Consultant warns NICE diabetic foot care quality standard statement 'flawed'

Diabetes targets will 'punish' GP commissioners and the NHS for failing to follow standards not in existing guidelines, a leading consultant has warned.

Amputated toe. Coloured frontal (left) and oblique (right) X-rays of the foot of a diabetic with an amputated second toe (Photograph: SPL)
Amputated toe. Coloured frontal (left) and oblique (right) X-rays of the foot of a diabetic with an amputated second toe (Photograph: SPL)

The NICE quality standard statement for diabetic foot care, which will be used to hold GP commissioners to account, is 'flawed' and must be rethought, according to consultant Professor William Jeffcoate.

It comes after Diabetes UK Professional Conference 2012 urged the NHS in England to tackle the 'postcode lottery' in foot care to avoid thousands of preventable amputations each year.

NICE's quality standard for adults with diabetes includes a statement on expectations around diabetic foot care.

This states: 'People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours.'

Professor Jeffcoate, who leads Diabetes UK's expert team on diabetic foot told the Diabetes UK conference in Glasgow on Wednesday: 'I've always been concerned by the wording of this document. This is a sort of punishment, a sort of threat, things that we have to do if we don't behave ourselves.'

He said the requirement that people with foot problems requiring medical attention should be seen within 24 hours by a multidisciplinary team was 'never specified in any of the [previous] guidance we've had, nor is urgent medical attention defined'.

He said: 'I think that the quality standard statement is flawed, and I sincerely hope it is revised before it becomes the statement on which commissioning is based.'

Professor Jeffcoate continued: 'There's a danger of being punished for failing to comply with standards which differ from current guidelines, using metrics which may be unmeasurable.'

Last week, Diabetes UK launched the Putting Feet First campaign after studies revealed people with diabetes are over 20 times more likely to have a lower limb amputation, and around 80% of the 6,000 diabetes-related amputations in England each year are preventable.

Professor Jeffcoate admitted foot care had been 'neglected' by diabetologists, with little formal training of doctors and nurses. 'All of this has led to an inconsistency in clinical care, both by generalists and specialists,' he said. 'Diabetic foot remains the 'Cinderella' of diabetes.'

The NHS's response must be to improve care and clinical consistency, he said. Each area of the UK needs to 'establish a foot protection team, a multidisciplinary team if we haven't got one, formalise training, and adopt the integrated foot care pathway that's been released by Diabetes UK,' he said.

But he said it was 'unclear' how current targets within the QOF would help GPs participate in this. A study presented at the conference in Glasgow this week showed no relationship between achievement of indicators for foot checks by practices and a lower rate of amputation.

The QOF this year has required GPs to assess risk of future foot problems, including ulceration. Professor Jeffcoate said: 'Many commentators have asked why on earth has [the QOF] not been linked to some action, instead of just classifying the risk. Why no requirement for referral for expert assessment? I think that's a fair point.'

A NICE spokesperson said: ‘Our quality standard on diabetes in adults was developed by a group of experts in the condition and we consulted with stakeholders during its development, including Diabetes UK. We are surprised by the comments made Professor William Jeffcoate, as neither he nor other representatives of Diabetes UK raised such comments during this consultation process. Also, it is important to note that Diabetes UK is one of our many endorsing publication partners for this standard.

‘In developing this statement, the Topic Expert Group used our recommendations from CG10 (Type 2 diabetes - Foot care) and CG119 (Diabetic foot problems - in patient management) and considered that the statement clearly and concisely represents the intent of these recommendations. It is important that the action does not solely involve referral within 24 hours, but also links to an assessment and treatment, as appropriate within this timeframe. For clarity the word ‘treated’ is used broadly in this context and covers the assessment of the patient, as well as the initiation of specific therapy.’

  • Our reporter Stephen Robinson will be reporting from the Diabetes UK Professional Conference 2012 today. Follow him on Twitter on @sh_robinson, and follow the event hashtag at #dpc12

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