A fish rots from the head, but the NHS may be rotting from the feet. Podiatry is not up there in the headlines, yet what’s going on in that unglamorous zone is an alarming microcosm of the downward path of the health service. This is a story of the NHS in England in retreat and the private sector filling the vacuum.
You know the big picture from the ever-worsening monthly figures: deteriorating A&E, ambulance and operation waiting times, and a steep rise in bed-blocking. As debts pass £2.5bn, the NHS feels the tightening financial tourniquet.
Now look at it through the prism of just one small corner, as seen from the feet up. Every week 135 people have amputations because diabetes has caused their feet to rot: their circulation goes and then the sensation in their feet, so they don’t notice damage done by rubbing shoes, stubbed toes or stepping on nails. Minor injuries turn into ulcers that if left untreated turn gangrenous, and so the toes, then the foot, then the leg are lost – horrific life-changing damage. Numbers are rising fast, with nearly three million diabetics. The scandal is that 80% of these amputations are preventable – if there were the podiatrists to treat the first signs of foot ulcers. But the numbers employed and in training are falling.
In his surgery, the head of podiatry for Solent NHS Trust, Graham Bowen, is unwrapping the foot of a lifelong diabetic to reveal a large missing chunk of heel, a great red hole nearly through to the bone. This man has already had some toes amputated. He has been having treatment with maggots, bandaged into his wound to eat the dead skin and help healing – and he is slowly improving. Everyone Bowen sees now is at similarly high risk. Small ulcers, incipient ulcers, the ones that need to be caught early (and cheaply) no longer get NHS treatment. “On the NHS we’re essentially firefighting the worst cases now,” says Bowen. “We are going through our lists and discharging all the rest of our patients.”
FacebookTwitterPinterest ‘On a 15-minute visit carers can’t check feet.’ Photograph: Andrew Bret Wallis/Getty Images
But not even all these acute patients get the same optimal treatments, due to the vagaries of the 2012 NHS Act. Solent, a community trust that covers mental health and a host of other services, is used by five different clinical commissioning groups (CCGs), including Southampton, Portsmouth and West Hampshire. Each has its own criteria for what it will pay for, and each is toughening those criteria. Depending on their address, some patients get the very best, others only get what their cash-strapped CCG pays for.
You need to know about diabetic feet to understand the difference in treatments: the conventional and cheapest treatment is a dressing and a removable plastic boot, and telling patients to keep their foot up for months. But patients who can’t feel their feet tend to take off the boot and hobble to make a quick cup of tea. “Ten minutes of putting pressure on the ulcer undoes 23 hours of resting it,” Bowen says, so it takes 52 weeks on average to heal ulcers that way. For £500 extra, a new instant fibreglass cast saves any pressure on ulcers and cures them within eight weeks.
Although the National Institute for Health and Care Excellence says this total-contact cast is the gold standard, most of Bowen’s CCGs won’t pay for it. I watched him putting one on a patient in under half an hour: after nine weekly replacements, that ulcer would be completely healed. For every 10 of the new casts, one amputation is prevented – and each amputation costs the NHS £65,000. Such is the madness of NHS fragmentation, divided between multiple commissioners and providers, all in serious financial trouble, that no one spends a bit more now for others to save later, even when the payback is so quick.
This clinic lost four podiatry posts to save money: though diabetic numbers soar, its budget has been static for five years. “Doing more for less,” he says with the same weary sigh you hear echoing through the NHS. As Bowen goes through the clinic’s books removing all but the most acute cases, he turns away diabetics whose problems should be caught early. He turns away others he used to treat: the old and frail who have become immobile due to foot problems; the partially sighted or people with dementia who have poor home care. On a 15-minute visit carers can’t check feet and find out if they are the reason someone doesn’t get out of bed, toes buckled in, leaving them needlessly incapacitated and heading for residential care sooner than necessary.
What happens to those he takes off his books? “They have to go private, if they can afford it. If not, then nothing.” He used to send them to Age UK, but lack of funds shut that service. Only 5% of podiatry is now done by the NHS so Bowen has set up TipToe, a private practice attached to his NHS clinic. It’s not what he wants, but it keeps prices low and all proceeds go to the NHS.
Alarm bells should ring here: how silently the NHS slides into the private sector. Labour leadership contender Owen Smith has flagged up his team’s research showing private practice has doubled since 2010. Now that many CCGs only pay for one cataract, how many go private for the second eye? As the Guardian’s health policy editor, Denis Campbell, has asked, how many more vital treatments will go this way?
Podiatry is the ground floor of the NHS hierarchy. The profession reckons the NHS in England needs 12,000 practitioners but only has about 3,000 – and that’s falling, despite so many high-risk diabetics needing weekly appointments. Next year podiatry trainees, like nurses, will no longer receive state bursaries, so fewer will apply. They tend to be older, with families, unable to take on a £45,000 debt for a job paying around £35,000 per year. Already student places have been cut by nearly a quarter in five years. Most of the 7,000 amputations a year are preventable. A shocking statistic: half of those who undergo amputations will die within two years.
Only in the details of what’s happening on the frontline can we understand the daily reality of Britain’s shrinking state. Step back and ask how it can be that a country still growing richer can afford less quality care than when it was poorer? Is that the country’s choice? As the NHS slides into the private sector, here is yet another public service in retreat.