James
My personal email is [log in to unmask]
Respond to me there and I will be happy to answer you.
Kind Regards
Ralph Graham
Consultant Podiatrist
Witham, Essex, U.K.
-----Original Message-----
From: A group for the academic discussion of current issues in podiatry
[mailto:[log in to unmask]] On Behalf Of James Sheridan
Sent: 04 March 2004 14:39
To: [log in to unmask]
Subject: Re: Toenail Maintenance
Dear Ralph,
Many Thanks for being so proactive. I believe that the original story is
irrelevant and it is now the marketing perception which is key. I have
just come back from exhibiting at the NHS Podiatry Managers conference
and while there listened to a very interesting talk by Steve West from
UWE Bristol looking at the macro-strategy of the Department of Health
and where Podiatry fitted in to the big picture. I suggest that the SCP
link in with Steve as soon as possible, as a Podiatrist and a Professor
of healthcare education his understanding of the plans for the NHS
should not be underestimated.
Last year I attended the American Pedorthic Footwear Association's
conference in Nashville and was interested in the lobbying fund that the
PFA had set up and even more interested in the fact that the PFA's
members were paying money into that fund to promote their professions
corner. I know this will be a distant gleam in the eye of any SCP
council member to expect extra funding from their members (NB The Irish
SCP asked for and received a substantial figure from all their own
members when it came to fight their own corner with the Irish
Government) but how can we look for an alternative Solution.
A number of Podiatrists are involved in talks with the HPC, D of H and
other bodies which have influence over the headline future of Podiatry.
In America the lobbying marketing would be very slick and these
representatives would be "armed" with research data to go in to fight
the cause. Is this happening in the UK I haven't seen any, but we do now
urgently need a central hub for research to be collated and then concise
high-impact data to be distributed to the relevant parties.
The Trade have offered marketing input to the SCP and I have also spoken
to the Podiatric Research Forum over the issue. We are generating
positive momentum here on the core issues but I agree with Mark Russell
that this is perhaps not the arena for this debate, but please tell me
where else can it be held.
Kind Rgds
Jamie Sheridan
-----Original Message-----
From: Ralph Graham [mailto:[log in to unmask]]
Sent: Wednesday, March 03, 2004 10:10
To: [log in to unmask]
Subject: Re: Toenail Maintenance
Mark,
I think this type of debate is far more valuable than discussions about
tactics which are so often only a matter of opinion without evidence.
Let me divide the general philosophy of NHS care from the specifics of
podiatric care. I am convinced that sooner or later a political party
will have to acknowledge that with rights comes responsibility. Your
example of the heroin addict maybe one where care is provided despite
self harm but perhaps the smoker may have to accept restrictions on
service. I have no particular fixed view save that we have to identify
the boundaries. To give you another example, IVF for the childless
couple but not the remarried 60 year old who fancies a second family.
To come to podiatry. As you say we have been centred on the provision of
care as seen from a fire fighting perspective. We are not a dental
service for feet. Maybe we should be, I think this sort of continual
service is what you are referring to. I would support the notion of
continuing foot health and such treatment as required. I think such a
model can be put to govt and get a hearing although we would have to
advocate the use of different levels of training if this was an NHS
provision. Our problem is that this is as much as anything a prevention
service and until very recently this was not a model accepted by the
NHS. Dentistry had sold itself as a prevention service and when
successful, as it has been recently promptly abandoned NHS provision.
Ask the teenagers you know how many have had any fillings and
extractions and you will discover very few. So dentists have opted out
of NHS care leaving the DOH stuck with the problem of how do you fund a
system that does more than line the pockets of a few and what do you get
in return. The DOH solution is too offer employed posts to dentists and
abandon the self employed contractors. The effect on us is that the DOH
is now very reluctant to set up any service where they fear much money
will be spent on a n expanding service they have not provided (or
costed) before and could have the same implications for future costs.
One point changed a couple of weeks ago with the publication of the
report that indicated that the NHS must become a health advisory and
prevention service if it is to control costs. Here we score well, not
just in the diabetic amputation arena, but in many others including the
impact on social care costs.
If this philosophical change is accepted by the govt then we should make
progress. We should see over the coming months.
As far as the management and Society people are concerned I think there
is a recognition that change is unavoidable if we want progress. NHS
provision can (and should) include the use of independent contractors
who may work alone or employ assistants. We need to be sure they are
paid an appropriate fee for the work and both sides get a good deal. For
once the Society can be in a good political position to make progress
and to influence change.
Kind Regards
Ralph Graham
Consultant Podiatrist
Witham, Essex, U.K.
-----Original Message-----
From: A group for the academic discussion of current issues in podiatry
[mailto:[log in to unmask]] On Behalf Of Mark Russell
Sent: 03 March 2004 09:12
To: [log in to unmask]
Subject: Re: Toenail Maintenance
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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