Ralph

These are extremely difficult and emotive issues – the judgement on who
should receive care based on a subjective analysis of the patient’s
lifestyle is complex and terribly problematical. I shouldn’t be in the
least surprised if at some point in the near future, a test case (under the
Human Rights Act), is applied against the NHS regarding access to free
healthcare. I guess that might be one way of ending the postcode lottery of
care that exists in many areas of the country.

I fully accept your point about smokers and vascular surgery, but this is a
moral maze we are entering here. Should heroin addicts be denied
healthcare – including methadone on prescription – because they lack the
willpower to give up the drug on their own? What about promiscuous gay men
who contract HIV and AIDS from multi-partner encounters? Many would say
that their disease is a result of their lifestyle choice, but should the
NHS deny care on that basis? What about self abusers who cut themselves as
a result of deep psychological scars? Who can really play the arbitrator in
these circumstances?

Your point about footwear is well made. Badly fitting or inappropriate
footwear probably accounts for the majority of problems that are
encountered in the podiatrist’s surgery today. The choice over fashion –v-
functionality is still a difficult one for many to make, even for the
elderly patient. Vanity still has its part to play. Give any girl a choice
between Jimmy Choo’s or Hotter Streams and I’ll know which one my money
goes on. You also have to take into account the communication skills of the
practitioner. It took me a long time to be able to speak clearly (and
unthreateningly) to patients about their footwear; to help them make their
choice from an objective viewpoint without feeling defensive or anxious
about what I was saying.

There are circumstantial pressures too. Patients know how difficult it is
to access NHS care – even more so now. There exists, as you well know, an
attitude (which has foundation) whereby patients are reticent about the
resolution of their symptoms because they fear they will be discharged and
removed from NHS lists altogether. This is certainly justified in my
opinion. Restricting access criteria has simply made that view more
trenchant and we find ourselves in the ridiculous position of having
patients giving false information about their medical history just so they
can remain on podiatry caseloads instead of being discharged. So when we
render advice about footwear, we must also understand that some patients
will feel that we are doing so, not only to get ‘rid of the corn’, but
to ‘get rid of them’.

That is part of the problem of running this service like a specialist ‘out-
patient’ department where we think that patients should be referred,
treated and discharged. That may be true for some aspects of our care
wound care, surgery, biomechanics – but this model doesn’t work for general
practice where patients will present at infrequent intervals for a variety
of common foot disorders. What we should have been concentrating on in the
NHS is improving access – making it easier for patients to be seen – rather
than restricting access. How much easier it would have been if we were able
to say to patients, ‘try and file your own toenails once a week, or have
your spouse/family help whenever possible – but when they become too
difficult/too long/too thick just pop back round to the clinic and we’ll
cut them for you whilst you wait’. If we were able to do this without the
implied threat of ‘discharge’ hanging over them, then I’d wager that
compliance rates would shoot up considerably.

It’s not the patients that are the problem. It’s the system. Ask the
majority of managers what impact scheduling systems have on their waiting
times/clinical congestion and they will look at you blankly. NHS
departments tend to use a ‘forward booking’ rather than a ‘direct access’
system. This works fine for an outpatient model, but not for general
practice. But never mind. The way NHS podiatry is contracting, it will only
be an outpatient service in the very near future, having discarded its
general practice patients to the private or voluntary sector.
Unfortunately, we have played the arbitrator. Unless we reform our services
quickly, I suspect we may now pay a heavy price.

Sincerely

Mark Russell


PS – of course, all this will be familiar to you if you were following the
debate, as David mentioned, on your old discussion forum. The complexities
of the scheduling system were detailed in a letter to your Journal in May
2002 entitled ‘Waiting Lists – The Solution’. This is what we meant
by ‘professional strategy and direction’. Are you and your colleagues in
the Society and podiatry management still reticent in discussing these
matters - or do you want to wait until the politicians start debating it
for us?

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