number of GPs who had a particular interest in, and enthusiasm for, diabetes care began to develop diabetes clinics within their practices.1 Published evidence suggested that these clinics provided a standard of care equivalent to that provided by hospital clinics.2 In 1990, a new contract for the provision of care in general practice introduced incentive payments for the provision of ‘chronic disease management programmes’, which included diabetes care.
The payments were fairly small, but encouraged more GPs to introduce dia- betes clinics in their practices.
In 1999, in a national questionnaire survey, 71% of practices questioned were running diabetes clinics, providing most of the routine care for 75% of their patients with diabetes.3 In the year 2000, a report from the audit commission reviewing secondary diabetes care in England and Wales found that many hospital diabetes services were overstretched with long waiting times for outpatient appointments.
The report concluded that hospital diabetes services were already under considerable strain, that little was taking place in the way of strategic planning and that options for coping with future demand needed to be explored urgently.
It suggested that one way forward is for primary care to provide more routine care for people with diabetes, leaving hospitals to concentrate on specialist care and professional support and training, while allowing patients to receive continuity of their diabetes care closer to home.4 Since then, the shift of routine diabetes care from secondary to primary care has been en- couraged by a number of government initiatives and policy documents.
These have included the Diabetes National Service Framework (NSF) and the new General Practitioner Contract Quality and Outcomes Framework, underpinned by clinical guidelines from the National In- stitute of Clinical Excellence (NICE).
The impact of these on diabetic foot care will now be discussed.
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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122 THE DIABETIC FOOT IN PRIMARY CARE
DIABETES NATIONAL SERVICE FRAMEWORK National Service Frameworks (NSFs) are statements of health standards and developments published by the Department of Health.
The Diabetes NSF was published in two parts.
The first was ‘Standards’5 published in December 2001.
The second ‘Delivery Strategy’6 was published in December 2002.
They contained few specific milestones and targets, unlike previous NSFs for other conditions.
The Standards document states that diabetes is the second commonest cause of lower limb amputation.
The Diabetes NSF is unique in having a specific standard around patient empowerment.
Standard 3 states that All children, young people and adults with diabetes will receive a service that encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle.
This will be reflected in an agreed and shared care plan in an appropriate format and language.
Where appropriate, parents and carers should be fully engaged in the process.
There is little specific mention of foot care in the document, but Standard 10 states that all young people and adults with diabetes will receive regular surveillance for the long term complications of diabetes.
Under this standard, the document states that diabetic foot problems are the most frequent man- ifestations of diabetic neuropathy.
Foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered foot care education, podiatry services and, where required, protective footwear.
Prompt treatment of foot ulcers can reduce the risk of amputation.
For those who require amputation, their rehabilitation can be optimised through the provision of care by integrated, multidisciplinary, rehabilitation, prosthetic and social support teams.
The Delivery document has virtually nothing specific to foot care.
It develops the concept of diabetes networks across the primary, secondary care interface to integrate diabetes care, but does not specifically mention how foot care fits into this model.
THE NEW GENERAL PRACTITIONER CONTRACT QUALITY AND OUTCOMES FRAMEWORK In the supporting documentation for the new GP contract,7 the authors note that under the old contract, volume rather than quality was the main emphasis.
The new contract addresses this imbalance through introducing a quality and outcomes framework based on best evidence.
High achievement against these quality standards is encouraged and will result in substantial financial rewards to practices.
The Department of Health states that the quality and outcomes framework represents, for the first time for any large health system in any country, that GP practices will be systematically rewarded on the basis of the quality of care delivered to patients.
The framework contains four domains.
Each domain contains a range of areas described by key indicators.
The indicators describe different aspects of performance.
The four domains are
, clinical; , organisational;
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NICE GUIDELINE: TYPE 2 DIABETES 123
, additional services; , patient experience.
There are a maximum of 1050 points in the whole of the four domains that are available to attain.
The clinical domain contains ten disease areas, for which there are a maximum of 550 points.
The diabetes area has a maximum of 99 points (approximately 10% of the total points available), spread across 18 clinical indicators.
The diabetes quality targets cover structure, process and outcome.
The 99 diabetes points are distributed between these as follows: structure (6 points) , practice diabetes register; process (35 points) , completing various tasks of clinical management; outcome (58 points) , demonstrating that people with diabetes achieve good standards of care.8 There are 2 of the 18 clinical indicators that refer specifically to foot care.
These are as follows: diabetes quality indicator 9 (DM9) , the percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months (minimum threshold = 25%, maximum threshold to earn full available 3 points = 90%); and diabetes quality indicator 10 (DM10) , the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months (minimum threshold = 25%, maximum threshold to earn full available 3 points = 90%).
This means that if a practice can demonstrate that 90% of the patients on the practice diabetes register have a record of foot pulses and neuropathy testing within the past 15 months, they will score the full 6 points.
Each point for the average practice of about 7500 patients with an average prevalence of diabetes is worth about £120 for 2005, 2006, so diabetes foot care can earn up to 6 × £120 = £720; and scoring the full 99 points of the diabetes clinical indicators gives an income of 99 × £120 = £11 880.
These methods of giving financial incentives for demonstrating good-quality evidence-based clinical care seem to be working.
The government was expecting that the average attainment would be around 850 out of the maximum 1050 points.
Many practices in the United Kingdom are on target to achieve around 1000 points.
The quality and outcome scores were published in Autumn 2005, and so this information will be in the public domain.
The average score for diabetes was 93 points out of 99 maximum.