Amputation concerns over missed diabetes foot care targets

New figures have highlighted how missed targets could be putting people with diabetes and foot ulcer at heightened risk of amputation.

The latest data from the National Diabetes Audit (NDA), which measures the effectiveness of diabetes healthcare, has revealed that on average, only 66.3 per cent of people with diabetes and a foot ulcer were seen by a foot specialist within the NICE-recommended 13 days in England and Wales during 2022/23.  

This represents a drop from 69 per cent being seen within this target timeframe the year before.

The pressure on services is evident in the latest statistics from the NDA, which show that five out of eight regions in England and Wales – the South East, Midlands, East of England, North East and Yorkshire and Wales – have seen a drop in the number of people with diabetes and foot ulcer being seen by a specialist foot care service within 13 days. 

A specialist foot care service is a team of diabetes foot care specialists, also known as a multi-disciplinary foot care team or service (MDFT/MDFS), that perform the first expert assessment of the foot ulcer.

The findings also show that on average, less than half of people with diabetes were alive and ulcer-free at 12 weeks, and that men with type 1 diabetes face the greatest risk of major amputation.

The NDA data highlights that many people across England and Wales are not receiving vital routine foot examinations – particularly those with type 1 diabetes – which can also help to reduce the risk of amputation.

‘Time is tissue’ when it comes to treating diabetes-related foot conditions – it is crucial when it comes to reducing the risk of amputation. A National Diabetes Foot Care Audit (NDFA) review published last year found that faster referral to a specialist foot care service leads to fewer severe ulcers and better 12-week outcomes for patients.

While there have been concerted efforts to reduce amputation rates, there were 7,957 major diabetic lower limb amputations in England between 2017 and 2020. During the same period, there were 21,738 minor amputations and 171,759 foot disease-related hospital admissions for people with diabetes. 

Eye-opening research in 2020, led by international diabetic foot expert Dr David Armstrong, looked at the death rate linked to diabetic foot complications in comparison to cancer in America.

They found that five-year survival rates for those who had undergone major amputation – above the foot – were worse than the pooled five-year survival rate of all cancers.

The researchers reported: “The mortality rate for people who undergo lower extremity amputation due to a diabetic foot ulcer remains alarming: more than half of people with a major amputation will be dead in five years.” 

The Joint British Diabetes Societies (JBDS) for Inpatient Care says that up to 70 per cent of people die within five years of an amputation and around 50 per cent die within five years of a diabetic foot ulcer.

A recent NHS Resolution report also underlines how the cost of health care for ulceration and amputation in diabetes has been estimated at almost one billion pounds per year.

In response to the NDA data, a company which supplies a 10-minute home test, Neuropad, that provides an early warning of diabetes-related foot problems, has said its technology has a “crucial role” to play in the drive to reduce amputations in people with diabetes.

The team behind Neuropad, which is on the NHS tariff, says its product could warn more people they have nerve damage before they are even aware there is a problem.

Nerve damage (peripheral neuropathy) to the feet is a common complication of diabetes. Its early identification means treatment can start early and reduce the risk of serious complications, including ulceration and amputation.

Damage to the nerves in the feet due to diabetes can result in the sweat glands not producing enough moisture – this is one of the earliest indicators of nerve damage. Neuropad sticks to the soles of the feet like a sticking plaster and checks for nerve damage by detecting minute quantities of sweat.

John Simpson is the managing director of Skyrocket Phytopharma, which supplies Neuropad.

He said: “This latest data from the National Diabetes Audit shows that there is still a long way to go in the prevention and treatment of diabetic foot ulcer but the good news is Neuropad can act as ‘the canary in the coal mine’. This is because it can provide an early indicator of nerve damage before you are even aware there is a problem.

“Prevention is always better than cure. The Neuropad test gives people a better chance of avoiding serious foot complications that arise from nerve damage, including amputation.

“Our aim is to help people with diabetes feel more confident when it comes to monitoring their foot health and providing a simple tool to do so, thereby improving their chances of avoiding a potentially life-threatening foot ulcer.”

Last year’s NDFA interval review, which covered the period July 2014 to March 2021, showed there has been a steady increase in ulcer episodes each audit year, from about 5,000 to about 25,000.

The National Diabetes Audit is a major national clinical audit, measuring the effectiveness of diabetes health care against NICE clinical guidelines and NICE quality standards, in England and Wales. The NDA is delivered by NHS England in partnership with Diabetes UK.