FOOT HEALTH
A matter of life and limb
In the hustle and bustle of managing a care home, it's easy to overlook the importance of foot health. If your first thought is that foot health merely involves routine toenail trims, you're not alone. However, it's time to challenge this perception. Leona Calderbank, Co-Director of Care Home Podiatry, leads the first national Podiatry service solely dedicated to serving care homes. In this article, Leona shares what care providers must consider about foot health and explains how best to support people.
Quality foot health treatments, delivered by certified professionals, should support your staff while significantly enhancing the quality of life for your residents, preventing falls and hospitalisations and even reducing the risk of amputation and premature death. Yes, you read that correctly, foot health really is a matter of life and limb.
Foot conditions are common
The truth is most of your residents will have some foot health concerns. A big study of older adults1 found:
• A quarter of adults over the age of 65 live with foot pain.
• 75% of older adults suffer from a nail condition.
• 60% have toe deformities.
• 58% have problematic calluses or corns.
• Bunions, cracked skin, ingrown toenails, fungal infections and ulcerations (wounds) are also common.
You might be thinking these conditions sound pretty minor, and yes, they can be, but they can also be early warning signs of more serious problems. For example, corns and calluses are caused by pressure on the skin – exactly the same thing which causes
pressure sores and foot ulcers, which can lead to functional impairments, reduced mobility, and increased risk of infection. Not what you want for your residents. Having a qualified, regulated professional in place to catch and treat these problems early helps prevent these more damaging or dangerous problems from occurring for your residents.
Foot problems reduce mobility
Having a foot concern affects your residents' mobility which significantly affects their quality of life. Studies have shown that foot pain significantly reduces people’s ability to walk, and their ability to carry out physical activities and interact socially2
Foot pain leads to a more sedentary lifestyle with reduced physical activity. This is associated with various health issues, including cardiovascular diseases, obesity, and respiratory problems, all of which can contribute to your residents' mortality.
Impaired mobility naturally results in a loss of independence, affecting your residents' ability to perform daily activities. This loss of autonomy may lead to social isolation and a decline in cognition and mental wellbeing, which not only impacts on your residents' overall health and longevity but also increases demands on your care staff.
Care professionals can now access volunteer support through the NHS and Care volunteer responders programme.
Volunteers help in simple ways. Check In and Chat volunteers provide friendly phone calls to people in need of a bit of extra companionship. Community response volunteers help with delivering essential shopping and medication.
The service is free of charge and open for referrals now.
Foot problems are linked to falls
Half of all care home residents fall every year. Falls are one of the most common causes of unplanned hospitalisation, hip fracture, and death in older adults living in care homes3
Recent scientific studies have shown that having a foot problem greatly increases your chance of having a fall. Foot pain, toe deformities and bunions are particularly linked to an increased fall risk4.
We’ve seen care homes investing money in all sorts of gadgets to reduce falls, but have you covered the basics that your residents are already paying for? Foot checks by qualified, regulated clinicians should be part of your routine fall assessments.
Diabetic foot problems are serious
One in four care home residents currently has diabetes5, with numbers expected to significantly increase over the next 30 years. Foot problems are one of the most serious issues faced by people living with diabetes. If your visiting foot health provider is just cutting your residents with diabetes' toenails, it is definitely time to reconsider your foot care provider.
Poorly controlled diabetes can cause the health of your residents' feet to deteriorate significantly:
• Loss of feeling – Diabetes can lead to nerve damage which causes tingling, burning pain and permanent loss of feeling in your residents' feet.
• Decreased circulation – Diabetes can contribute to the build-up of blockages in blood vessels, meaning less blood gets through. Healthy blood flow is essential to keeping bodily tissues alive.
• Foot deformity – Feet can begin to change shape as a result of changes in the muscles of the feet and legs. This often starts with clawing of the toes and can progress to developing a high-arched foot. These changes in shape make the foot more prone to rubbing in footwear and increase the pressure and friction on the sole of the foot when walking.
These changes then place your residents at high risk of very serious diabetic foot conditions including:
• Diabetic foot ulcers – wounds that can take months or even years to heal. Diabetic foot ulcerations can lead to infections, sepsis, the need for limb amputations and even death. Diabetic foot ulcerations have a higher mortality rate than breast, prostate and colon cancers6 The mortality rate within five years of a foot ulceration can be as high as 75%6
• Gangrene – where there is no longer enough blood supply to keep your residents' toes or feet alive and they start to turn black. In some cases, surgery can be performed to improve circulation, but in most cases, surgical removal (amputation) is required.
Given the health implications of poor foot health, you
would probably assume that every older person is entitled to foot care on the NHS. Sadly, and worryingly, that’s not the case.
NHS Foot Health departments generally have strict rules around who receives treatment. These are associated with the way your local NHS services are paid for by Integrated Care Systems (ICSs). To receive NHS foot care your residents generally must meet one or both of the following criteria:
1. Have a medical condition which places the foot 'at risk'.
2. Have a foot condition.
Only people who fall into criterion one would qualify for regular foot care, and even then, wait times between appointments are almost always over three months (except for those with diabetic foot wounds). That’s certainly not enough to prevent foot health issues from escalating and potentially impacting on the wider health of your residents.
Of course, you probably already know this and think you’ve got it covered by accessing a private foot care provider. However, the private sector brings a whole new set of problems…
1. Anyone can provide foot care
Are you aware that there are currently no rules, regulations or professional guidance governing who can provide foot health treatments to your residents? Literally anyone can do it.
If your residents need oral health treatments, you will only allow a dentist to treat them. What about foot health? Are you certain you are only using a qualified and regulated podiatrist/chiropodist? Anyone can turn up to your home, call themselves a foot care specialist and charge your residents to treat their feet… no qualifications or training are legally required. All they require is the consent of their patient. This has led to a huge variation in the quality and safety of care being delivered across the care home sector.
While you would definitely notice if your visiting dentist was going from resident to resident in a communal area using the same toothbrush, do you notice if your foot health provider does the same cutting toenails? No changing of instruments, no changing of gloves, no hand washing, no respect for your residents' dignity, and on their part no training or membership to any regulatory body to know that they are putting your residents at risk. The lack of regulations on who can provide foot care to your residents means you should never assume a visiting provider is qualified and regulated. Putting aside that an individual with no qualifications will not be able to treat the conditions and pick up on the early warning signs previously mentioned, not ensuring your visiting providers are qualified (and Health and Care Professions Council [HCPC] registered) leaves both your care home staff and residents extremely vulnerable.
2. There is little guidance for care home managers
You would expect in an industry as well established and monitored as care homes, with a service that is so essential and as widely accessed as foot health, that there must be some clear and comprehensive guidance for you on what your residents should have access to? Unfortunately, you’d be wrong.
The National Minimum Standards, Care Home Regulations 3rd ed 2006 sets out the Department of Health and Social Care's (DHSC) key guidelines for care homes in the UK. This document states that foot health should be part of your residents’ initial needs assessment and that you should provide access to chiropody.
That is it. Nothing further to guide you through the confusing process of finding an appropriate foot health provider and then knowing what services they should be providing to adequately fill the gaps left by NHS services. This is all the more worrying when you consider just how confusing the private foot care industry is.
3. The resident-clinician contract
As standard, private foot health is paid for directly by care home residents, meaning your care home is not directly involved in the transaction between the resident and the clinician. Too often this results in poor sharing of information between the clinician and your nursing team, resulting in a lack of continuity of care and foot health concerns escalating. This all too often culminates in your residents needing treatment that could, and should, have been avoidable. Similarly, with the resident-clinician transaction the private provider is not at liberty to add to a resident’s care plan, potentially leading to your nurses making significant errors in care. This was one of the CQC’s key criticisms of dental care in the care home sector.
4. Who is responsible?
In most cases, a visiting foot health provider will only have an informal agreement with the care home manager with no established contract or terms of business in place. This can lead to inconsistent and questionable clinical standards and health, safety, and infection control practices. With no formal contract in place, who is responsible for your residents’ feet – is it the employed nursing staff or the foot care provider who turns up every six to 10 weeks with no contract?
The lack of regulations and professional guidance on who can deliver foot health treatments to your residents, coupled with the lack of regulations and professional guidance on what these treatments should look like, create the perfect storm for inadequate foot health provision across the care home sector. This should not be neglected, especially when foot health has such a significant impact on your residents' overall
health outcomes.
To mitigate this, Care Home Podiatry’s ‘Campaign for Better Foot Health’ has put together a detailed step-bystep ‘how to’ guide. The guide simplifies the process of sourcing a foot health provider and provides clarity on the services you, and most importantly your residents, should be receiving for their investment. You can access this free guide here:
Campaign for Better Foot Health – Part Three – Care Home Podiatry
Your residents are already paying for their foot health treatments. The only difference between these treatments being a simple toenail trim or being comprehensive healthcare treatments that prevent pressure sores, ulcerations, falls, amputations, and mobility issues, is you demanding that your residents get what they rightly deserve.
It's time that your residents and your staff get more out of your foot health provider. It really is a matter of life or limb.
References
1. Dunn, J.E., Link, C.L., Felson, D.T., Crincoli, M.G., Keysor, J.J. and McKinlay, J.B., 2004. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. American journal of epidemiology, 159(5), pp.491-498.
2. López-López, D., Becerro-de-Bengoa-Vallejo, R., Losa-Iglesias, M.E., Palomo-López, P., RodríguezSanz, D., Brandariz-Pereira, J.M. and Calvo-Lobo, C., 2018. Evaluation of foot health related quality of life in individuals with foot problems by gender: a cross-sectional comparative analysis study. BMJ open, 8(10), p.e023980.
3. Rapp, K., Becker, C., Cameron, I.D., König, H.H. and Büchele, G., 2012. Epidemiology of falls in residential aged care: analysis of more than 70,000 falls from residents of bavarian nursing homes. Journal of the American Medical Directors Association, 13(2), pp.187-e1.
4. Menz, H.B., Auhl, M. and Spink, M.J., 2018. Foot problems as a risk factor for falls in communitydwelling older people: a systematic review and meta-analysis. Maturitas, 118, pp.7-14.
5. Sinclair, A.J., Gadsby, R., Penfold, S., Croxson, S.C. and Bayer, A.J., 2001. Prevalence of diabetes in care home residents. Diabetes Care, 24(6), pp.10661068.
6. Robbins, J.M., Strauss, G., Aron, D., Long, J., Kuba, J. and Kaplan, Y., 2008. Mortality Rates and Diabetic Foot Ulcers: Is it Time to Communicate Mortality Risk to Patients with Diabetic Foot Ulceration?. Journal of the American Podiatric Medical Association, 98(6), pp.489-493.
