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Hi all,
What do others think about non-pathological nails being treated by volunteers, specifically Age Concern, as was outlined by the Health Minister this morning on BBC Radio 4 ?

What are the ramifications for NHS podiatry?

Will the patients (who by definition must have some health or age-related problem which stops them reaching their feet) miss out on early diagnosis of new or existing - but worsening systemic conditions?

Is it better to have a lower tier of trained personnel, as in foot health professionals (as still trained by the private sector) or foot care assistants (as proposed by elements of the NHS), than to use volunteer untrained personnel, or personnel who have a poor level of rudimentary training ?
Regards,
David

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Hello David,

Most patients will not grumble as it's something for nothing. The problem with many old patients is that they do not have funds or are very reticent to pay for private treatment. They see it as their right to have free treatment on the NHS after paying "stamp" for decades; I can understand that view. And sometimes they cannot believe how expensive it is for private treatment (expensive being anything over £10 for some). If it does happen I would like to think sterile equipment will be used and mandatory on-going training/CPD for the volunteers. The problem is what happens when it goes wrong? Or will it matter?

Perhaps if the NHS outsourced to private practices, paying the chiropodist a fee and the patient also contributing a little as well. A bit like NHS dentistry.

Regards,
Graeme.

Hi Graeme,
Take your point about fees and patient willingness (or lack of) to pay them, and in fact would think that many people would find £10+ is expensive for a simple nailcut.
However, my info is that Age Concern are trading in nailcare as we speak . I believe there was some talk of patients purchasing and keeping their own instruments, but whether this happens, and whether the well-meaning Age Concern volunteer then goes on to "trim that corn" is another matter!

If you read the Paper published by Mark Russell in the Winter 2003 SMAE Journal you will have seen that his proposal was to devolve NHS podiatry into existing private practices. The Health Minister made it clear this morning that this would not happen under current administration - makes too much sense I suppose .
Regards,
David

Hi David,

But what is a "simple nail cut". Quite often patients say " I just need my nails cutting" and you find yourself presented with neglected feet, very long, thick nails, corns and calluses everywhere. Patients often understate what they need. £30 well spent in my opinion.

Even if it really is a simple nail cut (in your opinion as well) you still have all the equipment to pay for.

Cheers,
Graeme.

I agree, but then this highlights the value in having a podiatrist screen feet before treatment. Simple nailcare should only involve clipping non-pathological nails. Once we get into the scenerio of a well-meaning volunteer doing the screening - remember this may be someone with no training in footcare - problems are bound to occur.

Also, and something our government may not have considered, in the elderly conditions can change for the worse very quickly - last weeks jagged toenail may become this weeks grumbling infection. Next week - who knows !

Hi All
Just as an extension :- if equipment is to be purchased and kept by the patient how will it be sterilised ?? The government want to eradicate infection or so we are told , and Pods have to do CPD have effective infection controls in place and are accountable for that. Are we not running a definate two tier system and where will that stop ?? .Pehaps when the patients nippers are used to cut the dogs claws in between times we may have an outbreak of rabies ????
I have just taken a call from a new patient who "just wants has nails cut" he continued "I have a heart condition and I get out of breath trying to reach my nails" perhaps I should send him to age concern ??

Derek

Hello David

I'm rather busy at the moment to make comment but I shall return in a couple of days to give some input. In the meantime I've provided a link to the BBC website so subscribers can listen to the broadcast and make their own judgements. You need RealPlayer to listen but this can be sourced from the Today website under Audio Help if you don't already have it installed.

Cheers

Mark Russell

http://www.bbc.co.uk/radio4/today/listenagain/

Hi all

I would like to think that future generations are coming round to the fact that as an individual they are responsible for his/her own healthcare. It has always been my memeory that an individual contributed to dental care, and now more and more people seek out dentists for regular checks rather than wait until something hurts, trouble is in cambridgeshire NHS dentists are as rare as hens teeth!!

If say for instance age concern introduced such a scheme, in therory an individual (and by that I mean elderly) would need to be assesed prior to any type of treatment no matter how 'simple' it may need to be, so where is the saving in that.

As for a patient having his/her own instruments, a few patients I have in Hertfordshire have attended coffee mornings at their local GP surgeries and recieved lectures and video films on maintaing there own health, including footcare, and at the end of said presentations items were then put on sale, nippers being among them.......I think this must be what the MP on the radio referred to as 'empowerment'.

Alas the radio article was too short, but I thought the gent from the NHS put his point across succinctly enough, its a shame that not that many people listen to the radio that time of the day.

I my own heart I do believe things will change for the good, for all its faults, and you could say this about any organization, the HPC has given everbody a HUGE wakeup call.

Interesting times for all in this profession right across the board.

Thanks for letting me say my bit.

Cheers

David Donovan

It's all down to choices. I am sure you could get a "volunteer" to re-wire your house but most (sane) people would choose not to.

Regards,
Graeme.

I fully agree that podiatrists should not be cutting toenails where patients can manage themselves or where there are partners, family or carers involved. I have taken this position from the day I qualified in 1983. Each time a patient arrives at my surgery I assess whether they can actually manage to reach their feet. I watch them removing hosiery and shoes and often I ask them to touch the part of the foot that’s causing them a problem. If they can manage that task they can manage their nails. When they can’t I assess what their social circumstances are; who lives with them; what support services are involved; what their family position is. When I have established all these facts I make a decision what level of care is to be provided.

If they are incapable of reaching their feet and if they have no support whatsoever – as many of our old folks do – I get the FCA involved or when that isn’t an option, I cut their toenails myself. That task usually takes me less than one minute and the benefit for the patient far outweighs the cost to either me or the state. Consider also what that does in terms of 'marketing' for you and your profession as you have one very grateful person at the end of it.

The problem I have with the current approach by the NHS is that you undermine the whole professional relationship by setting access criteria. The argument that is made, is that only people with one or two medical conditions can receive NHS podiatry care. That is a ridiculously inequitable policy, which produces palpably unfair results. We do not provide a medical service; we provide a podiatric service. When we start excluding patients because they don’t meet certain medical criteria that spells disaster for the department and Trust and most importantly of all, for the patient.

The key to solving the problems we face is by improving access and increasing capacity whilst, at the same time, empowering the clinicians to make judgements on their own. The situation where you involve outside agencies like social care staff and Age Concern is a non-starter - trust me. I have spoken with Age Concern and a number of other charities who currently undertake nail care and they will be announcing a withdrawal from providing dedicated volunteers for this type of work. You’ll find that local authorities will take the same position too.This is a podiatry issue and we need to solve the difficulties ourselves, not by burdening others with it.

Besides from that, if we are going to use outside agencies, let’s consider the use of our own profession before we use any others – although we need to get an appropriate scheme in place first. But the NHS still needs to look at access – that’s critical. Many patients who we classify as ‘low need’ can and often do, develop serious and complex foot conditions, and because they have been discharged, they find it difficult to get back into the system, often to the detriment of their health. That is what we need to concentrate on and it's not actually all that difficult to achieve.

As I said previously, when I get a bit of time in the coming week(s) I'll spell out just what is needed by way of professional reorganisation. If that's okay with others.

Best regards

Mark Russell

Certainly ok by me Mark :)
Cheers,
David

Reading through the threads to this posting, I felt I had to reply.

One of my colleagues has had patients who have had to buy their own nippers for some totally untrained person to come and cut their nails!!

Most of us know the reality of this, and that is if it is for free, then people will embrace it. They do not understand the complications that can occur, or the reasons why a professional person should charge what they feel is an appropriate amount. I try to educate people to understand that podiatrist are not only nail cutters, but that they are also there to look out for other conditions that may affect their health!! Once they are aware of this, they seem to mellow.

Also, I do point out that nails are similar to hair, and they wouldn't expect the NHS to trim their hair, or would they!!

Thanks for that Angie,
It confirms, from another source, that this practice is actually happening right now.
Mark Russell (chap who was on Radio 4) is now a member of podiatry-arena and, hopefully, will be an active contributor. His information that Age Concern and other charities running this scheme are pulling out is heartening, but places the problem (and responsibility) of what to do with simple nailcare patients back in the lap of the UK government , and ultimately, ourselves.

A scenerio which has already been used to good effect in both the UK and AUS (and elsewhere for all I know) is that the podiatrist does the podiatry, and when ready, refers the patient to a lesser-trained person for simple nailcare :) .

Given that Graeme has already pointed out that patients feel £10 may be too much to pay for nailcare, how might we run a system similar to above, where good chiropody/podiatry care is provided at a reasonable (for both podiatrist and patient) cost, dovetailed with nailcare, so that those patients who need chiropody every 3 months can have their nails cut between visits at a lower cost?
Could the SMAE-trained foot health practitioner have a role to play here?
Regards,
David

I don't think the Smae trained FHP's would be interested in taking on just the nail care side of practising. They are trained to a higher level than that of a nail cutter, but I see where you are coming from. I think that a newly qualified practitioner would possibly welcome regular employment, but would soon want to move onto something more challenging!

I also don't think 'social nail care' would work in either a visiting or private practice, mainly for financial reasons. This being the case, then who is going to set this service up and who will offset the costs involved!! I doubt whether the NHS would be willing to put the money into it, as it would definitely not be a profitable enterprise. I am sure that most us know that simple nail cutting is not always simple, so how many pairs of feet an hour would be expected to be dealt with, and if you haven't completed the job - hard luck and see you next time!!

This is obviously going to be a hottly debated subject and I look forward to more comments.

Hi Angie,
I believe that a foot health practitioner (FHP) is exacly the right person for this type of work :) , for several reasons:
They are trained in footcare, but to a lesser standard than chiropodists.

They can recognise developing problems in feet , to refer back to the podiatrist.

They can benefit from working alongside more experienced personnel, so that as and when FHP role development becomes a reality (as I believe it will) they can make the choice of whether to stay as an FHP or do further training to qualify as a podiatrist.

They are trained in instrument sterilisation techniques.

They are not employed by the NHS and therefore have a need to build up their own practices.

Rather like dental hygenists, who do mundane work even though trained to a high level (many can administer local anaesthetic injections, for example) I believe the FHP, in the role of a simple nailcare provider, could be a useful adjunct to a private podiatry practice.
Regards,
David

Hi Angie, in reply to your post on social cutters, I myself are a FHP and I would like to think that I provide a better service than the typical nail cutters.
I have seen some of the examples of social nail cutters work lately, by age concern and I have seen them carry a carrier bag with assorted nail clippers which they reuse, nothing is sterile, its quite an eye opener, I have been told that they are sent on a 2 day nail cutting course.
I think that they are a menace, I have had more problems with them also causing ingrown nails.
I thought that this was just a problem in N.Somerset, but on all accounts its nationwide.
Hope to hear from you soon
Regards Cindy

Hi Cindy,

That story is quite shocking, although using a carrier bag full of assorted nippers is unlikely to form part of their Standard Operating Procedure (I hope). I wonder what the legal status of this activity would be.

Regards,
Graeme.

Hi all

Well there we have it :-

The NHS Pods are too important to cut nails
The Grandparented Pods are too important to cut nails
The FHP's are too important to cut nails and are now creating a new breed of "nail cutter" who will no doubt create yet another tier .

Last time I looked ,the toenails were part of the feet .I am a Chiropodist / Podiatrist I treat feet THAT IS WHAT I DO!!!! I am sick and tired of watching self opinionated practitioners talking themselves (and me) out of a job .

Here in the real world of the Independant Private Practitioner (IPP) I run a business .Like any other business that is not sheltered with regular wages ,holidays ,sick pay ,study leave ,etc ect, It runs on a profit and loss basis . If I am to make a profit I must have patients coming through my door and provide the service they require to the standard they require. I have done that for over 16 years very successfully . I now see Nurses doing cryosurgery and general footcare ,osteopaths and chiropractors doing orthotics (along with every high street store and magazine) all previously in the domain of(and given away by) the podiatrist .
Be warned if we keep on this self destruct path we will be swallowed up and like those of us from the dinosaur dynasty ,will eventually become extinct.

Mark Russell wrote an excellent paper for reorganisation of the profession which I am sure will be reproduced in this forum .The simple basis was to have differing degree's of practitioner .I think that is the only way forward but please let's have some patients left to treat !!!!

Oh and one last moan , can we please stop making financial advice and restricting patient choice a part of podiatry ??. I don't notice hairdressers @ £8.50 a fortnight for a perm , opticians @£150+ a pair for glasses or vets charging astronomical fees ,modifying their prices for anyone. Why should we ???


Regards

Derek

Hi all

Nail on the head there Derek...........its so easy NOT to see light at the end of the tunnel in this profession, and being in it for just over 12years I have seen people come and go and reasons being that they can't tolerate the them and us attitude, too much competition, "I trained for three years, and Joe Bloggs down the road done a 6 week course and they earn more than me" etc etc etc, I'm sure we all have heard them and more. IMO fees (a very sensitive subject) must always be non-negotiable, a TV repair man I had in recently charged £35 for the first 30mins then £25 for every 15mins thereafter.....plus parts!!!

If some body wants 'just' to have their toenails cut.....£28, and if I have to do a dozen of those a day...then so be it :) .

I can see in this country that once the HPC is up and running proper in July next year, carers and alike will be taught to cut nails, but it is my opinion that people will not stand for this for long accidents will happen, people will get hurt and eventually we will be back to square one again.

I actually think that this is an exciting time for this profession, it may not seem it now, judging from the agressive way people have put their point across on some forums (thankfully not this one), but you just have to ride out the wave of emotion and let it settle, the opportunities will soon be there, if they are not already. July next year will be a busy busy time, you got to either use it or loose it.

Regards

David Donovan

I'm not sure I can justify charging this much for a simple nailcut - were I in general practice I think I would prefer to hire a foot health professional (or someone with equal quals) to do the simple nailcare at a fee which won't put patients off (say £8?). That said it has to be recognised that to some extent we are subsidising the NHS, and it would be better all round if the NHS paid us to do this work :) .

I agree about the exciting times ahead - but not sure how the HPC fits in.
Regards,
David

Hi David,

Interesting idea, although practitioners working by themselves would have to charge more than your suggested £8 due to difficulties in getting the patients in and out of the clinic fast enough. The target group for a "simple nail cut" would invariably be elderly and sometimes it takes them 5 minutes to take off their coat, shoes and socks. Re-booking can be slow, and in today's litigious climate you will have to write something meaningful on their record card.
Perhaps they could be charged full rate for the initial assessment and treatment, say £30, and then £15 for their nail trim, scheduled for a 20 minute slot.
Please bare in mind though that many patients are more than willing to pay full price.

Regards,
Graeme.

I've used a 2-chair clinic in the past, and this works well for the "oldies".
Cheers,
David

Hi all

Just to put the record str8, I charge £28 for the initial visit, and £20 for subsequent treatments, an error on my behalf, I too think £28 is a lot for a nail trim! ......however, I would estimate that well over 60% of my elderly patient base require just a trim, and they appear more than happy to pay this amount.

I agree with Graeme, you may be 10 - 15 mins treating them, and easy that time again reorganising the next visit, shoes, coat, how the milkman forgot to leave an extra pint, etc etc, I am of the opinion that social interaction with the patient (up to a point) is an important part of our job, but there again where do you begin and end??

Like I said fees can be a sensitive subject, some one once said to me that it may costs a pound to do something and ninteen to know how too.

Regards to all

David Donovan

Hi all again

Almost forgot............with regards to the HPC, its mere being has given everybody a sudden shock, by way of:

'Oh my god its happened now what do we do'

Everybody will now have to get along with each other, those who practice as a little earner on the side charging fees a paperboy would find insulting, will be forced to rethink their position, CPD will/can only increase an individuals knowledge which benefits both the patient and the practitioner, this time next year there is the 'possibility' that we shall be about 4500 - 5000 chiropodists/podiatrists short, and with the advent of the FHP's still to make a mark on society this must open up opportunities for people either within the NHS and the private sector, the demand will have to be met, and I don't mean this in a monetary way (for once ).

As for a self regulatory body, sounds good written down, but would be an astronomical burden to self fund, by its nature would have to include representatives from all the societies/schools, can you imagine trying to make and agree a decision in that jungle!?

Ask a Chiropractor about the BCA, they're self regulating, now that does that makes interesting listening.

Regards to all (again)

David Donovan

[quote=Mark Russell]. Each time a patient arrives at my surgery I assess whether they can actually manage to reach their feet. I watch them removing hosiery and shoes and often I ask them to touch the part of the foot that’s causing them a problem. If they can manage that task they can manage their nails. When they can’t I assess what their social circumstances are; who lives with them; what support services are involved; what their family position is. When I have established all these facts I make a decision what level of care is to be provided.

I do all of the above with every patient and take pedal pulses ,skin integrity assesments etc .The equipment I use is sterilised in the vacuume autoclave I have recently spent £6000 on a lease over 5 years to include the twice yearly servicing costs and on the "simple nail cut" nail that is a bit on the thick side I use my new podo s44 drill (the two previous drills have worn out) it only cost a mere £1400 etc ect ect .

SIMPLE nail cut ???

Anyone can be a busy fool. Charge a pound and you can have a queue a mile long,work 20 hours a day and still not be able to afford to live and provide the best for ALL your patients.

I think there is a definate divide between the type of patient seen in the IPP world and the NHS world which is perhaps another qustion that needs to be addressed ??

Regards

Derek

Personally I wouldn't have any problem accepting £28 for a "simple nail cut". Isn't this what Scholl have been doing for years, and I don't see people complaining about them? The patients are still using the same equipment as would be used for more involved procedures. Roll on July 05 as from them I hope my minimum charge for all new patients will be £30. I would charge £40 if I could get away with it and the patients were happy. Business is business.
As for home visits I think as they involve a lot more carrying of equipment and general hassle then the target should be £50. Regretably I have yet to achieve this.

Regards,
Graeme.

Hi Again
Well I thought I had heard it all !!

I have seen a 74 year old female patient today complaining of "sore burning feet" .

I examined her and found her to have a structural problem and prescribed orthotics.Before I had finished explaining why she needed them she told me "I already have them !! I don't want anymore at that price !!" When I followed her comment's up she had been to a "multi-discipinary clinic" fairly local to me and been charged ...wait for it...

£700.00 for the orthotics (1 pair) ,£100.00 for some shoes (which were too big) and when she went back to complain they didn't work, 2 treatments of laser therapy at £25.00 at time which apparently made the pain worse !!

The practitioner concerned is a ? osteopath / ?" non manipulative" chiropractor (yes, apparently they have a pecking order as well) the patient was not sure what he was , who in my opinion has prescribed a totally incorrect orthotic which quite frankly was non functional.

She accepted my diagnosis and treatments left comfortable and happy and will be coming back for review in around 2 / 3 weeks at an appointment TBA.

Now I know it has been suggested by some that I as a (to use Mark Russells proposal) Podiatric General Practitioner should treat patients for around £8.00 a time for certain treatments ???

Perhaps we should all get into the biomechanic / orthotic game full time and without principle (as obviously this practitioner is) , get rich very quickly !!! ? :(

She also told me that whilst she was having her laser treatment she overheard another woman praising this practitioner for making her better ,and how it was worth every penny !!

I told this lady to go back and demand either a refund and referral or a successfull therapy. She did not want the confrontation and told me a friend of hers who was a patient of mine had assured her "I would cure her" !!
( thanks friend )

That is how it is in the real world . Patient choice ? Rip off ? , fair service?

I have my opinion I'm sure you have your own , but please don't tell me what to charge for doing a "proper job" and providing a fair, efficient and effective service to anyone who want's it even if it is ONLY Nail care they need .

Cheers
Derek

I don't think that there is any problem with a fair fee being charged for a full assessment before treatment (even if the patient only needs nailcare).

Where I think the problem lies is in charging a similar fee 6 or 8 weeks on, when, unless there is a galloping systemic condition present, a full assessment does not usually need to be carried out again. After all, in all honesty, how long does it take to palpate a couple of pulses.

I do not particularly advocate you charge less - I advocate using a foot health professional for the lesser work.
Regards,
David

At last, a forum that nurtures intelligent debate........I knew it was possible.

Changing the subject completely......I treat a number of patients with 'severe' learning difficulties, the major problem with them is the fact they will insist on going every where bare foot, some resorting to dragging there feet along the ground causing them in some instances to bleed. The carers do a truely remarkable job in trying to prevent this, but it is difficult.

I do have my way treating them both from a mental and chiropody point of view and this has obviously worked due to the number of pts that are referred to me, I perform nail cutting when they are receptive, and patching up and cleaning any minor wounds.....the question is has anybody else had experiences (Im sure you have) of treating such individuals, and is there any particular way you approach such cases, I just know that at some time or another I am going to be confronted with an 'Oh Jesus, where's the door' type scenario.

Regards

David Donovan

Hi David

I think in truth and I can obviously only speak for myself and as I said in an earlier post "IPP 's have a different type of patient"

My pratice has always seen an "acute " type of patient presenting in the surgery and the "chronic" patient presents more on the domicilliary side.

I run a "direct access" appointment system in the surgery so the patient chooses when(mutually) and how long it is before they re-visit .The only exception being if I need to do a follow up review on medical grounds .

With that in mind "nail cutting" in reality only comes in as part of another treatment or which is the more likely someone has messed up the patients nailcare and or caused them pain . Once I have sorted the patient out and educated them they either integrate me with their freebies on the NHS or manage themselves or come back because the want to .

The domicilliary side is becoming in my area a nightmare with the traffic and parking etc so my fee's reflect that which will put off many and I think that may be where the FHP's may find their skills may be required .

I try in all cases to educate the patients .My younger patient take great delight in me "telling off" Mum or Dad for hurting them when they cut nails , but I also point out that no-one ever gets told properly by their parents how to do it. They all get shown how to brush their hair,clean their teeth but their nails ??? Much blood was there ???

At the end of the day it all comes down to patient choice and with the elderly especially the governments attitude is that they must pay something towards their own well being and provide allowances to help (even if only a little) .I am afraid many take the money but still expect everything for free ,those days have passed :(

I happen to believe in the NHS and with all it's faults believe it to be one of the finest medical institutions in the world .That's why so many doctors train here , but we all know with the advancement of technology and the added expense along with underfunding something has got to go. I fought long and hard in my previous occupation to maintain patients rights and services but the uncaring NHS management that took over was like talking to a brick wall.

I now find myself in a similar situation in this profession and can only hope that common sense will prevail so we can all do what we want and continue to maintain or restore Quality of life.

Cheers

Derek