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SERVICE SPECIFICATION

Care Pathway/Service PodiatryCommissioner LeadProvider Lead Roger Whittaker Professional Lead for Podiatry servicesPeriod 1st April 2011 – 1st April 2012

1. Purpose

1.1Aims

To provide an open access to community-based specialist foot care service which includes the diagnosis, treatment and prevention of foot and ankle disorders for children and adults in line with the agreed access criteria. (Appendix 1).

To provide a comprehensive range of podiatric treatments (from nail care to very specialised treatments and minor surgical procedures) to patients with a clinical need. This will take account of podiatric need and non-medical vulnerability (through consideration of social circumstances and mental health).

To provide appropriate and up-to-date advice and information on all aspects of effective foot care to patients, carers and professionals

To effectively target and prioritise those patients with the greatest needs and vulnerabilities, offering a rapid response service where necessary

To provide a tiered approach to the care of people with diabetes complications.. To provide access to high quality, safe care that gives timely advice, early

interventions, assessment, diagnosis and treatment for patients according to their individual need

To contribute to improved care of those with long term conditions ensuring effective multi-disciplinary approaches where appropriate

To prevent long term mobility issues related to foot problems that are treatable To work across a variety of settings, enabling patients to access care closer to home,

facilitate attendance at appointments and improve targeting of at risk groups To offer a range of interventions by ensuring there is an appropriate skill mix within

the team and that skills are effectively utilised with the appropriate level of staff carrying out appropriate interventions.

To provide a comprehensive, ongoing, individual patient empowerment programme to enable patients to best manage their own care.

To provide a proactive discharge process ensuring appropriate patients are discharged from the service with appropriate information and support packages where available.

To provide a shared care approach ensuring communication and collaboration with relevant clinicians involved in the patients care

To provide information to aid service development including evidence of the benefits and impact of the service

To identify and address staff training and development needs To ensure the service is delivered in line with current policy, learning and best

evidence and provide appropriate governance for the service

1.2 Evidence Base

The evidence for the service is based on the following information. The findings will be used within the service to influence practice and to inform future commissioning decisions:

1. Research – national and local, quantitative and qualitative, piloting new ways of working

2. Service evaluation – to demonstrate what the service is achieving (including patient feedback)

3. Audit – to inform the delivery of care against the agreed standards / targets4. National and local clinical guidelines5. Management reports

The following information has been used to inform the service specification and should be utilised in completion of the provider’s Business Case:

COX J (2000) Report to the Strategic Services Review Board of South Staffordshire Health Authority. [October]

Whittaker.R.I.(2001) Review of Podiatry services South Staffordshire. Review of Podiatry Services Stoke-on-Trent Community Health Services (Vernon

and Walker, NHS Sheffield 2011) The Society of Chiropodists and Podiatrists A guide to the benefits of podiatry to

patient care (2010) Diabetes UK, 2009a Transforming community services (DH, 2009) Footcare Services for Older People: a resource pack for commissioners and service

providers (DH, 2009) Our NHS our future (DH, 2007) Supporting people with long term conditions: An NHS and social care model to

support local innovation and integration (2005) NICE guidelines for Diabetes (DH, 2004a) standard 10 National Collaborating Centre for Primary Care (2004) National Service Framework for Older People (DH, 2001a) Health Professions Council: www.hpc-uk.org Podiatry research database www.feetforlife.org www.diabetes.org.uk. www.nice.org York Diabetes information database.

http://yhpho.york.ac.uk/diabetesprofiles/foot/default.aspx

1.3 Staff Competence and Training

The Service Provider will comply with all the relevant legislation, national guidance, clinical governance frameworks and codes of practice appropriate to the service provided and the members of staff employed.

The Service must provide evidence to demonstrate that all staff are competent to undertake their role. The provider will ensure that an internal programme for learning and development is operational and that all staff participate in regular line management supervision, peer review and clinical supervision.

All podiatrists employed by the podiatry service will be registered with the Health Professions Council and work in line with Health Professions Council and Society of Chiropodists and Podiatrists code of conduct and professional standards.

All staff will be involved in annual appraisal, mandatory training and continuing professional development provided as a team and / or on an individual basis. Individual training and performance will be clearly linked to meeting the needs of the service.

The service will have a clear business plan which will inform the appraisal process. Staff

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http://www.nice.org/

http://www.feetforlife.org/

http://www.hpc-uk.org/

development priorities will be developed in the context of the business plan and personal goals will be identified to deliver clear service outcomes.

Annual audits on record keeping, infection control and patient satisfaction will take place. The service is also reviewed annually in line with “Standards for Better Health”.

1.4 General Overview

Foot health has a fundamental link to health and wellbeing of individuals and the economy. Infection, ulceration, amputation and disabling foot pain have a significant impact on mobility, independence, quality of life and a person’s ability to work or care for others. Research suggests that foot problems such as the presence of a corn, bunion or poor footwear are significant risk factors for patient falls, which can all be moderated with podiatry interventions.

The podiatry service is commissioned by South Staffordshire PCT was reviewed in 2000 and specific patient access criteria was applied to the service (Appendix 1) to minimise the referral of patients with minor Podiatry need and to target the service to those individual patient groups who were identified at greatest risk of limb threatening presentations. The department developed the first evidence based assessment tool for all patients wishing to access services (Appendix 4) and all patients receive vascular and neurological evaluations as well as

Evidence shows that in any given population between 50-91% of people will have problems with their feet. 80% of older people will have foot related problems and in an ageing society the prevalence of chronic foot problems is set to rise significantly. It is reported that the prevalence of more serious foot pathologies increase with increasing age. There is also evidence to suggest that one fifth of all people and one third of older people have painful foot problems.

Podiatry services are generally able to manage around 4% of the population and in South Staffordshire caseloads have remain relatively static at 30,000 patients up to 2010, providing 87,000 treatment episodes per year (2009/10).

1.5 Objectives

Implement access criteria, which clearly defines medical / podiatric risk (neurological problems, Diabetes, Rheumatology, Vascular problems, the immuno-suppressed, amputees, structural deformity) and vulnerabilities (mental health and social circumstances) and other appropriate categories of risk and also defines those patients not at risk who do not therefore require ongoing professional treatment

Prioritise patients to ensure early detection of foot problems and complications Short courses of treatment, one-stop-shop approaches and curative procedures

should be utilised where appropriate Ensure the service is responsive and flexible enough to respond to changing need

and demand Provide a comprehensive assessment and evidence based care plans for all patients

engaged in the service Provide early interventions and effective management of risk to prevent mobility

difficulties Target, assess and monitor at-risk groups to minimise deterioration, ulceration and

hospital admission Ensure patients are appropriately informed about high risk behaviours and work to

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support behavioural change Ensure appropriate numbers of patients are booked into all clinic sessions to

maximise capacity Ensure timely access to treatment to prevent deterioration in foot health Ensure effective demand management, including gate keeping, the management of

waiting lists and waiting times, via an appropriate clinic booking system and the implementation of efficiency measures in all clinics

Implement a strategy for identifying and reducing DNA rates in all clinics, including appropriate solutions to minimise and prevent missed appointments and to reduce wasted staff time

Provide, at least, weekly nail surgery and ulcer assessment clinics Discharge those patients with no podiatric need or those not assessed as vulnerable,

ensuring they are provided with information and packages of support to enable them to effectively self-care

Implement a system of second clinical opinions where patients disagree with the decision to discharge them from the service

Encourage a culture of innovation and identify best practice so this can be rolled out across the service

Continually assess and discontinue ineffective treatments or services Effectively utilise staff skills and match them against the requirements of the service,

including the training / use of assistants, specialists and extended scope practitioners to deliver the most efficient service

Ensure multi-disciplinary collaborative working with other specialist services across primary, secondary and social care

Interface / joint work with other appropriate services including musculoskeletal, vascular services, tissue viability services, secondary care surgical provision including the provision of multi / interdisciplinary clinics where appropriate

Deliver ongoing patient / carer education on foot health and healthy footwear Provide advice and information for GPs and other healthcare professionals and

inform them about how to manage foot conditions and when to refer appropriately to the service

Deliver ad hoc educational support for Practice Nurses and GP’s across South Staffordshire to ensure skills are updated and to respond to staff turnover

Deliver a minimum of annual training for residential and nursing homes to build capacity and more effectively manage demand

Deliver services in line with professional guidance and national best practice

1.6 On going outcomes including improving prevention Responsive and timely access to the service Early detection ensuring prompt treatment and prevention Improved targeting of the service to high risk and priority groups Prevention of the deterioration of foot problems Improved mobility and balance and reduced incidence of falls in older people Improved independence of vulnerable groups through good foot health Increased numbers of patients reporting they are able to self manage their foot

health / condition Patients (and carers where appropriate) report increased confidence in ability to self

care Improve the Services’ complaints record and achieve an increase in self reported

positive experience from patients / carers Reduce the number of PALS contacts relating to Access and Waiting Reduced need for secondary care intervention and reduced acute admissions for

problems related to foot complications Reduced incidence of ulceration and amputations Changes in patient / referrer behaviour leading to more appropriate referrals

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Improvement in physical health and quality of life Reduced foot related pain Improvements in the quality of care, appropriateness and speed of treatment Provide a source of knowledge and expertise for other healthcare professionals and

the general public

2. Scope

2.1 Service DescriptionThe service will offer a comprehensive range of specialist and clinical interventions ranging from health education and promotion, evidence-based patient empowerment (on a one-to-one basis) and the effective screening, triage, assessment, diagnosis and treatment of foot problems. This includes some core specialist podiatry, specialist care and the assessment and treatment of different lesions of the foot. The service will use a range of treatments, including- surgery, sharp debridement, pharmacology, wound management and therapies in conjunction with footwear advice and the provision of orthoses where appropriate. Effective care involves a partnership between patients and professionals.

In order to meet the individual needs of the people of South Staffordshire area the service should be tailored to respond to local variations in need. This may change rapidly and will vary across age groupings. The Service will be aware of issues of diversity, (e.g. the service should take into account the cultural diversity of the local population and the differing issues faced by patients living in rural communities).

The service will be innovative and strive for continual service improvement covering the following areas:

Advice and InformationTo support effective podiatric care the provider will ensure that foot health promotion, signposting and self care is an integral part of the service delivered at all levels to support effective self-care and control of risk factors. Advice and information will be accurate, up-to-date, consistent and easily accessible. This requires a regular review of knowledge and the appropriate training and supervision of staff, including administration and reception staff.

The provision of advice and information will be a core component of the service and will include support for tier 2 services e.g. GPs, Practice Nurses, primary care services and nursing and residential homes, in the form of advice, information and ongoing training programmes.

Self Care and Patient Empowerment and Signposting The provider will ensure patients can appropriately and safely manage their foot condition by building their confidence, skills and knowledge through the provision of patient empowerment, this will be facilitated by individual Podiatrists at every patient contact opportunity, including new patient assessment appointments. This will include foot health promotion to enable patients to be able to take more responsibility for their own foot health, support them and their carers where appropriate to self care.

FootcareThe service will deliver simple footcare procedures, defined as toenail cutting and skin care specifically for those patients, who for various clinical, medical, physical and vulnerability reasons are unable, or it is too riskyunsafe for them, to undertake themselves and who do not have carer support able to perform this.

The service will also routinely assess and provide expert information on footwear and help

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patients to make good choices about appropriate footwear to help prevent falls, make treatment plans more effective and prevent the development of new, or the deterioration of existing, foot conditions. The service will offer health promotion and signposting when problems arise such as deterioration in health status, support for hospital discharge and the reduction of re-admissions to secondary care.

Basic Podiatry servicesThe provider will offer evidence based assessment, diagnosis and treatment of common and more complex lower limb pathologies associated with the toenails, soft tissues and the musculoskeletal system, with the purpose of sustaining or improving foot health for patients with podiatric need and defined non-medical vulnerabilities. This includes:

Appropriate triage, assessment and treatment of those identified with foot health problems

Treatment of common foot lesions including in-growing toenails, bunions, heel spurs, infections

Vascular assessments including Doppler evaluation and PO2 pulse oximetry. Falls prevention – campaigns and initiatives to prevent falls particularly in older

people Dermatology of the foot - prevention of skin infections Advice, information, education and training

Specialist Podiatry

Foot complaints associated with Diabetes Assessment and management of high risk patients Specialist wound care clinics for complex foot ulcerations Diabetic foot screening and assessment Treatment of foot ulcerations Nail surgery under local anaesthetic and post operative care Biomechanics – assessment and treatment Orthoses manufacture Corticosteroid injections Musculoskeletal conditions such as plantar fasciitis, tendonitis and tendinopathy Specialist assessment and treatment of those with connective tissue disorders such

as Rheumatoid arthritis where appropriate. Specialist prevention, education, and training programmes designed and provided

across Staffordshire.

Nail surgeryThe service will provide effective procedures for partial or total nail avulsion in order to treat acute or chronic nail problems such as in-growing, thickened or misshapen nails. The provider will ensure that assessments and surgery are organised in the most efficient way possible to maximise the number of patients seen in each session.

Long-term and neurological conditionsThe provider will treat patients with long-term conditions such as diabetes, rheumatoid arthritis and neurological conditions to maintain the integrity of the foot in patients whose medical condition places them at risk of developing complex problems. The treatment for these patient groups will involve the provision of screening programmes, management and prevention of escalating foot problems, intensive management where required and foot health education support- also signposting to other services where appropriate e.g. falls services etc.

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OrthoticsThe provider will ensure the provision of foot orthoses, which modify or correct the patient’s biomechanical problem. This includes a range of orthoses from a simple heel raise or cushioning insoles, through to more bespoke and therapeutic devices to alleviate symptoms or to provide function realignment and change of gait. This service will only be provided to those patients who meet the access criteria for the service. The service will work across primary, secondary and tertiary care in the provision of musculoskeletal biomechanics to ensure a multi and inter-disciplinary approach to the provision of corrective foot devices and footwear provision.

Podiatrists within orthopaedic triage services will provide those services for patients who currently do not have access to Podiatry services and will with the support of imaging services support quick diagnosis and treatments to reduce the impact of patients being referred for Orthopaedic surgery or Podiatric surgery services.

The service will ensure that strategies are in place to reduce inappropriate referrals for costly bespoke specialist footwear and in the number of specialist shoes made but not worn and to reduce the number of return appointments for patients e.g. one stop shop models.

PodopaediatricsThe provider will offer advice, information, early intervention, preventative foot care and treatment of children to improve their mobility, correct early signs of foot deformity and improve general paediatric foot health to improve the gait, mobility and independence of children including children with special needs.

The service will also provide education to school Nurses and health Visitors to ensure that only appropriate patients are referred to the paediatric services.

The paediatric service will work with specialist services at Birmingham Children’s Hospital to ensure those patients that require referral for specialist care receive it in a timely manner.

2.2 Priority Groups: Patients with long term conditions including diabetes, vascular disease, rheumatoid

arthritis and neurological conditions such as stroke and Parkinson’s Disease Patients vulnerable to ulceration Patients who are at risk of or have a history of multiple falls Homeless people Children

2.3 Review of the serviceThe specification will be jointly reviewed by the provider and commissioner on an annual basis. In no way should this service specification preclude the service from innovating and / or developing new ways of working. The service will produce a quarterly report on activity monitoring the numbers of patients referred and discharged, re-referral rate and referral patterns..

2.4 Accessibility/acceptabilityThe service will be based on clearly defined evidence based criteria (Appendix 1) and referrals made to basic Podiatry service by GP only.

2.5 Whole System RelationshipsThe approach to delivery should be based on shared care i.e. communication between all clinicians looking after patients, with the appropriate level of staff carrying out appropriate interventions, and structured around the patient journey.

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The service will be expected to work alongside a number of other services and ensure patients move smoothly through the pathway by facilitating appropriate partnership working and onward referrals with:

Patients and carers Voluntary sector (e.g. Age Concern) General Practitioners Practice Nurses Social Services PCT Commissioners PCC Leads, both managerial and clinical Musculoskeletal Interface Service Community Physiotherapy teams Other provider services e.g. nursing and therapy teams Secondary care providers and Consultants from a range of specialties, including

Orthotists Public Health

2.6 InterdependenciesThe provider will interface seamlessly with the Musculoskeletal Interface Service, Diabetic and Vascular services, tissue viability services, Podiatric surgery services, secondary care surgical provision and all other services which would offer benefits to the patient.

2.7 Relevant networks and screening programmesThere are local and national networks that the service will be expected to link into in order to maximise patient effectiveness e.g. The West Midlands Podiatry Leadership Forum, The Staffordshire and Shropshire CPD development group, The Society of Chiropodist and Podiatrist special interest groups, local Universities.

2.8 EducationThe service will offer undergraduate student experiences for local education providers covering all professional groups where required. The service will interface with undergraduate Podiatry Colleges and engage with and take part invalidation of courses offered.

The service will also train and offer training opportunities for apprenticeship programmes and other foot care programmes to help develop and sustain its own workforce.

The service will engage with Strategic organisations and workforce plan appropriately and allow educational experiences to develop its current own workforce for its workforce the future.

3. Service Delivery

3.1 Service model The service will be provided by a team of podiatry assistants, podiatrists and enhanced scope practitioners. After initial assessment patients will either be:

Offered treatment and advice and discharged with information and self help advice Offered a one off treatment then discharged with information and self help advice Offered a course of treatment and then discharged on completion with information

and self help advice Offered long-term care - for those patients for whom discharge is not possible without

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placing the patient at risk Diabetic patients will be screened and discharged back to the GP / Practice Nurse

with information and self help advice where appropriate Low risk diabetics will be discharged back to their GP / Practice Nurse- and medium

risk patients with no podiatric need All other diabetic patients will be screened and treatment at agreed intervals based

on their level of risk and clinical need- this is dictated by the diabetes pathway-NOT clinical need. I.e. high risk pt with no podiatric need still requires appointments at least 3 monthly.

Each patients care will be reviewed annually and the service will ensure as a minimum they: Inspect patient’s feet Complete vascular assessment at least annually Evaluate and ensure the appropriate provision of

o Intensified foot care education o Specialist footwear and insoles o Skin and nail care

Ensure special arrangements for those people with disabilities or immobility and develop education packages to enable those with learnin disabilities to be aware of their care.

Offer self care advice and information Review the patient’s care plan

As standard practice the provider will book 20 minute appointments for all clinic, or 10 minute dressing appointments where required. All new patient assessment appointments will be 30 minutes to take into account the data capture requirements and record keeping and writing to GP’s. At the moment all new patients are booked in this way however due to the need for better and more informed record keeping appointments may have to be altered to 40 minutes.

All patients will be supported to maintain their own foot health. The patient and referrer / GP will be informed, in writing, of the outcome of the assessment, treatment plan and any review.

Patients not requiring podiatry intervention: standard letter / feedback to referrer within 5 working days following triage or initial assessment

Patients assessed as requiring routine care: standard letter / feedback to referrer within 5 working days

Patients requiring urgent care will be seen within 3 working days and standard letter / feedback to referrer within 5 working days

Discharge letters will be completed within 5 working days All patients will be informed of outcomes of their assessment and treatment plan

during consultations and review appointments as appropriate Patients will be informed of any referral plans or discharges to other services

3.2 Care Pathway(s)See Appendix 2

3.3 Facilities and Location Of ServiceThe service should be located within the geographical boundaries of Staffordshire. The service will offer domiciliary visits to patients assessed as housebound within the agreed protocol ( Appendix 5) and will also provide outreach as an innovative way of targeting at risk groups.

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3.4 Clinical Audit RequirementsThe provider will be required to report on clinical outcomes and quality of service provision including:

Number of onward referrals to other specialist services by the provider e.g. Orthopaedics/ Rheumatology and reasons for this

Patent satisfaction questionnaires – using the Boston Questionnaire before & after or Patient Global Improvement Index

Complaints and their outcomes Significant Incidents

The service is expect to deliver one locality based audit and one cross organisational audit per year.

3.5 Other Quality StandardsThe service should be provided within the key principles of the NHS constitution and will operate according to key standards and NICE guidance.

The provider’s premises should meet standards as specified by the Department of Health in its Building note 46.

3.6 Governance:The service will ensure that robust clinical governance processes are in place to include:

Incident reporting Infection Prevention and Control Significant Event Analysis Managing Alerts Compliance with national and local standards including NICE and National Service

Frameworks Compliance with locally and nationally agreed audits

The service would be expected to have regular audit meetings to discuss cases and peer reviews will be in place where appropriate and all staff to undergo a process of clinical supervision at regular intervals. The service will be expected to allow ad hoc external audit of the service if requested to do so.

The service will ensure that information relating to patients is safeguarded and take account of:

Patient confidentiality Caldicott Guardian PCT information sharing protocols Consent to treatment and use of information

The provider will work in ways that support national and local programmes and utilises IT in ways that maximise patient care taking account of:

Connecting for health Choose and Book Communication and use of E-Mail systems Participation in PCT audits and data collection

3.7 Infection Control and Operational SpecificationProviders should refer to Appendix 1 of The Health Protection Agency’s Guidelines for Infection Control in a Community setting. Providers should be able to demonstrate compliance with the above.

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i. Traceability of sterile surgical equipment and patient instrumentationThe service has in place a means of tracing sterile surgical equipment for nail surgical procedures. This enables the source of infection for example to be isolated to one cycle on the steriliser and enable patients to be identified and have immediate prophylactic treatment if required.

OR

The service will use single use disposable instrumentation for all nail surgical procedures.

General instrumentation use will be in compliance with MAC guidance documentation 1,2,&3. This may mean some patients are given their own instrumentation to be used on them if they are in a category identified in the Staffordshire and Stoke o Trent Partnership Trust protocol for Podiatry instrument use.

ii) DecontaminationCompliance with the National Decontamination strategy is preferable i.e. use of a Central Sterile Supplies Department (CSSD).

The provider must be able to demonstrate that all instruments are washed within an instrument washer and to be packed and vacuum sterilised or Gamma irradiated as appropriate. Handling of contaminated instruments should be kept to a minimum and universal precautions observed.

Where local decontamination is carried out the provider should be able to demonstrate that equipment and facilities are suitable for the purpose and are subject to proper maintenance, decontamination and calibration as appropriate.

iii) Nail surgery Documentation

Consent, either verbal or written must be obtained for each treatment intervention, written and documented clearly in the patients’ notes.. Where appropriate, copies of the consent form, operation note, anaesthetic record, any diagnostic results, copies of all correspondence to the patient and other parties should be included in the patient record. Copies of correspondence should be given to the patient if the patient requests them.

Post operative complications and advice given on post-operative care should be documented clearly in the patient’s notes.The provider will ensure that all clinical records should be treated confidentially, and kept secure at all times.

The service will produce monthly reports sufficient to complete the required Key Performance Indicators (KPIs) agreed with commissioners.

iv) ResuscitationA defibrillator, emergency drugs and Oxygen for cardiac arrest and anaphylaxis should be available at all times in centres where higher risk procedures are carried out. Basic life support equipment should be available at all centres..

All staff involved in this service should have adequate training in resuscitation and anaphylaxis. A protocol for resuscitation must be in place and all staff must be conversant with it.

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v) Clinical Waste & Sharps DisposalClinical waste should be placed in a foot operated waste bin. Yellow- Orange clinical waste bags should be removed at the end of each session / day and placed in a secure designated holding area for clinical waste.

vi) Risk ManagementThe provider should be able to demonstrate an appropriate system for recording, monitoring and reporting of risk issues and adverse events.

vii) ComplaintsThe service will deal with complaints and incidents in line with the PCTs policies and there will be a robust system for handling patient safety notices and alerts.

4. Referral, Access and Acceptance Criteria

4.1 Geographic Coverage / BoundariesThe service will be provided across South Staffordshire area.

4.2 Location(s) of Service DeliveryThe service will be delivered in community locations within the geographical boundaries of South Staffordshire in response to patient need. The service will take particular account of patients who live in rural and isolated communities. The service may be required to move sites in response to patient need/demand, The service will offer a domiciliary service in line with the agreed protocol, as well as in clinic locations and as an outreach service.

4.3 Days / Hours of Operation The operating times should between 8.30am to 5.00pm Monday to Friday, and clinics will operate for each day of the week. The hours that the service is open for must also be responsive to the needs of patients and therefore there should be provision for at least one session initially, that will be deemed out of hours, e.g. Monday to Friday between the hours of 5pm to 8pm or a Saturday morning. The service will ensure that staff work in clinics for a minimum of 42 weeks per year (this takes account of annual leave, sickness, study leave/CPD time and attendance at meetings). The service must ensure that a safe level of service is offered 52 weeks a year (excluding B/H and weekends).

4.4 Referral Criteria and SourcesAdults and children, registered with a GP from South Staffordshire CCG’s who meet the agreed service access criteria (Appendix 2). The provider will triage each referral. Self referral will be accepted from patients. All self referrals must be triaged by the specialist empowerment team.

4.5 Referral RouteOpen access direct referral and GP referral.

4.6 Exclusion CriteriaThe following conditions are not to be included within the service.Those patients not at risk and not requiring professional treatment as defined in the service criteria.5. Discharge Criteria and planning

Discharge Criteria:

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The service will operate a proactive discharge policy to ensure there is a flow of patients through the service, capacity is appropriately utilised and waiting times are kept to a minimum.

Discharge Planning:- The patient is informed about reasons for discharge The patient receives information, understands and can demonstrate how to self care The patient understands signs and symptoms of complications and what to do The patient is clear about how to re-contact / access the service again Information is sent to the patients GP (discharge summary including any aftercare if

required) Relevant advice and literature is given to carers/relatives

6. Prevention, Self-Care and Patient and Carer Information

The service will provide appropriate, accessible advice and information on prevention, self care and risks in a range of formats. All information should be produced in line with NHS Standards as outlined by www.nhsidentity.nhs.uk and should be checked and agreed by the Patient Panel.

7. Continual Service Improvement/Innovation Plan

The service will be expected to submit monthly data on performance against agreed Key Performance Indicators (KPIs) agreed with commissioners. The KPIs should be received by an agreed date each month, and cover the performance for the month immediately previous. The service must communicate with the commissioner regularly including attendance at joint meetings to discuss data definition, performance, service delivery, and any development issues.

The service will meet with the nominated Contract Manager to discuss performance of the service on a formal basis to agree on specific contract issues as they arise. Representatives of the commissioners will have access to the provider to undertake reviews of the procedures and systems utilised that are used to monitor service delivery.

8. Baseline Performance Targets – Quality, Performance & Productivity

Performance Indicator Indicator Threshold/Expected achievement

Method of Measurement

Frequency of Monitoring

Quality

Number of serious untoward incidents (All red and amber incidents to be reported to the PCT within 24 hrs)

Baseline required PCT Incident reporting

Annual report and reviewed via clinical review

Risk Register maintained and actions put into place

Register maintained Register maintained

Annual report and reviewed via clinical review

% of patients satisfied with the service

All patients who have

Baseline required Patient Satisfaction

Monthly report (including

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http://www.nhsidentity.nhs.uk/

Number of patient complaints / compliments received

used the service will be given a patient satisfaction survey to complete

survey

number of PALS contacts about access and waiting, total number of complaints

% of GPs satisfied with the service Baseline required GP Survey Annual Report

Total number of foot ulcersTotal number of amputations

Baseline required York database Annual report

Performance & OutcomesNumber of patients who are referred into the service

Baseline required Activity report Monthly

Number of patients who self refer to the service Baseline required Activity report Monthly

Number of patients triaged within 24 hours Baseline required Activity report Monthly

Number of patients with written care plan in place


Number of patients seen as first appointment


Number of patients who are followed up and specify method (e.g. face to face, telephone)


Number of patients who complete their course of treatment and are discharged


Number of patients referred for a second opinion and outcome Baseline required Activity report Monthly

Number of completed episodes of treatment Baseline required Activity report Monthly

Number of patients seen within 18 weeks from receipt of referral to first appointment

100% Activity report Monthly

Number of urgent patients seen within 10 working days


Number of treatments delivered outside ‘treat by date’ (exception reports)


Number of patients referred onto secondary care


Total number of patients on the Activity report Monthly

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caseloadDNA RateNumbers of clinics cancelled and reasons

7% Activity report Monthly

Number of patients on the first appointment waiting list and the number of weeks waiting.


Patient follow-up ratio Baseline required Activity report MonthlyNumber of patients with planned discharge Baseline required Activity report Monthly

Additional Measures for Block Contracts:-Staff turnover rates

Sickness levels

Agency and bank spend

Contacts per FTE

9. Activity

9.1 Activity

Activity Performance Indicators

Method of measurement

Baseline Target Threshold Frequency of Monitoring

See section 8

9.2 Activity Plan / Activity Management Plan

9.3 Capacity Review

Monthly meetings to discuss activity reports from section 8 will provide the opportunity to measure activity against the plan.

10. Currency and Prices

10.1 Currency and Price

Basis of Contract Currency Price Thresholds Expected Annual Contract Value

Block £ £

Total£ £

*delete as appropriate

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Appendix 1: LOCALLY AGREED ACCESS CRITERIA

1. Any person may be referred but they also have to possess a specific medically related problem identified in section 4 of this appendices and highlighted on the referral form.

2. School children of 16 years or under. (We do not provide treatments for verrucae).

3. Any person requiring nail surgical procedures for removal of part or a full nail to treat:

a. Fungal infections of nails.b. Bacterial infection of nails. (Adolescent ingrown to nails).c. Involuted or abruptly curved nails.

4. Specific medical related access.

Access will be available for the following classifications of patients irrespective of age classifications:

Diabetics. Rheumatoid arthritis. Severe peripheral vascular disease including Raynauds syndrome. Blood disorders whereby the immune status of the patient is compromised.. Neurological dysfunction. Medications affecting vascular or neurological state. School children with pain resulting from abnormal gait. Physical disability of hands. Connective tissue disorders. Dermatological disorders. (small simple areas of hard skin / corns are not classified

as Dermatological disorders). Patients with hip or knee joint replacements. Patients following joint fusion of Back and no social support. Patients requiring nail surgical procedures. Patients who cannot walk properly due to callous formation.

Exclusion criteria / Patients who will not be treated long term.

Patients that do not fit into the specific groups outlined above. These include:

Verrucae treatment requests. Expectant mothers. Patients who can provide self-care. Patients who do not comply with agreed treatment objectives. Patients with social / family support who can provide care. (This includes private

podiatry support) Low risk diabetes presentation with absence of diabetes risk complications or

requiring diabetes screening. Patients with small amounts of callous and corns that have no medical presentation

and hence are non-limb threatening. Patients with fungal infections of skin. Patients with mild / non-limb threatening biomechanical problems

GP completes referral details & sends to the local clinic/Health Centre

Patient accepted for long term care / maintenance and periodic

re-evaluation

Patient reviewed on a regular basis to see if risk classification

has changed.

Depending on referral category patient allocated to assessment clinic

Patient allocated a short term care package to improve foot health

Patient discharged with advice and health education

information

Patient assessed with evidence based risk assessment tool

Letter to GP on assessment outcome

Patient discharged with advice and health education

information

Letter to GP on outcome of treatment package

Letter to GP on incomplete or inappropriate referral

Appendix 2: PATHWAY FOR COMMUNITY PODIATRY SERVICE

What problem(s) does the patient have with their feet or lower limb?

What is the patients’ current medication and brief medical background?

APPENDIX 3: REFERRAL TEMPLATE Department of Podiatry

Request for assessment

Which of the following groups does your patient belong to (Please tick at least 1).

Diabetics. □ Physical disability of hands. □Rheumatoid arthritis. □ Connective tissue disorders. □Severe Peripheral vascular disease □ Dermatological disorders. □Blood disorders. □ Hip or knee joint replacements. □Neurological dysfunction. □ Operations on backs. □Medications. □ Nail surgical procedures . □School children under the age of 18. □ Severe, long standing foot pathology. □

Does the patient attend your surgery or the Hospital for consultations / prescriptions? YES / NO

Patient details

SurnameName

First names Address

Post code Post code

Tel NO

GP Patient details

SurnameGP Name

First names

Address

Post code

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APPENDIX 4: RISK ASSESSMENT FRAMEWORK1. C ATEGORY 2. FINDINGS 3. RISK 4. ABILITY TO SELF-CARE OR ACCESS TO SOCIAL SUPPORT Is the patient able to remove socks & hosiery themselves? Y/N Inability to

self care & no access to carer

If they cannot, who does this for them?

5. TISSUE STATUS Evidence of sub-callus extravasation? Y/N *Risk to

tissue status*Risk to mobility

Podiatric history of tissue breakdown in the previous year/chronic history?

Y/N

Severe & painful hyperkeratosis / lesions where non-intervention will severely limit mobility?

Y/N

6. VASCULAR STATUS Both pulses

absent either foot?

Y/N

A/C/MY/N

*Risk to tissue status

Refer for further vascular assessment

Site Right DP Right PT Left PT Left DPPulse palpation?+ present0 absentDoppler signal?A absentC continuousM monophasicB biphasicT triphasicCapillary refill time?

secs

secs

>4secsY/N

Gross oedema with fibrosis/No improvement after bed rest? Y/N7. NEUROLOGICAL STATUS SENSORY LOSS:

<4/6 either footY/N

Any absentY/N

Complete absence inpatient <65

yearsY/N

Sensory Loss

*with risk of damage during self care/carer care

*with tendency to tissue damage/lesions

*with no access to carer

Site R5

R4

R3

R2

R1

RH

LH

L1

L2

L3

L4

L5

10g monofilament+ present0 absentNeurotip(sharp)+ present0 absentSite RLM RMM RH LH LMM LLM25v/s tuning fork+ present0 absent

Learning disability with no access to carer/tendency for self neglect? Y/N *Risk of self neglect

8. MEDICAL STATUS Immunosupression with skin damage or damage likely during self care/carer care?

Y/N *Risk of neglect*Risk to carer*Risk of tissue damage*Risk of artificial joint dislocation

Blood clotting dysfunction with foot pathology & risk of damage during self care/carer care?

Y/N

Infective blood disorder with foot pathology (likely to put client/carer at risk)?

Y/N

Disability of hands which prevents self care with no access to carer? Y/NHip & knee replacements with no access to carer? Y/NSpinal ankylosis or surgical fusion with no access to carer? Y/NRegistered partially sighted and no access to carer? Y/N

9. Diabetic?

Retinopathy with no access to carer?Foot deformity (increasing risk of overloading or trauma)?

Suggest annual review for all diabetics, especially those with:Hypertension, dyslipidaemia, nephropathy, hyperglycaemia, MI or CVA, smoker

Y/N

Y/NY/N

Y/N

*Risk of neglect

*Increased risk of ulceration

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APPENDIX 5 DOMICILLIRY ASSESSMENT TOOL

Domiciliary Patient Assessment Tool January 2008

Name ……………………………………….. 5PK ……………………………

Address ………………………………………………………………………….

Assessing Podiatrist ……………………….. Date ……………………………

1. Are you completely confined at all times to your home? YES/NO

2. Do you leave your home to attend any other appointments? YES/NO

3. If yes, is this : Doctor YES/NODentist YES/NOOptician YES/NONurse YES/NOHairdresser YES/NOBarber YES/NOHospital Appointment YES/NO

4. How do you get to these appointments ? …………………………………

5. Are you able to use (please circle)

Car Voluntary transport Public Transport Taxi

6. Do you go to your local shops/post office YES/NO

7. Do you go out with your family or friends YES/NO

8. Do you attend a day centre or luncheon club ? YES/NO

9. Do you go on holiday YES/NO

9. Other relevant information…………………………………………………………………………………………Action:

Appointment booked for clinic Transport Appointment Domiciliary

Guidance Notes for staff:YES answers to any of questions 2-9 will result in clinic appointments being offered.Transport may be arranged if appropriate and available (i.e. if patients is not capable of using public transport)

If the patient is unhappy with your decision, a further assessment can be carried out by another colleague.

Alternatively, the complaints procedure can be involved.

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