Rapid access to multidisciplinary diabetes foot care teamsBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m773 (Published 04 March 2020) Cite this as: BMJ 2020;368:m773
All rapid responses
Dear Editor :In his excellent editorial, Professor Valabhji stresses the importance of rapid access to the multidisciplinary foot team (MDFT), ideally comprising referral by a Health Care Professional (HCP) within one working day and triage within the MDFT within one further day.
Following on from this editorial is the important question as to how can we make this happen in practice, as it is not taking place at present. A systematic review investigating delays in the management of chronic limb-threatening ischemia and foot ulceration in people living with diabetes reported that “median times from symptom onset to specialist health care assessment ranged from 15 to 126 days, with subsequent median times from assessment to treatment ranging from 1 to 91 days” . The National Diabetes Footcare Audit (NDFA) has shown that there is a substantial variation in the times between first HCP assessment and arrival at the MDFT. When considering an interval of two weeks between first healthcare assessment and arrival at the MDFT, the proportion of cases seen at the MDFT within this time interval, ranges from 12% to 97% between providers in England and Wales . Delays in referral to specialist teams have also been reported in Europe .
Why do these delays occur? Initially, there is the failure of recognition by persons with diabetes of such untoward events such as a break in the skin, swelling, redness or pain and also a failure of the appreciation of the seriousness of such events. Such persons may not have been educated about examination of the feet or the recognition of signs of infection and are uncertain as to what to do after noticing warning signs in the feet . In a retrospective study of 270 people with diabetic foot problems, the pre-hospital delay was a median of 46.5 days . The longest delays were independently linked with poor diabetic foot education and lack of knowledge concerning foot lesion warning signs .
Even after patients have reached an HCP, there may be delay in referring to the MDFT because of a failure to make a diagnosis. HCPs may fail to recognise infection or ischaemia in the absence of pain because of concomitant neuropathy . However, in support of HCPs, they have reported difficulties in accessing specialist diabetes foot services, citing funding constraints, lack of staffing and centralisation of services . An association has been noted between the number of HCPs in the referral pathway and increased delays in reaching the MDFT: the more complex the referral pathway, the greater the delay . Thus a number of reasons account for the delays including poor symptom recognition ,inaccurate health care assessment, and problems in accessing specialist services.
What are the effects of these delays? In a Norwegian cohort of people with diabetes and foot problems, those who were referred more than 52 days after ulcer onset to specialist care by a general practitioner had a 58% (SHR 0.42, CI 0.18–0.98) decreased healing rate compared to those who were referred earlier .. The NDFA reported that the longer it took for a person with diabetes and a new foot ulcer to reach expert care, the greater the chance of the ulcer being severe and not healed after 6 months and the more likely for the person to have a hospital admission within six months, involving foot disease, revascularisation and amputation [10,11]. In a study from Greece , the odds risk for major amputation increased by 3.5% for each additional day of delay in referral to the MDFT (95% CI, 1%-6%;P= .011) (12).
Although the major amputation rate is comparatively low in England, it is important to note that there were 7,545 major amputations in people with diabetes in England between 2015 to 2018 . The major amputation rate has been static from 2012 to 2018 and there is a post code lottery of a seven fold geographical difference in the incidence of major amputation [13,14]. However, access to an MDFT decreases the frequency of limb loss in people with diabetes and foot problems and it is important to get such people urgently to the MDFT 
This has been addressed by the iDEAL (Insights for Diabetes Excellence, Access and Learning) group, a multi-disciplinary team of diabetes specialists, who has produced a position statement called “ACT NOW Diabetes and Foot Care Assessment and Referral “ . ACT NOW is an acronym highlighting warning signs in the foot that could lead ultimately to an amputation. A is for accident (recent trauma to foot); C is for Change in foot colour or shape; T is for temperature change of the foot; N is for new pain in the foot; O is for oozing from a wound which is denoted by W.
If persons living with diabetes have any of these signs, they should be allowed and encouraged to refer themselves urgently and directly to the MDFT for rapid diagnosis and treatment to avoid the possibility of amputation. This should cut out delay in getting to the MDFT. The position statement also recommends that there should be increased instruction for all HCPS in the assessment of the foot and urgent referral to the MDFT and also a national foot education programme with practical information about foot self-care. The acronym ACT NOW should be the basis of a national campaign to promote rapid access to the MDFT. It would be similar to the campaigns that informed the heart attack and stroke campaigns which had such acronyms as STOP and FAST. Such an open access scheme will increase the need for more specialist diabetes podiatrists who are the gatekeepers of the MDFT but this could be financed by savings from the reduced number of major amputations.
An ulcer precedes 84% of major amputations which are thus preventable if the ulcer is healed quickly . It is vital to have rapid access to a modern MDFT which is equipped to carry out modern limb salvage . This should promote the healing of the ulcer and prevent avoidable major amputations.
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Competing interests: Attendance at the advisory boards for Urgo Medical and Bayer AG but this has not affected my Response dealing with the Rapid Access to MDFTS