Q&A: Let’s talk foot care with patients

Pharmacy colleagues may not always be comfortable discussing foot care with patients. The Pharmaceutical Journal spoke to five healthcare professionals to find what problems they face when talking about foot health with their patients, how they promote foot care and their views on multidisciplinary working to care for patients’ feet.

• Ben Merriman, pharmacist, Cohens Chemist
• Tony Schofield, owner and pharmacist, Flagg Court Pharmacy, South Shields
• Trevor D Prior, consultant podiatric surgeon, senior clinical lecturer, Queen Mary University of London
• Shereen Shams, diabetes high-risk foot inpatient co-ordinator, Homerton University Hospital NHS Foundation Trust
• Damian Newell, foot health practitioner, Pierremont Pharmacy, Broadstairs

Ben Merriman, pharmacist, Cohens Chemist

What barriers or challenges do you face when discussing foot care with patients?

I do not think there are many barriers preventing pharmacy staff discussing foot care. We are used to talking about all sorts of health problems with patients and foot care is just one of many topics we speak to them about. As well as responding to queries from patients, medicines use reviews (MUR) [an advanced pharmacy service in England conducted by pharmacists] are a perfect opportunity to be proactive and discuss this sort of thing; we can reinforce the importance of foot health with diabetic patients as part of general healthy living advice during an MUR, for example.

A couple of our branches also sell orthotic insoles and shoes to improve posture and to relieve heel or arch pain. Our staff are trained to discuss these matters with patients, and we also have a podiatrist on site who offers private consultations, so we can refer to them for treatment or advice if needed.

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How do you promote foot care to patients?

Feet take the entire weight of our bodies, and there are several matters that our staff can discuss with patients to help care for them. As healthy living pharmacies, we make a point of actively intervening in patients’ health and well-being; discussing the benefits of these interventions with patients often motivates them to change their lifestyle. We know that stopping smoking increases circulation, and losing weight will obviously relieve stress on the feet, for example. Those over the age of 60 are especially prone to foot problems, so any interventions made to improve health could offer tangible benefits to patients.

We also see the same patients every month, if not, more frequently, and build relationships with our patients. If we see ’Mr Jones’ walk with a limp or hear ’Mrs Smith’ mention that she’s bothered by her feet, we can use the personal relationships we have with our patients to discuss these matters and recommend treatment for them.

A referral service to a podiatrist would be a natural extension to the work we already do and would really benefit patient care

Is there potential for collaborative working and multidisciplinary teamwork in foot care?

Some sort of formal referral pathway between the NHS chiropody service and community pharmacies would be a great service to be able to offer. The minor ailments scheme offered throughout Cumbria has already shown that community pharmacies are able to refer patients appropriately to general practice. We have also recently seen a new ophthalmology referral scheme being introduced in the area for pharmacists or their teams who are concerned about any eye complaints. A service to allow referral of patients, especially those with diabetes, to a podiatrist would be a natural extension to the work we already do and would really benefit patient care and reduce the chances of complications arising from poor foot health.

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Tony Schofield, owner and pharmacist, Flagg Court Pharmacy, South Shields

What barriers or challenges do you face when discussing foot care with patients?

It can be difficult to initiate a discussion about foot care in an over-the-counter (OTC) situation in the pharmacy unless the patient is seeking advice or buying a foot care product. I’m a bit concerned about using ‘icebreakers’ because it implies it is a retail opportunity. Therefore, I currently would limit discussion about foot care to part of a medicines use review (MUR) with a diabetic patient. I believe, however, that my knowledge and entitlement to advise on foot care is rudimentary.

Good foot hygiene benefits everyone, not only diabetic patients, because people spend so much time on their feet

How do you promote foot care to patients?

During a conversation with a patient, I might seek to do a foot care initiative as part of a healthy living pharmacy campaign. Good foot hygiene benefits everyone because people spend so much time on their feet. A foot care regimen — such as removing hard skin, adequately moisturising, not allowing the space between toes to get wet for prolonged periods and ensuring that toe nails are sensibly looked after — is good not only for diabetic patients, but for everyone. Infections can be dealt with fairly well with the available OTC products available in most pharmacies. Many locally commissioned minor ailment schemes include foot issues but, of course, many areas do not have such a scheme and others are seeking to decommission them, which is a problem.

Is there potential for collaborative working and multidisciplinary teamwork in foot care?

If pharmacies were to develop and offer treatment and support for patients living with long-term conditions, I could see them taking over some services such as retinal photography (by referral to a local optician, many of whom have such equipment) and foot care. The latter is always takes the form of a cursory examination and, with adequate training, could be achieved in a suitably equipped pharmacy. Pharmacies could employ podiatrists to do it for them (some already do). In principle, pharmacists could refer patients to podiatrists as a consequence of unease about a general foot care consultation. In 40 years, I have done this a handful of times but that is mainly because NHS services have been almost impossible to access via pharmacy. Unfortunately, private podiatry or chiropody services are of variable quality in my experience.

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Trevor D Prior, consultant podiatric surgeon, senior clinical lecturer, Queen Mary University of London

What barriers or challenges do you face when discussing foot care with patients?

As a podiatric surgeon, patients come to see me because they have a foot-related problem. However, the biggest challenge is the patient’s perception around the nature of the problem they have and the potential solution.

Many patients take their feet for granted and expect there will be some magical cure that involves minimal intervention and optimum outcome. Unfortunately, many people expect foot pain to resolve in the first instance and do not seek help until the problem becomes more chronic and disabling. As a result, there is rarely a simple solution.

In my experience, the single biggest problem is inappropriate footwear. For a shoe to fit properly, it needs to be the shape of the foot (i.e. square), have a 1cm gap between the end of the longest toe and the shoe, and if this is the case, a lace or at the very least an adjustable strap.

The biggest problem is poor shoe choice — around 90% of patients wear the wrong shoe size, let alone an appropriate size

Our own study revealed that 90% of patients are wearing the wrong size shoe, let alone appropriate style. Thus, the single most common discussion I have is regarding the best shoe for the individual and this is a significant barrier. Many patients are extremely resistant to change, particularly women, and this often takes a lot of time and explanation. However, generally, if the pain is sufficient, patients are more compliant and we try to strike a balance regarding the right shoe for the right activity.

How do you promote foot care to patients?

This is an ongoing process of educating the patient on the nature of their specific problem and the range of treatment options. Patients tend to be far more compliant while they are actively managing a problem, but this compliance naturally falls off as the problem subsides.

It is therefore important to educate patients to appreciate the factors that could return and the options they have to minimise recurrence. The advice given includes appropriate footwear, exercises, use of orthoses, and basic skin and nail care.

Appropriate footwear is important, as well as alternating shoes daily to allow the natural sweat to dry out, which can help patients with problem such as increased sweating, odour and fungal infections.

We are becoming much better at advising patients regarding load management. As we are aware, the body is very good at adapting to stress and load, but it needs sufficient time to adapt. Therefore increasing the amount, intensity or frequency of any one activity runs the risk of overloading the tissues and causing pathology. If you asked most people to run a half marathon (assuming they are not a distance runner), they would expect to have discomfort during and after the run. Yet people will go for a much longer walk, participate in a charity event, suddenly start running or do a day of heavy gardening or walk further in inappropriate shoes. All of these factors can overload tissues and predispose to injury. Advising patients on a gradual increase in load can help prevent injury or the recurrence of injury.

Is there potential for collaborative working and multidisciplinary teamwork in foot care?

It is well established that multidisciplinary teamwork provides a much better level of care for patients but, unfortunately, this is not always as simple as expected. It is not always easy for patients to be seen by several practitioners in one setting or for appointments to be co-ordinated. However, collaborative working in which there are common pathways for care and regular discussions on these pathways or individual cases can certainly make a significant impact.

There is a real opportunity to improve patient care by better collaboration with pharmacists, particularly in the community. Common conditions can be easy to diagnose. Pharmacists can establish the level at which these conditions can be managed in the first instance with simple self-care interventions, and the point at which a specific professional referral should be made. A pathway could then be developed for conditions that are less frequent or more complex.

The development of a network of practitioners in the local area would allow advice to be communicated, and it is likely that the patients would be referred for professional care more quickly, avoiding chronicity.

Diabetic foot — which can deteriorate rapidly and result in lower limb amputation — is a particular area of potential benefit. In an optimum situation, the community pharmacist would provide patient education on self assessment and when to seek advice; and provide a preliminary assessment regarding the risks of neurovascular complications, ulceration and infection. With a developed list of local podiatrists and emergency facilities, patients can be provided a higher level of care far more quickly, which could prevent significant complications. This process is something that could be established on a national basis.

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Shereen Shams, diabetes high-risk foot inpatient co-ordinator, Homerton University Hospital NHS Foundation Trust

What barriers or challenges do you face when discussing foot care with patients?

I work in a team of podiatrists who work both across hospital outpatients and community care, and my role is specific to diabetes inpatient care. Our department accepts referral via GPs, other medical staff and self-referrals. Patients initially attend an assessment appointment for specific foot problems. These problems vary but challenges tend to follow a similar trend. I work in Hackney, London, where we have a broad range of patients attending clinics — patients’ education levels vary and some of the older patients do not read or write.

A large part of the community does not speak English as a first language. This can create a barrier to giving foot care advice and can be challenging, particularly if the patient needs to carry out part of the treatment at home (e.g. calf stretches).

As a team, we find many patients have other commitments and this can create pressures with attending appointments and following treatment plans. Attending appointments during the day can be difficult for patients who work.

We find that footwear advice is the most challenging for patients to comply with. There are several reasons for this, including affordability of appropriate footwear and the patient’s idea of what is a good shoe and what looks attractive.

We offer training and support to other professionals to ensure that information is shared with patients

How do you promote foot care to patients?

As a team, we offer training and support to other medical professionals to ensure that information is disseminated to patients who may require our service.

When patients attend for the first time, they are given detailed advice based on their specific needs. They are given leaflets relating to their condition along with their treatment plan.

We offer an SOS clinic in the community, which runs Monday to Friday for urgent diabetic foot complications.

Our team also run patient user groups, which enable patients to be involved in care planning and processes which have been set up within the service. This also gives us the opportunity to promote foot care to these focus groups.

We have a newly updated website, which is easily accessible to all hospital and community staff but also to the patients to read themselves.

Our team are setting up Twitter and Instagram accounts so that foot care promotion can be updated regularly.

Is there potential for collaborative working and multidisciplinary teamwork in foot care?

Our department comprises podiatric medicine, podiatric surgery and surgical appliances footwear. We have good communication within the team and we are able to refer swiftly and ensure that the patient has full access to the whole treatment approach.

We have an existing well-run multidisciplinary team based in the outpatients department for high-risk diabetics with foot complications. This team consists of the diabetes lead podiatrist, extended scope podiatrists, foot care assistants, the diabetes consultant, podiatric surgeons, the vascular team and the diabetes specialist nurse. We also have easy access to the plaster room for offloading, microbiology and radiology.

The community musculoskeletal team has also set up a smaller scale team that works on biomechanical conditions, which require more specialist input. The team has access to ultrasound, physiotherapy input and access to more specialised treatments.

My role requires me to co-ordinate treatment plans for patients who are admitted to hospital for diabetic foot complications. I work alongside the medical and therapy teams. I often give opinions and recommendations to the hospital staff so that patient care is optimum. Once a patient is discharged from hospital, I ensure there is a treatment plan in place and arrange outpatient appointments with the podiatry team to provide seamless, ongoing care.

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Damian Newell, foot health practitioner, Pierremont Pharmacy, Broadstairs

What barriers or challenges do you face when discussing footcare with patients?

I come across many different problems when dealing with people’s feet, some of which can be embarrassing. In my experience, reassurance is key. Telling the client or patient that everything will be OK and there is no need to worry goes a long way. There are always solutions to treating various foot problems, and there is nothing embarrassing about taking care of your feet. Patience is essential because it may take some time to build a rapport with the patient before you can proceed to talking about the ailment. Being calm and caring always helps.

I like to approach customers who come to the pharmacy and tell them that we offer a foot care service

How do you promote foot care to patients?

I like to approach walk-in customers who come into the pharmacy (for example, to pick up a prescription) and tell them that we offer a foot care service. We also promote this online via the pharmacy’s website. We also have promotional marketing materials, such as leaflets and flyers, which we leave on the pharmacy counter so people can pick them up and read about the service we provide.

Is there potential for collaborative working and multidisciplinary teamwork in foot care?

For those patients who have diabetes, it is vital that they get their feet checked regularly because they are at risk of getting diabetic neuropathy, which means they could lose sensation in their feet and not realise when there is an injury. This could lead to serious complications such as diabetic foot ulcers, among other things. Other healthcare professionals like pharmacists, nurses and doctors all feed into the care of diabetic patients and a collaborative approach is always better than working in silos.

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