Section 3: Policy context and background
The changing role of podiatry
In the past some NHS podiatry departments provided personal footcare as part of their core services, however to deliver safe and effective podiatry which ensures people with clinical need are prioritised for treatment, many NHS Boards across Scotland have reviewed and redesigned their services. Anecdotal evidence suggests an unintended consequence of this is a gap of some areas in provision of personal footcare services, such as toe nail cutting, for people who do not have a clinical need for podiatry. In response to concerns raised about availability of and variation in personal footcare services for people in Scotland, the Scottish Government established the National Footcare Working Group which has developed this guidance.
Personal footcare does not require the skills of a podiatrist, however podiatry services can play a role in signposting people to the resources to support self care and ensure that people who deliver a personal footcare service have the appropriate skills.
Planning and delivery of good footcare services clearly relies upon effective partnership working between health, social care, voluntary agencies and independent sectors.
It is important to note that the changing role of podiatrists is supported by national bodies. The Society of Chiropodists and Podiatrists for the UK in their document A guide to the benefits of podiatry to patient care (2010) outline the full spectrum of foot health care, from personal footcare through to podiatric surgery. The organisation worked closely with the Department of Health in England to produce Footcare services for older people: a resource pack for commissioners and service providers (2009)
For reference, the unique role of podiatrists is outlined in the box below.
- Podiatrists provide a comprehensive foot health service for conditions affecting the foot and lower limb. Through early intervention they play a key role in prevention of future lower limb and foot problems, including support for self care.
- Podiatrists assess, diagnose and provide treatment for a wide range of conditions of the lower limb, these may be caused by musculoskeletal problems or long term conditions such as diabetes.
- Podiatrists work in partnership with people to provide a variety of treatments which may be used to achieve pain relief and avoid potential problems, for example by use of insoles or nail or podiatric surgery.
- Podiatry services are important in keeping people mobile, independent and in preventing hospital admissions.
An increasingly older population - personal footcare and the links to national strategies
The demographic changes facing Scotland are well known; the number of people aged over 65 are projected to increase by 22% by 2020 and by 63% by 2035. The over 75 population is predicted to increase by 23% and 82% over the same periods, and the over 85 population will increase by 39% by 2020 and 147% by 2035. These changes, alongside a decade of financial challenges have reinforced the importance of enabling people to live healthy independent lives for as long as possible, preventing inappropriate hospital admissions and reducing dependency on care services.
The approach to meeting these challenges has been set out in Reshaping Care: a programme for change 2011-2021 (Scottish Government, Convention of Scottish Local Authorities (COSLA) & NHS Scotland, 2011) which has as its goal to 'optimise independence and well being of older people at home or in homely setting'. Closely aligned to this is Scotland's national dementia strategy (Scottish Government, 2010) which aims to ensure that people with dementia and their families are supported in the best way possible to live well with dementia. To support these programmes the government has committed to establishing an integrated approach to planning and delivering health and social care; this includes integration within the NHS and between primary and secondary care. New legislation will be needed to facilitate integration, including the establishment of Health and Social Care Partnerships (HSCP) with delegated integrated budgets. This will promote closer partnership working in planning and delivering services.
These programmes of work support the overarching ambitions of the Healthcare Quality Strategy for NHSScotland (Scottish Government, 2010) and Achieving Sustainable Quality in Scotland's Healthcare: a "20:20" Vision (Scottish Government, 2011) which aims to deliver safe, effective, person centred services based on individual needs, and seeks to support people to manage their own conditions to enable people to live healthy and independently for as long as possible in their own homes.
Good personal footcare clearly contributes to all these work programmes by helping older people to remain active, well and independent for as long as possible. Of particular relevance is the role that personal footcare plays in the prevention of falls and fractures and the resultant significant life changing problems these can go on to cause. Older people admitted to hospital after falling are more likely to be discharged to a care home than a comparative group of people admitted for any other reasons. The National Falls Prevention Programme works in partnership with key stakeholders to support Health and Social Care to adopt a co-ordinated and systematic approach to falls prevention as outlined in Up and About: pathways for the prevention and management of falls and fragility fractures (NHS Quality Improvement Scotland, 2010). Older people living in care homes are three times more likely to fall than older people living in their own homes, with the results of a fall often being more serious. The self assessment resource Managing falls and fractures in care homes for older people (SCSWIS & NHSScotland, 2011) outlines ways to reduce the incidence of falls; personal footcare for these people makes an important contribution to this work.
The important role that carers play in provision of health and social care has been recognised in Caring Together - The Carers Strategy for Scotland 2010-2015 (Scottish Government and COSLA, 2012). This highlights the need to ensure carers have appropriate information and training; in developing this personal footcare guidance we have tried to address this need by developing a series of supporting resources to meet the needs of a variety of different carers. The Change Fund Guidance for Local Partnerships 2012/13 (Scottish Government, 2012) specifies the use of some of these funds to support carers and asks partnerships to increasingly focus upon anticipatory care and preventative spend. Personal footcare services could fulfil the criteria for some of these funds in some Partnerships.
The National Delivery Plan for AHPs in Scotland provides an opportunity to align the contribution of AHPs to national priorities for health and social care. The plan calls for AHPs to lead and deliver more enabling services, shifting the focus away from professional dependency and towards supported self-management and resilience. Implementation of the guidance on personal footcare supports the overall aims of the plan.
Personal footcare as part of free personal care and residential care
Free personal and nursing care was introduced in Scotland on 1 July 2002 through the Community Care and Health (Scotland) Act 2002. Personal care is available without charge for everyone in Scotland aged 65 and over who have been assessed by the local authority as needing it.
Free nursing care is available for people of any age. Keeping fingernails and toenails trimmed is covered in the legislation as one of the personal hygiene aspects of personal care. Essentially any provision of care is based on a detailed assessment of the individual's care needs taking into account their preferences and those of their family and carers. If the individual's circumstances change a review assessment should be conducted and the local social work office is responsible for making suitable arrangements.
Local authorities will assess whether people requiring care at home or in a care home need personal care and will make available an agreed amount directly to the individual or their care provider. However, the local authority is expected to ensure that the resources are used in the most effective way to meet individual care needs.
Home carers can be educated to provide personal footcare as part of a personal care plan.
Personal footcare and links with the Scottish Diabetes Foot Action Group
The Scottish Diabetes Foot Action Group has several strands of work in progress which aim to prevent and reduce the incidence of foot disease and amputations in people with diabetes. All people with diabetes should undergo foot screening by a suitably trained person (Scottish Intercollegiate Guidelines Network: Management of Diabetes, Health Improvement Scotland, March 2010). This will result in the identification of the risk associated with the development a foot ulcer. These risk categories are; low, moderate, high or active foot disease.
Good personal footcare and daily checking of feet is important for all people with diabetes. Education regarding this should be provided during the screening appointment. For people who have been assessed as low risk, it is acceptable and safe for them or their family, friends or carers to carry out the personal footcare. For people who have been assessed as moderate risk, they or their family, friends or carers may still be able to carry out all or most of their personal footcare safely, following advice from the podiatrist.
Email: Jenny Ackland