UK podiatrists’ experiences of podiatry services for people living with arthritis: a qualitative investigation

UK podiatrists’ experiences of podiatry services for people living with arthritis: a... Background: Provision of podiatry services, like other therapies in the UK, is an area that lacks guidance by the National Institute for Health and Care Excellence. Many individuals living with arthritis in the UK are not eligible to access NHS podiatry services. The primary aim of this investigation was to understand the views of podiatry clinicians on their experiences of referral, access, provision and treatment for foot problems for patients who have arthritis. Methods: Focus groups were undertaken to explore, in-depth, individual views of podiatrists working in the UK to gain feedback on experiences of barriers and facilitators to referral, access, provision and treatment for foot problems for individuals living with arthritis. A purposive sampling strategy was adopted and two, semi-structured, focus group interviews conducted, involving 12 podiatrists from both NHS and independent sectors. To account for geographical variations one focus group took place in each of 2 predetermined ‘zones’ of the UK; Yorkshire and Hampshire. Thematic analysis was employed to identify key meanings and report patterns within the data. Results: The key themes derived from the podiatry clinician focus groups suggest a variety of factors influencing demand for, and burden of, foot pain within the UK. Participants expressed frustration on having a service that accepts and treats patients according to their condition, rather than their complaint. Additionally, concern was conveyed over variations in the understanding of stakeholders’ views of what podiatry is and what podiatrists aim to achieve for patients. Conclusion: Podiatrists interviewed believed that many individuals living with arthritis in the UK are not eligible to access NHS podiatry services and that this may be, in part, due to confusion over what is known about podiatry and access criteria. Essentially, podiatrists interviewed called for a timely renaissance of current systems, to newer models of care that meet the foot care needs of individual patients’ circumstances and incorporate national multi-disciplinary guidance. Through this project, we have formulated key recommendations that are directed towards improving what other stakeholders (including GPs, commissioners and users of podiatry services) know about the effectiveness of podiatry and also to futureproof the profession of podiatry. Keywords: Arthritis, Podiatry, Footcare, Service provision * Correspondence: L.A.McCulloch@soton.ac.uk Faculty of Health Sciences, University of Southampton, Highfield Campus Building 45, University Road, Southampton, Hampshire SO17 1BJ, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 2 of 8 Background emailed a brief overview of the study through the Provision of podiatry services, like other health therapies Colleges’ newswire. Those interested in joining the study in the UK, is an area that lacks guidance by the UK were emailed an information sheet, along with the National Institute for Health and Care Excellence. There contact details of the primary investigator (LMc). Inter- is a perceived lack of understanding of how to access ested podiatrists then contacted the primary investiga- treatment for foot problems, and limited understanding tor (LMc) for additional information, to have any of what podiatry services can offer, by both patients and further questions answered and be screened against the non-podiatric clinicians [1–6]. Many podiatry depart- project’s criteria. ments have recently felt themselves unsettled by job cuts A purposive sampling strategy was undertaken, and recent changes in how services are commissioned consistent with the qualitative study design adopted. has shifted focus towards management of acute wounds, Participants were selected according to time since quali- specifically for the management and prevention of limb fication, employer (NHS, independent or academia) and loss associated with diabetes [7, 8] The consequent im- experience of managing foot health for individual’s living pact of podiatry services reconfiguration of skill mix and with arthritis, to ensure the study would capture services, away from management of foot pain associated insightful and meaningful data from a diversity of ex- with other chronic conditions such as rheumatoid arth- perience, employments and perspectives. To enable a ritis and osteoarthritis, is not known. General Practi- ‘snapshot’ of 2 representative areas of the UK, 2 zones tioners (GPs) are consulted by 15% of the reported 20 were established; Yorkshire (North England) and Hamp- million people in the United Kingdom (UK) with symp- shire (South England) and a focus group interview was toms of rheumatic disease each year, forming up to 25% held in each of the zones. of a GPs workload [9]; with nearly 30% of the older population in chronic pain due to ‘arthritis’ [10]or a Procedure lessened quality of life [11], rheumatological disability is Each focus group was conducted by the main researcher predicted to be a major public health concern in the (LMc) supported by a second investigator (KE in coming years [12]. This loss of podiatry services from Yorkshire; AB in Hampshire) as note-taker to aid with the UK NHS potentially puts the most frail and vulner- reflection, transcription and subsequent coding. General able people at risk of mobility loss [13, 14]. The primary topics for discussion were identified with pre- aim of this investigation was to understand the views of determined ‘topic guide’ questions written prior to the podiatrists on their experiences of referral, access, focus groups. The topic guide was informed by, and con- provision and treatment for foot problems for patients structed from, the findings from analysis of a systematic who have arthritis. Arthritis was selected as the long-term review of the literature relative to evidence for podiatry condition to scrutinise due to feedback from our patient and foot care conducted by the team [19]. and public involvement (PPI) consultations as the one that Digital audio-recordings were transcribed, anonymised caused the most confusion over access to foot-care. and imported into a data analysis package (N-Vivo 11). Using this and manual methods, codes were generated Methods by noting recurring comments and used to categorise re- A qualitative research study design was employed to en- sponses by the researcher (LMc). The codes were re- able a deep exploration of podiatrists’ views, to gain feed- fined, compared and grouped into similar features which back on experiences of barriers and facilitators to referral, served as potential themes. Thematic analysis was iden- access, provision and treatment for foot problems for indi- tified as a suitable method to search for patterns related viduals living with arthritis. Focus groups were chosen as to podiatrists’ views on podiatry services for individual’s the most appropriate approach to capture a large amount living with arthritis [16, 18]. Emerging themes were dis- of information in a relatively short period of time [15]and cussed by the wider research team (LMc, AB, CB) for allowed us to not only to identify the issues that the podia- verification, identification of any additional areas of trists’ raised, but also allowed for the observation of how interest and consensus via discussion of patterns across podiatrists discussed the issues in a ‘natural’ social setting. the data. Potential themes were repeatedly discussed by The methods adopted reflected existing standards for ro- the research team to identify any alternative interpreta- bustness in qualitative research, deploying triangulation of tions. The process of verifying themes as a team pro- data, respondent validation and data saturation, which vided a more rigorous approach, different perspectives guided the final sample size [16–18]. and agreement on final themes. Participants Results Participants were recruited through their membership of The study recruited 12 participants in total, six to each the College of Podiatry UK. Potential participants were focus group. Of the clinical podiatrists interviewed, three McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 3 of 8 were solely NHS employed, three were solely in private “[HB1]: I think it’s still fairly common, from feedback practice, six worked in a variety of settings (including from staff for …the start of the consultation with a three working part-time in academia). NHS bandings new patient is actually getting them to understand (where applicable) ranged from 5 to 8. Fifteen codes why you want to know this.” You know, “what’s the were initially identified from the 2 focus group inter- medication got to do with you” et cetera. And that can views. Key themes were constructed via abductive ana- actually take up some of the initial time that actually lysis, and are presented in Table 1 with the subthemes when explaining about why it’s important and and one exemplar quote. An abridged summary, with actually you know “the feet are actually attached to excerpts of data drawn from the transcripts, is presented the rest of your body”, that type of conversation. below. Quotes are allocated alphabetical codes where re- quired, for differentiation. [HG2]: That’s the “what’s that got to do with my feet?” [HB1]: “Yes… a big sum of that time is actually about just starting to drill down and set the scene with the Theme 1: Evolving professional culture patient about what we’re trying to achieve. And then This theme presents clinical podiatrist’s perceptions on on to what they want to achieve. With a bit more how podiatry has become shaped historically. Whilst understanding why we’re taking medical history and current podiatry services are well received and valued, how it’s relevant to what’s happening in their feet.” participants vocalised a perception that procurement of services can be based on sketchy knowledge and absent And recent changes and streamlining of NHS manage- evidence: ment structures was discussed: “I know with my locality, the proposal that was sent by “We’ve lost a lot of that middle-management podiatry the CCG, it was decided that actually they lacked the managers, we haven’t got anybody really fighting for understanding about podiatry. And so it was, we our service at the moment. And just replying to the would buy our local level and then send back to them, comment about NHS practitioners, I’ve never, in the because otherwise they didn’t quite comprehend what whole time that I’ve practiced podiatry, ever seen such we did. And so we were able to divide it into our disillusionment. I think that everybody’s burnt out at separate areas, like nail surgery, routine care, diabetes work, I think that they’re being managed by people and then send it back to them so that they had more that don’tactually understand what’s happening.” [LG1] of an understanding of what we actually did. So that is a problem.” [Podiatrist: LB1] Theme 2: ‘Condition vs Complaint’ This is confounded by an inherent frustration at a This theme presents podiatrists’ unease on how podiatry continuing dearth of understanding, of the scope, depth varies within current healthcare systems, with inconsist- and value of podiatric practice, by non-podiatrists ent approaches causing inequality, discrimination and including patients: discrepancy. An over reliance on tick boxes, and appar- ent detriment of clinical autonomy, means that people who are not currently ‘at risk’ (but could potentially be Table 1 Key themes emergent from focus group interviews in the future) are able to access podiatry services, how- Themes with key quote Subthemes ever those who have high podiatric risk, but by tick box Theme 1: Evolving Professional Culture AHPs understanding standards are not classified as such, are thus ‘ineligible’. “Historically the commissioner’s never of Podiatry quite got around to finishing off writing Commissioning the specification” Patients understanding “I’m really reluctant to do that because a) you’ve got of Podiatry people with multi-pathologies and b) is it about the Theme 2: ‘Condition vs Complaint’ Inequalities and eligibility patient who’s got diabetes or is it that they’ve got “Is it about the patient who’s got diabetes Private sector versus NHS diabetic lower limb complications? Because the two or is it that they’ve got diabetic lower limb The current bandwagon complications? Because the two are Importance of Podiatry are quite different. And you know again it’s about back quite different.” in Arthritis to ‘we shouldn’t just be providing services to people Theme 3: Transforming and Sustaining Equipping Podiatrists with diabetes, it’s about services for people with lower Podiatry Building Podiatry limb complications’… back to what I said earlier about “We really need to go to the top and make Proposals for future some services that have got severe restrictions, you podiatry the same as dental care, the same as shape of Podiatry eye care, the same as hearing, audiology, you know you could be a 27 year old with diabetes playing know, we’re just off the radar.” rugby but you could technically get service because McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 4 of 8 you’ve got diabetes as opposed to actually having a people who see the patients when they present with need.” [HB1] those conditions…“and I’ve got sore feet” you know… “and actually got sore hands too”. But then it’s about The introduction of access criteria in practice is re- getting the training of podiatrists as well, you know, they ported to have created a culture of exclusion to many not just looking at the feet. If there are some red flags vulnerable people, with podiatric clinicians alluding to that come up like they do with diabetes…what do they cultures of ‘condition over complaint’ and ‘postcode lot- do in class about diagnosing arthritis? We all should tery’. Podiatrists refer to an unmet need of foot-care and be...we shouldn’t just be doing the squeeze test to feet, we the consequential risk of foot-health deterioration. Con- should be doing the squeeze test on the hands.” [HG1] fusion was felt to exist, around non-podiatrists’ under- standing what a status of high or low risk means. And If eligibility systems are used, they should be set with non-standardised criteria in use (‘pain’, ‘diabetes’ or nationally, evidenced, agreed across professional groups specific long-term health conditions) eclectic podiatric and used consistently, whilst embracing expert clinical services are being provided across the country. discretion. “They tend to put the commissioned service versus “We need care pathways … You know, I think we need service level agreements. So, a lot of diabetes services to subdivide all the things that podiatry offers and are commissioned. So they ‘have’ to provide that have a tick box assessment sheet that we can actually service, so even though we, in the acute trust run, you offer to somebody that’s diagnosed with arthritis and know, quite a full rheumatology foot service, as soon make sure that there is an effective referral system…for as we’re a man down in diabetes, people get pulled that patient to know what care is available and what from arthritis clinics, from rheumatology, to cover they can expect if they're presenting with certain diabetes. And that is just based on, purely conditions.” [LG1] commissioned services versus service level agreements. We have a service level agreement to provide Clinicians suggested a preference for access to podiatry treatment for Rheumatology patients…” [HG1] services being more person-centred, tailored to individuals: “I think there certainly needs to be evidence to show Theme 3: Transforming and sustaining podiatry that there should be a pathway whereby all these This theme captures practising clinicians’ views for the patients get some sort of similar assessment to identify future shape of podiatry in modern healthcare: what their initial needs are. And maybe on an annual basis or even a three-yearly basis or something, just to “It {resolving current constraints to podiatric access} ensure that then things can be identified early on to is multifaceted; it is conversations with the commissioners start actually taking place, whether it be footwear, about getting specification rights in the first place. It is whether it be on education or whether they need to discussions internally within health trusts around change medication or whatever else... It has to be put priorities and in some ways protecting what we’ve got … up the agenda.” [LG1] So the only way we can get around that {current constraints to podiatric access}, as I can see, is raising They propose a more multidisciplinary, coordinated the profile of the profession. Raising the knowledge and approach to patient services, specifically requesting that raising the value of what we do and the cost efficiency arthritis and other long term health conditions have of what we do.” [HB1] models of access and guidelines comparable to those for diabetes: Podiatrists want to see inequalities in service provision eliminated, offering a shift in the priorities of podiatric “Pathways. Referral pathways, just like diabetes ...a bit services to incorporate more long term conditions: more streamlined and a bit more easy to access.” [HG3] “Podiatry provides an opportunity to pick up long term “Make it more equal over the UK rather than just conditions in the early stages, so we know that dependant on personality, and really that sums up mechanically, arthritis in the foot is the second most what people said – going through more pathways, common site for presentation so podiatrists can be a focussing on multidisciplinary teams.” [HG4] guard responsible for aiding, for new diagnosis for a patient and show them …you know some red flags for “If we had a more multidisciplinary coordinated podiatry to go in, because they’re likely to be the approach it would be better for the patient. I know McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 5 of 8 that we have access to all these other professions but ‘foot care’ and embedding evidence within national and sometimes those communications, are blocked, not local guidelines [19–22]. The resultant key themes con- blocked but they are strained because you’ve got to structed from our investigation are discussed below: write a letter, and that’s got to go off, then someone’s got to sign it and… whereas if you had a better, Evolving professional culture multidisciplinary approach like we do in terms of Notably, podiatrists expressed key concerns of frustra- diabetes then those patients would go through proper tion that, although podiatry has evolved as a profession, routes a lot quicker” [HG1] there remains a sense of misunderstanding, by non- podiatrists and patients, of the scope of practice and They reported a need to work with other professionals ability of podiatrists in what they do. The revelation that to drive changes for more long term conditions: podiatrists believe their scope of practice is limited by the profile and image of the profession is not a new one. “And it's not just our profession that’ll link with them Earlier work has identified the hierarchical nature of the [public health], for the benefit of our patients because, health professions [21] and the way in which podiatry you know, podiatry is one of them, you could have has perceived itself as less visible and more misunder- ENT in there, you could have physio in there, you’ve stood than other comparable professions [22–24]. In our got other disciplines in there. They can all push this investigation, advances in scope of practice and a grow- agenda forward and start saying, yes, here’s another ing presence in multi-disciplinary team (MDT) working one, it's a long-term condition that we need to be doing were clearly considered important factors in raising the more for.” [LG1] profile of the podiatry profession, however were per- ceived more evident in specific fields, such as diabetes Clinicians believed access to podiatry services should foot care, and much less clear in primary care which is be transformed to fit modern healthcare needs, to meet also evidenced widely in the literature [25]. the needs of patients within an evolving healthcare sys- Key leaders in the profession, locally and nationally, were tem, which incorporates building in onward referral to lauded for the development of services in the past and private sector podiatrists, into the NHS service: concern was voiced over the increasing trend for managers responsible for defending, promoting and commissioning “Can I, can I bring something in there that’s quite podiatry services in today’s healthcare practices, to be non- important? We actually have a good NHS private podiatrists with limited knowledge of the scope of practice practice working relationship in our area, the culture of the profession. The vital role of key, charismatic charac- that we historically have had is that when a patient is ters in podiatry has been previously reported in the deemed no longer eligible for treatment, that they’re literature as being fundamental in developing and augment- discharged to the third sector. And you know, if you ing the profession in specialisms such as diabetes [26], actually have a dentist, and the NHS can't meet your podiatric surgery [27]and rheumatology [28]. dental needs, you’re recommended that you can seek dentistry privately, the same with seeing an optician.” ‘Condition vs Complaint’ [LG1] Whilst the podiatrists interviewed in this study believe that their services are valued and appreciated by their patients, they express concern that only certain people Discussion can access NHS podiatry care in the UK. Interestingly, Using focus group methodology and a thematic ap- despite the evidencing of outcomes, cost effectiveness proach to data analysis, this study has provided unique and quality of services being currently so important in insights into UK podiatrists’ (based in 2 distinct regions the procurement and commissioning of NHS services, of the UK, Yorkshire and Hampshire) perceptions of there continues to be a paucity of published evidence to barriers and facilitators to referral, access, provision and show the ‘value’ that patients attribute to UK podiatry treatment for foot problems for individuals living with services and the interventions that podiatrists use, both arthritis. Our overarching findings indicate that podia- in respect to its significant importance amongst health- trists experience frustration about the role and status of care delivery and its impact upon patients’ quality of life. podiatric services, the inequalities in service provision Patients who can afford it may choose to seek foot care (between regions and between individuals) and the loss expertise from the private sector, yet this excludes many. of clinical autonomy – fuelling an ethos of ‘condition The implications are made clear. In the UK, the majority over complaint’. The literature relating to foot healthcare of NHS podiatry care is initiated from within the pri- supports the need to transform and shape podiatry by mary care sector through referral from GPs [7]. Podiatric promoting the scope of practice, taking ownership of clinicians in this investigation suggested that Clinical McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 6 of 8 Commissioning Groups (CCGs), comprising primary services to ‘cope’. Alternative foot health providers were care GPs, were much less well informed about the po- broached, including charitable organisations and ‘nail tential health gains to be made through referral to bars’, where concerns were aired from both NHS and podiatry than perhaps other services, or in diabetes care, private sector practitioners, as were the incongruities of where MDT working enhances professional profiles. As jointly managing patients between multiple providers. a result, podiatrists in this investigation noted that com- This echoes the views of other experts advocating munity referral to podiatry is less well targeted than it podiatric intervention for those with foot health vulner- might be, given the lack of understanding of the roles ability and pathology due to long term health conditions and skills of modern podiatrists [29] among GPs and [36–39]. This, in turn, synchronises with NHS England’s other commissioners in primary care. This is reflective (2014) 5 Year Forward View [40] for a healthcare system of recent analysis of GP referral patterns for foot pain, that demonstrates improvements in service outcomes, which found that the majority went to orthopaedics [30]. improves preventative care, enables the frail and elderly Interestingly this reflects the cultural and socio- to stay healthy, independent and access individualised, historical context of the allied health professions, which person centred care. occupied a lesser position within a complex health Frustration was reported over the prioritisation of UK division of labour throughout most of the twentieth cen- NHS service provision according to the contract type, tury [23, 31]. with commissioned services having priority over service A sense of frustration was consistent through the dis- level agreements, often prioritising one patient group, or cussions on the disparity across the UK of accessibility clinic, over another. Furthermore confusion was to NHS podiatry services and the inequity between expressed, by podiatrists in our investigations, on behalf areas, patient groups and commissioning bodies. Eligibil- of service users not eligible to access podiatry services ity criteria, and the use of ‘tick box’ access, in combin- when acquaintances were. Feedback from people who ation with a national public health drive, appears to have have chronic conditions is consistent with this, indicat- resulted in open eligibility to podiatry services for some ing that patients are not accessing foot healthcare [1–3, patients, but limited or barred access for other patient 41] and that they are confused over referral pathways to groups who may have an equal or greater podiatric need. podiatry services [2, 42, 43]. Whilst this is positive and inclusive for ‘eligible’ people, it excludes others. This allows access to podiatry Transforming & sustaining podiatry services for people who may not need specialist podiatric Since the inception of podiatry in the early part of the intervention at the time, yet are able to access care be- twentieth century, podiatry models of care within the cause they have a specific condition, albeit not affecting UK NHS have remained fairly static and the model of their feet. This, in turn appears to be causing inequities access and care within private practice has remained of condition over complaint. Barriers towards accessing stable within the realms of financial accessibility [7]. podiatry care for individuals who have arthritis have Despite that, demand has shifted towards acute levels of been previously highlighted in other countries [32–34]. care within the UK NHS. Changes to service access in This is consistent with findings that the provision of foot the 1990s has led to resource allocation, guidance and care for people with rheumatoid arthritis is not driven prioritisation for patients with complex acute care needs, by foot health characteristics such as foot pain or foot predominantly diabetes [19]. related disability [32, 35] and indicates that the role of Provision of podiatry services for individuals with arth- podiatry in the prevention of deterioration of foot health ritis is an area that lacks guidance. Whilst participants of is partially, but not fully, recognised. this study acknowledged the presence of some foot Alone, medical or podiatric pathology can place a per- health guidelines for people with arthritic conditions, re- son at mild, moderate or severe podiatric risk status. ferring specifically to the Arthritis and Musculoskeletal With comorbidities, this risk increases, in some cases Alliance (ARMA) and NICE guidelines [44] for people significantly [36, 37]. Podiatrists are aware of the risk with arthritis, they reported little recognition of, nor suf- status and vulnerability of patients who do not have ficient emphasis placed on, the use of these relevant their podiatric needs met, including those who are ineli- guidelines by non-podiatry health professions or pa- gible for NHS care but cannot afford private sector care. tients. The deficiency in specific guidance for foot health From the concerns podiatrists expressed on behalf of for people arthritis conditions appears to be in contrast their service users, came some consideration of alterna- to the vast plethora of guidance available for foot care tive foot care options that the public access. Private services and intervention for people with diabetes [19]. practice was represented positively in providing valuable Indeed, current literature suggests existing foot health services, from both private sector and NHS practi- guidelines for people with arthritic conditions are not tioners, including suggestion that it enables NHS being utilised to their fullest advantage and there is a McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 7 of 8 recognised need to improve the implementation of such Clinicians are keen to explore alternative ways to pro- guidance [45]. Whilst new models of foot care for indi- mote podiatry services for procurement and new models viduals who have inflammatory arthritis have been pro- of service provision, to be more reflective of people’s in- posed [43, 46, 47] the recognition, development and dividual circumstances and believe that setting and implementation of guidance and pathways for other long implementing nationally set guidance is the optimal way term conditions that affect the feet (including osteoarth- to inform commissioning of podiatry services towards a ritis) is necessitated in a similar format to those for more inclusive service provision. people with diabetes. Abbreviations Podiatrists in this investigation considered that current ARMA: Arthritis and Musculoskeletal Alliance; GP: General Practitioner; UK health recommendations on recognition, transform- NICE: National Institute for Health and Care Excellence ation, sustainability and public health [40, 48]tobea Acknowledgements timely opportunity for the profession to promote and re- The authors would like to thank all the participants of the study and Andy establish podiatry’s full scope of practice to all stake- Stow and Adam Thomas from the College of Podiatry who helped with study recruitment. holders (patients, service managers, commissioners and other health professionals). They too encourage the de- Funding velopment of new care models for podiatry, to meet the This study was supported by a project grant from the College of Podiatry. burden of foot pain in the UK and demands of modern CB is currently being supported to undertake Fellowship from The National Institute for Health Research. The views and opinions expressed herein are healthcare. Podiatry has long been encouraged to those of the authors and do not necessarily reflect those of National Institute become more versatile and involved in preventative for Health Research, NHS or the Department of Health. healthcare [7, 49] and this now coordinates with recom- Availability of data and materials mendations for all AHPs [48]. Podiatrists interviewed The data that support the findings of this study are available from the believed change was needed, to sustain the provision of corresponding author upon reasonable request. services and profession. Authors’ contributions CB, AB, AR, RP, DP, AJ and NA conceived the study. KE led on the systematic Strengths and potential limitations review of evidence for podiatry that underpins the topics for this study. LMc This study examined the perceptions of podiatrists in conducted the focus groups and extracted and produced the first draft. KE and AB collected notes and observed participants within the focus groups. two regions of the UK, as a potentially representative LMc, AB, CB, analysed the data. LMc, AB, AR, KE, RP, DP, AJ, NA and CB snapshot. By using the experiences of 2 diverse groups critically reviewed the academic content and participated in producing the of podiatrists from two disparate regions, rich text and final draft. All authors read and approved the final manuscript. themes have been generated. Limitations are acknowl- Ethics approval and consent to participate edged as both are in England, therefore data may not be Full ethical approval was gained (IRAS: 15/SW/0251). All participants provided wholly representative of the four home UK nations written informed consent. Governance for the study was approved by the (England, Scotland, Wales and Northern Ireland) mean- Faculty of Health Sciences, University of Southampton Ethics Committee via the ERGO (Ethics and Research Governance Online) online approval system. ing proposed themes may be more or less significant in other areas. This may, however, align with high degrees Competing interests of variation in specialist rheumatology service provision Dr. Alan Borthwick is Editor UK and Prof Catherine Bowen is the Deputy Editor UK of the Journal of Foot and Ankle Research. It is journal policy that across the UK, wherein podiatry remains a notably editors are removed from the peer review and editorial decision-making poorly represented profession [50]. processes for papers they have co-authored. The remaining authors declare no conflicts of interest in relation to this work. Conclusion The burden of foot pain for individuals living with arth- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in ritis in the UK is not insubstantial, yet many cannot ac- published maps and institutional affiliations. cess NHS podiatry services [7, 51]. The key themes derived from the podiatry clinician focus groups suggest Author details Faculty of Health Sciences, University of Southampton, Highfield Campus that there are a variety of factors influencing demand Building 45, University Road, Southampton, Hampshire SO17 1BJ, UK. for, and burden of, foot pain within the UK. Primarily, Faculty of Medicine & Health, Leeds Institute of Rheumatic & participants expressed frustration on having a service Musculoskeletal Medicine, Leeds, UK. Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK. that accepts and treats patients according to their condi- tion, rather than their complaint. 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Graham ML (2006) The Origins and Development of Podiatry in Britain 1969 to 1996, PhD thesis, University of Essex. 28. Graham A (2017) Foot health education for people with rheumatoid arthritis’ PhD thesis. 29. Health and Care Professions Council. Standards of Proficiency: Chiropodists/ Podiatrists. 2014 Available from: http://www.hcpc-uk.org/publications/ standards/index.asp?id=41 [cited 19th May 2017]; http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Foot and Ankle Research Springer Journals

UK podiatrists’ experiences of podiatry services for people living with arthritis: a qualitative investigation

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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Orthopedics; Rehabilitation
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Abstract

Background: Provision of podiatry services, like other therapies in the UK, is an area that lacks guidance by the National Institute for Health and Care Excellence. Many individuals living with arthritis in the UK are not eligible to access NHS podiatry services. The primary aim of this investigation was to understand the views of podiatry clinicians on their experiences of referral, access, provision and treatment for foot problems for patients who have arthritis. Methods: Focus groups were undertaken to explore, in-depth, individual views of podiatrists working in the UK to gain feedback on experiences of barriers and facilitators to referral, access, provision and treatment for foot problems for individuals living with arthritis. A purposive sampling strategy was adopted and two, semi-structured, focus group interviews conducted, involving 12 podiatrists from both NHS and independent sectors. To account for geographical variations one focus group took place in each of 2 predetermined ‘zones’ of the UK; Yorkshire and Hampshire. Thematic analysis was employed to identify key meanings and report patterns within the data. Results: The key themes derived from the podiatry clinician focus groups suggest a variety of factors influencing demand for, and burden of, foot pain within the UK. Participants expressed frustration on having a service that accepts and treats patients according to their condition, rather than their complaint. Additionally, concern was conveyed over variations in the understanding of stakeholders’ views of what podiatry is and what podiatrists aim to achieve for patients. Conclusion: Podiatrists interviewed believed that many individuals living with arthritis in the UK are not eligible to access NHS podiatry services and that this may be, in part, due to confusion over what is known about podiatry and access criteria. Essentially, podiatrists interviewed called for a timely renaissance of current systems, to newer models of care that meet the foot care needs of individual patients’ circumstances and incorporate national multi-disciplinary guidance. Through this project, we have formulated key recommendations that are directed towards improving what other stakeholders (including GPs, commissioners and users of podiatry services) know about the effectiveness of podiatry and also to futureproof the profession of podiatry. Keywords: Arthritis, Podiatry, Footcare, Service provision * Correspondence: L.A.McCulloch@soton.ac.uk Faculty of Health Sciences, University of Southampton, Highfield Campus Building 45, University Road, Southampton, Hampshire SO17 1BJ, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 2 of 8 Background emailed a brief overview of the study through the Provision of podiatry services, like other health therapies Colleges’ newswire. Those interested in joining the study in the UK, is an area that lacks guidance by the UK were emailed an information sheet, along with the National Institute for Health and Care Excellence. There contact details of the primary investigator (LMc). Inter- is a perceived lack of understanding of how to access ested podiatrists then contacted the primary investiga- treatment for foot problems, and limited understanding tor (LMc) for additional information, to have any of what podiatry services can offer, by both patients and further questions answered and be screened against the non-podiatric clinicians [1–6]. Many podiatry depart- project’s criteria. ments have recently felt themselves unsettled by job cuts A purposive sampling strategy was undertaken, and recent changes in how services are commissioned consistent with the qualitative study design adopted. has shifted focus towards management of acute wounds, Participants were selected according to time since quali- specifically for the management and prevention of limb fication, employer (NHS, independent or academia) and loss associated with diabetes [7, 8] The consequent im- experience of managing foot health for individual’s living pact of podiatry services reconfiguration of skill mix and with arthritis, to ensure the study would capture services, away from management of foot pain associated insightful and meaningful data from a diversity of ex- with other chronic conditions such as rheumatoid arth- perience, employments and perspectives. To enable a ritis and osteoarthritis, is not known. General Practi- ‘snapshot’ of 2 representative areas of the UK, 2 zones tioners (GPs) are consulted by 15% of the reported 20 were established; Yorkshire (North England) and Hamp- million people in the United Kingdom (UK) with symp- shire (South England) and a focus group interview was toms of rheumatic disease each year, forming up to 25% held in each of the zones. of a GPs workload [9]; with nearly 30% of the older population in chronic pain due to ‘arthritis’ [10]or a Procedure lessened quality of life [11], rheumatological disability is Each focus group was conducted by the main researcher predicted to be a major public health concern in the (LMc) supported by a second investigator (KE in coming years [12]. This loss of podiatry services from Yorkshire; AB in Hampshire) as note-taker to aid with the UK NHS potentially puts the most frail and vulner- reflection, transcription and subsequent coding. General able people at risk of mobility loss [13, 14]. The primary topics for discussion were identified with pre- aim of this investigation was to understand the views of determined ‘topic guide’ questions written prior to the podiatrists on their experiences of referral, access, focus groups. The topic guide was informed by, and con- provision and treatment for foot problems for patients structed from, the findings from analysis of a systematic who have arthritis. Arthritis was selected as the long-term review of the literature relative to evidence for podiatry condition to scrutinise due to feedback from our patient and foot care conducted by the team [19]. and public involvement (PPI) consultations as the one that Digital audio-recordings were transcribed, anonymised caused the most confusion over access to foot-care. and imported into a data analysis package (N-Vivo 11). Using this and manual methods, codes were generated Methods by noting recurring comments and used to categorise re- A qualitative research study design was employed to en- sponses by the researcher (LMc). The codes were re- able a deep exploration of podiatrists’ views, to gain feed- fined, compared and grouped into similar features which back on experiences of barriers and facilitators to referral, served as potential themes. Thematic analysis was iden- access, provision and treatment for foot problems for indi- tified as a suitable method to search for patterns related viduals living with arthritis. Focus groups were chosen as to podiatrists’ views on podiatry services for individual’s the most appropriate approach to capture a large amount living with arthritis [16, 18]. Emerging themes were dis- of information in a relatively short period of time [15]and cussed by the wider research team (LMc, AB, CB) for allowed us to not only to identify the issues that the podia- verification, identification of any additional areas of trists’ raised, but also allowed for the observation of how interest and consensus via discussion of patterns across podiatrists discussed the issues in a ‘natural’ social setting. the data. Potential themes were repeatedly discussed by The methods adopted reflected existing standards for ro- the research team to identify any alternative interpreta- bustness in qualitative research, deploying triangulation of tions. The process of verifying themes as a team pro- data, respondent validation and data saturation, which vided a more rigorous approach, different perspectives guided the final sample size [16–18]. and agreement on final themes. Participants Results Participants were recruited through their membership of The study recruited 12 participants in total, six to each the College of Podiatry UK. Potential participants were focus group. Of the clinical podiatrists interviewed, three McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 3 of 8 were solely NHS employed, three were solely in private “[HB1]: I think it’s still fairly common, from feedback practice, six worked in a variety of settings (including from staff for …the start of the consultation with a three working part-time in academia). NHS bandings new patient is actually getting them to understand (where applicable) ranged from 5 to 8. Fifteen codes why you want to know this.” You know, “what’s the were initially identified from the 2 focus group inter- medication got to do with you” et cetera. And that can views. Key themes were constructed via abductive ana- actually take up some of the initial time that actually lysis, and are presented in Table 1 with the subthemes when explaining about why it’s important and and one exemplar quote. An abridged summary, with actually you know “the feet are actually attached to excerpts of data drawn from the transcripts, is presented the rest of your body”, that type of conversation. below. Quotes are allocated alphabetical codes where re- quired, for differentiation. [HG2]: That’s the “what’s that got to do with my feet?” [HB1]: “Yes… a big sum of that time is actually about just starting to drill down and set the scene with the Theme 1: Evolving professional culture patient about what we’re trying to achieve. And then This theme presents clinical podiatrist’s perceptions on on to what they want to achieve. With a bit more how podiatry has become shaped historically. Whilst understanding why we’re taking medical history and current podiatry services are well received and valued, how it’s relevant to what’s happening in their feet.” participants vocalised a perception that procurement of services can be based on sketchy knowledge and absent And recent changes and streamlining of NHS manage- evidence: ment structures was discussed: “I know with my locality, the proposal that was sent by “We’ve lost a lot of that middle-management podiatry the CCG, it was decided that actually they lacked the managers, we haven’t got anybody really fighting for understanding about podiatry. And so it was, we our service at the moment. And just replying to the would buy our local level and then send back to them, comment about NHS practitioners, I’ve never, in the because otherwise they didn’t quite comprehend what whole time that I’ve practiced podiatry, ever seen such we did. And so we were able to divide it into our disillusionment. I think that everybody’s burnt out at separate areas, like nail surgery, routine care, diabetes work, I think that they’re being managed by people and then send it back to them so that they had more that don’tactually understand what’s happening.” [LG1] of an understanding of what we actually did. So that is a problem.” [Podiatrist: LB1] Theme 2: ‘Condition vs Complaint’ This is confounded by an inherent frustration at a This theme presents podiatrists’ unease on how podiatry continuing dearth of understanding, of the scope, depth varies within current healthcare systems, with inconsist- and value of podiatric practice, by non-podiatrists ent approaches causing inequality, discrimination and including patients: discrepancy. An over reliance on tick boxes, and appar- ent detriment of clinical autonomy, means that people who are not currently ‘at risk’ (but could potentially be Table 1 Key themes emergent from focus group interviews in the future) are able to access podiatry services, how- Themes with key quote Subthemes ever those who have high podiatric risk, but by tick box Theme 1: Evolving Professional Culture AHPs understanding standards are not classified as such, are thus ‘ineligible’. “Historically the commissioner’s never of Podiatry quite got around to finishing off writing Commissioning the specification” Patients understanding “I’m really reluctant to do that because a) you’ve got of Podiatry people with multi-pathologies and b) is it about the Theme 2: ‘Condition vs Complaint’ Inequalities and eligibility patient who’s got diabetes or is it that they’ve got “Is it about the patient who’s got diabetes Private sector versus NHS diabetic lower limb complications? Because the two or is it that they’ve got diabetic lower limb The current bandwagon complications? Because the two are Importance of Podiatry are quite different. And you know again it’s about back quite different.” in Arthritis to ‘we shouldn’t just be providing services to people Theme 3: Transforming and Sustaining Equipping Podiatrists with diabetes, it’s about services for people with lower Podiatry Building Podiatry limb complications’… back to what I said earlier about “We really need to go to the top and make Proposals for future some services that have got severe restrictions, you podiatry the same as dental care, the same as shape of Podiatry eye care, the same as hearing, audiology, you know you could be a 27 year old with diabetes playing know, we’re just off the radar.” rugby but you could technically get service because McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 4 of 8 you’ve got diabetes as opposed to actually having a people who see the patients when they present with need.” [HB1] those conditions…“and I’ve got sore feet” you know… “and actually got sore hands too”. But then it’s about The introduction of access criteria in practice is re- getting the training of podiatrists as well, you know, they ported to have created a culture of exclusion to many not just looking at the feet. If there are some red flags vulnerable people, with podiatric clinicians alluding to that come up like they do with diabetes…what do they cultures of ‘condition over complaint’ and ‘postcode lot- do in class about diagnosing arthritis? We all should tery’. Podiatrists refer to an unmet need of foot-care and be...we shouldn’t just be doing the squeeze test to feet, we the consequential risk of foot-health deterioration. Con- should be doing the squeeze test on the hands.” [HG1] fusion was felt to exist, around non-podiatrists’ under- standing what a status of high or low risk means. And If eligibility systems are used, they should be set with non-standardised criteria in use (‘pain’, ‘diabetes’ or nationally, evidenced, agreed across professional groups specific long-term health conditions) eclectic podiatric and used consistently, whilst embracing expert clinical services are being provided across the country. discretion. “They tend to put the commissioned service versus “We need care pathways … You know, I think we need service level agreements. So, a lot of diabetes services to subdivide all the things that podiatry offers and are commissioned. So they ‘have’ to provide that have a tick box assessment sheet that we can actually service, so even though we, in the acute trust run, you offer to somebody that’s diagnosed with arthritis and know, quite a full rheumatology foot service, as soon make sure that there is an effective referral system…for as we’re a man down in diabetes, people get pulled that patient to know what care is available and what from arthritis clinics, from rheumatology, to cover they can expect if they're presenting with certain diabetes. And that is just based on, purely conditions.” [LG1] commissioned services versus service level agreements. We have a service level agreement to provide Clinicians suggested a preference for access to podiatry treatment for Rheumatology patients…” [HG1] services being more person-centred, tailored to individuals: “I think there certainly needs to be evidence to show Theme 3: Transforming and sustaining podiatry that there should be a pathway whereby all these This theme captures practising clinicians’ views for the patients get some sort of similar assessment to identify future shape of podiatry in modern healthcare: what their initial needs are. And maybe on an annual basis or even a three-yearly basis or something, just to “It {resolving current constraints to podiatric access} ensure that then things can be identified early on to is multifaceted; it is conversations with the commissioners start actually taking place, whether it be footwear, about getting specification rights in the first place. It is whether it be on education or whether they need to discussions internally within health trusts around change medication or whatever else... It has to be put priorities and in some ways protecting what we’ve got … up the agenda.” [LG1] So the only way we can get around that {current constraints to podiatric access}, as I can see, is raising They propose a more multidisciplinary, coordinated the profile of the profession. Raising the knowledge and approach to patient services, specifically requesting that raising the value of what we do and the cost efficiency arthritis and other long term health conditions have of what we do.” [HB1] models of access and guidelines comparable to those for diabetes: Podiatrists want to see inequalities in service provision eliminated, offering a shift in the priorities of podiatric “Pathways. Referral pathways, just like diabetes ...a bit services to incorporate more long term conditions: more streamlined and a bit more easy to access.” [HG3] “Podiatry provides an opportunity to pick up long term “Make it more equal over the UK rather than just conditions in the early stages, so we know that dependant on personality, and really that sums up mechanically, arthritis in the foot is the second most what people said – going through more pathways, common site for presentation so podiatrists can be a focussing on multidisciplinary teams.” [HG4] guard responsible for aiding, for new diagnosis for a patient and show them …you know some red flags for “If we had a more multidisciplinary coordinated podiatry to go in, because they’re likely to be the approach it would be better for the patient. I know McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 5 of 8 that we have access to all these other professions but ‘foot care’ and embedding evidence within national and sometimes those communications, are blocked, not local guidelines [19–22]. The resultant key themes con- blocked but they are strained because you’ve got to structed from our investigation are discussed below: write a letter, and that’s got to go off, then someone’s got to sign it and… whereas if you had a better, Evolving professional culture multidisciplinary approach like we do in terms of Notably, podiatrists expressed key concerns of frustra- diabetes then those patients would go through proper tion that, although podiatry has evolved as a profession, routes a lot quicker” [HG1] there remains a sense of misunderstanding, by non- podiatrists and patients, of the scope of practice and They reported a need to work with other professionals ability of podiatrists in what they do. The revelation that to drive changes for more long term conditions: podiatrists believe their scope of practice is limited by the profile and image of the profession is not a new one. “And it's not just our profession that’ll link with them Earlier work has identified the hierarchical nature of the [public health], for the benefit of our patients because, health professions [21] and the way in which podiatry you know, podiatry is one of them, you could have has perceived itself as less visible and more misunder- ENT in there, you could have physio in there, you’ve stood than other comparable professions [22–24]. In our got other disciplines in there. They can all push this investigation, advances in scope of practice and a grow- agenda forward and start saying, yes, here’s another ing presence in multi-disciplinary team (MDT) working one, it's a long-term condition that we need to be doing were clearly considered important factors in raising the more for.” [LG1] profile of the podiatry profession, however were per- ceived more evident in specific fields, such as diabetes Clinicians believed access to podiatry services should foot care, and much less clear in primary care which is be transformed to fit modern healthcare needs, to meet also evidenced widely in the literature [25]. the needs of patients within an evolving healthcare sys- Key leaders in the profession, locally and nationally, were tem, which incorporates building in onward referral to lauded for the development of services in the past and private sector podiatrists, into the NHS service: concern was voiced over the increasing trend for managers responsible for defending, promoting and commissioning “Can I, can I bring something in there that’s quite podiatry services in today’s healthcare practices, to be non- important? We actually have a good NHS private podiatrists with limited knowledge of the scope of practice practice working relationship in our area, the culture of the profession. The vital role of key, charismatic charac- that we historically have had is that when a patient is ters in podiatry has been previously reported in the deemed no longer eligible for treatment, that they’re literature as being fundamental in developing and augment- discharged to the third sector. And you know, if you ing the profession in specialisms such as diabetes [26], actually have a dentist, and the NHS can't meet your podiatric surgery [27]and rheumatology [28]. dental needs, you’re recommended that you can seek dentistry privately, the same with seeing an optician.” ‘Condition vs Complaint’ [LG1] Whilst the podiatrists interviewed in this study believe that their services are valued and appreciated by their patients, they express concern that only certain people Discussion can access NHS podiatry care in the UK. Interestingly, Using focus group methodology and a thematic ap- despite the evidencing of outcomes, cost effectiveness proach to data analysis, this study has provided unique and quality of services being currently so important in insights into UK podiatrists’ (based in 2 distinct regions the procurement and commissioning of NHS services, of the UK, Yorkshire and Hampshire) perceptions of there continues to be a paucity of published evidence to barriers and facilitators to referral, access, provision and show the ‘value’ that patients attribute to UK podiatry treatment for foot problems for individuals living with services and the interventions that podiatrists use, both arthritis. Our overarching findings indicate that podia- in respect to its significant importance amongst health- trists experience frustration about the role and status of care delivery and its impact upon patients’ quality of life. podiatric services, the inequalities in service provision Patients who can afford it may choose to seek foot care (between regions and between individuals) and the loss expertise from the private sector, yet this excludes many. of clinical autonomy – fuelling an ethos of ‘condition The implications are made clear. In the UK, the majority over complaint’. The literature relating to foot healthcare of NHS podiatry care is initiated from within the pri- supports the need to transform and shape podiatry by mary care sector through referral from GPs [7]. Podiatric promoting the scope of practice, taking ownership of clinicians in this investigation suggested that Clinical McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 6 of 8 Commissioning Groups (CCGs), comprising primary services to ‘cope’. Alternative foot health providers were care GPs, were much less well informed about the po- broached, including charitable organisations and ‘nail tential health gains to be made through referral to bars’, where concerns were aired from both NHS and podiatry than perhaps other services, or in diabetes care, private sector practitioners, as were the incongruities of where MDT working enhances professional profiles. As jointly managing patients between multiple providers. a result, podiatrists in this investigation noted that com- This echoes the views of other experts advocating munity referral to podiatry is less well targeted than it podiatric intervention for those with foot health vulner- might be, given the lack of understanding of the roles ability and pathology due to long term health conditions and skills of modern podiatrists [29] among GPs and [36–39]. This, in turn, synchronises with NHS England’s other commissioners in primary care. This is reflective (2014) 5 Year Forward View [40] for a healthcare system of recent analysis of GP referral patterns for foot pain, that demonstrates improvements in service outcomes, which found that the majority went to orthopaedics [30]. improves preventative care, enables the frail and elderly Interestingly this reflects the cultural and socio- to stay healthy, independent and access individualised, historical context of the allied health professions, which person centred care. occupied a lesser position within a complex health Frustration was reported over the prioritisation of UK division of labour throughout most of the twentieth cen- NHS service provision according to the contract type, tury [23, 31]. with commissioned services having priority over service A sense of frustration was consistent through the dis- level agreements, often prioritising one patient group, or cussions on the disparity across the UK of accessibility clinic, over another. Furthermore confusion was to NHS podiatry services and the inequity between expressed, by podiatrists in our investigations, on behalf areas, patient groups and commissioning bodies. Eligibil- of service users not eligible to access podiatry services ity criteria, and the use of ‘tick box’ access, in combin- when acquaintances were. Feedback from people who ation with a national public health drive, appears to have have chronic conditions is consistent with this, indicat- resulted in open eligibility to podiatry services for some ing that patients are not accessing foot healthcare [1–3, patients, but limited or barred access for other patient 41] and that they are confused over referral pathways to groups who may have an equal or greater podiatric need. podiatry services [2, 42, 43]. Whilst this is positive and inclusive for ‘eligible’ people, it excludes others. This allows access to podiatry Transforming & sustaining podiatry services for people who may not need specialist podiatric Since the inception of podiatry in the early part of the intervention at the time, yet are able to access care be- twentieth century, podiatry models of care within the cause they have a specific condition, albeit not affecting UK NHS have remained fairly static and the model of their feet. This, in turn appears to be causing inequities access and care within private practice has remained of condition over complaint. Barriers towards accessing stable within the realms of financial accessibility [7]. podiatry care for individuals who have arthritis have Despite that, demand has shifted towards acute levels of been previously highlighted in other countries [32–34]. care within the UK NHS. Changes to service access in This is consistent with findings that the provision of foot the 1990s has led to resource allocation, guidance and care for people with rheumatoid arthritis is not driven prioritisation for patients with complex acute care needs, by foot health characteristics such as foot pain or foot predominantly diabetes [19]. related disability [32, 35] and indicates that the role of Provision of podiatry services for individuals with arth- podiatry in the prevention of deterioration of foot health ritis is an area that lacks guidance. Whilst participants of is partially, but not fully, recognised. this study acknowledged the presence of some foot Alone, medical or podiatric pathology can place a per- health guidelines for people with arthritic conditions, re- son at mild, moderate or severe podiatric risk status. ferring specifically to the Arthritis and Musculoskeletal With comorbidities, this risk increases, in some cases Alliance (ARMA) and NICE guidelines [44] for people significantly [36, 37]. Podiatrists are aware of the risk with arthritis, they reported little recognition of, nor suf- status and vulnerability of patients who do not have ficient emphasis placed on, the use of these relevant their podiatric needs met, including those who are ineli- guidelines by non-podiatry health professions or pa- gible for NHS care but cannot afford private sector care. tients. The deficiency in specific guidance for foot health From the concerns podiatrists expressed on behalf of for people arthritis conditions appears to be in contrast their service users, came some consideration of alterna- to the vast plethora of guidance available for foot care tive foot care options that the public access. Private services and intervention for people with diabetes [19]. practice was represented positively in providing valuable Indeed, current literature suggests existing foot health services, from both private sector and NHS practi- guidelines for people with arthritic conditions are not tioners, including suggestion that it enables NHS being utilised to their fullest advantage and there is a McCulloch et al. Journal of Foot and Ankle Research (2018) 11:27 Page 7 of 8 recognised need to improve the implementation of such Clinicians are keen to explore alternative ways to pro- guidance [45]. Whilst new models of foot care for indi- mote podiatry services for procurement and new models viduals who have inflammatory arthritis have been pro- of service provision, to be more reflective of people’s in- posed [43, 46, 47] the recognition, development and dividual circumstances and believe that setting and implementation of guidance and pathways for other long implementing nationally set guidance is the optimal way term conditions that affect the feet (including osteoarth- to inform commissioning of podiatry services towards a ritis) is necessitated in a similar format to those for more inclusive service provision. people with diabetes. Abbreviations Podiatrists in this investigation considered that current ARMA: Arthritis and Musculoskeletal Alliance; GP: General Practitioner; UK health recommendations on recognition, transform- NICE: National Institute for Health and Care Excellence ation, sustainability and public health [40, 48]tobea Acknowledgements timely opportunity for the profession to promote and re- The authors would like to thank all the participants of the study and Andy establish podiatry’s full scope of practice to all stake- Stow and Adam Thomas from the College of Podiatry who helped with study recruitment. holders (patients, service managers, commissioners and other health professionals). They too encourage the de- Funding velopment of new care models for podiatry, to meet the This study was supported by a project grant from the College of Podiatry. burden of foot pain in the UK and demands of modern CB is currently being supported to undertake Fellowship from The National Institute for Health Research. The views and opinions expressed herein are healthcare. Podiatry has long been encouraged to those of the authors and do not necessarily reflect those of National Institute become more versatile and involved in preventative for Health Research, NHS or the Department of Health. healthcare [7, 49] and this now coordinates with recom- Availability of data and materials mendations for all AHPs [48]. Podiatrists interviewed The data that support the findings of this study are available from the believed change was needed, to sustain the provision of corresponding author upon reasonable request. services and profession. Authors’ contributions CB, AB, AR, RP, DP, AJ and NA conceived the study. KE led on the systematic Strengths and potential limitations review of evidence for podiatry that underpins the topics for this study. LMc This study examined the perceptions of podiatrists in conducted the focus groups and extracted and produced the first draft. KE and AB collected notes and observed participants within the focus groups. two regions of the UK, as a potentially representative LMc, AB, CB, analysed the data. LMc, AB, AR, KE, RP, DP, AJ, NA and CB snapshot. By using the experiences of 2 diverse groups critically reviewed the academic content and participated in producing the of podiatrists from two disparate regions, rich text and final draft. All authors read and approved the final manuscript. themes have been generated. Limitations are acknowl- Ethics approval and consent to participate edged as both are in England, therefore data may not be Full ethical approval was gained (IRAS: 15/SW/0251). All participants provided wholly representative of the four home UK nations written informed consent. Governance for the study was approved by the (England, Scotland, Wales and Northern Ireland) mean- Faculty of Health Sciences, University of Southampton Ethics Committee via the ERGO (Ethics and Research Governance Online) online approval system. ing proposed themes may be more or less significant in other areas. This may, however, align with high degrees Competing interests of variation in specialist rheumatology service provision Dr. Alan Borthwick is Editor UK and Prof Catherine Bowen is the Deputy Editor UK of the Journal of Foot and Ankle Research. It is journal policy that across the UK, wherein podiatry remains a notably editors are removed from the peer review and editorial decision-making poorly represented profession [50]. processes for papers they have co-authored. The remaining authors declare no conflicts of interest in relation to this work. Conclusion The burden of foot pain for individuals living with arth- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in ritis in the UK is not insubstantial, yet many cannot ac- published maps and institutional affiliations. cess NHS podiatry services [7, 51]. The key themes derived from the podiatry clinician focus groups suggest Author details Faculty of Health Sciences, University of Southampton, Highfield Campus that there are a variety of factors influencing demand Building 45, University Road, Southampton, Hampshire SO17 1BJ, UK. for, and burden of, foot pain within the UK. Primarily, Faculty of Medicine & Health, Leeds Institute of Rheumatic & participants expressed frustration on having a service Musculoskeletal Medicine, Leeds, UK. Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK. that accepts and treats patients according to their condi- tion, rather than their complaint. 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Journal of Foot and Ankle ResearchSpringer Journals

Published: Jun 5, 2018

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