Podiatry Review May/June 2012

ISSN 1756-3291

Podiatry Review Volume 69 No.3. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal May / June 2012

• Diabetes News • Arthritis News • Branch News

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M AY/ J U N E 2 0 1 2 V O L 6 9 N o . 3

The Institute of Chiropodists and Podiatrists Academic Editor Robert Sullivan Dip.Pod.Med., BSc (Hons), PGCert, LA., PGCert.

Pom's., PGCert N&Skin Surg., PGDip. Pod. Surg., FIChPA., SARSM., MInstChP.

Editorial Assistant Bernadette Willey bernie@iocp.org.uk

PODIATRY REVIEW Contents Editorial ......................................................................................3

Editorial Committee Mrs F H Bailey MInstChP Mr W J Liggins FInstChP, FPodA, BSc (Hons) Mrs J A Drane MInstChP Advertising Please contact Julie Aspinwall secretary@iocp.org.uk Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport Merseyside PR9 0TL 01704 546141

Predictors of adherence to a multifaceted podiatry intervention for the prevention of falls in older people Martin J. Spink, Mohammad R. Fotoohabadi, Elin Wee, Karl B. Landorf, Keith D. Hill, Stephen R. Lord and Hylton B. Menz...........................................................................4 Profile ‐ Sarah Bowen, BSc MInstChP...........................................9 HPC Professionalism in Healthcare Professions Research Report Beverley Wright, MInstChP, BSc (Hons) PGCE, PGDIP ..................10 Podiatry as a Profession: My path to becoming a Podiatrist and my experience as a newly qualified practitioner: Part 4 Deirdre O’Flynn, BSc Podiatry, MInstChP ....................................14 The Personal Development Portfolio Iain B. McIntosh, BA (Hons) MBChB, FFTMRCPS(Glas) .................16

www.iocp.org.uk Diabetes News..........................................................................19 Arthritis News...........................................................................22 Branch News.............................................................................24

Printed by Mitchell & Wright Printers Ltd, The Print Works, Banastre Road, Southport PR8 5AL 01704 535529

Obituary - Fred Beaumont........................................................29

ISSN 1756-3291

HPC Information .......................................................................32

Annual Subscription

£30 UK £45 Overseas

Chiropody - A very worthwhile career Janet Mannion .........................................................................30

Classified Adverts .....................................................................34 Diary of Events..........................................................................35

© The Institute of Chiropodists and Podiatrists.

The Editor and the Institute of Chiropodists and Podiatrists accept no responsibility for any opinions expressed in the articles published in the Journal; and they do not accept responsibility for any discrepancies in the information published. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior written permission of the publishers.

National Officers.......................................................................36

EXECUTIVE COMMITTEE L-R Julie Dillon, Colette Johnston, Joanne Casey, Martin Harvey, Heather Bailey, Bill Liggins, Jacquie Drane, Robert Sullivan, David Crew, Valerie Dunsworth, Michele Allison, Ann Yorke page | 01

FIRST AID

Is your First Aid Certificate up to date?

We would like to remind members that the HPC standards of practice 2b4 state that all registrants "be able to use basic life support skills and to deal safely with clinical emergencies".

Failure of compliance with HPC standards of practice could lead to an allegation of ‘fitness to practice being impaired’.

Also, the Health and Safety Executive point out that ; “The Health and Safety (First-Aid) Regulations 1981 require employers to provide adequate and appropriate equipment, facilities and personnel to ensure their employees receive immediate attention if they are injured or taken ill at work.

These Regulations apply to all workplaces including those with less than five employees and to the self‐employed.

Detailed information can be found in: First aid at work. The Health and Safety (First Aid) Regulations 1981. Approved Code of Practice and guidance.

The HSE also go on to say: “ The Health and Safety (First-Aid) Regulations 1981 require employers (this includes the SelfEmployed) to provide suitable first‐aid equipment, facilities and personnel so that immediate assistance can be given to employees if they are injured or become ill at work. Regulation 3(2) states that in order to provide first aid to injured or ill employees, a person isn't suitable unless they have undergone

the right training and qualifications approved by HSE and any additional training if required.”

The Institute Emergency First Aid at Work Course is an intensive and very costeffective full day HSE approved course, that fully satisfies the requirements of places of employment with up to 50 persons and lasts for 3 years. As the potential for Anaphylaxis and Cardiac collapse is higher in healthcare situations, especially so for members undertaking Local Anaesthesia or other advanced procedures, the course includes additional training in Adrenaline use and advanced airway management including Oropharangeal (Guedel) Airways and Bag Valve Masks. Courses can accommodate up to 12 people and are taught and assessed by the Institute’s Faculty of Education own HSE recognised trainer.

Please telephone 01704 546141 to register your interest.

Note to Branch Secretaries: If enough members of your branch request, we will be happy to organise first aid training locally. Please contact Head Office to make arrangements.

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EDITORIAL

As a new editor has not yet been appointed by the Executive of The Institute of Chiropodists and Podiatrists, it falls to me, as Academic Editor, to step into the breach; for an opinionated person such as me this is not a good thing as it means becoming a diplomat. It is enough to say that the incoming Editor has some interesting shoes to fill.

I have been Academic Editor of this publication for the last two years and have overseen the transition from the previous format to this one; it is gratifying to see the standard of the articles included has grown and that we have become a peer review publication. Without a strong team and good leadership this would not have happened.

As this Journal continues to grow, it is of vital importance to me that we do not lose our core reader, and that the Review continues to deliver quality material to a wide diversity of readers. The publication has to have something of interest for ALL of us.

This Review sees articles from our regular contributors like Beverly Wright, an interesting technical article from Sam Wright, Marketing Manager of the Langer Group on Morton’s Neuroma and some revealing information from Diabetes UK and the shocking “national disgrace” of diabetes related amputations. As well as these, there is information on the HPC revised Standard of Acceptance for Allegations relating to fitness to practice. This you can read for yourselves and form your own opinion. In my view any improvement on the old standards is a step forward.

Among other articles in this publication, I would like to bring your attention to the article presented

by Newcastle University Scientists who are funded

by Arthritis Research UK. May is the officially recognized month for raising the awareness of this disease on a European level. As podiatrists and professionals dealing with feet, we come across many sufferers of this condition. Are we able to give the necessary advice and treatment based on evidence? Is our CPD up to date? Professor Alan Silman, medical director of Arthritis Research UK says, “Although modern treatments have changed the outcome for many patients with rheumatoid arthritis, firstly not all patients respond to them and secondly, even in those patients who do respond in some way, we can’t completely get rid of the inflammation that damages their joints.” As podiatrists and foot care professionals how can we help improve the quality of life for these patients?

For the month of May let’s focus our CPD learning on arthritis.

Robert Sullivan, Academic Editor

Dear Readers, Firstly, I have to pay tribute to Roger Henry, the previous Editor of Podiatry Review. When he took over the Editorship of the then Chiropody Review, it was a small A5, black and white ‘House Journal’.

Under his Editorship, it has grown, literally and metaphorically, until it has reached its present stage.

A colorful, A4, double columned journal, with a peer reviewed section and a bold statement in the presentation of the cover. The title has been changed to ‘Podiatry Review’ to reflect the changes in the profession and the advertisements – on which we depend to keep the inevitable rises in the price of printing and postage down – have increased. Each issue is packed with up to date information for the members of the Institute, regular columns and articles of general interest are to be found as well as increasingly technical articles on professional matters. The latter includes material on Continuing Professional Development and Branch and Area Council Seminars are advertised as well as details of Branch meetings in the ‘Forthcoming Events’ section. Roger made his decision to resign the Editorship alone and no-one was more surprised to see his announcement in the last journal than the Editorial Committee; however, his decision is respected, as is his achievement. Whilst it is to be hoped that this achievement will be recognized throughout the Institute, the real reward of any Editor is the satisfaction of a job well done.

In this number of the journal, you will find a report on the successful Midlands Branch Seminar which was centred on various aspects of diabetes mellitus. You may have noted the rather surprising title “Lizard Spit and all that” and wondered what it meant? Well, research continues apace into the condition and a recent discovery has proved to be almost revolutionary in the treatment of Type 2 diabetes. A drug, exenatide (commercially known as Bydureon and in a shorter acting form as Byetta), has been produced from components of the saliva of the Gila Monster – a lizard found in the desert areas of the southern United States of America and the northern areas of Mexico. The significant point of exenatide is that it stimulates insulin secretion as well as inhibiting glucagon and can be taken as triple therapy with such oral drugs as Metformin, sulphonylureas and long acting insulins. The drug was approved by the National Institute for Clinical Excellence in October of 2011 and Bydureon can be taken as a once weekly injection. As the population becomes more aware of the condition and the observed symptoms, more attention will be given to the effects as the disease progresses. Diabetes has been described as both an epidemic and a pandemic. The raw figures are alarming.

The most recent audits suggest that 2,455,937 of the population are affected in England, 223,4494 in Scotland, 160,533 in Wales, 72,693 in Northern Ireland and 84,266 in the Republic of Ireland. This roughly equates to 5% of the population.

However, it is known that in all the countries mentioned, there are vast numbers of undiagnosed diabetics who nevertheless suffer to a greater or lesser extent from the major systemic effects of diabetic retinopathy, nephropathy, neuropathy and macro and micro-vascular disease. Although both type I and type II diabetes is increasing markedly, it is type II or non-insulin dependent diabetes which is becoming more prevalent and it is these patients who are more likely to be seen in podiatry practices. All GP practices are now funded for an annual foot check; however, with the discharge of ‘non-at risk’ patients from the NHS, it is entirely possible that some will slip through the net. Some colleagues may be retained by GP practices to carry out screening, whilst some GPs may refer patients for treatment. The chiropodist/podiatrist is in a unique position to not only carry out diagnostic tests but to supply advice on lifestyle improvement and very specific treatment as well as onward referral if that is indicated.

The Institute is very aware of the difficulties that lie ahead for both this group of patients and the practitioners treating them. It has accordingly made contact with ‘Diabetes UK’ and appointed Mr Alisdair Reid as the Institute Liaison Officer.

Further information will shortly become available.

Bill Liggins, Chairman Executive Committee

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Predictors of adherence to a multifaceted podiatry intervention for the prevention of falls in older people Martin J Spink1,2, Mohammad R Fotoohabadi1, Elin Wee1, Karl B Landorf1,2, Keith D Hill3,4,1, Stephen R Lord5,6 and Hylton B Menz1* Abstract — Background Despite emerging evidence that foot problems and inappropriate footwear increase the risk of falls, there is little evidence as to whether foot-related intervention strategies can be successfully implemented.

The aim of this study was to evaluate adherence rates, barriers to adherence, and the predictors of adherence to a multifaceted podiatry intervention for the prevention of falls in older people.

Methods The intervention group (n = 153, mean age 74.2 years) of a randomised trial that investigated the effectiveness of a multifaceted podiatry intervention to prevent falls was assessed for adherence to the three components of the intervention: (i) foot orthoses, (ii) footwear advice and footwear cost subsidy, and (iii) a home-based foot and ankle exercise program. Adherence to each component and the barriers to adherence were documented, and separate discriminant function analyses were undertaken to identify factors that were significantly and independently associated with adherence to the three intervention components.

Results Adherence to the three components of the intervention was as follows: foot orthoses (69%), footwear (54%) and home-based exercise (72%). Discriminant function analyses identified that being younger was the best predictor of orthoses use, higher physical health status and lower fear of falling were independent predictors of footwear adherence, and higher physical health status was the best predictor of exercise adherence. The predictive accuracy of these models was only modest, with 62 to 71% of participants correctly classified.

Conclusions Adherence to a multifaceted podiatry intervention in this trial ranged from 54 to 72%. People with better physical health, less fear of falling and a younger age exhibited greater adherence, suggesting that strategies need to be developed to enhance adherence in frailer older people who are most at risk of falling.

Background Falls in older people are a major public health problem, with one in three people aged over 65 years falling each year [1,2]. Fortunately, several interventions have been developed that have successfully reduced the rate of falls in this group, including exercise, home modifications in those with visual impairment, cataract surgery, and withdrawal of psychotropic medications [3-6]. However, for falls prevention programs to be effective, sufficient adherence to the intervention is required [4,7]. Previous studies have found that adherence to falls prevention strategies vary depending on the type of intervention, ranging from 42 to 87% for exercise [8,9], 50% for home modifications [10], and as low as 35% for withdrawal of psychotropic medications [3].

Identification of older people who are most likely to adhere to intervention recommendations would assist in the effective targeting of falls prevention programs and may help target those who may need greater support to implement recommended interventions. Several factors have been shown to be associated with greater adherence to interventions for preventing falls, such as male sex [11], living with others (compared with living alone) [11], having a caregiver [10,11], believing that interventions are effective in preventing falls [10], infrequent feelings of loneliness [12], low self-perceived probability of falling [12] and better physical and cognitive abilities [12].

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In response to emerging evidence that foot problems [13] and inappropriate footwear [14] increase the risk of falls, we recently completed a randomised trial which found that a multifaceted podiatry intervention was effective in reducing the rate of falls by 36% in community-dwelling older people with disabling foot pain [15]. This trial used three main interventions: (i) foot orthoses, (ii) footwear advice and footwear cost subsidy and (iii) home-based foot and ankle exercises. In this article, we examine the adherence and the barriers to adherence in this trial as well as predictors of adherence for each component of the intervention from our randomised trial. In doing so, we aimed to determine the most effective way to translate the findings of our falls trial into clinical practice.

Methods The data used in this study were collected during a randomised trial of a multifaceted podiatry intervention to prevent falls in older people, the details of which have been reported elsewhere [15,16]. The sample for the study described here consisted of all participants randomised to the intervention group (n = 153).

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Participants Participants were recruited in Melbourne, Australia, between July 2008 and September 2009 using a database of people who were accessing podiatry services at the La Trobe University Health Sciences Clinic, Bundoora, Victoria, Australia, and by advertisements placed in local newspapers and on radio. Participants were eligible if they: were community dwelling; aged 65 years or over; were cognitively intact (defined as a score of ≥ 7 on the Short Portable Mental Status Questionnaire) [17]; reported disabling foot pain (defined as foot pain lasting for at least a day within the last month and a positive response to at least one item on the Manchester Foot Pain and Disability Index [MFPDI]) [18], and; had an elevated risk of falling (defined as either a history of a fall in the previous 12 months, a score of > 1 on the Physiological Profile Assessment (PPA) tool [19] or had a time on the alternate stepping test of > 10 seconds) [20]. Exclusion criteria included neurodegenerative disorders, lower limb amputation, inability to walk household distances (10 metres) without the use of a walking aid, limited English language skills or lower limb surgery within three months prior to the initial assessment or planned lower limb surgery within a period of three months following the scheduled initial assessment. The Human Ethics Committee of La Trobe University approved the study (ID: 07-118) and all participants provided written informed consent.

Procedure/trial design Participants were initially screened by phone for eligibility, then assessed at baseline and at six months after baseline by an assessor blind to group allocation. There were two assessors (MRF and EW), both of whom were experienced physiotherapists. Each participant was tested by the same assessor at both the baseline and six month follow-up

appointments. After obtaining written informed consent, the baseline assessment was conducted. Group allocation (randomisation) was then undertaken and the intervention was administered to those in the intervention group by MJS, a podiatrist. Participants were randomly allocated to either the usual care control group or the multifaceted podiatry intervention group. Permuted block randomisation with mixed block lengths of four and six participants was undertaken by the investigator (MJS, the person administering the intervention) using an interactive voice response telephone service provided by the National Health and Medical Research Council Clinical Trials Centre at the University of Sydney, Sydney, Australia. This occurred during a single session at the La Trobe University Health Sciences Clinic.

Intervention The intervention group was provided with a multifaceted intervention package consisting of: (i) Foot orthoses: prefabricated, full length, dual-density orthoses manufactured from a thermoformable cross-linked closed-cell polyethylene foam with a firm density base and a soft density top cover (Formthotics™, Foot Science International Ltd, Christchurch, New Zealand) were issued to each participant who was not currently wearing customised or prefabricated orthoses. Consistent with the manufacturer’s instructions, the orthoses were heat-moulded to each participant’s foot shape. The orthoses were then appropriately customised using 3 millimetre thick Poron® [16], a urethane foam, to redistribute pressure away from plantar lesions (e.g. calluses) that were identified on the participant’s forefoot. Participants were requested to wear the orthoses in their outdoor footwear at all times. (ii) Footwear advice and provision: participants’ outdoor footwear was assessed using a validated footwear assessment form [21]. Participants with inappropriate footwear (defined as a heel height greater than 4.5 cm, or any two of; no fixation, no heel counter, a heel counter that could be compressed greater than 45 degrees, a fully worn or smooth sole, or a shoe heel width narrower than the participant’s heel by at least 20%) were counselled regarding the specific hazardous footwear feature/s identified, and were provided with a handout on what constitutes a safe shoe [22,23]. They were then provided with the contact details of an extra-depth and medical grade footwear retailer and asked to purchase a more appropriate pair of shoes. The purchase of footwear was assisted by the provision of an AUD$100 voucher. (iii) Home-based foot and ankle exercise program: participants were asked to perform a standardised 30 minute home-based exercise program three times per week for six months aimed at stretching and strengthening the muscles of the foot and ankle. All participants were prescribed the same exercise program and were instructed to increase the number of repetitions or resistance at a self-paced rate based on their ability to perform the exercise with no pain during the movement and no muscle soreness the following day.

Participants were provided with a daily exercise diary to document their adherence to the program and were instructed to return these each month in provided postage-paid envelopes.

Participants were contacted by MJS at 1, 4, 12 and 20 weeks by telephone to answer any queries and to promote adherence to the program. The participants were asked through informal questioning whether there were any exercises they were unable to complete and advised on an appropriate course of action on how to complete the exercise. Where participants reported they were unable to complete the exercise program the prescribed number of times, the benefits of foot and ankle strength in relation to balance and falls prevention were reiterated. Where applicable, they were also asked about their usage of the orthoses issued in the trial and the footwear they were recommended to purchase. The need to wear the orthoses and the new

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footwear they had purchased as frequently as possible was emphasised.

Where it was reported that the orthoses were uncomfortable, they were asked to attend the La Trobe University Health Sciences Clinic where podiatry consultation was provided at no cost to the participant to adjust the orthoses. Where the participants were reluctant to purchase new footwear, the benefits of appropriate footwear in preventing falls was further emphasised.

Baseline predictors of adherence As well as sociodemographic data, a number of measures were collected at the baseline assessment as potential predictors of adherence. These included: a fall risk score using the PPA [19], the pain and function subscales of the MFPDI [18], the short Falls Efficacy ScaleInternational (FES-I) [24], the mental and physical component summary scores of the Short Form Health Survey (SF-12) [25], history of a fall or falls in the previous 12 months, university education (defined as completing three years of tertiary education) and the hours of planned and incidental physical activity over the past week, recorded using the Incidental and Planned Exercise Questionnaire [26]. Foot-related data were also collected, including the presence of hallux valgus (documented using the Manchester scale [27]) and the region of the foot where pain was present.

Evaluation of adherence To evaluate adherence to the exercise intervention, participants were provided at baseline with a daily exercise diary to document each day they completed the exercise program. They were provided with postagepaid envelopes and instructed to return the exercise diary each month.

For orthoses and footwear adherence, participants were asked at the six months follow-up assessment how often they wore the orthoses and the new footwear (“most of the time”, “some of the time”, “a little of the time” or “none of the time”).

For the orthoses and footwear interventions, participants who reported wearing the orthoses or new footwear “most of the time” or “some of the time” were considered to be adherent. Participants were classified as having adhered to the exercise program if they reported completing 50% or more of the recommended exercise sessions.

Statistical analysis The data were analysed using SPSS version 17.0 (SPSS Corp, Chicago, Ill, USA). Comparisons between participants who adhered to recommendations (“adherers”) and those who did not (“non-adherers”) were determined separately for each of the three interventions using the chi-square statistic for dichotomous variables and independent samples t-tests for continuous variables. Variables that were found to significantly different (p < 0.05) between adherers and non-adherers were then entered into a discriminant function analysis model to determine their relative importance in predicting group membership, as well as to determine the most important determinants of adherence for each intervention. Discriminant analysis performs a similar function to logistic regression but differs in the assumption that the independent variables are normally distributed and variance is equal across groups [28,29] , in which case discriminant function analysis is considered to be a more powerful and efficient analytical strategy [29].

Results Characteristics of the study population The sample consisted of 153 participants (47 men and 106 women) aged 65 to 91 years (mean age ± SD = 74.2 ± 6.0 years). Although over half the sample had experienced one or more falls in the preceding 12 months, they were considered to be active relative to Australian guidelines for physical activity for older people [30], undertaking on average greater than three hours per week of planned physical activity.

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Intervention adherence A total of 103 participants (67%) were issued with foot orthoses at baseline, and 16 participants (15%) were lost to follow-up. Overall, 71 (69%) were adherent to the orthoses intervention. Inappropriate footwear was identified at the baseline assessment in 41 participants (27%) and 3 participants (7%) were lost to follow-up. Overall, 22 (54%) were adherent to the footwear intervention. A total of 149 participants (97% of the sample) completed six months of home-based exercise with 109 (72%) being adherent to the exercise intervention. The group completed 68% of the total number of exercise sessions, although adherence declined steadily over the six months of the trial with 83% of the total exercise sessions being completed in the first month and 53% in the last month.

Participants who were unable to fit the orthoses in the shoes that they wanted to wear (56%) or who found the orthoses to be uncomfortable (38%) accounted for the majority of the reasons for non-adherence with the use of the orthoses. Non-adherence to the footwear intervention was mostly due to the participants declining to purchase new footwear (76%). The main reasons given for failing to complete the exercise sessions were poor general health (18%), a pre-existing condition/limitation (18%) and lack of time (15%).

Predictors of adherence For the orthoses, age was the only variable significantly associated with differences between adherers and non-adherers, with lower age being associated with better adherence. A significant difference was found between participants who adhered to recommendations compared to non-adherers for the SF-12 physical score for both the footwear intervention and the exercise intervention with a higher score (i.e. better health status) being associated with better adherence. For the footwear intervention, greater adherence was also associated with less fear of falling (determined by a lower FES-I score).

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For the orthoses intervention, age classified participants into the adherent or non-adherent group with an accuracy of 62.1% following validation (Wilks’ λ = 0.93; p = 0.014). For the footwear intervention, the combination of the SF-12 physical score and the FES-I classified participants into the adherent or non-adherent group with an accuracy of 71.1% following validation (Wilks’ λ = 0.78; p = 0.014). For the exercise intervention, the SF-12 physical score classified participants into the adherent or non-adherent group with an accuracy of 63.1% following validation (Wilks’ λ = 0.95; p = 0.007).

Discussion The aim of this study was to evaluate adherence, barriers to adherence and the predictors of adherence to a multifaceted podiatry intervention recently found to be effective in preventing falls in older people [15].

Adherence to the three components of the podiatry-related falls prevention interventions in this study were broadly similar, with 72% classified as adherent for exercise, 69% for foot orthoses and 54% for footwear. Few strong predictors of adherence were identified, although we found some evidence that people with better physical abilities, a lower fear of falling and participants with a younger age were more likely to adhere to the recommended interventions.

There are no previous studies that have reported adherence to the use of foot orthoses in older people, although high adherence has been reported in younger, sporting and symptomatic people [31]. The level of adherence (69%) in this study suggests that the prefabricated orthoses we used were well tolerated, and are therefore a suitable intervention for future research investigating foot-related problems in older people.

However, footwear suitability needs to be carefully considered, as the most frequently reported reason for non-adherence was difficulty accommodating the orthoses in existing footwear.

In regard to footwear, this study concurs with several previous studies that have reported the reluctance of older people to change their footwear to improve foot health or to reduce the risk of falling [32-34]. Of those who were non-adherent to the footwear intervention, 76% declined to buy new footwear, despite receiving advice as to the potential hazards of their footwear as well as being provided with a voucher to partly cover the costs. This reluctance has previously been attributed to the unique role of footwear as both an item of clothing and a health-related intervention [35]. Given the somewhat conflicting requirements of aesthetics and function, it is likely that full adherence to footwear interventions will continue to be difficult to achieve, particularly in older women.

While direct comparisons are difficult due to variations in the definition of adherence, method of reporting and exclusion of dropouts across trials, the level of adherence to the exercise program reported here is comparable to previous exercise-based interventions in older people [36]. The progressively declining rate of adherence over time observed in this trial, where 83% of the total requested exercise sessions were completed in the first month and 53% in the last month, has also been reported previously [37]. This is despite the participants being contacted by telephone at a number of intervals by the researchers to promote adherence to the program, indicating that further strategies are required to maintain adherence over the longer term.

In previous studies, the strongest motivators of adherence to exercise have been shown to be self-efficacy (the concept that a person is capable of performing a course of action to attain a desired outcome) and outcome expectation (the belief that specific consequences will result from specific personal actions) [38,39]. While these factors were not directly evaluated in this study, it is probable that our sample may have been biased towards volunteers with a heightened interest in and commitment to the intervention, as another 195 people who initially expressed interest in the study declined participation at study entry, primarily due to a reluctance to commit to the extended study period [15] . Furthermore, none of the participants who completed the trial

indicated the reason for failing to complete the exercise sessions was that they did not feel the exercises were beneficial. Nevertheless, irrespective of an individual’s belief in the benefits of regular exercise, several barriers to actually undertaking exercise were identified, such as lack of time and having a pre-existing condition that may make exercising uncomfortable [38,40].

The absence of strong predictors of adherence reported here is consistent with a number of other falls prevention trials [10,12,41]. However, the predictors identified in this study generally indicated that participants with better (i.e. “healthier”) scores were more adherent. This is similar to previous studies that have shown those who have a history of regular exercise and better general health are more likely to adhere to exercise [12,39,42] . This indicates that the participants with the poorest physical function, and thus the ones who may have benefited most from the interventions were the ones most likely to have poor adherence. Many may have benefited if they were identified early as potential nonadherers and encouraged to continue participation. We hope that the findings of this study will assist in the development and implementation of pre-intervention screening that could be used in public health programs.

The translation of falls prevention interventions into clinical practice is difficult and requires further investigation. Previous studies indicate that many older people attribute falls to environmental factors [43] and even though they may recognise the relevance of falls prevention recommendations addressing physiological factors, they believe such recommendations to be useful for people other than themselves [43,44].

Furthermore, it has also been reported that some older people consider falls to be inevitable [44], which suggests that messages to promote health and independence may be more effective than advice on strategies to specifically prevent falls [44,45].

Consequently, to improve adherence to falls prevention strategies, future research should consider the psychosocial aspects of self-efficacy and outcome expectation in more detail. Furthermore, it would be important to establish whether providing participants with the poorest physical function (i.e. those most likely to be non-adherers) increased attention and reinforcement would result in higher levels of adherence.

There are some limitations associated with this study. Firstly, as previously mentioned, the sample may have been biased towards volunteers with a heightened interest and commitment in the intervention. Secondly, adherence to the interventions was reliant on self-report by participants and the accuracy of this information could not be verified. Thirdly, adherence to the footwear intervention may have been impaired by not providing appropriate footwear at no cost to the participants. The approximate cost of appropriate footwear was AUD$150 to $250, requiring a significant contribution in addition to the AUD$100 voucher given to those participants who were recommended to purchase new footwear. Finally, care needs to be taken in generalising these findings, as all participants were living independently in the community, had foot pain and an increased risk of falling, and regularly accessed podiatry services. Whether the same adherence would be achieved in residential care settings or in older people without foot pain requires further investigation.

Conclusions In older people with disabling foot pain and an increased risk of falling, adherence to a multifaceted podiatry intervention was found to be 69% for foot orthoses, 54% for footwear and 72% for exercise. Few strong predictors of adherence were identified, although participants with better physical health, less fear of falling and a younger age exhibited greater adherence. Further research is required to maximise adherence with recommended multifaceted podiatry falls prevention interventions, particularly in frailer older people who are at greater risk of falls.

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27. Garrow AP, Papageorgiou A, Silman AJ, Thomas E, Jayson MIV, Macfarlane GJ: The grading of hallux valgus: the Manchester scale. J Am Podiatr Med Assoc 2001, 91(2):74-78.

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3. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM: Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999, 47(7):850-853. PubMed Abstract

28. Portney LG, Watkins MP: Foundations of clinical research: applications to practice. 3rd edition. Upper Saddle River, N.J.: Pearson/Prentice Hall; 2009.

29. Tabachnick BG, Fidell LS: Using multivariate statistics. 5th edition. Boston: Pearson/Allyn & Bacon; 2007.

4. Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA: Randomised controlled trial of prevention of falls in people aged > = 75 with severe visual impairment: the VIP trial. BMJ 2005, 331(7520):817. PubMed Abstract | Publisher Full Text | PubMed Central Full Text

30. Sims J, Hill K, Hunt S, Haralambous B: Physical activity recommendations for older Australians. Australas J Ageing 2010, 29(2):81-87. PubMed Abstract | Publisher Full Text 31. Landorf KB, Keenan AM: Efficacy of foot orthoses. What does the literature tell us? J Am Podiatr Med Assoc 2000, 90(3):149-158. PubMed Abstract

5. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH: Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009, (2):CD007146.

32. Fortinsky R, Iannuzzi-Sucich M, Baker D, Gottschalk M, King M, Brown C, M T: Fall-risk assessment and management in clinical practice: Views from healthcare providers. J Am Geriatr Soc 2004, 52:1522-1526. PubMed Abstract | Publisher Full Text

6. Harwood RH, Foss AJE, Osborn F, Gregson RM, Zaman A, Masud T: Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol 2005, 89(1):53-59. PubMed Abstract | Publisher Full Text | PubMed Central Full Text

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7. Nikolaus T, Bach M: Preventing Falls in Community-Dwelling Frail Older People Using a Home Intervention Team (HIT): Results From the Randomized Falls-HIT Trial. J Am Geriatr Soc 2003, 51(3):300-305. PubMed Abstract | Publisher Full Text

34. Williams AE, Nester CE, Ravey MJ: Rheumatoid arthritis patients’ experiences of wearing therapeutic footwear - A qualitative investigation. BMC Musculoskelet Disord 2007, 8(1):104. PubMed Abstract | BioMed Central Full Text PubMed Central Full Text

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35. Williams AE, Nester CE, Ravey MJ, Kottink A, Morey-Klapsing G: Women’s experiences of wearing therapeutic footwear in three European countries. J Foot Ankle Res 2010, 3(1):23.

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9. Liu-Ambrose T, Khan KM, Eng JJ, Janssen PA, Lord SR, McKay HA: Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized controlled trial. J Am Geriatr Soc 2004, 52(5):657-665. PubMed Abstract | Publisher Full Text

37. King MB, Whipple RH, Gruman CA, Judge JO, Schmidt JA, Wolfson LI: The performance enhancement project: Improving physical performance in older persons. Arch Phys Med Rehabil 2002, 83(8):1060-1069. PubMed Abstract | Publisher Full Text

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Am J Occup Ther 2001, 55(6):641-648. PubMed Abstract | Publisher Full Text

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11. Hill KD, Moore KJ, Dorevitch MI, Day LM: Effectiveness of falls clinics: An evaluation of outcomes and client adherence to recommended interventions. J Am Geriatr Soc 2008, 56(4):600-608. PubMed Abstract | Publisher Full Text

39. Resnick B: Testing a model of exercise behavior in older adults. Res Nurs Health 2001, 24(2):83-92. PubMed Abstract | Publisher Full Text 40. Schutzer KA, Graves BS: Barriers and motivations to exercise in older adults. Prev Med 2004, 39(5):1056-1061. PubMed Abstract | Publisher Full Text

12. Sjösten NM, Salonoja M, Piirtola M, Vahlberg TJ, Isoaho R, Hyttinen HK, Aarnio PT, Kivelä S-L: A multifactorial fall prevention programme in the community-dwelling aged: predictors of adherence. Eur J Public Health 2007, 17(5):464-470. PubMed Abstract | Publisher Full Text

41. Martin KA, Bowen DJ, Dunbar-Jacob J, Perri MG: Who will adhere? Key issues in the study and prediction of adherence in randomized controlled trials. Control Clin Trials 2000, 21(5):S195-S199. Publisher Full Text

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15. Spink MJ, Menz HB, Fotoohabadi MR, Wee E, Landorf KB, Hill KD, Lord SR: Effectiveness of a multifaceted podiatry intervention to prevent falls in community-dwelling older people with disabling foot pain: a randomised controlled trial. BMJ 2011, 342:d3411.

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• * Corresponding author: Hylton B Menz h.menz@latrobe.edu.au Author Affiliations

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1

Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora Victoria, Australia

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2

Department of Podiatry, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria, Australia

3

Division of Allied Health, Northern Health, Epping, Victoria, Australia

21. Menz HB, Sherrington C: The Footwear Assessment Form: a reliable clinical tool to assess footwear characteristics of relevance to postural stability in older adults. Clin Rehabil 2000, 14(6):657-664. PubMed Abstract | Publisher Full Text

4

Preventive and Public Health Division, National Ageing Research Institute, Parkville, Victoria, Australia

5

Neuroscience Research Australia, Randwick, Sydney, NSW, Australia

6

School of Public Health and Community Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia

22. Commonwealth of Australia: Don’t fall for it. Falls can be prevented! - A guide to preventing falls for older people. Canberra, ACT: Commonwealth of Australia; 2007.

23. Menz HB: Foot problems in older people: assessment and management. Edinburgh; New York: Churchill Livingstone; 2008.

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Email: Martin J Spink m.spink@latrobe.edu.au - Mohammad R Fotoohabadi m.fotoohabadi@latrobe.edu.au - Elin Wee e.wee@latrobe.edu.au - Karl B Landorf k.landorf@latrobe.edu.au - Keith D Hill keith.hill@latrobe.edu.au - Stephen R Lord s.lord@neura.edu.au - Hylton B Menz h.menz@latrobe.edu.au The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2318/11/51

PROFILE

Sarah Bowen London Branch After about 5 years of procrastination and reading a lot of articles in Podiatry Review by former students of the BSc in Durham, I finally bit the bullet and enrolled for the degree year. Like most other people, my main fear was the statistics module. As a self-diagnosed dyscalculic, with a lifelong distaste of all things mathematical, I decided to embrace the challenge. If I could just say ‘Yes I can’, instead of ‘No, I can’t’, I might succeed. My first step was to download onto my Kindle ‘Excel for Dummies’, and was mystified when it referred me to the workbook on the CD. That was a good lesson. I made a note to myself, do not download a book that comes with a CD onto your Kindle. I spent a month before the course began teaching myself Excel. This helped a lot. Then came Induction week. It was great to meet the rest of the masochists who had enrolled on the course, and to realize we were all fairly horrified at what we had let ourselves in for. I left the Stats course at the end of the week, in tears and just as confused as when I’d started it. Yet, somehow, despite my fears, things did begin to come together if I just took it step by step. Once I got the stats out of the way, I ploughed on to the next least favourite module and worked my way through that. I became quite ruthless in my approach, as time was of the essence.

I loved the Pharmacology, Podogerentology module and the Psychology module. The research modules were challenging but satisfying when completed.

I am delighted that I passed, and feel a sense of accomplishment. It was a lot of hard work, every weekend spent studying as due to my working day study wasn’t a

possibility in the evening. It was great to meet other people like myself on the course, and though we live all over the place, our group emails and odd phone calls gave us a sense of camaraderie and encouragement. It just shows what you can do when you say ‘Yes, I can’.

Dear Editor Re: Roger Henry On behalf of myself and Mike Potter, at the University of Southampton, we were disappointed to learn that Roger Henry would be stepping down as editor of Podiatry Review after many years at the helm of the Institute’s journal. Undertaking such a task often is difficult, onerous and goes without recognition or reward. As regular readers of the journal we would like to thank Roger for a great job of editing the journal over the years and say that we recognise his hard work and wish him well in his future endeavours.

Yours sincerely

Dr. Ivan Bristow Lecturer Direct tel: +44 (0)23 80595262 Email: ib@soton.ac.uk page | 09

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HPC Professionalism in Healthcare Professionals Research Report Beverley Wright, MInstChP, BSc (Hons) PGCE, PGDip On 7th November, 2011 I attended an event at the London headquarters of the HPC to view the findings of the fourth study in a series of commissioned research that is exploring professionalism in healthcare professionals.

contribute to a better understanding of what professionalism means and how it may promote and enhance the future of the health care sector and the professionals who are engaged in each of their practices.

With a gathering that included representatives of many of the 13 HPC regulated bodies and many other regulators and organisations that had been invited to observe and gather their views on the monograph of the fourth in a series of research relating to the HPC registered professions such as: the General Medical Council (GMC), Department of Health (DH), National Health Service (NHS), Nursing and Midwifery Council (NMC), Chartered Institute of Chiropractors and General Social Care Council (GSSC), which subject to parliamentary approval of the Health and Social Care Bill, are expected to transfer to the HPC in August 2012.

The introduction to the afternoon proceedings began with a presentation given by the HPC Chair followed by a presentation of the research findings given by Gill Morrow, Senior Research Associate of the Medical Education Research Group at Durham University, who provided an insight into the many methods and qualitative information provided by their research and data.

Anna van der Gaag, President of the HPC and Chairperson for this event welcomed and introduced the latest stage of research currently being investigated to contribute to the HPC’s understanding of regulation in the Health and Social Care sector, and to the wider and various audiences who are also interested in this area.

The Chair referred to George Bernard Shaw’s observations made in the last century, where he stated that all professions “were a conspiracy against the laity”. But since Mr Shaw’s time much has become apparent and written in regard to professional practice and the contributions made by professionals to society. It is clear that professionals should apart from practicing their specialist skills interact and respect the members of the public, families, patients and service users with clear communication, and to behave in such a manner that reflects the highest standards of probity. This is the aim of the HPC within the standards they set and require all their registrants to meet, by upholding the standards of conduct, behaviour, and just as importantly meet competence levels required by each profession’s practice areas.

The Chair also referred to the relatively small amount of literature published in the area of ‘Professionalism’ more specifically in the professions that the HPC regulate and the exploration of student and educators perceptions. The concept of professionalism is not well defined conceptually or methodology and much of the literature involving professionalism focuses on competency, or the way in which something is taught, developed, measured and assessed.

Therefore, the undertaking of research in this area commissioned by the HPC, conducted by Durham University and funded by the Department of Health will, it is hoped 10 | page

The aim of the presentation allowed the audience to gain information on this study and what the students and educators were being tasked to do in the quest of seeking their perspectives on professionalism. This would then follow with a discussion from each of the tables of representatives present to reflect and review key questions to obtain further information for the benefit of the HPC. The introductory presentation ‘Perceptions of professionalism: what does it mean for health and social care professionals?’ Outlined the challenges to professionalism, research into professionalism, workshops and the plenary discussion. The changes that will be made in professional practice in the 21st century would encompass the technology, demographics, workforce and culture. Influences on professionalism were described to incorporate individual values; professional bodies, which are all very important to the process of professionalism; clinical governance, system regulators, peer groups,which has a huge impact on professionalism; patient voices (which need to be much louder and more assertive); as well as professional regulators, but each in their own right has an impact. The HPC’s intention for doing this research came about from the government white paper that had different reforms and the Trust Assurance and Safety (2007) challenged all regulators to consider a revalidation process for their registrants.

Enabling Excellence (2011) suggested there was a wide area of risk as ‘one size does not fit all’ and placed an emphasis on developing the evidence base. It identified that regulators were dealing with more concerns of conduct than competence and that there was very little research on professionalism in HPC registered professions. The evidence from the HPC fitness to practice hearings reveals the extent of conduct and other issues (HPC Fitness to Practice Annual Report, 2011). An example of these proceedings were:

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• • • •

Dishonesty Crossing boundaries Lack of respect for patients and service users Lack of accountability – such as record keeping

Some reports on the HPC website such as the Durham University commissioned research have initiated the revalidation to the fitness to practice documents. So the progression to the HPC programme of research on revalidation has engaged the HPC to seek an externally commissioned work on the perceptions and measurement of professionalism; multivaried analysis on fitness to practice and CPD data; and an exploration of patient feedback tools. In addition to looking at complete works of research that will review existing revalidation processes implemented by International regulators, and those implemented, or are being developed by other UK regulators.

Gill Morrow followed with a presentation on ‘Perceptions of professionalism in three healthcare professions’, which she described the study’s background information and the issues that surrounded professionalism, such as: fitness to practice concerns, the problems during training that can have an impact later during an individuals career, which in all cases can be rather complex and hard to define.

The aim of the study was to explore student and educator perspectives regarding professionalism and to find what constitutes professional and unprofessional behaviour. The methods engaged to obtain data was gained from 20 focus groups of 112 educators and students, from 3 professions podiatry, occupational therapy and paramedics. The private sector was not included in this study.

The key findings revealed that professionalism is complex, which includes attitudes, behaviours and appearance. In addition to situational judgements made by a professional in the course of a profession’s actions, which could be an underlying skill. It was also apparent that employers need to provide active and positive support to their employees in regards to professionalism.

The study has found that it was necessary to understand the many ways of professionalism, which for the purposes of this report I will include only quotes made by podiatry students that took part in this study. Although, this as with other quotes not made apparent here, may also reflect the behaviours of other professions too.

Professionalism is complex, with no single definition These were defined as: • Holistic, all-encompassing • Expression of self – individual values, core beliefs

What is professional behaviour?

• Good clinical care • Unprofessional behaviour “... I followed (a podiatrist) on visits... it was get in, get out, finish early as I can, not checking if the patient’s medication had changed or anything like that down to really poor infection control with instruments.” (FG15, podiatry student from Morrow et al 2011).

• Attitudes towards the job; colleagues; patients; service users • Communication – verbal, non-verbal, written “The way that you speak to people and the gestures that we use, we’re not kind of rushing people in and rushing people out again.” (FG15, podiatry student from Morrow et al 2011).

• Treating people equally • Appearance and presentation ο Important to all 3 professions ο Link to public health messages – educating and modelling “If you’re going to go into somebody’s house and say those shoes aren’t any good, with 15 inch heels on...” (FG16, podiatry student from Morrow et al 2011).

Situational awareness and judgement The ability to read a situation and judge the appropriateness of behaviour in a specific context and within the realms of each professions and HPC code of conduct. This we know and understand does come from experience: • • • • •

Communication – forms of address Use of humour – with patients/service users; colleagues Conveying information – appropriate level and amount Potential physical danger – personal safety Negotiating boundaries while building relationships

Influences on professionalism, which focus on the influences of understanding and behaviours: • Upbringing, early experiences • Education, experience and role modelling ο Teaching and guidance ο Drawing from good and bad examples – risks of inappropriate modelling ο Educators’ responsibility as role models ο Peer learning • Patient and public expectations All the above may be influenced by cultural and religious factors page | 11

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Role of regulators: • • • •

Guide for minimum standards of practice Provision of sanctions Baseline level of professionalism Contextualised in practice

Organisational context: • Organisational support for professionalism ο Support of management

To obtain the necessary findings for this study, four training organisations (3 education universities and 4 NHS Trusts) were recruited where training programmes take place for the identified three professions. Two of the four organisations were related to paramedic training to reflect on the different training routes available to that profession.

Twenty focus groups, with a total of 112 participants, were conducted and addressed: • Interpretation of the term ‘professionalism’;

ο Management example

• Sources of understanding of professionalism;

ο Working environment

• Indicators of being professional or unprofessional;

Conclusions Gill Morrow stated that professionalism teaching could focus more explicitly on ‘how to know what is appropriate’ as well as on ‘what is appropriate’. In addition to employers and regulators considering how professionalism is fostered and developed positively and proactively.

Video Presentation A short 3 minute video clip followed the research presentation. Don Berwick speaking on what ‘Patient Centredness’ really means. The following themes were identified: • Lack of reliability from core indignity • Loss of influence • Abuse • Lack of communication involving the service user • Contextual aspects • Confidentiality • Loss of our sense of identity • Choice – because they have no choice • No holistic care framework • Right and proper care • Care that is individual and appropriate for each of us.

Questions and answers followed the presentations.

Summary of the research This study of professionalism in healthcare professionals looks to increase the understanding of three HPC regulated professions, these being chiropodists/ podiatrists, occupational therapists and paramedics with the aim to explore what is perceived as professionalism from both students and educators. The study looks at why and how professionalism or lack of it may also be identified.

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• The point at which people are perceived to become ‘a professional’.

Participants’ interpretation of ‘professionalism’ encompassed many varied aspects of behaviour, communication and appearance that was not restricted to just uniforms. In addition it also included the holistic concept that encompassed all aspects of practice.

The data revealed that individual characteristics and values, which are learned early in life and through education and the work place; in addition to role playing, play a large part in the development of awareness and appropriate actions in the different context of professionalism. However, it also indicates towards a number of other factors, which include organisation support, workplace, expectations of others, service users and their specific needs, as well as the patient encounter. It was also discovered that regulations do provide basic guidance and signposting of what is appropriate and unacceptable, and what also became apparent was that regulations only acts as a baseline for behaviour.

The overall view encountered of professionalism regardless of training, profession, or status as student or educator, regarded the key to professional behaviour being due to personal interaction and context; and in particular the importance of judging a situation.

To conclude it was found that professionalism was not just a set of descrete skills, but a meta-skill of situation awareness and contextual judgements, which can allow individuals from any profession and professional scenario, to learn and develop from their communication, technical and practical skills. It has been suggested that the true skill of professionalism is not so much in knowing what to do, but knowing when to do it, and from an educators perspective making students aware of this.

Discussion groups All professionals, educators, advocacy groups and regulators present having been left to reflect on the final slide of the afternoon, regarding professional practice in the 20th Century, which showed Muir Gray’s (Director of the Rightcare programme) statement:“The 20th century was the century of

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the professions. The 21st Century is the century of the patient”. Where we were then asked to participate in discussion groups on each of our respective tables to focus on the following key questions: • How is my practice evidence based?

• How is my practice values based?

• How do we as regulators, educators, advocacy groups promote greater awareness and action on professionalism?

My table was made up of representatives from the NMC, GSSC, HPC and another podiatry organisation. Gill Morrow came to sit on our table to observe the discussion, reprofessionalism, before we disseminated our findings to the Chair, researcher and rest of the representative audience. The summary of the points reflected on were as follows: We agreed that while important, professionalism is a nebulous concept and so difficult to pin down. What is appropriate professional behaviour will depend on a number of variables including: context and the individual you are dealing with (i.e. age, gender and cultural differences will be relevant).

Clearly it is partly about values and characteristics, some of which an individual brings with them and some of which are developed We were very taken with the idea of dynamic

decision making i.e. the ability to judge the right thing to do and the right way of doing it depending on the context and the people you are interacting in. HPC guidance/regulations about conduct and performance set a useful baseline Eps need to develop relevant values/characteristics and the ability to make dynamic decisions. The importance of role play, practice placements and reflecting on experience, performance and behaviour during education is therefore vital.

If individuals are trained to reflect on practice and to evaluate behaviour and conduct, then this has to be supported and facilitated by employers. The involvement of employers/ service users in the design and implementation of educational programmes is therefore vital to: • ensure that they influence what is taught and how to • ensure that they are aware of what is taught and how this can be taken on board as part of employment practice.

References Berwick, D. (2009) the epitaph of profession British Journal of General Practice 59:128.

Don Berwick ‘what patient centredness really means’ www.You Tube HPC (2011) Fitness to practice annual report www.hpc-uk.org Morrow, G; Burford, B; Rothwell, C; Carter, M; McLachlan, J; Illing, J (2011) Professionalism in healthcare professionals www.hpc-uk.org Van der Gaag, A, (2011) President of the HPC, and Chairperson of the HPC research event. www.hpc-uk.org

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Podiatry as a Profession: My path to becoming a Podiatrist and my experience as a newly qualified practitioner: Part 4 Deirdre O’Flynn, BSc Podiatry, M.Inst.Ch.P This month I am going to discuss a very interesting case of Onychocryptosis that was presented to me in the Clinic in Midleton at the beginning of February. Since qualifying in May last year I have learnt an abundant amount of knowledge and developed my clinical skills greatly. The topic I am about to discuss I found challenging and thought provoking and I hope that my readers will feel the same.

Mr P is a 20 year old male smoker who is a student attending a University in Cork. He presented to the clinic with a throbbing painful toe with tenderness upon pressure. A detailed medical history was taken. The patient was also asked questions about sporting activities, family and social history.

Mr P disclosed to me that he had a phobia about cutting his nails. He had no history of any illnesses or diseases. He had said his diet was poor and snacked regularly on noodles and processed food from the supermarkets. He had been to see the doctor a few weeks previously with his sore toe, and he had been prescribed a course of antibiotics.

Mr P is very active and plays a lot of sports, mainly Gaelic football. On further discussion I discovered his toe had been sore for a number of weeks. Mr P had been playing a lot more football because his team had been winning all their matches.

They eventually won the final match of the championship. Mr P did not want to let his team down with complaints of his sore toe so kept it quiet for a few weeks.

Figure 2

present. Localised Hyperhidrosis can additionally be observed.

There was also a pungent odour (Lorimer et al.2002).

I asked Mr P to remove his socks and shoes. The extent of neglect was very apparent. I performed a vascular assessment by checking pulses, capillary refill and temperature. I also checked the colour and skin texture.

My short term treatment plan involved pre plus post operative antiseptic. I reduced all nails. The right 1st toe was bathed with a saline solution. I then applied a dressing with Inadine and Amergel and the toe was covered with a sterile dressing of Melolin and Tubular gauze. I explained to Mr P that he would require surgery to have the nail removed. Failure to look after his foot could develop into gangrene and the consequence could be amputation. I advised the patient to rest over the weekend and to wear an open toe shoe.

Mr P also showed me his right leg. He had received a graze from Astroturf. It was about 15cm on the lateral aspect of his quadriceps. This appeared to be infected. It was red, hot and Mr P mentioned he was feeling tired. There were also signs of slight swelling (Lorimer et al.2002).

The following week Mr P came in for Surgery in the clinic at Midleton, my colleague Mr Sullivan performed the surgery. He executed a total nail avulsion under local anaesthetic. He didn’t use any phenol but packed the open wound with Kaltostat and Amergel and dressed it with a sterile dressing.

Upon further examination of his 1st toe on the right foot I could see it was very badly infected. Figure 1 and Figure 2 shown below are the initial pictures I took. As can be observed the toe was red, shiny, swollen and oozing of pus.

The prolonged penetration of the nail into the medial and lateral sulcus prevented normal healing and hyper granulation was

Mr P was advised to keep his feet elevated and not to drive for 24 hours. He had been instructed to take painkillers if he required them. Advice was also given to take vitamin C, as this may help to speed up the wound healing. The following day he came into the clinic for a dressing change. He had rested the night and was not complaining of too much discomfort. I very carefully removed the dressing and as instructed from Mr Sullivan I removed the packing. Mr P looked down at his toe and suddenly felt very faint. I immediately opened the window and lay him back on the couch. His face had lost its entire colour. The initial shock of seeing his toe, post surgery, had caused him to feel faint. After a few minutes the colour slowly came back to his face and he was feeling better. I redressed his

Figure 1

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toe and advised him to rest over the weekend. I made a follow up appointment for the following week and advised Mr P that if he had any problems over the weekend, to telephone immediately.

He was given our mobile numbers.

from under the bed clothes because he didn’t want the pressure on his toe.

This rationalized the extreme coldness. I gave him advice on how keeping his foot warm would aid and quicken the healing process of the wound.

Figure 3 shows the toe one day post surgery.

Figure 4 shows the toe 9 days post surgery. There is granulation tissue Figure 3 present, the swelling and redness has reduced. The wound appears to be healing well.

He had been conscience and complying with all the advice that was given to him.

This was an unusual case because Mr P had a phobia about cutting his nails and his dedication to sport made him ignore his infected toe Figure 4 for a number of weeks.

His poor diet and his smoking impaired the healing. After approximately four weeks he was discharged from the clinic.

Mr P returned the following week and his toe was healing slowly. I performed a vascular assessment on the patient again. On examination his foot was ice cold. I was slightly concerned that his circulation may be diminished. After further discussion Mr P explained that he had kept his foot out

Next month I’m going to talk about Podofix nail brace which is used to treat involuted nails.

References: Lorimer, D. French, G. O’Donnell, M. Burrow, G, J. 2002. Neale’s Disorders of the Foot: Diagnosis and Management. 6th Ed. Edinburgh. Churchill Livingstone.

Fig 1. Fig.2. Fig.3. Fig.4. March 2012 from file held at Midleton Foot Clinic

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INFORMATION

The Personal Development Portfolio Iain B. McIntosh, BA (Hons) MBChB, FFTMRCPS(Glas) Former chiropody schools inspector The personal development portfolio (PDP) is a wordy label for a career‐long record of achievement, significant events and learning. As health professionals we live in a litigious age when people are well aware of their rights and less cognisant about their responsibilities.

Patients are encouraged by Government to complain about treatment and report malpractice. Designed to identify dangerous practitioners and incompetence, this can also encourage patients to complain about the trivial and bring criticism to those who are operating diligently and competently. There has been a doubling of the rate of litigation in the NHS in England within a decade.

Most practitioners try to provide a service dictated by professional guidelines and recognised good practice, but being human, sometimes fail and systems can break down. Communications are disrupted; computers default and sterile and surgical procedures may go awry. Risk of harm to patients is an unavoidable feature of clinical practice and reduction of risk should be a proactive, integral part of professional work. All involved in health care are vulnerable to error and have a duty to continually seek improvement in individual personal practice, which should encompass critical event analysis, audit and continuing professional development. Over every practitioner’s working lifetime, adverse events with patients will inevitably arise. How they are dealt with, will determine whether they proceed to formal complaint or litigation. Shortcomings can bring verbal and formal patient complaint and the unwanted intrusion of regulatory authorities.

The Health Professions Council will investigate formal complaints of professional malpractice, misconduct and incompetence. It demands competence and the demonstration of skills and knowledge, as evidence that a practitioner can practise effectively and safely. With measures in place to prevent errors and reduce potential patient damage. A registered health professional must protect the health and well-being of people who use or need services, in every circumstance.

Standards of conduct, performance and ethics are laid down by the Health Professions Council. The Health Professions Order of 2002 states that these standards have to be kept under review.

Questions can suddenly arise about professional expertise, competence and capability of work. The right to practice can be threatened and disbarment from the professional body rears its head.

Habits of a lifetime, practical procedures, post graduate education, continued professional learning, manual, mental and professional skills and organizational ability can suddenly be the focus of external attention. Every scrap of evidence of good practice, continuing professional education and patient appreciation suddenly becomes invaluable to oppose any suggestion that practice has not been up to the norm expected of a professional. How can one prepare for such an unwelcome intrusion? What is needed to confirm good professional behaviour and that systems and skills meet external demands?

Ownership of an up to date PDP will prove a valuable tool to confirm status and ongoing commitment to remain up to date in knowledge and skills. Its creation is not an onerous task and if diligently maintained, the data can provide conclusive evidence that will sway any examining body to accept a decision in favour of professional competence and capability to practice within professional guidelines. Practically it consists of a docketed document file into which certificates of attendance, conference attendance records and attainment and skills’ awards can be filed for posterity. These can be easily lost and mislaid with the passage of years.

There needs to be a compartment for notes of significant event analyses and one for commendations from patients and feedback surveys. An accompanying loose leaf file with dated entries of inclusions and a section to record professional objectives, their acquisition and reflection on events and the learning from them and post graduate education. A comprehensive portfolio is always at hand to confirm continued competence to practice. The PDP is now as necessary to practice as the scalpel and the drill.

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Appraisal and realization have been instituted by some governing bodies to ensure compliance with regulations. This means emphasis on self-assessment of educational needs, the setting out of educational objectives and year–on evidence that these have been met.

Competence, expertise and skills have to be advanced or at least maintained. The professional has to have insight and awareness to identify and recognise areas of organisational and clinical need, to determine where educational endeavour should be targeted. In a busy practice, particularly a single-handed one, there may be scant time to consider weaknesses and strengths, time has to be prioritised and further education may be neglected and forgotten, if there is not a written record in place. Dates of courses, significant and critical events, although prominent at time of occurrence, may blur in memory with passage of months and years and supportive evidence may be wanting when the focus of regulatory attention. The PDP must be created and maintained in readiness for any untimely appraisal. This process needs to be habitual and if considered regularly and documentation updated weekly need not be too onerous.

The PDP. Doctors, nurses and practitioners in professions allied to medicine now diligently builds up PDP and record attendance at courses and lectures. They add to the weight of evidence within the portfolio by undertaking audit and critical or significant event analysis. The latter can be done quickly and effectively. It assists self‐appraisal, enhances record keeping, promotes change of routine, habit and practice and provides solid evidence in the PDP that the individual is analysing and reviewing work for good and bad practices.

A significant event in working practice is any occurrence thought by someone in the practice to be significant in the care of patients or the conduct of the practice (Pringle 1995). A significant event may be critical in nature having posed a serious threat to the patient or, the outcome may have potentially serious consequences for the practitioner. It may have been a close escape from serious mishap or, be a personal or systems failure affecting practitioner and/or the practice. Many significant events are however breakdowns in communication, arrangements, routines and a slip of professional standards. The incident has to be of sufficient consequence to merit retrospective consideration and analysis, with a view to changing routines, practices and systems.

The analysis should promote change as a response, to ensure the situation will not arise again and illustrate there has been learning from the event. Key questions in the analysis are:-

• • • •

What happened?

How did it happen.

Why did it happen?

What has to be done to ensure it does not happen again?

Investigating the ‘Why and How’, may reveal discrepancies in procedure, behaviour, record system or notes. With insight these can be identified and addressed. Changes in the system and in personal behaviour may be instituted to ensure that a recurrence of the event is unlikely. If event and analysis are recorded, it can be included in the PDP to reassure an external appraiser that quality of practice is being monitored and endeavour made to improve practice. For instance, there is potential for infection and litigation if a patient is pricked by a discarded needle or scalpel blade, or the sudden collapse of a patient during treatment may point up the weakness in cardiopulmonary respiration CPR response. Analysis may reveal the absence of a sharps’ box and the need for better sharp disposal and CPR training. Significant event analysis may point up shortfalls, but may also show that the system and the professional response has been exemplary and a formal record of the event demonstrates to peers and invigilators that professional standards are being met and practice is being monitored.

INFORMATION

Significant events need a standardised analytic approach. Key considerations in the analysis:• The description of what happened should be detailed, with setting and role of involved people.

• The impact of the event on patient, professional and practice needs to be considered.

• What were the underlying reasons for the occurrence?

• Were there failings in competence, skill and conduct?

• Were actions in the best interest of the patient and if not where was the inadequacy?

• Were guidelines followed and duties carried out in a professional ethical way?

• Was personal conduct beyond reproach?

• Were communications with the patient effective?

• Were the records accurate and in sufficient detail?

Reflection on the conclusions provides opportunity to learn from the experience and institute changes to ensure the situation does not arise again. The individual professional must show insight into the occurrence, an understanding of its causation, the implementation of beneficial change and reflection on its consequences. The process can become a routine part of practice with critical event analysis a mandatory response to a seriously adverse event to provide a defence against litigation.

Two techniques are used in management of error, the “Person “and the “Systems” approaches. The “Person” approach concentrates on unsafe acts by the provider such as an event due to carelessness, inattention, or skill failure in a procedure. The “system” approach focuses on set systems of working and how failure in the system leads to downstream adverse event. This may result from poor training, or

inadequacy or misuse of equipment. Failure to recognize the need for scrupulous sterility procedures when dealing with the skin of a diabetic patient may result from poor training and lack of expertise and knowledge – human failing, whereas the inadequacy of the sterilising equipment to function effectively may be a systems failure.

The PDP files should hold a note of courses attended with certificates of attendance with a note of educational objectives, their attainment and any change in practice which results and any commendations from grateful patients. Brickbats tend to be remembered for the grief they bring, but patient appreciation may not be registered, or be long delayed. A grateful patient finally contacted me to thank me for her treatment 30 years after the event! These letters provide feedback evidence confirming good practice and should be retained.

Professional perils will threaten if complaints or adverse events are ignored. They should serve as a warning of the need to monitor professional behaviour and be seen as a learning exercise to promote change in behaviour, routine and habit, to ensure similar circumstances do not recur. Mistakes and near misses, even of a predominantly personal nature, should be considered an opportunity to learn and adapt and a time for reflection. They should always be considered for significant event analysis looking at human error, system failure and latent conditions, or be the trigger for an audit of practice procedures. The PDP is a useful repository for significant analysis results, change instituted to safeguard and improve practice and a file resource for patient commendations, educational courses attended and training objectives. Its creation and maintenance may prove vital in regulatory appraisal and a crucial defence in establishing probity, competent educational endeavour.

References Pringle E M, Bradley C et al 1995 Significant event auditing. Occasional paper 70 Royal Coll.Gps. Pub.RCGP London

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DIABETES NEWS

Sheila Thorn Dies aged 81

continued to use these same old-fashioned syringes up until about five years ago – I suppose it was just what I was used to!

Diabetes UK were very sad to announce that Sheila Thorn, whose recent media work has helped raise awareness of diabetes, passed away at the age of 81.

Through my connections at King’s, I went on to become a senior cardiac technician, working until only a few years ago. As well as seeing changes in the treatment of diabetes over the years, I also saw a lot of medical advances through working in hospitals – I saw the introduction of ECGs and open heart surgery right from the front line.

Sheila’s inspirational story touched many people with diabetes, and was very well received on Facebook. Sheila (pictured right) saw developments in insulin through the ages, having originally been treated by Dr Frederick Banting, one of the discoverers of insulin.

She was also the first child to be treated by RD Lawrence, who co-founded Diabetes UK along with the novelist HG Wells.

As well as seeing changes in the treatment of diabetes over the years, Sheila also saw many medical advances through her work as a senior cardiac technician in hospitals – which included witnessing the introduction of ECGs and open heart surgery from the front line.

Richard Lane, President of Diabetes UK knew Sheila well. He said, “Sheila was a good friend of Diabetes UK and we are very sorry to hear of her death.

“Only a few weeks ago, she did media interviews on our behalf to help raise awareness of diabetes. The response on Facebook to those interviews showed that she was an inspiration to people with the condition and she will be missed by all those who knew her.

This is Shelia’s Story 80 years of insulin: diabetes hasn’t stopped me doing anything I’ve wanted to

“I don’t know life without diabetes: I was diagnosed with the condition as a baby in Canada, about 80 years ago, and was lucky enough to have been put under the care of Dr. Banting, one of the discoverers of insulin, who put me straight onto insulin injections. In those days, not many people knew anything about diabetes so I say I was lucky because I was in the right place at the right time to have been treated by someone at the forefront of diabetes treatments. At that time, we lived on a ranch in rural Canada so we got to the local hospital by kayak and it took us more than a day to get to Toronto hospital by train.

My mother used to give me my injections until I was old enough to do it myself. In 1937, when I was nearly seven, we came to the UK as my parents wanted me to have a British education. I was the first child to be treated by RD Lawrence at King’s College Hospital. Lawrence, who had just a few years earlier founded the Diabetic Association (which later became Diabetes UK), was a real character; he would inject himself in front of me in his office during consultations. He always looked very smart in a morning suit and would have a snack on his desk in case he needed it to give him a boost.

Growing up, I never let diabetes get in the way of anything. My mother was particularly keen for me to be a normal little girl and not be seen as an invalid. I played tennis doubles for my school and my teachers would leave a snack at the net just in case I started to feel woozy! When I think about it now, they were very understanding.

Of course, taking insulin in those days was a very different affair to nowadays. I injected myself with reusable glass and metal syringes and would have to sharpen the needles myself. In fact, I 18 | page

My husband of nearly 50 years, Ray, and I had a healthy son born at King’s. In those days it was normal procedure for pregnant ladies with diabetes to have a Caesarean around six weeks before the natural due date, as there was a worry that the babies would be too big at birth otherwise. Apart from that, I can’t remember any special monitoring or treatment for my diabetes during pregnancy.

And I was back to work just three weeks after the birth!

Healthy eating has always come naturally to me and I’ve never really eaten sweets or chocolate. I do like the treat of a Kit-Kat when I have a hypo though! I’m still surprised at how little people understand diabetes – even people who have it – and how they don’t see how important it is to live a healthy lifestyle.

Up until about three years ago I’d never had any health problems and hadn’t suffered too much with hypos. But then I started to have severe night time hypos – it was a worrying time for me and my husband and a few times we had to have the ambulance come out in the night. When having a hypo one day, I fell and broke my hip and while I was on bed rest I got blood blisters on my heel – I really wasn’t used to sitting still for so long!

Unfortunately, this led to the amputation of my lower leg which means I now have to use a wheelchair and have to pay for extra care at home. I can’t ever remember having foot checks and it may be that had I got all the checks I needed I could have been spared the amputation. This year I’ll be having my second ever retinopathy check in all the 80 years I’ve had diabetes.

I believe I’m the oldest person in England with an insulin pump, which I started using nearly two years ago, and it’s completely changed the way I look after my diabetes. Instead of the extreme swings in my blood glucose levels (I’ve been known to go as low as 1.7 and as high as 30!) and the scary night-time hypos I was having, I now run on an average of 7mmol/l. I’m checking my levels more than I ever have before and it’s obviously paying off – I’ve had almost no hypos since I’ve been on the pump.

I’m convinced that, even though the pump can be expensive for the NHS, it has got to be cheaper than the emergency home visits and hospital appointments I needed for my hypos before. I really believe that anybody who can use a pump should be put on one.

It’s been 90 years since people started using insulin to treat diabetes. It’s certainly kept me alive for over eight of those nine decades and has allowed me to have a family, a career and enjoy life to the full.

On this special anniversary, after living with diabetes for 80 years myself, my message to people with diabetes would be this: do exactly what your diabetes physician tells you to do!”

DIABETES NEWS

Only a fifth of young adults with diabetes get all the health checks they need people, with only half of those with Type 2 diabetes achieving the average measurement of blood glucose (HbA1c) treatment target.

Only a fifth of young adults aged 16 to 24 with diabetes receive the recommended care checks for their condition, according to research presented at the Diabetes UK Professional Conference 2012.

"Gap in care for young people"

The study analysed data from the 2009–10 National Diabetes Audit (NDA) to identify that those aged 16 to 24 are the least likely of all age groups in England to receive the health checks and services they need. Only one in five young adults gets all the health processes recommended by the National Institute for Health and Clinical Excellence (NICE), including eye examinations and foot checks.

Lead researcher Dr. Bob Young, from Salford Royal Hospital, said, "This study not only shows a gap in care for young people, but also highlights the negative outcomes this can have in the way of serious health problems. Care quality for younger people with Type 1 and Type 2 diabetes is poor. Systems of care for young and working age people with diabetes should be specifically targeted for improvement."

This poor management of diabetes in young adults increases the chance of life-threatening complications later in life: we are therefore urging the NHS to do more to stop young adults with diabetes falling through the gap between children’s and adult healthcare services.

Through the 15 healthcare essentials campaign, Diabetes UK aims to empower people with diabetes to influence their own care and to influence the NHS to improve. We want people to use the checklist and, if there are any gaps in care, raise the issue with their healthcare team.

"Huge emotional and financial cost"

Diabetes are currently undertaking work to improve service provision of foot care for people with diabetes in England, and to pilot the auditing of this provision. There are three aspects to this work: Looking at the structure of services. This has already resulted in foot care being included in DiabetesE (a web-based service improvement tool that supports implementation of the NICE Quality Standard for Diabetes); Piloting the auditing of foot ulcer management; Diabetes foot care activity profiles.

Simon O’Neill, Director of Care, Policy and Intelligence at Diabetes UK, said, "It is crucial that young people with diabetes have access to all of the care checks they need to manage their condition properly, as this can help keep their diabetes under control and enable them to live long and healthy lives. But this study shows the quality of care for young adults is not good enough.

"There are likely to be a number of reasons for this, but one of them is that the change from children’s to adult services is currently not smooth enough. When the time comes to leave paediatric care, young people with diabetes should know exactly what to expect as they make that step. They need easy and convenient access to these services. Our 15 healthcare essentials, which outline the minimum healthcare services for people with diabetes, highlight the importance of this smooth transition. At the moment, we recognize that too many young people are falling off the radar in terms of diabetes care.

"By improving healthcare at this stage of life, the NHS can help prevent the huge emotional and financial cost of young people developing complications such as heart disease, stroke, kidney disease, blindness and amputation."

“Poor control – and complications – common” Despite the widely held view that life-threatening complications only affect older people, these problems, often associated with poor diabetes control, are extremely common in a younger age group. Although under-55s make up around a quarter (24 per cent) of people with diabetes, the same demographic accounts for more than 60 per cent of End Stage Kidney Disease (ESKD) in those with Type 1 and 15 per cent of those with Type 2 diabetes. More than one in ten of all heart attacks and 15 per cent of major amputations in people with the condition occur in this same age group.

Poor diabetes control and management, often the cause of complications, was found to be common in this same age group.

Data from the study show that adults under 55 years old are less likely to achieve their target blood glucose levels than older

Audit data on the management of foot ulcers are being tested in 20 pilot sites. Data collection started in September 2011 on all new cases of diabetic foot ulceration for a period of three months.

Information on when the ulcer is healed or the outcome at 12 months (whichever is soonest) will also be collected. An analysis of the baseline characteristics will be presented at the Diabetes UK annual professional conference in March 2012. The National Diabetes Audit 2013 will be expanded to include further measures relating to foot care resulting from the findings of these projects.

The diabetes foot care activity profiles have been developed to provide information on the in-patient care of people with diabetes who are admitted to hospital for a range of foot care conditions. They are designed to allow those involved in the provision of this care to appreciate the scale of activity and relate this to similar trusts across England. The data used are from the Hospital Episode Statistics database and cover all episodes of inpatient care between April 2007 to 31 March 2010 (published August 2011) and April 2008 to March 2011 (published January 2012). A diabetes foot care profile is available for every primary pare trust in England.

NHS Diabetes has also launched national and regional foot care networks to bring together best practice such as integrated foot care services, up-to-date guidance and tools. NHS Diabetes has produced a commissioning guide for foot care that includes an intervention map detailing all of the elements needed for the service and a service specification template. page | 19

DIABETES NEWS

Call for an end to "National Disgrace" of diabetesrelated amputations Diabetes UK has today launched a campaign to bring an end to the "national disgrace" of thousands of preventable amputations in people with diabetes, as new research has once again highlighted the unacceptably poor levels of foot care for people with the condition.

The Putting Feet First campaign, launched at the Diabetes UK Professional Conference 2012 in Glasgow, highlights the fact that people with diabetes are over 20 times more likely to have a lower limb amputation. About 80 per cent of the 6,000 diabetes-related amputations in England every year are preventable.

Reduce amputations by 50 per cent By demanding an end to the postcode lottery of NHS foot care, we aim to reduce diabetes-related amputations by 50 per cent within five years.

A new study presented at today’s conference suggests that an unacceptably high number of hospitals are failing to comply with National Institute for Health and Clinical Excellence guidance on when to refer patients to specialist foot care. Meanwhile, a separate study at University Hospitals Birmingham NHS Foundation Trust has found that fewer than half of patients admitted with emergency diabetes-related foot problems had the blood supply to their feet assessed, whilst little more than a quarter were assessed for nerve damage.

Huge variation A further study, published in the journal Diabetologia, found that people with diabetes are 20 times more likely to undergo an amputation. By comparing figures from Primary Care Trusts across England, the researchers also found a huge variation in the rates of amputation. The figures revealed a tenfold difference in amputation rates, from two amputations in every 10,000 people with diabetes, to 22 in every 10,000.

In light of the findings, William Jeffcoate, one of the chief researchers on the report, called for a more integrated approach to foot care. He said, "Foot disease is very complicated and a single professional hasn't necessarily got the skills to manage every aspect of it.

"And that's why I believe that only if you can gather a multi-disciplinary team and make sure that people have rapid access to assessment by such a team, it's only in that way that we think you can provide the best service."

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Putting Feet First We hope that this new research will highlight the importance of healthcare professionals supporting the Putting Feet First campaign by making sure they understand the foot care people with diabetes should be getting, and the potentially devastating consequences of this not happening. We want everyone with diabetes to get a thorough annual foot check, and foot ulcers in people with the condition to be referred to specialist diabetes foot care teams within 24 hours.

And as well as demanding better NHS foot care, we are trying to raise awareness of the issue so that people with diabetes understand how important it is that they look after their feet, and know that they should be checking them regularly.

"National disgrace" Barbara Young, Chief Executive at Diabetes UK, said, "A single preventable amputation is one too many and so the fact that thousands of people in the UK are enduring unnecessary foot amputations is nothing short of a national disgrace.

"A big part of bringing this to an end is giving people with diabetes information about how to look after their feet, as many of them are not even aware that amputation is a potential complication. But we also need to make sure they understand what healthcare they should be getting.

"The difference between losing a foot and keeping it" "The sad fact is that there are large parts of the country where diabetes foot care is not good enough, and the two studies presented at our conference today highlight yet more examples of people not getting the care they deserve.

Quality of care makes a big difference to amputation rates.

Foot ulcers can deteriorate in a matter of hours, so failing to refer someone quickly enough can literally be the difference between losing a foot and keeping it.

"Amputations have a devastating effect on quality of life and so every amputation that results from poor healthcare is a tragedy. Put together, these add up to a scandal that is one of the reasons that life expectancy for someone with diabetes is significantly shorter than for the general population. It is a scandal that needs to be brought to an end."

For more information contact Diabetes UK www.diabetes.org.uk

PRESS RELEASE

It’s all happening in 2012 at TalarMade ‐ New team recruits and staff promotions Following the recent appointment of TalarMade’s new Managing Director – Ian Leddy - Ian, along with company CEO, Bernie Crewdson, are pleased to announce the following new team recruits and structural changes.

Ian says, ‘The forthcoming period promises to be an exciting time for the company as we seek to realise the growth potential of our significant investment in systems, products and marketing. We have delivered what I (and many in our industry) believe is the best Orthopaedic Product catalogue in existence as well as the largest own branded product range in the UK. We will shortly go live with the new TalarMade website which I know will contribute significantly to our growth plans. All of this is supported by our enviable reputation for customer service and reliability in terms of delivery and quality.

Our new team structure will create a solid foundation which will allow us to move forward at pace and deliver even further growth.

Rob Bradbury becomes Clinical Director. Rob has been with the company just over a year and in that time has helped to grow the business significantly. His role is now to deliver our education programmes and provide professional support to our business development team as well as managing key accounts.

Ian Shaw becomes Financial Director. Ian has worked for TalarMade for just over 3 years successfully managing the company finances and investment program. Ian will also assume overall responsibility for the Customer Service, Purchasing and Logistics functions.

Sarah Woodward becomes Marketing Director. TalarMade has seen double digit growth percentage figures over the past 12 months which has been largely down to the marketing effort led by Sarah in conjunction with her team in the Stockport based office.

Tracey Rhodes and Barry Emms have joined TalarMade as Business Development Managers covering the North and South of the UK respectively. Both Tracey and Barry have established themselves as respected professionals in the orthotics industry and will be highly valued members of the TalarMade team.

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ARTHRITIS NEWS

News fro m Arthrit is Res e arc h U K May is officially recognized as National Arthritis Month The goal during this month is to raise awareness of the disease and get a better understanding to those who suffer from it. Arthritis is a life‐changing disease that currently has no cure, so treating the disease is extremely important.

New potential target for rheumatoid arthritis Newcastle University scientists, in work funded by Arthritis Research UK, have discovered a new way of potentially treating rheumatoid arthritis. This works by preventing damaging white blood cells cells from entering the joints. Using a unique drug, they are able to stop destructive white blood cells migrating from the bloodstream into inflamed tissue and so preventing them causing further injury. In rheumatoid arthritis the body's own immune system attacks the joints. Typical approaches for treatment involve blocking the signals in the body which activate the immune system to attack the joint. In contrast, this new strategy will prevent damaging white blood cells from entering the joints in the first place. Lead author Dr Graeme O'Boyle described the agent's action: "Imagine that the damaged joint is covered in flags which are signalling to the white blood cells. Traditional treatments have involved pulling down the flags one by one but what we have done is use an agent which in effect 'blindfolds' the white blood cells. Therefore, they don't know which way to travel and so won't add to the damage."

Publishing in PNAS the Newcastle University scientists describe how the agent called PS372424 prevents activated T cells, the white blood cells which cause the damage, from migrating towards the site of rheumatoid arthritis. To show the effectiveness of their new treatment, they have developed a new mouse-model of arthritis which has a human immune system. They discovered that PS372424 22 | page

blocked the ability of human T cells to move towards a pouch of synovial fluid from patients with active rheumatoid arthritis. In the work they found that PS372424 binds to a specific receptor CXCR3 which is only found on activated T cells. This targets the 'blindfold' to only these T cells, and leaves other white blood cells unaffected. As Dr O'Boyle explains: "By desensitising damaging white blood cells using CXCR3 they are not directed to migrate towards rheumatoid sites. The advantage of this system is that it is much more specific than current medications and may not compromise the immune system."

Professor Alan Silman, medical director of Arthritis Research UK said: "Although modern treatments have changed the outcome for many patients with rheumatoid arthritis, firstly not all patients respond to them and secondly, even in those patients who do respond in some way, we can't completely get rid of the inflammation that damages their joints. "This research is very exciting, as although it is in its early stages, if it can be transferred to humans it could shut down the inflammation that causes rheumatoid arthritis."

The next stage of the work is to engineer PS372424 to improve its drug-like properties with a view to getting it ready for clinical trial.

Reference: A CXCR3 agonist prevents human T cell migration in a humanized model of arthritic inflammation. Graeme O'Boyle, Christopher Fox, Hannah R Walden, Joseph DP Willet, Emily R Mavin, Dominic W Hine, Jeremy M Palmer, Catriona E Barker, Christopher A Lamb, Simi Ali, John A Kirby. PNAS MS# 2011-18104R

ARTHRITIS NEWS

Tight swaddling linked to rise in baby hip problems The growing practice of wrapping babies tightly in blankets, known as 'swaddling', is causing an increase in the number of infants with hip problems, an expert has claimed.

Professor Nicholas Clarke, a consultant orthopaedic surgeon at Southampton General Hospital has witnessed an increase in cases of hip dysplasia, which he believes is linked to tight swaddling.

Usually, a baby's hips - which are loosened during birth strengthen and recover naturally during the first three to four months of life. But Professor Clarke revealed that by swaddling infants too tightly, some mothers are preventing their babies from flexing and strengthening these joints. He said that swaddling is becoming increasingly common, after the practice fell out of favour in the 1980s.

"Now, I and my colleagues across the UK and in America are witnessing its revival, with swaddlers being advertised on the internet that tightly wrap babies. For the hips, that is exactly what you don't want to happen," he revealed.

"While many cases of hip dysplasia are down to genetics or other conditions, swaddling is becoming an increasingly prevalent cause once again and that is extremely frustrating because it is something parents can control, yet only last week a mother brought her baby to my clinic tightly wrapped."

Professor Clarke revealed that around one in every 20 full-term babies has some degree of instability in their hips and that treatment is only successful in around 85 per cent of cases. He noted that swaddling can be done safely as long as the baby is not rigidly wrapped and has enough room to bend its legs.

Sue Macdonald, education and research manager at the Royal College of Midwives, agreed that the "seemingly innocuous" practice of swaddling can cause "significant" problems for babies.

"Normally a baby will lie with the hips flexed, and swaddling may reduce the degree to which the baby can keep this natural position," she explained.

Dr Andreas Roposch, a consultant orthopaedic surgeon at Great Ormond Street Hospital, who is leading an Arthritis Research UK funded study into the causes of hip dysplasia, said: "Hip dysplasia is the most common musculoskeletal disorder in infancy, and occurs when a baby is born with a shallow or deformed hip socket, enabling the ball of the hip to slip out. We know that there are a number of factors that can make babies more at risk of hip dysplasia including family history, breach delivery and joint instability.

"To stop babies developing severe hip dysplasia, which will require treatment, it is important that a baby's hips are able to move freely and are not tightly bound together or permanently forced in to straight positions, which often occurs with swaddling."

Women with early rheumatoid arthritis 'have worse symptoms than men' Women tend to experience greater levels of disability than men in the early stages of rheumatoid arthritis, a study has found. Scientists at Sweden's Linkoping University analysed long-term data on 149 men and women who enrolled in a study shortly after being diagnosed with rheumatoid arthritis.

Participants were followed for eight years, starting between 1996 and 1998, with researchers recording information on disease activity, pain, grip force, functional impairment, walking speed, activity limitation and medication use. They found that the pattern of disease activity differed little between men and women over time, with patients typically showing improvements during the first year after diagnosis and remaining stable for six years.

However, the researchers observed that at the seven and eight-year follow-up appointments, women typically showed a greater degree of deterioration than men. Women also tended to have more physical limitations than men at all follow-up appointments, as well as lower grip force and slower walking speed. This was despite the fact that men and women showed similar levels of disease-modifying antirheumatic drug (DMARD) use.

Writing in the journal Arthritis Care & Research, the study authors concluded: "Despite similar medication, women had more disability than men.

"The discrepancy between disease activity and disability indicates unmet needs for multi-professional interventions to prevent progressing disability and patients at risk for disability need to be identified early in the process." page | 23

BRANCH NEWS

4th Midland Area Council Education Seminar – 11th March 2012

Podiatrists and chiropodists from varied backgrounds gathered at the Village Hotel, Solihull, for the fourth Midland Area Council Education Seminar on 11th March 2012.

Valerie Dunsworth, MAC committee member, introduced IOCP President Heather Bailey who then welcomed the delegates. Diabetes was the chosen theme and Heather reminded delegates of the current heightened press interest in this endocrine condition and the need for podiatrists to be well aware of not only the potential foot complications, but also the general nature of the condition in order to offer holistic advice to patients.

Valerie then welcomed Jane Sennett, a specialist nurse in diabetes and experienced educator, whose presentation gave an overview of diabetes with particular attention to medical management.

She reviewed the current interventions and detailed the more recent agents that are now available for prescribing to lower blood glucose and retain homeostasis. The illustration of the Gila monster leading to the synthesis of the incretin mimetic exenatide (Byetta) was most intriguing .

Morning /lunch and afternoon breaks allowed delegates to view a range of podiatric equipment and medication, most comprehensively displayed by the corporate exhibitors.

Gareth Hicks, from Bailey Instruments, gave a talk explaining how to use and interpret neurological and vascular assessment equipment. He discussed a large range of products and described their relevance to assessment of patients with diabetes. A hands-on session with the Doppler device, hammer and tuning fork was incorporated with delegates enjoying the “touchy-feely” experience. He also demonstrated perspiration assessment with the use of “sweat” plasters, pink good, blue bad!

After lunch Michelle Weddle, representing Algeos, spoke on the subject of silicone orthotics with an emphasis on the diabetic foot. A number of materials are available, differing in hardness and rate of curing. She demonstrated how the materials should be applied whilst addressing questions from the attendees. Another “touchy-feely” period permitted delegates to wrap each other’s toes with customised silicone mouldings. It was all very colourful, but the colours are important in differentiating the relative cured hardness, and hence the appropriateness of application.

For the final session Jim Osborne, an optometrist with a particular interest in diabetes, delivered a talk entitled “an eye on the feet”. Following a brief review of the microvascular structures and the anatomy of the eye, images of the retinas of patients with diabetes were shown. The eye allows a view of microvascular changes in action and delegates observed haemorrhages and lipo-protein deposits that occur in the eye. These changes also occur elsewhere, including the foot, as endothelial compromise results from poor glycaemic control in the presence of diabetes.

The day concluded with a closing address and a message of thanks to the MAC members for organising the study day from Bill Liggins.

We all enjoyed catching up with old friends and making new ones and the day proved an enjoyable way of notching up CPD points to benefit our practices and patients. Why not join us at our next seminar!

Pam Osborne Birmingham Branch

24 | page

BRANCH NEWS

Southern Area Council 2012 Spring Seminar On 24 March, the Southern Area Council hosted their 2012 spring seminar at Anglia Ruskin University. This is the 2nd year the SAC seminar has taken place at the Chelmsford campus, which is fast becoming a popular venue for Institute members.

As the Chairperson and member of the SAC Committee, I know only too well the challenges of organising a seminar, especially in the current economic climate.

As we all know times are hard, particularly in light of pursuing and aiding Continuing Professional Development (CPD). However, despite the increasing economic challenges faced by all, I was thrilled to see an enthusiastic and motivated gathering of health professionals attend the seminar with a programme of morning lectures and afternoon workshops.

The seminar’s key note speakers were all colleagues from Anglia Ruskin University: Dr Andy McVicar presented a Lecture on the Control of Posture and Movement, and Dr Raj Mootanah gave a talk on her gait analysis research. In the afternoon Anand Kannan presented a workshop on Emergency Airway Management; followed by a workshop given by Carol Ellis and myself Beverley Wright, on Reflexology and Relaxation Techniques.

The event was well attended, not only by IOCP Officers and members, but also by other chiropody and podiatry organisations, such as the British School of Chiropody, and also suppliers from Algeos and Canonbury, who provided the trade fair.

Overall, the seminar was well received, helped by an excellent lunch and plenty of refreshments. In addition, to the seminar’s programme and speakers that provided an interesting, informative and thought provoking day.

I wish to thank everyone who attended the seminar. In particular, special thanks must go to all the seminar’s keynote speakers, Heidi from Algeos and Stephen from Canonbury and the Institute’s President Heather Bailey and Chairman Bill Liggins, who do so much to support our events. I would personally like to give my grateful thanks to those that make events like these possible, and make them a success – Jeannie Sadler (SAC Secretary) and Flavia Tenywa (SAC Treasurer).

I would like to add a very special mention to Salome Thurura who won the Human Anatomy and Physiology book in the raffle.

The book was kindly donated and signed by one of the authors Dr Andy McVicar, who presented a lecture earlier that day.

Salome kindly presented the book she won to the President (who I might add bought lots of raffle tickets with the Chairman in an attempt to win the book) at the end of the seminar and I would like to acknowledge her kindness and generosity for her very thoughtful act – thank you Salome.

I look forward to seeing you all again next year.

Beverley Wright Chairperson, Southern Area Council

I had great pleasure welcoming the Institute’s President Heather Bailey and Chairman Bill Liggins to the seminar as special guests of the SAC. The Chairman gave a brief speech on the organisation and provision of education and CPD events, including the value and impact these events have on health professionals and their service users. In addition, the President kindly offered her services by drawing the raffle at the end of the day with the monies raised going to support local charities.

Chester North Wales, Staffs and Shrops Branch Branch Meeting Chester North Wales Staffs and Shrops branch had their branch meeting on 26th February and had a presentation with a difference. We always have a podiatry related topic for the presentation but this time we were delighted to have Malcolm Wright, Chartered Accountant.

The Agenda covered Tax, Practice Profitability and Marketing. A brief summary of allowable expenses, business structure, whether or not it is better to be a limited company was discussed. Also covered were relevant life policies, profitability ratio’s and how to increase income earnings by using a pricing model. Malcolm Wright also lecturers at Liverpool John Moores University and Chester University and runs his own accountant company Elpizo.

Malcolm handed out detailed printouts explaining what we should be doing to make our tax easy to deal with and to understand and to help make our business more profitable.

Also attending was Ben Stead from Canonbury who set up a trade stand. Ben offered a generous discount for orders over £100. This was an excellent presentation and every member attending went away with something to consider in their own practices. Thanks go to Miriam Moorcroft our CPD Officer for organising the presentation.

Denise Willis Secretary page | 25

CONDITION CORNER

Mortons Neuroma Sam Wright, Marketing Manger, The Langer Group Morton's neuroma (also known as Morton's metatarsalgia, Morton's neuralgia, plantar neuroma and intermetatarsal neuroma) is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the third and fourth intermetatarsal spaces but can also appear between the 2nd and 3rd. This condition tends to occur in more than 4 times more women than men and can affect people of any age. It is a type of entrapment neuropathy and is characterised by numbness and pain. The pain is often relieved by removing footwear.

Signs and symptoms 1. Pain on weight baring 2. Shooting pains towards the toes 3. Burning pain on the sole of the foot 4. Can feel like the patient is walking on a pebble 5. Numbness in toes (around half) 6. Paresthesia 7. Often presents between 3rd and 4th metatarsal heads

Diagnoses • X-ray can rule out any other pathology • Direct pressure applied between the metatarsal heads will replicate the symptoms • Compression of the forefoot squeezing the metatarsal heads together compressing the transverse arch may induce pain or a click, Known as mulder's click or sign

What are the treatment options?

• Conservative treatment to address any biomechanical abnormality • Orthotics to open out metatarsal spacing including a metatarsal pad (dome) • Corticosteroid injections • If conservative treatments fail, patients will be referred onto surgery for a neurectomy • Some people are starting to use Cryogenic neuroablation is an alternative to neurectomy surgery • Look at the patients' footwear and discuss weather more room may be required. A good way to demonstrate tight shoes is to draw around the patients foot on a piece of paper and then place the current footwear on top and see if there is any over spill from the template

Orthotic adaptions that could help with Morton's Neuroma A metatarsal pad (dome) can be added to any prefabricated or custom made orthoses. A standard metatarsal pad is placed 2/3rds on the shell and 1/3rd off the shell with the centre being of the pad being placed in the 3rd metatarsal head area. The metatarsal dome is usually made from PPT as it's cushioned foam but can be made out of more rigid materials or built into the shell. The aim of the dome is to open out the joint spacing in order to reduce the amount of compression of the plantar nerve.

• Ultra sound scan can show swelling in the nerve

Differential diagnoses • Capsulitis, an inflammation of the ligaments that surround a joint • Intermetatarsal Bursitis • Freiberg's disease, osteochondritis of the metatarsal head. Be careful when palpating the area as not to confuse pain in the metatarsal head rather than the intermetatarsal space • Neurological pain should be ruled out from further up the body such as tarsal tunnel syndrome peripheral neuropathy or even pain from the lower back 28 | page

Emerald Way Stone Business Park Stone, Staffordshire, ST15 0SR +44 (0)845 678 0182 www.langergrp.com Basic Biomechanics Courses 2nd & 3rd March (Dublin) 19th & 20th March (Taunton) 23rd & 24th April (Leeds) Click http://langergrp.com/education for more information

OBITUARY

Fred Beaumont by his son Julian Fred began working as a chiropodist in 1952 in Northumberland Square, North Shields. In 1955 he moved his practice to 1 Grafton Road Whitley Bay, where it remained until his retirement. He became an active member of the Institute. He was dedicated to the furthering of his profession and proud of his membership. One wall of Fred’s study is filled with Institute memorabilia.

Fred also kept a scrap book of significant events and achievements in his life as a chiropodist. Include in this are newspaper clippings, letters, the annual Institute dinner dance, and many photos mainly of Fred and Dorothy at the dances.

One of my earliest memories as a little boy, is of disgracing myself at the Annual Dinner and Dance held at the Cliffs Hotel Blackpool (April 1967). I also recall having to be on best behaviour in 1976 when Dad hosted the 21st Dinner and Dance at the Airport Hotel, Newcastle. My sister Miriam, presented the bouquets, and I was kept sensibly in the background.

Fred wrote prolifically and had many articles published both in professional journals and newspapers. In 1971 is article, “Fresh air in the surgery,” was published in the Chiropody Review and won him the Douglas Stuart Forbes award (a past president). He received his cheque for 5 guineas at the annual Blackpool conference, and his rise to acclaim in the field of Chiropody and Podiatry seemed to be set.

In 1973 Fred was awarded the Certificate of Merit, “ in recognition of outstanding service on behalf of the Institute and in the cause of the profession.” This was only the second time the award had been made, and he received a letter of congratulation from the House of Commons.

At the time Dad was branch secretary, on the National Executive and Chairman of the Private Practice Committee. (Although these are titles I heard regularly throughout my childhood, the reader is probably more familiar with their significance than I am. For me they meant more meetings and hours at the typewriter for Dad.) After many years of service and dedication, in 1998 Fred was elected President of the Institute of Chiropodists and Podiatrists at the annual conference in Southampton. I remember Dad saw this as the crowning achievement of his career. He was thrilled. The next few pages of scrapbook are filled with letters and cards of congratulation.

In 2000 Dad was re-elected president and in 2001 he was granted Life Membership of the Institute and, in 2003 Fred was appointed Life President of the North East branch.

Fred was also on the Board of Education and taught and lectured for many years. Until very recently he remained Press and Public Relations Officer.

Throughout a long and productive career, it is clear that Fred influenced and mentored many. Readers who knew him will have their own memories and will agree, I’m sure, that although Dad was the epitome of professionalism, he also recognised the importance of the social aspect of Institute Membership and took every opportunity to party.

Writing this article has been very difficult, Fred was an inspiration to all of us and is sadly missed.

Julian Beaumont Dear Editor, It was with sadness that I learned belatedly of the death of Fred Beaumont. Fred was my immediate predecessor as President of the Institute in 2000. Although I knew Fred and his wife Dorothy going back to the early eighties. He was delighted for me upon my election as President. He was a man of great knowledge and wit, always straight to the point.

He and I had many a long chat over the past and the future of the Institute and our profession over a wee dram of single malt. We jointly shared the view for a completely autonomous profession of chiropody/podiatry with its own Register, Just like medicine, dentistry have, and the osteopaths succeeded into achieving (Fred was an Osteopath also). He and I could see history repeating itself without complete closure, as so it has come to pass, with new titles and varying degrees of training emerging outside of the HPC register.

Fred was a great source of wisdom and council to me a President over my six years in office, especially through the HPC registration process. I always followed him with the same opening words of my address at the AGM’s “Dear Fellows & Members”.

He will never be forgotten for his great work, May he rest in Gods light.

Andrew Farrell (Past President IOCP)

Dear Editor, How saddened I was to read, in Podiatry Review, of the death of my good friend, Fred Beaumont.

In his Christmas card of only 3 months ago, all he complained about was having to give up driving due to pain in his knees! That was so typical of Fred, always a doer never a moaner. Fred was good company. When our executive meetings were in London, He, I and Dorothy also, if she was there, would go for dinner on the Friday evening away from the other executive committee members so that we would not be talking ‘shop’ all evening. What good times they were! Most people only saw the professional side of Fred and his devotion to the Institute but there was a great fun side to him. I am so pleased to have seen that.

Thanks Fred.

With happy memories, God Bless Stanley Harrison, Past President IOCP

page | 29

ARTICLE

Chiropody - A Very Worthwhile Career Janet Mannion In 1998 I found myself at a crossroads. I was 50 years old but still wanted to work at something worthwhile.

My husband saw an advertisement for a Chiropody Course in a national newspaper and the dye was set. I applied to the Cheshire School of Chiropody for the Course and to the North Wales Training and Enterprise Council for a grant.

With a grant that paid half the cost of the training and a career development loan to help me with the remaining costs, I started my training early in 1999.

I qualified in December 1999 and went straight into trying to build a domiciliary round. Sometime later, I was also able to pen a clinic attached to our cottage.

I was gaining confidence slowly. It can be daunting assessing and treating new patients without any experienced backup. Then came the HPC registration. I filled in the forms and failed to qualify. I went to an interview in London and failed.

My self-esteem was very low - as was my feeling of professional worth. Should I call it a day before I had even really started? Should I re-register as a foot care clinician?

No! I had worked hard to earn the title of Chiropodist so I jumped at the chance to attend the weekend courses designed in partnership with the Society and the Institute of Chiropodists and Podiatrists.

I thoroughly enjoyed and benefitted from this extra training. For me it was a form of consolidation and, when I received HPC acceptance and became a member of the Institute of Chiropodists and Podiatrists, I forged ahead with my career far more confidently.

By the time I retired in December 2011 I had dealt with many patients.

In my early days, one bank holiday, a district nurse phoned and asked if I could call on a patient who, recently out of hospital, was complaining of pain in her toes. Forgoing the leisurely day that had been planned, I made the decision to do the 38 mile round trip.

As I walked into the house an overriding smell was unmistakable. I actually put the blame on an elderly dog asleep in its basket.

30 | page

The pain had eased, I was told, but obviously an assessment was needed so I proceeded to remove the bandage that the nurse had put on. Bits of skin came away with the dressing to reveal two toes completely black and emitting the nauseating odour.

An ambulance was called, friends informed and full assessment notes made. A return visit later confirmed that gangrene had been the cause and two toes had been removed but otherwise, fortunately, a full recovery was made. Luckily my decision to forgo a bank holiday break to make a visit had been well rewarded.

So in conclusion I would like to thank the Institute for all of its help and the many courses that I have enjoyed for CPD - help that has made my career as a chiropodist professional and enjoyable. Whilst I hope to enjoy my retirement, I know that I will miss the career that I very nearly didn’t have!

Janet Mannion Retired Member Cheshire North Wales Branch

RAMBLING ROADS

‘Pulse’, the General Practitioner’s journal of 15th February carries an article by Nigel Praities on knee operation restrictions. GPs have been faced with increasing restrictions on referral for knee replacement surgery. Primary Care Trusts have introduced restrictions based on the severity of symptoms and Body Mass Index of over 30. However, the post-surgery outcomes of no less than 2,131 osteoarthritis suffers showed that this form of treatment ‘offered very good value for money’ since patients gained an average of 1.3 Quality Adjusted Life Years. Body Mass Index was not relevant and costs rose the longer the surgery was delayed leading the authors to determine that the restriction of this form of surgery to those with the worse symptoms was false economy.

Why does influenza sometimes kill but in other cases manifest as a minor infection? Debora MacKenzie reported in New Scientist 31st March, that research carried out by Paul Kellam and colleagues at the Sanger Institute in Cambridge involved the breeding of mice with a mutation which stopped them making a protein named IFITM3 which is normally manufactured by cells in response to interferon, a chemical that turns on antiviral defences. It was found that strains of ‘flu which do not normally affect mice – including the 2009 pandemic - virus left the animals without IFITM3 severely ill.

Further research showed that people in intensive care with severe pandemic, or even seasonal ‘flu were 17 times more likely to carry the mutated non-functional gene than those without. The mutated gene has become more common in the last 10,000 years since humans began raising livestock and developed ‘flu as a result of cross infection. The protein also affects viruses such as those causing Dengue and West Nile fevers and suggests that a drug which mimics IFITM3 might help in fighting all of those viruses.

Nature (Nature, DOI:10.1038/nature10922) notes that a homonym fossil foot discovered in Ethiopia dating to 3.4 million years ago has an opposable hallux like an ape and that would have been used to grasp tree branches.

All other homonims from the time have higher arched feet without an opposable hallux. It seems highly likely therefore, that there were at least 2 kinds of protohuman walking around in Africa at that time.

The potential changes to commissioning of delivery of care via the NHS system, or ‘GP Commissioning’ still causes controversy. An essay by Lucy Reynolds and

Martin McKee in the Journal of The Royal Society of Medicine Vol.105 No.1 illustrates some of the perceived difficulties. It is, as yet, far from clear exactly what the division of responsibilities entail. Some GPs are very enthusiastic since the previous system of commissioning

by PCTs has a mixed record; however, others point out that the implementation of the proposals is bound to be very complex and require particular skills to evaluate, negotiate, deliver, monitor and deal with the inevitable problems. It is suggested that many GP commissioning consortia will sub-contract management to commercial organisations such as American health insurance companies who have acquired significant presence in NHS commissioning since the last government’s Framework for procuring External Support for Commissioners. The writers are concerned whether it will be possible to sustain quality without rationing patient care. They go on to use recent examples of social care in which care has been provided by less qualified staff where clinical errors have been made. Budget deficits have already been noted in NHS South West Essex, and a list of 213 treatments for which GPs can no longer refer has been circulated. The issue is huge but the private podiatrist may be well placed to offer constructive and cost effective treatments within their area of expertise.

The web site ‘Podiatry Arena’ has re-visited the important subject of toenail phenolisation in pregnant or breastfeeding females. Animal experiments show that phenol when applied to certain parts of the body is toxic.

Whilst this seems obvious, there is no positive proof that a foetus in utero might be affected by the chemical when applied in limited quantities to the nail bed or that breast milk is affected. The general consensus of opinion is however, that since toxicity has been found in animal experiments, the treatment should be avoided in pregnant or breastfeeding females. In cases in which the condition of the nail becomes recurrently infected to the extent that the general health of the mother might be compromised, and more conservative measures are ineffective, the patient should be referred to a colleague for incisional techniques within a hospital setting. There is no evidence to show that local anaesthetic solutions can adversely affect a foetus. However, interventions using local anaesthetic solutions should be avoided in the first trimester of pregnancy.

Achilles Hele page | 31

HPC NEWS

Fitness to practise – revised Standard of Acceptance for Allegations In December 2011, Council approved changes to the Standard of Acceptance for Allegations Practice Note which means that this document is now a policy document and no longer a guidance document.

sometimes contact us asking about how to supervise those tasks and who is responsible for making sure that the task is carried out safely and effectively. We have written this article to answer those questions.

To ensure that allegations are considered appropriately, the new policy document sets out a modest and proportionate threshold which allegations must normally meet before they will be investigated by the HPC. That threshold is known as the ‘Standard of Acceptance’.

Delegating tasks

In relation to allegations, our primary concern is that registrants are ‘fit to practise’, in the sense that they have the knowledge, skills and character to practise their profession safely and effectively. However, fitness to practise is not just about professional performance. It also includes acts by a registrant which may have an impact on public protection or confidence in the profession or the regulatory process. This may include matters not directly related to professional practice. Our proceedings are designed to protect the public from those whose fitness to practise is impaired’.

They are not a general complaints resolution process, nor are they designed to resolve disputes between registrants and service users or to punish registrants for past mistakes.

It is important to highlight that although allegations are only made against a small minority of HPC registrants, investigating them properly is a resource intensive process.

Therefore, it is important to ensure that the available resources are used effectively to protect the public and are not diverted into investigating matters which do not raise cause for concern.

The new policy document now includes a more detailed description of what key elements of the standard of acceptance mean, details of time limits on dealing with cases (with caveats as to when that time limit will not apply), and further detail around the resolution of matters at a local level.

If you have any questions about the changes to the document, please contact the Fitness to Practise Department. A copy of the Standard of Acceptance for Allegations policy can be found on our website at www.hpcuk.org/publications/policy.

Focus on delegation and supervision Many of our registrants (‘you’) work in teams where they delegate tasks to other practitioners. Registrants 32 | page

You may on occasion delegate a task to someone else.

This could be to a professional, practitioner or assistant.

When you delegate a task, you are asking someone else to carry out that task on your behalf.

The standards of conduct, performance and ethics (available at www.hpc-uk.org/publications/standards) say: “Whenever you give tasks to another person to carry out on your behalf, you must be sure that they have the knowledge, skills and experience to carry out the tasks safely and effectively. You must not ask them to do work which is outside their scope of practice […] If someone tells you that they are unwilling to carry out a task because they do not think they are capable of doing so safely and effectively, you must not force them to carry out the task anyway.” This means that when you ask someone to carry out a task on your behalf, you should make sure that the task you are asking them to carry out is within their competence and that you believe they can carry out the task safely and effectively.

We recognise that many of our registrants work for an employer and must therefore follow the employer’s protocols about how tasks are delegated and who within the team is responsible for particular tasks. In those situations, the employer is responsible for making sure that the individuals they employ are appropriately qualified to carry out a particular task. In circumstances where an employer has clearly certified that an employee working with you is competent in certain areas, you would be able to be reasonably sure that they have the knowledge, skills and experience to carry out those tasks.

If you do not work for an employer, or manage a service yourself, you may want to consider developing your own policy or procedures around the delegation of tasks.

Supervising tasks When you ask someone to carry out a task, you must give them appropriate supervision. We do not set how closely you should supervise them, as the level of supervision would vary depending upon a number of factors.

HPC NEWS

These factors could include the nature of the task, the risks associated with that task and the frequency with which the individual carries out that task. In addition, your workplace may have its own procedures on how you should supervise tasks.

Instead, the supervision that you provide must be appropriate and make sure that the individual carrying out the task completes it safely and effectively.

Responsibility for the task Sometimes registrants contact us because they are worried about delegating a task to someone else.

Often their concerns arise because the person they are delegating the task to is not a registered professional, perhaps because the person works as an assistant. They are worried that they would be held responsible if something went wrong whilst the person was carrying out the task on their behalf.

As a registrant, you are responsible for your own actions but not for the actions of others. This means that when you delegate a task to someone else, you are responsible for making the decision to delegate that task.

However, you are not directly responsible for how the individual then carries out that task.

You are responsible for the appropriateness of your decision to delegate the task. You must make sure that when you delegate a task, your decision to delegate it is reasoned and informed and in the best interests of your service users.

This means that you must draw on established good practice, employer protocols and your professional judgement when you decide to delegate a task. So long as your decision to delegate a task is a reasonable one, then it is unlikely that these decisions would affect your registration.

This article is part of a series looking at our standards. We would welcome any comments you may have about this article or any suggestions of topics for the future. You can contact us by emailing policy@hpc-uk.org

Shoe for Swollen Forefoot A new, part-elastane, part-leather shoe from Cosyfeet is specially designed for ladies whose feet swell only across the forefoot. Called the Karina, this sporty looking shoe is roomy and flexible at the front, yet narrower at the back, for a secure, comfy fit for those without significant swelling around the heel or ankle.

The Karina’s innovative design incorporates extra-stretchy, elastane panels along each side, so it won’t put pressure on joints, bunions or swellings.

“This shoe is specifically for ladies with swollen feet but who have less or no swelling at the ankle and therefore have a tendency for the heel to slip in wider fitting footwear,” says Cosyfeet Managing Director, Andrew Peirce. “It’s the first of its type and fulfills a very real need.”

The Karina has a seam-free toe area which is ideal for sensitive feet. It is also deep enough to allow for orthotics or insoles if required, and has a flexible, shock‐absorbing sole.

Its soft, micro-suede lining and padded tongue and collar combine to make this an exceptionally comfortable shoe.

The Karina has touch-fastening straps which expand as the foot flexes, while holding it securely. The strap is designed to stretch 40% of its length, so that even a very swollen forefoot can be accommodated in comfort.

Cosyfeet’s new Karina style comes in Black, Latte, Loganberry and Navy, in sizes 3 to 9, priced £67.00 (or £55.83 if you qualify for VAT relief due to a chronic medical condition).

For more information see www.cosyfeet.com/karina or call 01458 447275. page | 33

CLASSIFIED

r ooms v acant a r Le Ne Mi t CHe LL Ha i r & Be a Ut Y Arlene currently has a room vacant which would suit a self employed Chiropodist/podiatrist in a very busy salon, in Kilmacolm, Scotland. This would be an excellent opportunity for someone. If anyone is interested call Arlene on 07949615571 or 01505871280.

Chiropody s upplies

Chiromart UK ‘WHY Pa Y Mo r e ?’

Suppliers of Autoclaves and Chiropody Surgery Equipment. Single items to full surgery set ups. Quality used and new. Also your equipment wanted, surgery clearances, trade- ins and part exchange CASH WAITING.... www.chiromart.co.uk Tel: 01424 731432 (please quote ref: iocp)

Practices f or s ale t o r q Ua Y, d e v o N r e t i r e Me Nt s a Le Surgery/D.V. Est 25 years Income £17K over 3 days Scope for Expansion - £17K Tel: 01803 211616 Wa t f o r d , He r t f o r d s Hi r e An opportunity arises due to retirement, for an approved practitioner to continue a long established and profitable surgery. Ground floor shop premises with seven day access and low inclusive rent. Proper introduction and handover will be given to my patients with after support if required. Available free of charge although a reasonable contribution for the modern equipment, if wanted will be required. Profit from day one.

Write in first instance with your identity and contact details to Box No 1201 Podiatry Review, 27 Wright Street, Southport, PR9 0TL s o Ut H Li NCo LNs Hi r e Three bedroom detached house with integral surgery for sale - London 55 Minutes by rail.

Lovely historic market town in one of the best areas of the country.

Lots of benefits including one of the best Grammar schools in the country.

Established over 30 years. 20,000 population unopposed.

Sale to include all equipment (if required) - ready to walk in and start!

Wonderful opportunity - Further details 01778 426101.

Sale due to retirement.

AMBER CHIROPODY SUPPLIES Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including: * In s tru m e n ts & E q u ip m e n t * D o m ic ilia ry * P a d d in g & A p p lia n c e s * S te riliz a tio n * D re s s in g s & A d h e s iv e s * D ia g n o s tic s * B io m e c h a n ic s * R e ta il P ro d u c ts To view our website/online store please visit:

w w w .a m b e rs u p p lie s .c o .u k 34 | page

DIARY

!!

May 2012

July 2012

6

Leeds Bradford Branch Meeting 10.00 a.m.

Oakwell Motel, Low Lane, Birstall Tel: 01924 475338

1

Wolverhampton Branch Meeting 9 a.m. start Please telephone for details 0121 378 2888

14

West Middlesex Branch Meeting 8 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

7

Surrey and Berkshire Branch Meeting 7.30 Pirbright Tel: 0208 660 2822

20

Essex Branch Branch Meeting 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

9

West Middlesex Branch Meeting 8 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

20

Leicester and Northants Branch Meeting 10.00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details 01234 851182

2

Southern Area Council Meeting at 1 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF Tel: 01992 589063

Leicester and Northants Branch Meeting 10.00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details 01234 851182

8

Southern Area Council Meeting at 1 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF Tel: 01992 589063

9

South Wales and Monmouth Branch Meeting 2 p.m.

Village Hall, Cardiff Tel: 0292 033 1927

9

West of Scotland Branch Meeting 11.00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH Tel: 0141 632 3283

10

West Middlesex Branch Meeting 8 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

12

Hants and Dorset Branch Meeting 7.45 p.m.

Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: 01202 425568

16

Western Branch Meeting 12.15 p.m.

Liverpool Womens Hospital, Blair Bell Education Centre, Crown Street, L8 7SS Tel: 01745 331827

30

East Anglia Branch Meeting Barrow Village Hall, Nr Bury St Edmunds IP29 5AP Tel: 01473 830217

30

Essex Branch Branch Meeting 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 Please note there will be a first aid course preceding this meeting

26

1

September 2012

June 2012 3

10

10

13

14

24

24

Leeds Bradford Branch Meeting 10.00 a.m.

Oakwell Motel, Low Lane, Birstall Tel: 01924 475338 West of Scotland Branch Meeting 11.00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH Tel: 0141 632 3283 Western Branch Meeting 11.45 a.m. Algeos Tour and presentation on Orthotics. Algeos, Bridge Industrial Estate, Speke Hall Road, L24 9HB Tel: 01745 331827 Hants and Dorset Branch Meeting 7.45 Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: 01202 425568 Lecutre: A potpourri of dermatology â&#x20AC;&#x201C; Paula Oliver Birmingham and the Shires Branch meeting 8 p.m.

Red Cross Centre, Evesham, Worcs Tel: 01905 454116 Chester North Wales Staffs and Shropshire Branch meeting. The Dene Hotel, Hoole Road Chester Tel: 0151 327 6113 South Wales and Monmouth Branch Meeting 2 p.m.

Village Hall, Cardiff Tel: 0292 033 1927

1

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DIARY

October 2012

January 2013

4

Birmingham and the Shires Branch meeting 8 p.m.

Red Cross Centre, Evesham, Worcs Tel: 01905 454116

6

Chester North Wales Staffs and Shropshire Branch AGM and meeting. The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113

7

Chester North Wales Staffs and Shropshire Branch meeting. The Dene Hotel, Hoole Road Chester Tel: 0151 327 6113

12

Surrey and Berkshire Branch AGM and Meeting 7.30 p.m.

Reading Tel: 0208 660 2822

13

Western Branch AGM 12.15 p.m. Liverpool Womens Hospital, Blair Bell Education Centre, Crown Street, L8 7SS Tel: 01745 331827

13

Wolverhampton Branch AGM 10 a.m. start Please telephone for details 0121 378 2888

16

Hants and Dorset Branch AGM 7.45 p.m.

Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: 01202 425568

17

Birmingham and the Shires Branch AGM and meeting 7.30 p.m.

Red Cross Centre, Evesham, Worcs Tel: 01905 454116

20

East Anglia Branch AGM Barrow Village Hall, Nr Bury St Edmunds IP29 5AP Tel: 01473 830217

20

Nottingham Branch AGM 10.00 a.m.

Feet & Co, 85 Melton Road, West Bridgford, Nottingham. NG2 6EN. Tel 0115 9313492

20

West of Scotland Branch AGM 11.00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH Tel: 0141 632 3283

20

Leicester and Northants Branch AGM 10.00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details 01234 851182

26

Southern Area Council AGM at 1 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF Tel: 01992 589063

27

Essex Branch Branch AGM 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

27

Midland Area Council AGM Tel: 07790 350109 for more information

7

Wolverhampton Branch Meeting 9 a.m. start Please telephone for details 0121 378 2888

15

Surrey and Berkshire Branch Meeting 7.30 p.m.

Pirbright Tel: 0208 660 2822

21

Midland Area Council Meeting Tel: 07790 350109 for more Information

November 2012 4

South Wales and Monmouth Branch Meeting 2 p.m. Village Hall, Cardiff Tel: 0292 033 1927

4

West of Scotland Branch Meeting 11.00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH Tel: 0141 632 3283

12

West Middlesex Branch Meeting 8 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

22

Birmingham and the Shires Branch meeting 8 p.m.

Red Cross Centre, Evesham, Worcs Tel: 01905 454116

23

Hants and Dorset Branch Meeting and Social Event 7.45 The Sir Walter Tyrrell, Lower Canterton, Nr Lyndhurst SO43 7HD Tel: 01202 425568

25

25

36 | page

Essex Branch Branch Meeting 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 Leicester and Northants Branch Meeting 10.00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details 01234 851182

NATIONAL OFFICERS

National Officers

National Officers Area Council Executive Delegates

Branch Secretaries

Branch Secretaries

Area Council Executive Delegates

Scottish Area Council Mr A Reid M.Inst.Ch.P

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