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Clinical governance

Discuss how clinical governance has been used to develop quality of podiatric services for diabetic patients in the UK.

Clinical governance sits at the heart of the government's quality agenda for the NHS and, indeed, the wider health care arena. The statutory duty now placed on everyone working in health care is that of overall quality improvement, year upon year, backed up by the evidence to prove it. In relation to podiatry within the UK, clinical governance aims to improve the quality of care for diabetic patients by drawing up guidelines which must be followed by all organisations within the NHS. According to Huntington et al (2000), clinical governance is about promoting continuous improvement as well as establishing baseline standards. Despite advances in knowledge and treatment, Cavanagh et al (2005) state that as many as 12-25% of patients with diabetes will develop foot ulceration at some stage of their disease. The International Diabetes Federation (2005) believe that through the implementation of appropriate care strategies which include a multidisciplinary team approach, close monitoring, patient education and education for healthcare professionals, such statistics may be significantly reduced.

Education plays a fundamental role in ensuring high quality clinical care is given to each diabetic patient and is significant to the implementation of clinical governance. It is important to acknowledge the changes which have taken place in relation to the education of podiatrists and other healthcare professionals alike. The Health Professional Council (HPC) introduced continuous professional development (CPD) within the UK in order to achieve the high standards of care expected. CPD has been defined by Weigh et al (1999) as “a process of lifelong learning for all individuals and teams which meet the needs of patients, and delivers the health outcomes and health priorities of the NHS and enables professionals to expand and fulfil their potential.” From August 2008 the HPC requires each podiatrist to maintain a portfolio of their CPD, which may be called upon at any given time for investigation. Although not a new regulation it will ensure that individuals are ultimately responsible for managing their own CPD, and that they should identify their own learning needs and decide best how to meet them. However, it is also essential that organisations should identify staff needs and facilitate solutions, taking account of organisational development, (Northern Ireland Department of Health, Social Services and Public Safety, 2001). Although education of staff is paramount it is also essential to ensure that the patient receives appropriate education regarding their condition. McIntosh (2007) states that structured education is an essential component of every patient care plan. Both the International Diabetes Federation (2005) and Foot in Diabetes UK and associates (2006) advise that practitioners should explain the reason for foot screening and discuss with the patient their individual level of risk. They believe that this will promote patient-centred care and, through negotiation, plans for future surveillance can be agreed. In addition the NICE guidelines also state that a major part of screening, prevention and treatment of the diabetic foot depends on the education of the patients themselves as self care is vital (NICE guidelines, 2004). Early detection through the increased awareness of the patient can in turn prevent serious complications from occurring and also prevent possible amputation (Department of Health, 2007).

Risk management simply means practising safely and “It aims to develop good practice and reduce the occurrence of harmful or adverse incidents” (RCN, 2000). Guidelines such as NICE and CREST have played an imperative role within clinical governance as they have provided podiatrists with a template for risk management of the diabetic foot. Evidence supports regular foot screening for all patients with diabetes to identify those at risk of foot ulceration and amputation (Singh et al, 2005). Early identification of such risk factors allows practitioners to investigate prompt evidence based strategies to prevent and manage diabetic foot problems. Following a basic foot examination, the patient can be classified according to their risk status. The International Consensus on the Diabetic Foot (1999) introduced a simple classification system for identifying the at risk foot and has subsequently been adapted for use in other published guidelines such as NICE (2004) and that of Frykberg et al (2006). In addition to outlining treatment for existing and newly diagnosed diabetic patients such guidelines also outline how different types of wounds should be prevented and treated and when emergency wound care is required. NICE (2004), state that a newly developed wound should be investigated by a multi-disciplinary foot care team within 24 hours. The team would be expected to undertake a comprehensive assessment and develop a management plan based on best evidence, but also tailored to meet the needs of the patient.

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