Footing the bill for diabetes

The world’s first Diabetic Foot Clinic was opened in 1981 at King’s College Hospital by Professor Michael Edmonds.

Since I jointly set up the Diabetic Foot Clinic at King’s College Hospital in 1981, I have seen how multidisciplinary care can have a huge impact on patient outcomes. Specialists working together under one roof can intervene and stop the progression of a disease which, if untreated, can swiftly lead on to tissue necrosis and gangrene. But, if I had to pick the one crucial thing that has really revolutionized our practice – helping to achieve a 50 per cent reduction in major amputations – it is that we have open access to the clinic for our patients. Of course, we have routine appointments, but if patients notice a problem they can walk in and be seen straight away. There is nothing high-tech about this innovation, but it works beautifully.

The reason is that speed is of the essence when it comes to treating diabetic foot problems. The progression from initial scratch to wet gangrene can take as little as 48 hours. Staphylococci and streptococci bacteria, as well as other bacteria, can easily invade open wounds and multiply rapidly. They are toxic and cause thrombosis in the blood vessels leading to a rapid reduction in blood supply, which makes the infection worse. In minutes, bacteria can start spreading along the tendons and ligaments and the diabetic immune system, which is already compromised, is unable to fight back.

There is a short window of opportunity when we can do something about it, and after that, it is often too late. Of course, many diabetic patients don’t experience such a rapid decline, but many do.

I don’t think health care workers and many policy makers understand the extreme speed with which this situation can arise. Many health care workers simply do not appreciate how fast infection, in the foot of a diabetic patient, can progress. So too many diabetic patients may have to wait to be seen when an infection is taking hold. It may be days before the patient gets help when an amputation is the only option left. But a short course of antibiotics would have done the trick two days earlier.

Our patients don’t have to wait, and in fact, we encourage them to come in even if they only have suspicions. In view of the speed of onset of diabetic foot infection, we also give some of our patients, at high risk of infection, broad-spectrum antibiotics which they can take immediately they start to notice an infection developing. We trust them to use them appropriately. I know that there is a push to reduce antibiotic prescribing across the board, but antibiotics should be promptly prescribed for diabetic patients with a foot infection as this can destroy the foot in hours Antibiotics are rapidly required in these circumstances and should not be restricted.

All clinicians need to more proactive when it comes to looking after the feet of diabetic patients. Many feet have related nerve damage which means they may not feel any discomfort even when an infection is moving like a tsunami through their lower extremities. Patients don’t necessarily even get a mild fever – the body’s normal reaction to raging infection, because the nerves are failing to transmit the message that there is infected and necrotic tissue in the foot back to the brain.

What I have learned over the years is that wherever hospitals and clinics can receive patients quickly, getting them assessed and treated with antibiotics without delay, the outcomes are excellent. Speed really can get these patients out of trouble.

At the moment, around 70 per cent of hospitals have multidisciplinary foot clinics for diabetic patients staffed by specialist podiatrists supported by nurses, orthotists, diabetologists and surgeons but it should be 100 per cent of hospitals. These clinics should also encourage ‘walk-in’ patients, like we do. Diabetic foot ulcers and amputations lead to long term disability and cost at least £650 million each year to the economy and the health service (or £1 in every £150 the NHS spends )The gatekeepers of the multidisciplinary foot clinics are usually the specialist podiatrists. Establishing a multidisciplinary clinic, staffed by 2 specialist podiatrists, in hospitals without such clinics, would need an investment of just £200,000 per year per hospital. The maths is simple and so is the solution. So why can’t we just go ahead and make it happen?