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A DIABETIC Portland woman claims she is at risk of losing a toe because waiting lists for a public podiatrist have blown out to six months.
Poor blood circulation means Brenda McDougall, 71, needs regular podiatry appointments to prevent callouses and corns, and to keep long nails in check. ``One of the most important things (for diabetics) is to look after our feet,'' she said.
``If you don't look after them, you get gangrene. You can lose a toe, a foot or even a leg.''
But Mrs McDougall has been forced to wait six months for an appointment with a podiatrist at Portland and District Community Health Centre, under the Home and Community Care program.
She wrote to Health Minister Bronwyn Pike, which prompted a response from the Department of Human Services. ``But they didn't tell me anything I didn't already know,'' she said. ``My last appointment was on November 24 last year. It's nearly six months and it's just getting worse and worse.''
A Portland and District Community Health Centre spokesman said he was unaware of Mrs McDougall's case, but acknowledged a waiting list of up to six months was a grave concern.
A podiatrist was funded for two days a week but resources had been stretched since Glenelg Shire decided to stop its podiatry service in 2002. ``But I'm pretty sure our podiatrist would have catered for anyone at risk,'' he said.
Attempts to curb waiting list numbers had been made, with fourth-year students from Latrobe University in Melbourne and the University of South Australia set to complete clinical placements under a qualified podiatrist's supervision from next month. In consultation with DHS, the health centre was also trying to transfer funds from other units into Primary and Community Care. ``We recognise there is a heavy demand for podiatry services,'' the spokesman said.
In Parliament last week, the member for South West Coast, Denis Napthine, called on the State Government to increase funding for south-west public podiatry services. ``People with diabetes in the Portland region both need and deserve access to a public podiatry service,'' he said.
``If they are forced to wait extraordinarily long periods, as they are at present, even more serious health complications can set in, and the bill for this will have to be picked up by the Government.''
A spokeswoman for Aged Care Minister Gavin Jennings said the Victorian Government would continue lobbying the Federal Government to match funding for Home and Community Care programs throughout the state.
There is an almost identical situation here in the UK.
The resources to provide Podiatry services to the uk population are woeful.
The NHS Podiatry service is having to contnually review provision and eligibility for that provision.
It is increasingly becoming a HIGH RISK service.
There is also an increasing use of education to enable the potential pts to be able to safely self care. or the pts relatives carers are taught how to provide that care which is what a normal person would do for them selves.
Taking the incident in the post>
Long nails.
Pt could be shown how to file nails weekly after washing bathing. Also told where to buy a suitable file for that purpose.
Corns and callus.
Health education so that pt wears footwear that is suitable for their needs, as this is primary cause of corns callus.
The provision of appropriate orthotics insoles to reduce the causative forces leading to the presenting pathology.
The NHS either here in UK or in AUS cannot underwrite the actions of someone who has no intention of attempting to improve thier own situation.
I would also speculate that this person could avail themselves of the services of a Private Practitioner if they so desired.
Does the pt smoke drink etc.
If so then they have made a life style choice to spend their financial resources in causing ill health rather then in improving their health status.
Just providing routine nail care and chipping skin is not a responsible way to deal with this kind of situation.
UNLESS OF COURSE the pt has advanced Diabetic related disease eg PVD NEUROPATHY etc etc and this is complicated by the ravages of time eg advanced Osteo Arthritis etc etc which would indeed lead to increased morbidity and a greater need for appropriate podiatric care.
Newspaper articles are very good at editing the boring bits out of a story to make it more senasationalist.
In order to lose a digit or more to gangrene there is a specfic chronology of events that is required to take place.
You dont just cut a toe and it drops off.
So Education has a large part to play in prevention of limb loss in at risk groups.
In Diabetics it comprises of a few distinct preventative management processes.
A Healthy Diet
A Modicum Of Exercise.
A Normal Body Weight
DO NOT SMOKE AT ALL
A WEE DRAM of your favourite tipple daily
Well managed and controlled Blood Sugars
Suitable FOOTWEAR
All of the above the pt can do for themselves. It is simplistic but it is reasonable.
I am concerned here in the UK by the no of:
Obese unfit heavy smokers who cannot see their feet let alone examine them who believe it is the Dr 's fault that the Dr does not keep the diabetes well controlled.
How old are these guys ???????????
30-45 years of age.
These people are essentailly the walking dead.
What they fail to understand is that Diabetes Kills Slowly.
A mini stroke here a mini stroke there, a mild heart attack, breathlessness. Increasing loss of mobility due to body weight induced knackered knees ankles and hips. Dodgy eyesight. Impaired Kidney function. Ones todger can no longer defy gravity.
The list is endless.
When one meets these pts who are enduring this mess one is not always able to be sympatehetic as they have tried so very hard for so long to achieve this state that when they achieve it they want soemone else to put it right and to do so quickly with the minimum of fuss.
A recent survey by Diabetes UK Scotland also highlighted patients' concerns that their appointments are being 'stretched out' longer. Their worry is that without good footcare the end result is amputation.
OK there may well be cases where that could be the risk and the patients need to be seen very frequently but we need to know what a patient's risk level really is before we can make judgements about what course(s) of action that the patient and their health service can take in order to protect the feet from diabetic foot disease, ulceration and amputation.
There are still some myths around diabetes, particularly the one that keeps coming back at us: 'I've got diabetes so I can't cut my toenails'
(I can hear you all groaning!!)
This has been put about by many health professionals, GPs and Consultants over the years in a well intentioned attempt to protect patients from accidental injury. However this blanket approach doesn't take into account the majority of people with diabetes who have no complications that would put their feet at risk, who are perfectly capable of looking after their feet and would be rather insulted if we suggested they were not able to do so.
Many of us (pods-or maybe we're shropodists, fogive me it's Friday) have been busy trying to re-educate our medical and nursing colleagues and thankfully the 'no nail cutting' statement is heard less and less.
In my experience the patients who are complaining the loudest are often those who have the least dangerous problems and who, with a little bit of help and advice could manage well with only an annual foot screening.
I sympathise very much with DAVOHorn's rant which points to people taking more responsibility for their own health.
However when health deteriorates, no matter the cause, we still have a duty of care.
So while Mrs Jones (often a low risk patient) is complaining that she had to cut her own nails between podiatry appointments, Mr Smith has developed a foot ulcer because there aren't enough 'Foot Protection Clinics' where patients who have loss of protective sensation, abnormal foot pressures and callus can get the sort of advice, footwear, orthotics and regular callus reduction they really do need in order to keep their feet.
In what we politely term Western Civilisation there is a simple premise for the provision of healthcare.
That is that healthcare where needed should be provided to those in need of that healthcare at a time that is relevant and that the cost is borne by the state either wholy or partially.
So a simple example of what is going on with our world of Podiatry is.
The organisation is funded for 100 UNIT CONTACTS PER ANNUM.
There is no guidance as to what a unit contact should cost or what it should try to achieve.
But you have 100.
So you look at your population and have to decide how to allocate those 100 to the population you are serving.
Where we (the profession & government) should start is by commissioning population based needs assessment. Until we have good research giving reliable information on the prevalence of foot/gait pathology, we will never know how many Podiatrists etc. will be needed to provide what and how many treatments.
There have been studies in the past, which are helpful, but I would suggest that we need a much more in-depth and larger scale study(s).
Then we would be able to answer your question more accurately and with greater authority.
Using your analogy, how do you know that 100 units is right, may be its too many and 'we' are being ineffective in our management of patients, may be its woefully inadequate and therefore the whole system is compromised - perhaps it needs to be 1,000 units? may be although 'we' are trying to prioritise the use of our 100 units (say treating high risk patients) we would have greater long-term effects if we concentrated on preventing foot/gait problems or at least treating them aggressively as early as possible, 90 units purely for paediatrics 10 units for limb salvage for those who we are now not treating!
I have been asked many times (including the Scottish Parliaments Health Committee) how many podiatrists do we need and the honest answer is we do not know, I am confident it is far more than we have, but I do not know how effective 'we' are in treating foot/gait problems in the long-term, so I cannot even project whether there is a need for more and more podiatrists in the future, or whether with some increase in the number of Podiatrists now and significantly better foot ill-health prevention etc. whether we might in the longer-term need less Podiatrists!
Growing elderly populations, 'epidemic' of diabetes, greater patient expectations would all seem to cry out for more Podiatrists or more people engaged in treating foot/gait problems (I am not being deliberately controversial, but there are and likely to be in the future more people engaged in foot care).
Regards
Stephen
__________________
'There are no problems - only opportunities to be creative' :)
There are about 120 public sector podiatrists in Victoria who can each work about 1600 hours a year. If 75% of this time is spent treating patients (allowing time for management, quality, service development, education etc.etc.) this is 151,200 hours of podiatry or 302,400 half hour appiontments.
Patients would usually present anywhere between 1 and 52 times per year, but if we average it at 6, this allows for 50,400 people to attend public podiatry in Victoria in a year or 1.25% of the Victorian population.
Of course there are going to be waiting lists etc.
__________________ Stephen Tucker Calvary Health Care
We're facing this challenge at the moment in our Community Health Centre.
Unfortunate "historical" events of this centre mean that the vast majority of clients want appointments every 6 weeks. In the past they have received them, no questions asked, no assessments certainly no-one discharged to self-care. No differentiation between high risk and low risk (of course how would you know if you don't asses them??)
I've been here 6 weeks, and am dismayed on a daily basis.
I have mobilised the "troops", we're preparing a statement to our Board of Management telling them we have to have an active discharge policy.
People who NEED the service should get it.
People who don't need the service should be assessed, educated and treated short-term if required.
If we continue to add 10 patients a week to our service, and discharge none of them, how can we expect anything other than a clogged, non-responsive service that is doing NO preventative work (there is no Biomech Ax form in the building! )
If we're not running a prioritised, needs-based service, how can we know ANYTHING about the demand for Podiatry in this area? I'm sure half of the people who initially enquire about an appointment don't bother giving their contact details when they find out it'll be 6 months before they're seen.
I would love to know how you are going with this.
There is still a remarkable lack of support from community health managers to podiatrists who are actully trying to improve services for their community.
I am still yet to read the article which explains how long toenails are a 'health' problem yet we seem to be spending an awful amount of the health dollar on this (and a lot of time talking about it). I work in an acute hospital and have never heard of anyone being admitted to get their toenails cut, but a number of them want them cut after they get here. Even when we don't get to them, the patients still get discharged, so it's obviously not keeping them in hospital.
Is there any research on this? How do long toenails really affect mobility?
If we all stopped cutting toenails what would happen?
Would there still be life as we know it?
The mind boggles....
ERP.
The only INTELLIGENT reason i have ever HEARD OF for cutting the nails of a Hospital patient is when those nails are so long and neglected that the tissues of the legs become torn and damaged leading to Ulceration Infection Gangrene Amputation.
trouble is with even this i have never come across personally or in deed heard of second HAND an incident where this is what happened.
So it is a potentail incident.
Self Neglect has many other issues not just nails.
HAIR TEETH NAILS HYGIENE SKIN PROBLEMS DUE TO POOR HYGIENE INSECT INFESTATIONS ETC ETC
If we all stopped cutting toenails what would happen?
Well it's obvious...the sky would fall and the earth would stop spinning!!!
Quote:
There is still a remarkable lack of support from community health managers to podiatrists who are actully trying to improve services for their community.
I've had two completely unsupportive managers (standard responses to a dischargee complaint "You don't want to cut your nails? Well we'll book you in to see the other Podiatrist then and she'll see you every 6 weeks").
I've also had an amazingly supportive manager (an ex-OT....the only ex-boss who was not an ex-nurse?? Co-incidence? I think not!) It took us 9 months of hard work and thick skin with the manager deflecting 5 complaints that went as high as the Minister for Health and we ended up with a fantastic service where we could go an entire day without picking up a pair of clippers.
An amazing achievement for a Community Health Podiatry Service!!
My current centre is very slowly heading in the right direction...assessments are all being done, people are being discharged, RP's are being extended and complaints to the receptionist are decreasing!! It'll be at least another 6 months before it's working well most days.
Putting the boot into podiatry waiting list
certainly no-one discharged to self-care. No differentiation between high risk and low risk (of course how would you know if you don't asses them??) 
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