The aims, interventions tested, lessons learnt, results and conclusions of the National Diabetes Foot Care Audit (NDFA) Quality Improvement Collaborative have been published in a new report.
In 2018 and 2019 the NDFA was commissioned to produce a collaboration focussed on improving footcare. A total of 20 diverse teams came together to share ideas and explore areas of the footcare pathway and this resulted in securing eight case studies from services in England and Wales.
Since it was established in 2014, the NDFA has consistently found that having a severe ulcer is strongly linked with worse outcomes for people with diabetes. This includes lower rates of healing, higher rates of major amputations and higher risk of death.
It is vital that all people with diabetes who have a foot ulcer, or are at an increased risk of developing one are seen quickly. Early referral means that ulcers will be less severe and will lead to better outcomes.
The NDFA team wanted to support improvement in footcare for people with diabetes. Consultation with healthcare professionals, people with diabetes and policy makers clearly identified that this should focus on reducing the time to, and wound severity at, specialist assessment.
This focus recognises the findings of the national audit and the known costs to people with diabetes and to services. Specifically, it sought to improve:
- Patients’ prompt access to a healthcare provider upon developing a wound
- Prompt primary care referral for specialist assessment
- Availability of specialist assessment appointments
This work was undertaken through the creation of a National Diabetes Foot Care Audit Quality Improvement Collaborative (NDFA QIC).
NHS Digital and Diabetes UK invited services in England and Wales, which wanted to set local improvement aims related to the above aspects of care, to apply to become part of the NDFA QIC.
Each service was asked to identify a multidisciplinary team relevant to their local improvement aim(s) including, for example, a consultant diabetologist, a vascular specialist, a podiatrist, a GP or practice nurse and/or a quality improvement professional. Teams were also asked to provide evidence of support from their Trust Chief Executive and to make a commitment to meet monthly.
Commenting on the NDFA Quality Improvement Collaboratives, Professor William Jeffcoate, NDFA Clinical Lead, said: “The field of diabetic foot ulcers has always been a neglected one – despite its very considerable importance in terms of suffering and cost.
“It is also a very difficult field in which to improve the quality of overall care because this relies on the effective integration of multiple professional groups. It is primarily for such reasons that this QIC programme is so relevant and the main themes that emerge from the reports from individual centres are so valuable.
“It is interesting that different centres chose different targets in making the necessary changes to the structure of care but it is so encouraging to learn how much effort has been made in relation to professional education and of the obvious appreciation of all those involved.
“But despite some new barriers also being identified, it is clear that this work has resulted in considerable improvements in outcome in some centres – even within the short space of 12 months – with a general trend to earlier referral of new cases, improved documentation of performance and reducing incidence of major amputation.
“One centre has also been able to report what is arguably the most important result of all: that of decreasing ulcer onset in a population at risk. It is very much to be hoped that the experience and enthusiasm gained in this project can now be used to stimulate continuing improvement throughout England and Wales.”
In total, 25 teams applied to be part of the NDFA QIC. and together they took part in facilitated webinars and teleconferences, received coaching to devise and plan delivery of the developed local improvement plans and shared resources.
Each NDFA QIC team identified and tested interventions to achieve their aims of reducing the time to, and wound severity at, specialist assessment.
These interventions fell into five main types:
- Educational approaches for health care professionals
- Educational approaches for people with diabetes
- Collaborative working
- Building capacity
- Improved use of systems and processes