The Legs Matter campaign is seeking to improve the care of patients with lower limb wounds. It is widely recognised that there are considerable variations in clinical practice/services which can lead to delays in diagnosis and ineffective or inappropriate treatment plans. This results in increased health service spending, plus a greater burden on clinical resources and elongated patient suffering due to extended healing times.
In 2017/2018, more than 1 million people in the UK had active lower limb ulceration, which was a 37% increase of prevalence since 2012/2013 (Guest et al, 2020). The increase in prevalence has been linked to a substantial increase in resource consumption, with patient management costs increasing by 48% from 2012/2013 to 2017/2018. There has been a call for structural changes within the NHS in order to manage this increasing demand and improve patient outcomes (Guest et al, 2020).
The National Wound Care Strategy Programme (NWCSP) has developed specific NWCSP lower limb clinical recommendations that could help turn the tide by reducing this burden (NWCSP, 2020). Therefore, Legs Matter is calling for the UK-wide implementation of the NWCSP lower limb clinical recommendations.
It is important to remember that the NWCSP lower limb recommendations do not just focus on leg ulcers but also provide a clear strategy for patients with foot ulceration. This has led to an agreed anatomical boundary line, helping clinicians to define a leg ulcer or a foot ulcer (Figure 1).
Figure 1. Leg and foot ulcer positions
The NWCSP has highlighted many unwarranted variations in access to services for patients with foot ulceration. In the 1980s diabetes-related foot disease was often described as the ‘Cinderella’ of diabetes but the development of diabetes multidisciplinary foot teams in the late 1980s and early 1990s led to a significant improvement in care for this vulnerable group. Although Cinderella may still not have got to the ball, most patients with diabetes foot ulceration can now access a multidisciplinary team (MDT). This MDT approach is designed to target the underlying cause, ensure appropriate debridement/wound management and ensure the vital element of off-loading, which is paramount to any care. However, a patient with a foot ulcer who does not have diabetes (the new Cinderella), can struggle to access appropriate care and often falls between services. There is added confusion when it comes to patients who develop a pressure ulcer of the heel following a hospital stay. Would that patient be under the care of the nursing teams, podiatry team or the diabetic foot MDT? Clearly clarity is needed.
Podiatrists have a huge skill base, they are all educated to degree level and have been trained to become foot experts, understanding foot structure, function, mechanics, dermatology, neurology and the vascular system related to the lower limb. In addition, sharp debridement is a core aspect of undergraduate podiatrist training and many podiatrists have excellent wound management skills/knowledge.
To optimise the healing in patients with foot wounds we need podiatry input or as in this analogy Cinderella needs to go to the ball! That is why the NWCSP recommends that all patients with a foot wound are referred to podiatry services. This is already happening in some areas across the country but, for many others, there will be challenges in terms of commissioning and delivering this new way of working.
One very positive outcome of different clinical professions collaborating and working together, is the breaking down of traditional professional boundaries and the focusing on the specific individual's capability to practice. With the appropriate training and skill why can't a podiatrist apply compression bandaging, or a nurse debride surrounding wound callus? The focus needs to be on the right care at the right time provided by clinicians with the appropriate skills and knowledge. Health Education England now speak about advanced clinical practitioners rather than advanced nurse practitioners and regionally there has been the appointment of podiatrists into vascular specialist practitioner roles and nurses into lead roles within diabetic foot services. All these changes can only be to the benefit to the patient.
Nationally we need to be calling for implementation of the NWCSP recommendations, including specifically the Cinderella of wound care the non-diabetes-related foot ulcer as Legs Matter believes that all patients with wounds should have equal access to services.