Foot In diabetes UK

Who: Scott Cawley Where: Cardiff and Vale NHS Trust, Wales Contact: Scott.Cawley(at)CardiffandVale.wales.nhs.uk

Scott, tell us bit about how you became involved with the foot in diabetes.

I’ve worked for the Cardiff and Vale NHS Trust for twenty plus years and specifically in the field of diabetes for the last 12 years. Within that time I have worked closely with our medical colleagues to provide diabetic foot clinics in the University hospital of Wales. The last 5 years has seen the development of a diabetes team of podiatrists, who now provide education, screening and diabetic foot management in both the community setting and secondary care, as well as to vulnerable and housebound patients. As a community podiatrist it has given me the opportunity to cross boundaries and set up multidisciplinary working between secondary and primary care and to develop rapid access to vascular and orthopaedic teams in providing diabetic foot services.

So, what’s your typical working day?

No one day is the same as with the nature of patient or referrals. I work across all boundaries but in particular podiatry-led diabetic foot clinics in University hospital of Wales and community. A typical day would start with answer phone messages and then e-mails, starting at 8-30. The morning would be 6 - 7 patients with diabetic foot ulcers or compromised foot health being treated. Some may need referrals to other specialists, x-rays or antibiotic prescriptions. The later being a problem, as we do not have PGDs and have to write to the GP’s if there is no medic around. The Tuesday afternoon is a designated podiatry-led foot clinic, which is designed to see 7 patients, however this is often overbooked due to this being a clinic for new case referrals. The clinic starts at 2.00 and finishes often at 5.00. I have the support of a motivated podiatrist assistant who will assist me and take referrals from the wards and primary / community colleagues. Do I take work home? Yes!!!!! Updating knowledge from articles, internet and writing up relevant documents as required.

How did you first become interested in working with the foot in diabetes?

An opportunity came up as someone left the foot clinic in University Hospital, Wales. I was keen to volunteer to take over the clinic, as I found this group of patients to be challenging - from treatments to psychological behaviour adherence. Yes it was the right decision however hard it seems at times.

Why does this speciality appeal to you as a career choice, and who, if anyone influenced / motivated / guided you in this area of work?

The opportunity to help patients at all stages of their disease, from screening and education to treatment in preventing limb loss, has required us to develop a modernised role. This is now rightfully often seeing podiatrists take the lead roles in running diabetic foot clinics. I enjoy the challenge this brings in developing inter-professional and cross boundary working.
Early influences would be Ali Foster, Mike Edmonds and Keith Harding. The latter I still work with and I was at the first European wound conference he set up in Cardiff. Later influences were Jestyn Harries, the hospital practitioner I worked with, who had been running these clinics for 30 years and then there is the researcher himself Neil Baker. All these people showed me drive and enthusiasm.

What have been your best and worst moments at work and why?

The worst moment is always when someone loses a leg, knowing the prognosis and life expectancy they have left. One moment which will always remain in mind, is when I was interviewing a patient about the effect that having diabetes had on him. I asked ‘So, has diabetes affected you in anyway?’ he replied ‘No’. I said, ‘But you have been coming each week for a year with a foot ulcer?’ He replied, ‘Yes but I come to see you’! The shock reality that he now saw it as a social event and that he had transferred his problem onto me as a ‘parent’ has made me change practice. It showed me the fine line in patient - practitioner relationships.

The best moments are in developing the service and seeing recognition of podiatrists as the integral lead in diabetic foot management. Recently it has been the close connections we have achieved with the orthopaedics and vascular teams and the creation of two new posts in diabetes in Cardiff. One to focus on community wound care, with links to the renal unit and the second a preventative role in clinical projects around diabetes.

Do you have any coping strategies you can share with us that get you through the worst bits?

I wish there was a simple strategy. Having a very supportive manager has helped and a good team of diabetes specialist podiatrists. We now have monthly analysis clinics once a month where we can review case histories and service deliveries. Being able to refer direct into orthopaedics and vascular team is invaluable. The new FDUK I see as a way of offering support, being made up of peers with a vast amount of experience.

Do you have any new projects that you are trying to develop at the moment?

I was recently involved in looking at quality of life and health utility to differing severity of peripheral neuropathy with my medical colleagues. This has just been printed in the Diabetologia and questions if the use of a self-administered neuropathy questionnaire (NTSS6-SA) could identify neuropathy in patients, either in conjunction with or in preference to other clinical measures, as a more reliable way to identify diabetes peripheral neuropathy.
On the horizon we will be looking at patients with renal disease and the foot care they receive. The new post holder in conjunction with the team will undertake this role. Jill Cundell from Ireland has been very helpful through FDUK in sharing their experiences and audit.

What do you feel are currently the most challenging issues for people working with foot in diabetes in 2007?

There are two major issues at present:
1. Podiatrists are moving the boundaries in developing a modernised role, which require us to develop competencies commensurate to the position.
2. The service delivery and commissioning of services in diabetic foot management. We have been reviewing our services for a while and have been developing wound clinics in the community, which sits nicely with the design for life document in Wales. But I understand there is great concern around practice based commissioning in England. This is something we will be closely monitoring.

This is where I see the FDUK taking a lead, through representation on relevant government bodies etc and influencing policies and practice.

Thanks Scott..