Maintaining foot care services for people with diabetes

 

“This is a fantastic example of how clinical collaboration across the Trusts, community and primary care services in south east London ensured patients at high risk of diabetic foot complications still received a high-quality service and positive experience. It also facilitated teams to work together as a network and for all members of the multidisciplinary team to come together and support each other within their own organisations and across the network during the pandemic.”

Dr Natasha Patel, Diabetes Consultant Guy’s & St Thomas’ NHS Foundation Trust & Dr Prakash Vas, Diabetes Consultant King’s College Hospital NHS Foundation Trust – Diabetes Clinical leads for the South East London Diabetes Foot Network

Challenge / Problem Identified

People attending diabetic foot clinics require regular check-ups to keep their feet healthy and reduce the risk of amputation. (Nationally, around 20 foot amputations take place every day as a result of complications from diabetes).

In normal practice, patients are reviewed on a fortnightly basis, with some seen weekly by secondary care multidisciplinary foot care teams (MDFTs).

During COVID-19, it has been essential to find alternative ways to continue this support to maintain high-quality, intensive diabetes foot care.

The South East London Diabetes Foot Network, which covers seven London boroughs and a population of two million, wanted to ensure continued access to a diabetic foot service for patients with acute or limb threatening problems (current and new), and that  all new referrals were reviewed within 24 hours.

Actions Taken

In mid-March 2020, the Health Innovation Network (HIN) rapidly introduced an interim diabetes foot navigator role, staffed by two project managers and supported by a network of diabetes foot specialists.

Working from home, their remit was to connect people across organisational boundaries, linking hospital MDFTs and community teams. They developed a comprehensive COVID-19 plan, detailing how both existing patients and new referrals would be managed.

A substantive navigator was recruited, who started in post in mid-April 2020.

Key elements of HIN’s support included:

  • Implementation of virtual support, operated by specialists using Pando™ (a secure communication tool for healthcare professionals) and Microsoft Teams software, accessible by all members of the network.
  • Daily capacity conference calls to match appointment needs with capacity across the network.
  • A proactive primary care pathway for high-risk diabetes foot problems.
  • A proforma for telephone triage.
  • An information governance (IG) agreement across organisations covering the use of virtual tools.
  • Production of process flow diagrams and guidance explaining the proposed new model.

Impacts / Outcomes

By introducing a network-wide diabetes foot navigator, the coordination of urgent diabetes foot care was maintained, while supporting high-quality pandemic response planning.

The navigator has enabled the rapid adoption of modern technology tools to facilitate access to expert diabetes advice.

Analysis of one group of seven patients who have had virtual reviews shows they were reviewed by an expert clinician within five minutes of requesting one on Pando. Of these patients, four were upgraded to a hospital clinic for urgent review and one was admitted to hospital on the same day.

The project successfully achieved high levels of partnership support:

  • The South East London MDFT COVID-19 plan was signed by all seven boroughs and the regional NHS England and NHS Improvement team.
  • The proforma for calling high risk diabetes foot patients was agreed by South East London CCG’s COVID-19 command structure.
  • Use of the Pando™ communication tool was agreed across organisations by IG leads.

Lessons Learned

  • Because clinical staff were being shielded or redeployed to COVID-19 areas it meant an agile system was required and teams came together and covered for each other across the traditional boundaries of organisations e.g. smaller and bigger units working together.
  • The traditional reluctance to fully embrace technology was overcome by necessity.
  • Teams broke silos to overcome lots of practical obstacles like home visits, clinic capacity, primary care reviews and antibiotic protocols.
  • The daily team conference calls also allowed teams to support each other during an unpresented time.

Future Plans / Next Steps

After the pandemic response is downgraded, it is anticipated this role may continue as a supportive non-clinical intervention.

Data is currently being collected by the Diabetes Foot Network to assess the impact of this new model of care on amputation rates.