Martin

My suggestion for NHS podiatry care is as follows.

1.   A specialist core service, hospital based, delivering care in two
distinct areas – podiatric medicine and podiatric surgery. Podiatric
medicine for the care of the ‘high risk’ patient only – diabetic foot
syndrome, rheumatology, wound care & etc. No routine chiropody or nail
care; no routine diabetic screening; no general practice services.
Podiatric surgery is self explanatory.

This would be funded from the existing budget – circa. £120million p/a,
however there would be substantive differences from the existing set-up.
Firstly, the number of podiatrists directly employed by the NHS would fall
considerably. Removing the general practice components from a specialist
service would negate the need for a workforce of nearly 4,000 podiatrists.
I suggest a core service need only retain 1,000 specialist practitioners in
podiatric medicine who would be integrated within the multidisciplinary
teams. This would remove the need for podiatry ‘managers’ and release
additional funding for front-line clinical services. Thus the day of health
centre clinics, caravans and domiciliary visits would be over for the
salaried NHS practitioner.

From the clinician’s perspective, there would need to be a new grading
system – preferably structured the same way as other disciplines -
consultant led with registrars, senior registrars and trainee residents and
the care would be delivered under an out-patient model i.e referral-
>treatment->discharge. Patients would be referred, via the
multidisciplinary team; by general medical practitioners and by general
podiatric practitioners. There would be no static caseloads.

The establishment of podiatric surgery is dependent on a number of factors –
 successful integration with the rest of the surgical fraternity, theatre
access & etc, but if funding was made available from the existing podiatry
budget (as opposed to ‘new’ funding which might be seen as being diverted
from orthopaedics), we should be able to make the case fiscally as well as
clinically for an expansion of the podiatric surgeon’s role. Numbers – I
have no idea – this will depend on the demand for foot surgery and the
availability of surgical facilities. Perhaps parity with podiatric medicine
specialists and structured on the same basis? That being so we would have
half the workforce directly employed by the NHS than we have at present.

From the patient’s perspective, care at the NHS specialist service would be
free at the point of delivery. There would be no patient contributions and
the clinicians would be directly employed on a salaried basis with the
hospital trust. There would be no more community PCT salaried chiropodists
or podiatrists – no senior I’s or II’s and no ‘over assessment’ of low-risk
diabetics. Treatment directed where it is needed most, by the most
appropriately trained individuals, being paid respectable salaries – not
ones linked to AfC grades.

2. General podiatric practice NHS scheme using accredited practices.
Patients would access directly – without the need for referral – and would
be free to choose whatever practice or clinician whenever they want or need
to. Clinicians would be self employed and see a mix of fee paying and non
contributory patients under a new NHS contract (let’s leave funding and
reimbursement methods for the moment) in what would be, for all intent and
purpose, a partnership agreement with the State. Which patients would
qualify for free care? I suggest only those on low incomes – basic state
pensions, income support, students and schoolchildren of parents on low
incomes. Part contributions for patients with medical conditions such as
diabetes – the State could pay for an annual examination and screening
appointment and perhaps some aspects of their clinical care through a
managed care fee programme. The same could apply for other patient groups
too – such as the treatment of common foot disorders for patients on anti-
coagulant Rx for instance. Simple nail care would be provided at this level
with exemptions again for patients on low incomes. We could have an
interesting debate on what conditions/patients would be exempted from fees,
but at the end of the day it would be for the government to decide – not
the profession - what care it wants to pay for. Such a scheme would need to
be regulated and monitored by a practice inspectorate (jobs for the
redundant podiatry managers?) and would make the case for a dedicated
registrar absolutely imperative given the differentiation between
specialist and general practitioner.

In conclusion, I do not advocate a ‘free for all’ NHS podiatry service. The
State does not fund all aspects of podiatry practice at the moment and the
prospect of it doing so in the future is both unrealistic and unhealthy for
the profession and its patients. We do need clarification on what care the
State wants us to provide – not the vague ‘contract’ we have at present –
but detailed specification on ‘what and to whom’. Once we have that we can
go forward in designing a sustainable and vibrant practice base for the
future.

David (Wylie).

I agree with all you have written but I am not surprised in the slightest.
Would you not agree that it is time for the profession to determine the
contract with the NHS rather than the other way around?

Kind regards.

Mark Russell

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