The Other Side 14:
Interview with a Podiatrist
Neil Baker is Research Diabetes Specialist and Research Podiatrist at Ipswich Hospital NHS Trust. On Target talked to him about purchasing in this increasingly important specialist area of healthcare.
1. As a specialist in diabetic foot care, what purchasing decisions are you involved in making?
A wide range of products and services can be purchased to facilitate the optimal care of those with diabetic foot problems. One of the responsibilities of a clinical manager is to make careful decisions regarding the purchase of equipment, consumables and services used to care for the high-risk foot in diabetes. Two areas where decisions have to be made regarding appropriate purchasing (excluding staffing) are wound care products and surgical appliances.
There are a myriad of different wound care products on the market, which can make deciding between products A and B very confusing. There is very little robust scientific data that would suggest that one dressing is better than another, so unit costs and treatment costs play a large role in decision making.
Diabetic foot ulcers require very frequent redressing to monitor for infection and deal with exudate absorption problems, so choosing a dressing that has a high unit cost or is not widely available (i.e. to both primary and secondary care settings) would be wasteful.
Therefore, unless a specific feature is required from a dressing (e.g. eschar rehydration), a simple non-adherent low unit cost dressing that can be changed frequently is an obvious choice.
Purchasing surgical appliances is more complex, as one is purchasing not only a product but also a professional service. Additionally, factors such as patient compliance with prescribed footwear are a difficult area. Spending several hundred pounds on a pair of shoes that are never worn because they do not look like ‘high street’ shoes is a pitiful waste of resources. When purchasing both products and services, ensuring that all patients have a choice of styles, colour and leather types helps to reduce this issue.
We have chosen to use a single company that has a shoe fitter attending our clinic, for several reasons. Firstly, the company specialises in diabetic footwear and so is used to accommodating not only patients’ feet, but also some of the common compliance issues. They have a working understanding of diabetic foot problems and the disasters that can arise through poorly prescribed or fitted footwear. Secondly, there is a direct link between the clinic and the factory floor via the company’s visiting shoe fitter, so any fitting problems etc can be dealt with very swiftly. Thirdly, developing a working relationship with one specialist supplier allows for unique patient requirements, and for product developments to be undertaken effectively.
2. What aspects of sales meetings do you find helpful? What aspects do you find unhelpful?
The facets of sales meetings that I find useful are learning of any new developments in products or new ways of purchasing etc.
Unhelpful facets relate to covering the same Neil Baker old ground or sales pitch. Obviously any new research on a product is useful; however, case studies – especially relating to wound care products – I find frustrating and not particularly helpful, as these are often passed off as research when they are not.
3. How are current changes in hospital practice affecting what you purchase and how you purchase it?
The biggest changes at present are the shift of services from secondary to primary care and changes in service level agreements. The net result of these is that budgets are being held to more account, with a ‘no overspend’ policy being strictly adhered to.
Factors such as patient compliance with prescribed footwear are a difficult area. Spending several hundred pounds on a pair of shoes that are never worn because they do not look like ‘high street’ shoes is a pitiful waste of resources.
Thus rationalisation of what and how much is being purchased is coming more and more to the forefront. So, for example, the idea that the hospital will pay for ‘shoes for life’ for those who require specialist shoes is being looked at closely, which may mean that in the near future GPs may have to pay for prescribed orthoses including shoes, or even provide orthotic services themselves.
Traditionally, this service provision and the revenue costs have been provided by the acute hospital trusts.
4. How are current changes in hospital practice affecting what you purchase and how you purchase it?
There is a distinct possibility that diabetic foot ulceration may be managed in community settings in the future, rather than in hospital-based clinics. This could only be effective if there were a clearly-defined infrastructure in place, with professionals who have the necessary competencies, expertise and experience. Additionally, there would need to be a fast-track system for urgent admission of patients with infected or ischaemic feet, and the facility to follow patient care through onto the wards. At present, I do not think this is achievable without significant investment. If the change happens without such investment, amputations will increase and patient care will be compromised.
The role of consultant allied healthcare professionals, especially podiatrists, is likely to grow in the next decade. Also, foot care protection teams dedicated to the diabetic foot are likely to become established and hopefully commonplace in primary care.