A Demographic Evaluation of UK Podiatry Services

A Demographic Evaluation of UK Podiatry Services Dr Lisa Farndon Podiatric Development Facilitator Podiatry Services Integrated Community Care Directorate Sheffield Teaching Hospitals NHS Foundation Trust June 2016 1

A DEMOGRAPHIC EVALUATION OF UK PODIATRY SERVICES METHOD In order to determine the characteristics of the current patient population managed by UK podiatrists a survey questionnaire was developed to get a snap shot of practice on one day (Appendix 1). The design was based on a previous survey of patient population characteristics [1] and after consultation with a number of clinicians and podiatry managers. This survey was piloted on 20 podiatrists and amended slightly based on feedback received. The survey was then sent to all practising members of The Society of Chiropodists and Podiatrists, 7426 electronically via Survey Monkey and 769 as paper surveys sent out to members where no email address was available. The survey was also launched at the annual delegate assembly in April 2015, promoted in the May edition of Podiatry Now and a letter sent to all branch chairs to maximise response rates. Members were asked to only complete the survey once if they had received it by more than one method. The total sample was 8195. RESULTS 1552 responses were received via Survey Monkey and 304 as paper copy, a total of 1856 (representing a 23% response rate). Seventy four per cent of respondents were female and 25% male (5 stated other and 23 respondents did not answer this question). Podiatrists Age Range The age range of respondents is shown below. The majority (64%) were aged between 41 and 60 years. 61-70 6.57% 51-60 29% 70 + 0.33% missing 1.99% 21-30 8% 31-40 19% 41-50 35% 2

Region of work The largest number of respondents were from the South East, followed by the North West and Scotland. All regions of the country were represented. REGION RESPONSE % S/East 289 15.57 N/West 249 13.42 Scotland 206 11.1 S/West 197 10.61 Yorkshire & Humber 141 7.6 London 140 7.54 E/Midlands 133 7.17 S/Midlands 126 6.79 East of England 106 5.71 N/East 89 4.8 Wales 84 4.53 N/Ireland 75 4.04 missing 21 1.12 TOTAL 1856 100 Main Work Sector When asked which sector members worked in, 41% replied that they worked solely in private practice whilst 35% worked in the NHS all of the time. A number of respondents (23%) worked in both private practice and the NHS. Education 0.5% Semi-retired 0.4% Private Practice/NHS 23% Other 0.1% Private Practice 41% NHS 35% 3

Main Work Sector and Gender The ratio of females and males working in both private practice and the NHS were of a similar order. Male % Female % Private Practice 24 76 NHS 19 81 Combined work sectors Of the respondents who worked in both the NHS and private practice, 80% worked in the NHS half or more of their working week whilst 31% worked over half of their time in private practice. Number of patients treated on one clinical working day Over half of respondents (61%) treated between 10-20 patients in their clinical day, with 27% treating less than 10 patients and 12% treating more than 20. Some respondents replied that they had a short clinical day due to working part-time or carrying out other duties. Treatment Site Twenty eight per cent of treatments were carried out in private practices/private hospitals, 26% in GP surgeries or health centres, followed by 20% of treatments in patients own homes. 30 25 In a private practice clinic/private hospital In a GP surgery/health centre % response 20 15 10 5 In patients' own homes In a hospital site In nursing/residential homes Other (please specify) In a surgical unit/theatre 0 A large number of other treatment sites were stated. These included prisons, commercial sites and homeless shelters. 4

Age range of patients Responding podiatrists treated patients of all ages, but the largest proportion of patients were aged between 62-83 years. Eighteen per cent of patients were aged over 83 years. >83 yrs 18% <18 yrs 9% 18-39 yrs 14% 62-83 yrs 34% 40-61 yrs 25% Medical Problems of Patients The majority of patients seen had multiple medical conditions. The most frequent were diabetes (19%), osteoarthritis (16%) and heart disease/disorders (13%). % response 20 18 16 14 12 10 8 6 4 2 0 Diabetes Osteoarthritis Heart disease/disorders Peripheral vascular disease No medical problems Rheumatoid arthritis Neurological disease Mental health problems/dementia Cancer Learning disabilities 5

A comparison of medical conditions seen in patients by practitioners that work either wholly in the NHS or wholly in private practice in rank order RANK NHS Private Practice 1 Diabetes Osteoarthritis 2 Osteoarthritis Heart disease/disorders 3 Heart disease/disorders Diabetes 4 Peripheral vascular disease No Medical problems 5 Neurological disease Peripheral vascular disease 6 Rheumatoid arthritis Mental health problems/dementia 7 Mental health Neurological disease problems/dementia 8 No Medical problems Rheumatoid arthritis 9 Cancer Cancer 10 Learning disabilities Learning disabilities Types of Foot Problem Twenty six per cent of patients seen had corns and/or callus and 21% had thickened, fungal or involuted toenails. Twelve per cent had a foot ulcer and 11% had foot problems affecting the musculoskeletal system (MSK). Many patients were treated for multiple foot problems. % response 30 25 20 15 10 5 0 Corns &/or callus Thickened, fungal or involuted nails Foot ulcer MSK problems Diabetes foot screening O/C Foot infection Other VP 6

A number of other foot problems were treated by respondents. These included gangrene, trench foot and Charcot joints. A comparison of foot conditions seen by practitioners that work either wholly in the NHS or private practice in rank order RANK NHS (n=520) Private Practice (n=616) 1 Corns and/or callus (2996) Corns and/or callus (4629) 2 Thickened, fungal or involuted toenails (2467) Thickened, fungal or involuted toenails (3190) 3 Foot ulcer (1900) 4 MSK problems (e.g. tendonitis, fasciitis) (1057) 5 Required diabetes foot screening (960) 6 Foot infection (556) 7 Onychocryptosis (485) 8 VP (2) Podiatry Treatment MSK problems (e.g. tendonitis, fasciitis) (689) Onychocryptosis (586) Required diabetes foot screening (330) Foot infection (264) Foot ulcer (124) VP (72) The most frequent treatments carried out were the reduction of corns and callus (19%). Fifteen per cent of patients received foot health or footwear advice and 11% received a podiatry assessment. Four per cent of patients had podiatric surgery and 6% were given public health advice. This included advice about weight management, smoking and exercise. 7

% response 20 18 16 14 12 10 8 6 4 2 0 Comparison of treatments provided by podiatrists working either exclusively in the NHS or private practice in rank order RANK NHS (n=520) Private Practice (n=616) 1 Foot health/footwear advice (3595) Reduction of corns/callus (4786) 2 Reduction of corns/callus (3026) Foot health/footwear advice (2737) 3 Podiatric assessment (2005) Podiatric assessment (1679) 4 Wound care (1994) Nail care (1520) 5 Diabetes assessment/screening (1300) MSK/biomechanics (598) 6 Public health advice (1029) Public health advice (561) 7 MSK/biomechanics (1023) VP treatment (433) 8 Nail care (699) Diabetes assessment/screening (383) 9 Podiatric surgery (293) Wound care (221) 10 Nail surgery (240) Nail surgery (88) 11 VP treatment (32) Podiatric surgery (14) 8

A number of other treatments or interventions were carried out by podiatrists. These included; offloading with a cast, peripheral vascular assessment and pressure ulcer prevention. Follow up treatment Thirty four per cent of patients were followed up for core podiatry treatment at routine return times, but 21% were receiving intensive treatments at short return times. Eleven per cent of patients were discharged to self-care and 9% were referred on to other health care professionals and specialists. Annual review 7% Referred on 9% Other 4% Discharged to self care 11% Intensive treatment 21% Self referral 14% Core treatment 34% DISCUSSION In 2015 there were 12,912 podiatrists registered with the Health and Care Professions Council. Of these 10,342 were members of The Society of Chiropodists and Podiatrists (SCP) of which 8,205 were practising members. Eighty per cent of registered podiatrists were members of SCP [2]. The response rate to this survey was 23%. The age range of respondents and gender ratio was very closely matched to that of practising members of SCP (Appendix 2). As a representative sample this data should inform future workforce planning for the profession. For the NHS workforce, Health Education England (HEE) has the role of ensuring the right numbers, skills, values and behaviours of health care workers are available to meet the needs of patients [3]. This is important with an ageing population, many of whom are suffering from complex and multiple medical conditions. Seventy three per cent of respondents treated 10 or more patients in one day. Recent NHS benchmarking data also showed the high numbers of patients seen by podiatrists when compared with other health care professionals, with podiatrists treating over 50% more patients than physiotherapists [4]. These treatments were carried out most frequently in private practices/private hospital sites and GP surgeries/health centres. Just over 20% of respondents provided treatment in patients own homes. A wide variety of other sites were also used to provide treatments; some in commercial or recreational facilities but also prisons, homeless centres and a Ministry of Defence rehabilitation centre. Podiatrists treat all ages of the population which is confirmed by this survey. However, 52% of patients were aged 62 years or older, with nearly a fifth being over 83 years. This is due to the prevalence of foot conditions increasing with age. 9

A national survey of members of SCP was carried out in November 2013 [1]. Though the response rate was low (3%), the results indicated the wide range of health problems podiatry patients suffer from and the many different clinical activities undertaken; the most common treatments were to the skin and nails. It is difficult to compare these studies as medical conditions were grouped differently but the authors of this previous survey found that the most common medical problems suffered by podiatry patients during the survey period were osteoarthritis and rheumatoid arthritis, respiratory disorders, neurological diseases and heart disease. In this current study diabetes was the most frequently cited condition followed by osteoarthritis and heart disease though both surveys acknowledged the co-morbidities that many podiatric patients present with. The main foot conditions presenting were corns and/or callus, nail pathologies, foot ulcers and MSK foot problems with many patients being treated for more than one problem. Just under 10% of patients required diabetes foot screening and it is anticipated that this will rise with the increasing prevalence of diabetes year on year. When comparing results from respondents working either exclusively in private practice or NHS some differences were noted. Six hundred and sixteen podiatrists in private practice carried out 4629 treatments for corns and/or callus and 3190 treatments for thickened, fungal or involuted nails in one day compared with 2996 treatments for corns and/or callus and 2467 for pathological nails by 520 NHS podiatrists. NHS podiatrists saw 1900 foot ulcers and 960 patients who required diabetes screening compared with 124 foot ulcers and 330 diabetes screening in private practice. A large range of other foot problems were also seen by respondents including structural deformities, necrosis, Charcot joints and sports injuries. A review of 2187 podiatry consultations from an Australian University podiatry clinic also found that the most common symptomatic foot problems presenting were nail problems, corns and callus followed by plantar fasciitis and tendonitis. The most common structural complaints reported were pes planus and hallux valgus [5]. The most frequent treatment activities carried out were reduction of corns and callus, giving foot health or footwear advice and 11% of patients received a podiatry assessment. Four per cent of patients had podiatric surgery and 6% were given public health advice. When comparing treatments carried out by private practitioners and NHS podiatrists there were some interesting differences. Five hundred and twenty NHS podiatrists working exclusively in the NHS carried out 1994 wound care treatments and 1300 diabetes assessments/screening compared with 221 and 383 respectively by 616 private practitioners. Private practitioners carried out more nail care and verruca treatments and less podiatric surgery than NHS colleagues. A large array of other treatments were also carried out indicating the extended scope and specialist skills that many podiatrists possess including injection therapy and prescribing medication. Also some treatments were carried out as part of multi-disciplinary working again highlighting the contribution podiatrists can make to managing long term conditions in conjunction with other health care professionals. Eleven per cent of patients were discharged to self-care after their treatment; however 55% of patients were either seen at intensive follow up periods or routine return times. This illustrates the large proportion of patients who require ongoing treatment from podiatrists to sustain their foot health, this was confirmed by previous research [6]. Interestingly 9% of patients were referred onto other health care professionals reflecting the important role podiatrists have in the management and signposting of patients with complex or multiple health conditions. A number of other options were also mentioned by respondents including telephone reviews and admission to hospital. 10

CONCLUSION Survey data from this project has highlighted the current profile of patient s treated by UK podiatrists and shows some differences across private practice and the NHS. It also indicates the high numbers of people that are treated, which is further evidenced by NHS benchmarking data, and some previous studies. Podiatrists are a valuable workforce, especially in the public sector where they see 50% more patients than physiotherapists and have a higher proportion of patient facing time when compared with other Allied Health Professionals [4]. Many podiatrists have an extended scope of practice which is defined as: a discrete knowledge and skill base additional to the recognised scope of practice of a profession and/or regulatory context of a particular jurisdiction [7]. In time this can become part of usual practice. Such skills are used both in individual practice and when podiatrists work as part of multi-disciplinary teams to provide care often to people with complex medical conditions and long term conditions. Health Education England recommend that the future NHS workforce should have adaptable skills responsive to evidence and innovation to enable whole person care, with specialisation driven by patient rather than professional needs [3]. Innovative commissioning in terms of multi-disciplinary teams to treat people with MSK problems can reduce the burden on secondary care and be cost effective with good outcomes. As the economic burden of a growing aging population continues, podiatrists along with colleagues in health and social care will need to improve preventative care wherever possible. NHS England s Five Year Forward View emphasises the role of prevention and public health [8]. Podiatrists are perfectly placed to enable prevention in many areas, including diabetes, rheumatology and orthopaedics. The opportunity to expand the public health role of podiatrists is huge, to make every contact count. This will need investment and time as well as developing more skills in influencing behavioural change, perhaps using techniques including motivational interviewing. Over a quarter of the population in England have a long term condition, many people have multiple conditions and this section of society use approximately 50% of all GP appointments [9]. The NHS Outcomes Framework [10] lists enhancing quality of life for people with long term conditions as one of the five domains. This survey shows that a large proportion of patients that access podiatry services have one or more long term condition, the most frequent ones from the survey being diabetes, osteoarthritis, heart disease and peripheral vascular disease. Podiatrists can make a contribution to providing care for this group of the population by keeping them pain free, mobile and in turn promoting independence. The known increasing prevalence of diabetes [11-14] will pose an enormous challenge to health care services in the future. The podiatry profession needs to promote how enhanced screening of people with diabetes (and pre diabetes) can reduce the development of serious foot problems, keeping people out of hospital and maintaining mobility. This may be more easily demonstrated if services take part in The National Diabetes Foot Care Audit [15] which will allow diabetes foot care services to measure their performance against NICE guidelines in three areas: structures, processes and outcomes. This is to ensure that appropriate services are available for the treatment of diabetic foot disease and in turn to reduce the incidence of amputations. It will also allow services to benchmark their performance. It is linked to The Patient Experience of Diabetes Services survey which will measure patient experiences in primary care and specialist services. 11

Screening for Peripheral Arterial Disease and delivering first line treatment and education could also be increased, again to reduce the potential burden on secondary care. Expansion of nail surgery services emphasising cost effectiveness, cure rates and patient satisfaction could also be promoted more widely to commissioners. Similarly this could also be done in podiatric surgery in regions where there is not already an established service. Modelling and cost benefits for some podiatric interventions will enable the profession to further evidence its effectiveness in terms of cost, quality of life and sustaining mobility. The Chartered Society of Physiotherapy have produced a falls prevention economic model which shows how investing in physiotherapists can result in a reduction in falls and in turn save money [16]. They claim for every 1 spent on physiotherapy a 1.50 return on investment is achieved. This model is available for individual trusts to add their own information to make projections about potential savings when investing in physiotherapy services. This type of model could be developed for the podiatry profession in a number of specialist areas such as diabetes. This could help provide information to commissioners illustrating the possible cost savings that could be achieved with investments in podiatrists. As Townson recommends, more evidence is needed to support the impact podiatrists can have on the UK population whilst highlighting the potential increasing unmet need for podiatry due to an ageing population [17]. The profession needs to promote the unique contribution it can make to sustaining foot health, mobility and independence. References 1. Townson, M. and D. Delves, Membership Data Collection Survey. Podiatry Now, 2014. April: p. 28-29. 2. The Society of Chiropodists and Podiatrists, Podiatry Figures, personal correspondence from L, Ambrose. 2015: London. 3. Health Education England (2015) Workforce Plan for England - Proposed Education and Training Commissions for 2015/16. 4. NHS Benchmarking Network, Results of Benchmarking Community Services. 2015. 5. Bennett, P.J., Types of foot problems seen by Australian podiatrists. The Foot, 2012. 22(1): p. 40-45. 6. Farndon, L., The function and purpose of core podiatry: An in-depth analysis of practice, in Faculty of Health and Wellbeing. 2006, Sheffield Hallam University: Sheffield. 7. Health Workforce Australia, Queensland Health Practitioners' Models of Care Project: evaluation, learning and upscaling of results for a national audience - Final Report. 2014: Queensland. 8. NHS England (2015) The NHS Five Year Forward View. 9. NHS England (2015) NHS Outcomes Framework - 5 domains resources. 10. Department of Health, Public Health Outcomes Framework for England - 2013-2016. 2012, Department of Health: London. 11. https://www.diabetes.org.uk/about_us/what-we-say/statistics/state-of-the-nation-challenges-for- 2015-and-beyond/ 12. https://www.diabetes.org.uk/in_your_area/scotland/diabetes_in_your_area_scotland/ 13. https://www.diabetes.org.uk/in_your_area/wales/diabetes-in-wales/ 12

14. https://www.diabetes.org.uk/upload/in%20your%20area/diabetes%20uk%20n%20 Ireland/State%20of%20the%20Nation%20201213.pdf 15. Health & Social Care Information Centre (2015) National Diabetes Foot Care Audit. 16. Chartered Society of Physiotherapy (2014) The Cost of Falls. 17. Townson, M., Developing a sustainable podiatry workforce for the UK towards 2030. 2014, The College of Podiatry,The Society of Chiropodists and Podiatrists. Appendix 1: AN EVALUATION OF UK PODIATRY SERVICES 1. What gender do you identify as? 2. What is your age? Male Female Other Prefer not to answer years 3. What region do you work in? Scotland N/West N/East Yorkshire & Humber S/Midlands E/Midlands Wales London S/East S/West East of England N/Ireland 4. What sector do you work in? (If you work in more than one sector please indicate the % of time in each) Private practice % NHS % Education % Semi-retired % Other (please state) 5. How many patients did you treat today or on your last working clinical day? Less than 10 10-20 More than 20 6. How many patients did not attend your clinic on this day (without prior notice being given?) 7. Where did you provide this treatment? (you can tick more than one) In a GP surgery/health centre In a surgical unit/theatre In patients own homes In a hospital site In a private practice clinic/private hospital In nursing/residential homes 13

Other/additional information (please specify) 8. Of the patients treated on you last working clinical day, how many were of the following ages? <18 years 18-39 years 40-61 years 62-83 years >83 years 9. Of the patients that you saw on your last working clinical day, how many had the following general medical conditions? Diabetes Osteoarthritis Rheumatoid arthritis Neurological disease (eg MS, stroke) Heart disease/disorders Cancer Learning disabilities Peripheral vascular disease Mental health problems/dementia No medical problems Other (please state) 10. Of the patients you treated on your last working clinical day, how many had the following foot problems? Thickened, fungal or involuted toenails Onychocryptosis Corns and/or callus Foot ulcer Foot infection Verruca Musculoskeletal problems (eg tendonitis, fasciitis) Required diabetes foot screening Other (please state) 11. How many had the following treatments? Podiatric assessment Diabetes assessment/screening Nail care only Reduction of corns and/or callus Treatment to verruca Nail surgery (inc pre-op assessment & dressings) Podiatric surgery (inc pre-op assessment & dressings) Wound care MSK/biomechanical treatment (eg exercises, strapping, orthoses) Foot health/footwear advice Public health advice (eg smoking cessation, falls prevention) Other (please state) 12. From the patients you saw on your last working clinical day, what was their follow up? Discharged to self care Core treatment at normal return times Self referral Intensive treatment at short return times Annual review in podiatry Referred onto other services 14

Other (please state) Appendix 2 Comparison of respondents age compared with the age range of practising SCP members (including podiatric surgeons) AGE RANGE (yrs) SCP practising members Survey respondents 21-30 31-40 41-50 51-60 61-70 Over Female Male 70 9% 22% 34% 26% 7% 1% 73% 27% 8% 19% 35% 29% 6.57% 0.33% 74% 25% (some missing) 15