SOUTHAMPTON MEDICAL SOCIETY
President: Dr Nigel Dickson FRCGP
The Southampton Medical Society met to hear the Foott Memorial Lecture on the 1st of February 2023 . The President was in the chair. The lecture was delivered by Professor Clifford Shearman OBE BSc FRCS MS., Emeritus Professor of Vascular Surgery, University of Southampton. The President introduced Prof. Shearman who spoke to the title “Changing the World - Feet First”
Professor Shearman said that diabetic foot complications had been an interest for all his clinical life. He described the six steps of change with regard to the diabetic foot.
Phase 1. Recognition that there is a problem.
The commonest complication of diabetes is foot ulcers. There is an individual lifetime risk of 25% and up to 5% of diabetics will be having treatment at any one time. These patients are 24 times more likely to end up having an amputation than the general population. Forty five per cent of these ulcers will heal in one year and twenty-five percent will never heal.
Every 30 seconds a diabetic somewhere in the world has an amputation The outcome after amputation is poor. Only 1/3rd of the amputees will become fit again. But, he said, 85% of amputations could be avoided with rapid and correct treatment. In the UK there are more than 200 amputations a week and of these 45% will be for diabetic complications.
Phase 2. Enthusiasm.
Determination to attack the problem through education and research. Diabetes UK produces literature for diabetic patients on how and when to seek help, and other advice on diabetes. There is now public health information available, from a variety of sources, which is a result of research.
Phase 3. Research.
A great deal of research has been done. It was observed that diabetics with foot ulcers commonly had diabetic neuropathy with reduced sensation and a lack of muscular strength due to a myopathy. They commonly had ischaemia and a lack of collaterals. There tended to be a rapid progression of pathology after ulceration started. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, surgical debridement and drainage of infection should be considered within the first 24 hours. Once the foot is made safe, revascularisation should be undertaken in those with significant arterial disease. The research showed that treatment needed to be commenced within 3 days to prevent the ulcers becoming established with inevitable complications. Time is Tissue he said.
Phase 4. Implementation.
It is not all gloom. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries. Finland put in place a national programme of public awareness very early on. As a result the number of amputations fell. Unfortunately there has never been a national programme in the UK. However Southampton and a few other hospitals around the country set up a foot protection protocol in the first decade of this century. This included an algorithm for the treatment of foot ulcers. Revascularisation was performed where needed. Amputation rates fell in the partaking hospitals. The result of this research programme in financial terms, which cost only £150,000, produced enormous savings for the NHS compared with standard treatment As a result eventually National Guidelines were issued.
Phase 5. Persistence. Unfortunately due to decreased funding the whole system has shrunk away since 2015. Diabetics are 6 times more likely to lose a leg now.
The National Diabetes Foot Care Audit in 2017 reported significant variability and deficiencies of care throughout England and Wales, with emphasis on change in the structure of healthcare provision and commissioning, improvement of patient education and availability of healthcare access. They found:
Only 82% of diabetics have diabetic footcare
Only 71% of clinics could see the patient quickly
46% of new ulcers would have to wait to be seen for more than 2 weeks.
Political pressure is needed he said.
Phase 6. Litigation. The NHS paid out £2.75 billion in 2021. It has a liability of £8.82 billion. It costs the service £8 billion annually.
The claims for clinical negligence are numerous. These include delays in referral, failure to expedite treatment, lack of coordination and lack of multidisciplinary care.
In consequence GIRFT [Get It Right First Time] was set up by the government in 2017. GIRFT liaises with NHS England regional teams to support putting recommendations into local practice.
Professor Shearman said teamwork is essential for best practice in diabetic footcare.
The President thanked Professor Shearman for his lecture on such an important subject. It was extremely interesting. He said that Southampton was very lucky to have had Professor Shearman as their surgeon.
There being no other business the meeting was closed.