1. The Ealing Experience and Vision for the Future: Dr Sanjeev Mehta, Consultant Diabetologist, Ealing Hospital NHS Trust
Dr Sanjeev Mehta
Consultant in Diabetes and Endocrinology
Ealing Hospital NHS Trust
Integrated Care Organisation
Incorporating the Community Services of Brent, Ealing, and Harrow
19 April 2017
London Foot Network Meeting

2. London Foot Network Meeting
Overview
My background
Diabetic foot care in Ealing in 2010
Progress over the past 3 ¾ years
Challenges ahead
Questions
19 April 2017
London Foot Network Meeting

3. London Foot Network Meeting
My background
London Graduate
Specialist Registrar, Diabetes and Endocrinology, NW Thames Rotation
Locum Consultant in Diabetes and Endocrinology, Central Middlesex Hospital, June – December 2009
Consultant in Diabetes and Endocrinology, Ealing Hospital, January 2010 to date
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London Foot Network Meeting

4. Lower limb amputations in diabetic patients in Ealing, 2009/10
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London Foot Network Meeting

5. Diabetic Foot Service – Ealing Hospital 2009/10
Recently established diabetic foot clinic (Consultant Diabetologist and podiatrist with input from Tissue Viability Nurse)
50 new referrals seen in the previous 12 months
Vascular surgery clinic run in parallel
Twice monthly diabetic foot Multidisciplinary Team (MDT) meetings (Diabetologist, Interventional Radiologist, Vascular Surgeon, Orthopaedic surgeon, Podiatrists, Tissue Viability Nurse)
No antibiotic guidelines in place for management of diabetic foot infections
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London Foot Network Meeting

6. Antibiotics – consensus statement
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London Foot Network Meeting

7. Antibiotic guidelines
Spring 2010 – Trust antibiotic guidelines written (by myself and the Associate Specialist in microbiology)
Spring 2010 – Microbiologists start attending diabetic foot MDT meetings
January 2011 – Locum Consultant in Infectious Diseases appointed – starts attending diabetic foot MDT meetings
Autumn 2011 – out-patient antibiotic service established for patients who need long term iv antibiotics (eg for MRSA osteomyelitis)
January 2013 – first revision of Trust antibiotic guidelines
19 April 2017
London Foot Network Meeting

8. Access to clinic and increasing capacity
Simple, mainly “tick-box” referral form developed
Referral by post, or fax
Early referral encouraged
Specialist registrars encouraged to come down to clinic and see patients under my supervision
Last year ~150 new referrals seen
Podiatrists now do a daily clinic in the hospital – dedicated slots available to review in-patients
19 April 2017
London Foot Network Meeting

9. London Foot Network Meeting
Teaching and Training
Healthcare professionals
Diabetic foot MDT meetings
Diabetic foot clinic
Education courses and talks for General Practitioners and Practice Nurses (e.g Warwick certificate in Diabetes Care)
E-star events
Hospital Grand Rounds
Junior Doctor (including CMT and GPVTS) teaching
Diabetic foot study day
Patients
Structured Education Courses (eg “Right Start”)
Regular podiatry input and reinforcement of key messages
“Lets talk about diabetes” initiative
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London Foot Network Meeting

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Other initiatives
Summer 2011 – In-patient Integrated Care Pathway developed
September 2011 – Focus on foot care at Diabetes Team “Away Day”
December 2011 – Diabetic Foot Study Day – free to all staff in Ealing Integrated Care Organisation
2012 – Formalisation of our Foot Protection Team
Participation in the London Diabetic Foot Network
Involvement in the amputation root cause analysis audit
Involvement in the KCH Charcot PTH study
19 April 2017
London Foot Network Meeting

11. Diabetic Foot Disease Profile
Data available for every CCG in England on the National Diabetes Information Service website
Examines the scale of inpatient care of people with diabetes who are admitted to hospital for a range of footcare conditions
Data compiled from Hospital Episode Statistics and covers episodes of hospital care over the preceding 3 years, including:
Total episodes of inpatient care for diabetic foot disease
Total nights in hospital due to diabetic foot disease
Episodes of care when an amputation is performed in those with diabetes
19 April 2017
London Foot Network Meeting

12. Diabetic Foot Disease Profile – Ealing PCT
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London Foot Network Meeting

13. Diabetic Foot Disease Profile – Ealing CCG
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London Foot Network Meeting

14. Diabetic Foot Disease Profile – Ealing CCG
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London Foot Network Meeting

15. Diabetic foot Disease Profile – Ealing CCG
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London Foot Network Meeting

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Where are we now?
41% reduction in amputations over 2 years since Diabetic Foot Disease profiles first published
Total amputations (major & minor) currently half the average for all CCGs in England
Major and minor amputation rates both significantly below the average for all CCGs in England
Episodes of care in hospital and numbers of days in hospital for diabetic foot care significantly below the average for all CCGs in England
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London Foot Network Meeting

17. London Foot Network Meeting
Challenges ahead
Centralisation of vascular (and renal) services
Potential for fragmentation of care
Need for clear pathways and means of communication
Shaping a Healthier Future
Lack of an integrated “Diabetes Budget”
Reaching and treating the most vulnerable patients
Demand management
Reducing in-patient length of stay
Prevention of hospital acquired foot ulcers
Casting
19 April 2017
London Foot Network Meeting

18. London Foot Network Meeting
Lessons learnt
Try and do the basics well
Many heads are better than one!
Audit your amputations (and learn from this)
Know and use your audit / outcome data
Education, education, education!
Beware of complacency
19 April 2017
London Foot Network Meeting

19. London Foot Network Meeting
Acknowledgements
All members of the multidisciplinary foot care team, Ealing Hospital NHS Trust
Community Podiatrists and the foot protection team, Ealing Integrated Care Organisation
Dr Jonathan Valabhji
Dr Wing May Kong
Professor Michael Edmonds
Miss Stella Vig and the London Foot Network
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London Foot Network Meeting

20. Thank you for your attention
Questions?
19 April 2017
London Foot Network Meeting