Where were you on World Diabetes Day?

Diabetic Foot, The, Winter, 2005 by Alistair McInnes

I had the privilege and pleasure of speaking at the first diabetic foot seminar to be held in Nicosia, Cyprus, on 12 November 2005. The conference was organised by the Cyprus Society of Chiropodists and Podiatrists, the Cyprus Diabetic Association and the Cyprus Association for the Study of Diabetes. I was also asked to lead a discussion on the future for diabetic foot services on the island in light of the development of the National Plan for Diabetes and the Cypriot Government's proposal to create a new national healthcare system. There are a number of complex issues regarding diabetes foot services on the island and the UK model of care is regarded by many healthcare professionals as a 'gold standard' for them to emulate in the future.

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Following on from the conference--which took place on World Diabetes Day (14 November) and focused on the threat of amputation and diabetic foot disease--I had the opportunity to visit a number of booths that had been set up throughout Nicosia, where healthcare practitioners and members of the Cyprus Diabetic Association were drawing attention to the increasing prevalence of diabetes in Cyprus (5.1% in 2003 and rising; http://www.eatlas.idf.org/prevalence [accessed 21.11.2005]). The enthusiasm and dedication demonstrated by all those involved was most impressive and I wish them well for the future.

Diabetic foot services in the UK

My experience in Cyprus led me to consider the future for diabetic foot services in the UK, where wide disparities remain in health outcomes throughout the country and between different socioeconomic groups (Department of Health [DoH], 2005c). However, when the aforementioned UK 'gold standard' model of care is adopted (that is, when fully resourced, appropriately organised and fully trained dedicated multidisciplinary foot care teams are available), there is no doubt that the burden of morbidity and mortality that manifests as diabetic foot disease can be significantly reduced (Bakker, 2005).

With the UK Government's requirement for increased legislation to reform the NHS (DoH, 2000), some proposed changes may pose a threat to the future provision of diabetic foot services. One of the major concerns arises from the document Commissioning a patient-led NHS (DoH, 2005b). With the anticipated merging of primary care trusts (PCTs) to form larger PCTs and a separation of the commissioning from the provider function, there is a worry that devolved practice-based commissioning may lead to a fragmentation of diabetic foot services. The political drive appears to comprise the provision of local services by the primary care sector and a diminution of services provided from the hospital sector.

Optimum diabetes services result from integration of all providers (despite organisational boundaries), with better health outcomes and a reduction in health inequalities (DoH, 2005c). It would be a terrible irony--given the potential benefits of Agenda for Change (DoH, 2005a) and the Knowledge and Skills Framework (DoH, 2004) to the NHS workforce and patients--to see a dismantling of the multidisciplinary diabetes foot team that I believe operates best in the hospital setting. Patients with diabetic foot disease present with multiple pathologies and often require urgent and prompt attention from many hospital services that the multidisciplinary team may access immediately. If this service is diminished in any way, to quote Dr Mike Edmonds (Consultant Physician, King's College Hospital Diabetic Foot Clinic, London), from the 2nd Annual Diabetic Foot Journal Lecture, in October,

  'it would be nothing short of a betrayal of our patients.'

The new commissioning arrangements have to be carefully managed to preserve good practice and desirable outcomes of care. Perhaps the fears that many healthcare practitioners have expressed will be assuaged by the fact that the National Service Framework for diabetes (DoH, 2003) and the National Institute for Health and Clinical Excellence (NICE; formerly National Institute for Clinical Excellence) guidelines (NICE, 2004) will inform the commissioners and preserve the hospital-based multidisciplinary foot care team. In addition, the National Diabetes Support Team will provide backing for online diabetes services via local diabetes networks; 87% of PCTs are now part of a whole-system diabetes network or community (Diabetes UK, 2004).

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There are many examples of recent innovative excellent practice in the management of diabetes (DoH, 2005c), and there is no doubt in my mind that there is a requirement to expand the diabetic foot services in the community setting so that appropriate seamless care can be provided in the most cost-effective and clinically effective fashion. The commissioners have a very challenging and complex task ahead.

It is perhaps gratifying to hear that Patricia Hewitt, the Secretary of State for Health, say from the House of Commons on 25 October that

  'community staff employed by PCTs will continue to be employed by PCTs
  unless and until the PCT decides otherwise, following full public
  consultation' (UK Parliament, 2005).