England: Foot and limb losses must be cut
New data has highlighted wide variations in amputation rates for diabetics across hospitals
Mark Nicholls reports
Much of the newly revealed variation in amputation rates in England is due to many diabetics not receiving nine key care processes, including checks on weight, blood pressure, blood glucose, cholesterol, urine and, in particular, consistent foot care checks.
Figures contained in the NHS Health Atlas in Variation of Healthcare show how, in the south west of England, amputations are three in 1,000 diabetes patients, which is almost twice the level in the south east.
However, there are examples where hospitals have seen dramatic reductions in amputations by introducing simple and inexpensive foot care management clinics to offer patients support and advice.
The Health Atlas says that to reduce major amputations, more integrated multi-disciplinary specialist diabetes foot teams (MDT) need to be established. At Ipswich Hospital, in the east of England, the amputation rate has fallen significantly since the MDT was established 11 years ago. At that time there were 36.4 amputations per 10,000 people with diabetes, now there are 6.7.
Dr Gerry Rayman, Head of the hospital’s diabetes department, said that a key element of their success came through lesions being efficiently identified, assessed and patients prioritised as low, moderate or high risk and then treated accordingly. ‘Patients with moderate risk can be given support in the community, but those at high risk need to be seen immediately by the knowledgeable Multi Disciplinary Foot Team,’ added Dr Rayman, who is also the national diabetes lead for inpatient diabetes for the NHS in England.
Further liaison with interventional radiologists and vascular surgeons is then an important element in helping to avoid unnecessary amputation. And, he pointed out, preventative treatments also need to be put in place, such as identifying foot ulcers before they become serious or infected.
Diabetes can lead to a loss of sensation in the feet so minor injuries can become badly infected without the patient noticing. If the infection becomes too severe, amputation of a foot, or the leg below the knee, becomes the treatment of last resort. As well as obvious benefits to the patients, he said there are clear cost savings to the health system by implementing prompt treatments to avoid amputations. Across England, there are about 70 amputations a week on type 2 diabetes patients but the Health Atlas says that 80% of amputations could be prevented.
Diabetes UK is also concerned about amputation levels and the need for consistent foot checks after figures for 2007/2008 showed that 23% of people with diabetes did not have a foot check. The charity is now working with the Department of Health to address the regional differences in amputation levels. Diabetes UK chief executive Barbara Young said the findings ‘demonstrate that the NHS is failing to provide universally high quality care across the country and shows that diabetes care is still a postcode lottery’.
The charity says that with access to high quality care, patient education and effective diabetes management, there is no reason why people with diabetes should not live long and healthy lives, particularly because 95% of diabetes care is patient self-management. She added: ‘Diabetes is the single most common cause of lower-limb amputation in the UK. Foot checks as part of the annual review should be a given and any injuries or ulcers that are detected need to be assessed as soon as possible by an expert team.’
The UK government has published the Health Atlas to try and improve care and eradicate regional variations in quality of care. The amputation difference is one of the most striking revealed in a series of 34 ‘maps’, which also covers stroke, heart disease and asthma treatment.
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