Podiatry Services

Wednesday 4th December 2013 Westminster Hall

11:00

[Andy Sawford (Corby) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Mr Robertson. I am pleased to have secured the opportunity to speak about podiatry services. I hope the Minister will forgive me if I speak a little briskly, but there are a number of issues that I want to cover. I am delighted that other hon. Members also wish to contribute.

In my constituency, which covers Corby and east Northamptonshire, podiatry services are delivered through Northamptonshire Healthcare NHS Foundation Trust. In May this year, the Nene clinical commissioning group and the Corby CCG initiated a public consultation on their proposal to make changes to the delivery of podiatry services, based on categorising the needs of patients as high, medium or low risk. I received letters from constituents and had constituents attend my surgery. For MPs, multiple contacts from constituents is sometimes a warning sign that there might be a problem. My constituents were concerned about the consultation, first, because they regarded it as ineffective, as it failed to communicate or engage with the users of podiatry services to any reasonable degree, and secondly because they thought it token. We know that the public are at times sceptical about consultation exercises, and with reason. It does not help when they see them as being more about selling a solution—a predetermined decision—than about genuinely engaging people in finding the best way forward.

We all recognise that services need to change for all sorts of reasons, not least due to our ageing population and the financial challenges that our local health care providers face. We MPs want to engage in consultations in which the public are genuinely involved and in which we feel that there has been rounded discussion about how best to work together, across the public sector and the different parts of the health system, to find the best way forward.

[Jim Shannon (Strangford) (DUP)]

Podiatry is important for everyone, and those who need treatment in particular. The optician will diagnose things that other people might not see; the podiatrist, too, can diagnose things that are wrong with someone’s body—for example, he can spot the onset of diabetes and other health issues, including in elderly people who do not know they have them. Does the hon. Gentleman agree that podiatry is vital in checking for ailments that someone does not know they have?

[Andy Sawford]

The hon. Gentleman is absolutely right, and I shall turn to that point in describing the consequences of some of the changes in my area. There is a pattern across the country. I am sure that he, too, will be concerned to ensure that services are available in his area.

On 30 July this year, the clinical commissioning groups announced that their governing bodies would approve the cessation of “low risk” podiatry. They have been unable to explain to me what the standard assessment process will be for categorising patients in that way. They qualified the announcement by stating that the decision would not apply to children or vulnerable groups, which was a response to the strong feedback that the public and I, and perhaps other hon. Members, gave. I challenged the Nene CCG on the definition of “vulnerable groups”, and it told me that the term refers to

“The frail elderly and people who are likely to neglect foot-care for financial reasons”.

That is good to hear, but it is not clear who will make that assessment, and on what basis. We must ensure that the most vulnerable can access care.

[Mr Philip Hollobone (Kettering) (Con)]

I congratulate the hon. Gentleman on securing the debate. He is serving his constituents extremely well on this issue. I had an e-mail from a constituent who says:

“I have an appointment this morning, where I am expecting to be told that I shall not be receiving any more services from”

the podiatrist.

“I have Psoriatic Arthritis in my hand and feet and other joints”,

and

“insoles made to help me walk. ‘I am unable to reach down to do my feet myself’ I told the podiatrist, to which he replied, It can’t be helped. He then said I would have to get my husband to do my feet.”

She goes on to say that her husband

“has issues himself, I cannot ask him to do yet another task for me.”

That is an example of a vulnerable person who clearly does not feel that she has been included in the exemptions that the hon. Gentleman describes.

[Andy Sawford]

I thank the hon. Gentleman for his intervention. I welcome his support for the debate. He is assiduous in working on local health matters; indeed, we have worked together on some issues. I welcome him raising his constituent’s concern. It illustrates the worry about the impact of the changes and the reality of people already being advised that services will be withdrawn—even those who the hon. Gentleman and I would hope would fall under the definition of “frail” or “vulnerable”, including those who may not be able to afford care.

Access is part of the problem. At the same time when the consultation exercise was carried out, the foundation trust reviewed its estates and facilities to make savings. It closed some podiatry clinics and relocated some services, making them more difficult to access. We are talking about people who may not have transport or who may have mobility issues, so difficulty in accessing services is a further problem.

In Northamptonshire, 107 private podiatrists are registered with the Society of Chiropodists and Podiatrists. I am grateful to the society for its helpful briefing for today’s debate. Those private podiatrists are expected to provide care to low-risk patients. Costs vary across the area, so will the Minister comment on how we can safeguard our constituents’ interests by ensuring that costs are affordable where people are told that they must meet costs themselves and that as many people as possible are not charged at all where there is a clear need, in accordance with the CCG’s stated wish to include the frail and vulnerable?

I have received letters from Northamptonshire Healthcare NHS Foundation Trust podiatry staff, who told me that their jobs were being put at risk. There have been 16 whole-time equivalent podiatry posts lost, including leadership posts and the posts of musculoskeletal and diabetes specialists. That is inconsistent with the Government’s stated aim of maintaining high-quality clinical services. The reductions will create a high level of clinical risk by putting patients at an increased risk of falls, ulceration and amputation. We all want to ensure that our local hospital services, for example, can meet growing needs. We do not want more people presenting at accident and emergency or needing hospital admissions because they were not effectively treated through podiatry services.

The staff in the local podiatry service down-banded to bands 5 and 6 will be expected to carry out the same role that they currently deliver at bands 6 and 7. The view of the Society of Chiropodists and Podiatrists is that that is a deskilling or de-professionalisation of the service. I am concerned about that. Podiatry is not the most glamorous or attractive part of medicine. Not everybody wants to deal with people’s feet, for reasons we can all understand, but such work is incredibly important. Those who do it are proud of their professional skills, and we do not want them diminished, or want people not to be paid at the right level for their qualifications, because in the end that will lead to a recruitment problem

I understand the importance of the quality, innovation, productivity and prevention challenge to the national NHS strategy. I met the chief executive of the Northamptonshire Healthcare NHS Foundation Trust on Friday to discuss the issues. She talked to me about the rationale behind the changes, but she also said that there had been “learnings”. What I am learning is that the term “learnings” in health care usually means, “We recognise that we didn’t go about this in the right way. We perhaps rushed too quickly.”

Does the Minister accept that if people cannot access services where they are needed, the changes in Northamptonshire, and perhaps other areas, could create long-term problems and prove to be a false economy? I hope she agrees with that. Will she look at the staffing changes in Northamptonshire? I was asked on BBC Radio Northampton this morning what an Adjournment debate achieves, and I said that one thing is that the Minister will take an interest in what is happening in my area. I hope that one outcome of today’s debate will be that she will look at the changes in Northamptonshire, if she has not had a chance to do so already.

I do not want the Minister to override the proper role of local decision makers in deciding on the best pattern of services in our area, but a sense check on the Government’s intentions around the shift to prevention and the best use of resources, and how short-term decisions are made locally to find savings, may be a counter to that.

There seems to be a contradiction between the Department of Health’s vulnerable older people’s plan and policies that put older people at higher risk through the downgrading of incredibly important and much valued services. Along with the demographic time bomb that the NHS is facing, there is also a diabetes challenge; 2.9 million people, or 4% of those in the UK, have been diagnosed with diabetes.

[Nick Smith (Blaenau Gwent) (Lab)]

I congratulate my hon. Friend on securing this debate. I recently visited the foot clinic at the Aneurin Bevan hospital in Ebbw Vale in my constituency about a fortnight ago, and I spoke to the fantastic podiatrists there. They told me about the huge and growing demands on their services because of diabetes. Does he agree that raising awareness of diabetes and the effect that it can have, particularly on people’s feet, is really important?

[Andy Sawford]

I thank my hon. Friend for his supportive intervention. He is absolutely right that diabetes can cause problems for people’s feet. Also, by examining people’s feet, the podiatrist can diagnose cases of diabetes and ensure that people get the treatment, help and support that they need. I am concerned that some of the estimated 850,000 people who are undiagnosed might continue to go undiagnosed if podiatrists are not able to provide proper, professional attention to people’s feet when they come into contact with them.

The National Institute for Health and Care Excellence clinical guidance on the prevention and management of diabetic foot complications sets out a foot care management plan to reduce the risk of problems occurring in those with diabetes. It is the clear view of the Society of Chiropodists and Podiatrists that there are not enough podiatrists to comply with the NICE clinical guidelines. We might expect the society to make that argument, but it chimes with my concerns locally that we have lost 16 podiatrists in our area. At a time of increasing diabetes, a reduction in podiatrists gives me real cause for concern, because the society’s view might be right.

Some 500,000 hospital beds in England each year are occupied by people with diabetic foot ulceration—more than all other diabetes complications combined. Only breast and prostate cancer have a higher mortality rate than diabetic foot ulceration. The number of amputations in England has risen from 5,700 in 2009-10 to more than 6,000 in 2010-11. It is reported that, given the increasing incidence of diabetes, more than 7,000 amputations will be performed on people with diabetes in England alone by 2014-15, unless urgent action is taken. If we look at our acute hospital budgets and compare the costs of a bed and of performing an operation and amputation—not to mention the impact on the individual concerned—we see that an increase in amputations in our area could prove far more expensive than continuing to provide the podiatry services that people have come to expect.

Does the Minister accept that the prevention and management of foot disease in people with diabetes is an essential component of every commissioned diabetes pathway, and does she share my concern that 80% of amputations each week are preventable? That is a stark figure. Can she give me an undertaking that clinical outcomes for vulnerable older people, including those with diabetes, will not worsen in Northamptonshire?

I wish to mention briefly some other issues in the short time I have left. By standardising best practice in the work of podiatrists in the UK, there is the potential to make net savings and reduce the number of accident and emergency admissions and amputations. NICE clinical guideline 119 looks at best practice. I hope that the Minister will consider how we can make sure that that guideline is followed in Northamptonshire with the resources available.

Finally, there needs to be greater parliamentary and public attention to podiatry issues. I very much welcome hon. Members’ attendance at this brief debate, and their interest and support. The subject is not particularly glamorous. Toenails, amputations and ulcerations are not things we want to think about over our breakfast, but they are important issues, particularly for some of the most frail and vulnerable people.

11:15

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It is a pleasure to serve under your chairmanship, Mr Robertson. I congratulate the hon. Member for Corby (Andy Sawford) on securing this important debate. He is right to say that podiatry might not be at the more glamorous end of the health service, but of course it is important. I had a very good meeting with Diabetes UK within the first few weeks of taking on my new job as the Public Health Minister. Many of the points that he has raised were stressed, particularly the link with diabetes and with unnecessary and avoidable amputations. Being unglamorous does not mean that it is not important. I think we can agree about that.

The Government know that receiving personal care that is responsive to people’s needs is absolutely essential, and the service that podiatrists provide to local communities is vital in helping people to maintain their mobility, independence and well-being. We know that many other good things flow from maintaining mobility and independence.

Healthy feet allow people to be active and to exercise, which, as we know, has numerous benefits: maintaining better weight, improving muscle and bone strength, and keeping people’s emotional and mental health in a good place. There has been a lot of discussion about the isolation and loneliness of some older people, and the more active they can be, the less likely it is that they will be isolated and lonely.

With the elderly being the fastest-growing age group in Britain, increasing pressure is being put on health care, which will be reflected in the demand for podiatry care. Ensuring people have got healthy feet, preventing falls in older people, and proper and regular foot care can alert us to the early signs of other, more serious health issues, which is obviously important in people with diabetes.

Diabetes, arthritis and blood circulation problems are of particular concern, and they are big priorities for all parts of the NHS. Sometimes people are concerned that individual services or conditions are not always specifically named, but NHS England has very clear direction, through the NHS mandate, about looking after long-term conditions and older people, and podiatry is a key component of that mandate.

[Jim Shannon]

Will the Minister ensure that podiatry home visits continue for people—probably those in rural locations—who are unable to access the surgeries?

[Jane Ellison]

Access is an important factor. The hon. Gentleman is right to highlight the fact that improving and maintaining access is important.

Sometimes education is about making sure that people understand when to seek help and what the warning signs are. Podiatry is an important component of early alert work, as well as an important provision for older people and for people with long-term conditions. In situations in which services need to be changed, the NHS commitment is to make sure decisions are made in a clear and transparent way, so that patients and the public can understand how services are planned and delivered.

Through the mandate, NHS England is responsible for services and for working with local clinical commissioning groups to ensure that their services are based on the needs of the local population within the resources available—the hon. Member for Corby acknowledged the constraints—and there has to be evidenced-based best practice.

An important part of the reforms was to establish CCGs at the level at which commissioning decisions are informed. They are closer to their local communities and can respond to local needs, but they have access to good advice through NHS England, clinical senates and local professional networks. That commissioning process also takes into account the local authority’s views, with regard to the joint strategic needs assessment and, of course, the local health and well-being strategy, so these decisions do not exist in a vacuum: they are taken within a framework, all of which is geared towards local services responding to the needs of local people.

Of course, a big part of that—it is something I am always keen to stress—is the engagement with local democratically elected representatives. I am really pleased that the hon. Gentleman is so engaged with this issue. Whenever I have the chance to talk to people from any part of the health service in the course of my work, I stress the need to keep local councillors and local MPs closely informed and to work with them in making these key decisions, because I know that we are often the early warning signal when people have concerns. Like the hon. Gentleman, I have had people come to my surgery about these issues and that has been an early alert about when people might have concerns. It also allows us to respond to concerns that perhaps arise sometimes when a misunderstanding of a decision is causing undue alarm.

[Andy Sawford]

On the point about misunderstandings, the Minister is right. I do not want to alarm people across my area about services that they may still be able to access, but will she look at this issue in relation to Northamptonshire? If she has any opportunity to talk to the local CCGs or Northamptonshire Healthcare NHS Foundation Trust, will she ask them to make clearer what guidance there is and what assessment process there will be to ensure that people who can still access these services know that they can do so and are assessed as being in the group that can still access them?

[Jane Ellison]

The CCGs and NHS England are obviously aware of the debates that we have here in Parliament; I always undertake to draw to the attention of the correct parts of the NHS the debates that we have here. It is obviously not for me to tell CCGs what to do or what to commission. However, this is the whole point such debates —to highlight Members’ concerns, to give Ministers a chance to respond to them, and to explore how more could be done to allay those concerns and respond to them—so I am very happy that we are getting this discussion on the record.

The hon. Gentleman raised the issue of the education and training of podiatrists. Health Education England is working to ensure that there is an appropriate balance between supply and demand. We have already talked about the likelihood—indeed, the certainty—that demand for podiatry services will grow, because of our ageing population. HEE looks at the number of training places being commissioned. In collaboration with HEE, employers are also obviously keen to ensure that there are sufficient podiatrists to deliver the services that are needed. HEE will publish the national work force plan for England in early December—so, any time now. This year, providers have forecast their future work force requirements, which are obviously based on local service demand and which local education and training boards have moderated, to make adjustments for their education and training commissions. That piece of work is being gauged sensitively to look at local demand and the need for service provision. The assessment will be available in the published plan, which will show the position right across England.

Obviously, that process looks to the future, but we already know that the number of podiatrists working in the NHS has increased during the last 10 years, from 2,916 full-time equivalents in 2002 to 3,067 full-time equivalents in 2012, which is an increase of about 5% during that time. We are also continuing to develop the profession. The hon. Gentleman rightly highlighted that this is an area in which we need growing expertise. We introduced legislation that came into force on 20 August 2013 that enables podiatrists and physiotherapists to prescribe independently, following recommendations from the Commission on Human Medicines. Therefore, podiatrists who successfully complete education programmes approved by the Health and Care Professions Council, including conversion courses to allow existing supplementary prescribers to become independent prescribers, can begin to prescribe independently in 2014. That is a helpful step forward. Extending prescribing in this way will also help to support the key role that podiatrists play in shifting care into the community and improving the patient experience. It will benefit patients by making it more convenient for them to get treatment, as well as hopefully freeing up some valuable GP time.

We recognise that some of the people accessing podiatry services will be vulnerable; we have talked about that issue and the hon. Gentleman expressed his concern about it in his speech. We are reviewing how primary care, urgent and emergency care, and social care services can all work together as part of the integrated out-of-hospital response, looking at the whole person and considering the essential point that the hon. Gentleman made about how we can keep people out of hospital when they do not need to be there, by doing the good early alert work and ensuring that things do not progress to a point where we have the unnecessary amputations that he described.

To support that vision, the Government are working with NHS England on an out-of-hospital care plan for vulnerable older people. In doing so, we are engaged with patients, carers, and health and social care staff—all those important groups—to test those proposals and implement them. The final plan will be published later. I think that the hon. Gentleman will realise from recent announcements that my right hon. Friend the Secretary of State for Health has put enormous emphasis on the need for joined-up thinking about supporting people, particularly the frail elderly, and that is a clear priority that we have talked about a lot. All the things that the hon. Gentleman mentioned in his speech this morning are part of that process, to ensure that people understand that they have a named GP who can support them and to ensure that we spot signs of problems early. That personalised, proactive primary care is essential.

[Andy Sawford]

I see the Minister looking at the clock and I sense that she has a little more to say, but can she just say whether GPs will be able to refer people to podiatrists, in such a way that the service is free? Can GPs be a helpful way of ensuring that people in Northamptonshire who really need this service can get it?

[Jane Ellison]

Right across the country I would absolutely expect GPs, when they see the warning signs of problems, to alert people to the need for further care. That is one of the advantages of having a named GP; hopefully, they will spot the signs of problems early and recommend whatever the appropriate services are. That is very much part of the system that we envisage.

However, we also need multi-disciplinary teamworking; we need people to be joined up in their thinking. Obviously podiatry services are part of that. The hon. Gentleman has eloquently raised the concerns of his constituents and his own concerns this morning. One of the things that he focused on was the question of who are low-risk patients and how is someone assessed as low-risk. I understand that the CCGs involved modified their recommendations for future service provision in response to feedback received during the consultation, so children and vulnerable patients will still be able to access community podiatry services. However, I sense that his concern is that further work might be needed to flesh that plan out, and I know that the CCGs will have heard him express that concern; he has put it on the record today, saying that he is still concerned that those recommendations might still not be fully understood and that he would like to see more work done in that regard. I believe that the analysis carried out by the CCGs showed that only 1% of low-risk patients move into the medium or high- risk categories, but I know that he will want to have ongoing discussions about the nature of that assessment and about that figure.

I also believe that the CCGs involved took into consideration the number of local independent podiatrists who are registered with their professional body, with regard to the low-level community-based care. They are also rightly exploring the potential of developing a broader range of low-level foot care and podiatry services via the third sector and social enterprises, as part of their emerging health and well-being strategy. That is the right thing to do. Some of these services do not need to be delivered by a clinician of any sort; sometimes they might be delivered more appropriately in another setting. I believe that one of the advantages of an increasing emphasis on local planning and integrated service planning at a local level is that people can think outside the box about where certain services—particularly these important early alert services and low-risk services that can prevent people from becoming a higher risk—can be delivered.

The hon. Gentleman has put his concerns on the record; it is right that MPs have the chance to do that. The local CCGs will have heard the concerns that he and other Members who have intervened in this debate have raised, and I am sure that they will be looking to respond to and allay them. However, some of those concerns were based on speculation about what might happen if this piece of work is not got right, and it is important that we find the balance between having due concern about what might happen if services are not got right and if the commissioning of them is not right, and at the same time sending a very clear signal to those people who have medical concerns, such as diabetes or the early onset of other problems, that they must seek help and that they will receive that help. They must not be put off seeking help because of concerns about the future commissioning of services.

It was useful to put all these issues on the record, and I am sure that the hon. Gentleman’s local CCGs and other CCGs will be looking to respond further to the concerns that he and other hon. Members have outlined today.

11:29

Sitting suspended.