aged 18 or over
able to give consent to participate in the study
working within one of the 2 predefined project zones
confirmed consultant diagnosis of rheumatoid arthritis (RA patient group)
or confirmed medical diagnosis of osteoarthritis (OA patient group)
have lived experienced of foot problems
currently employed as an NHS Commissioner
employed NHS General Practitioner
unable to speak English
unable to understand English
aged under 18
unable to give informed consent
inflammatory arthritis diagnosis, other than rheumatoid arthritis
unable to cognitively participate in focus group discussions
unable to cognitively participate in telephone interviews
Focus group 1
Focus group 2
Focus group 3
Focus group 4
Number of Participants (female:male)
Number of Participants (female:male)
1. Systems working together
/ Navigation of care pathways
• Referral and access to podiatry/foot care for people with RA and OA
• Different systems and service configurations for podiatry in the NHS: musculoskeletal and diabetes services
• Commissioners as ‘brokers’ to achieve more productive collaborations
• Education on what the podiatry / foot care services provide for people with RA or OA.
• Variations in cost effectiveness of podiatry services
• Split systems of care (community v acute)
• Guilt at wasting resources
3. Understanding what podiatry services have to offer
• Right person, right place at the right time
• Podiatrists as leaders of foot health services
• Service requirement in relation to training standards to meet care needs
4. Person factors of foot pain
• Arthritis is invisible as people do not complain
• Foot pain affects quality of life, physical and mental wellbeing
• Traditional clinical approaches encourage dependencies
5. Facilitators to foot care
• NICE guidelines
• Stakeholder events
• Increase focus on supporting self-management strategies
Theme one (systems working together)
“… a GP has to be jack of all trades and master of none, really, haven’t they? Because they’ve got to be able to pick up anything from anybody and then know where to transfer them”. (Patient-code- LP1).
“It’s still the initial reluctance to get somebody to actually physically want to take your sock off and look at your foot. Because the minute you mention foot, faces glaze over”. (Patient-code- S3).
“Well, we don’t really have one stop shops. We’ve got lots of specialists”. (Patient-code- LP11).
“Yes, I think also having a condition that affects your mobility has a big impact on your health and wellbeing overall. So, you may then, like you mentioned be reluctant to leave your home, then you’ve lost that social engagement if you don’t... perhaps you live on your own then loneliness becomes an issue. So, and then that has another impact on social care services too. So, mobility I think and we all take our mobility completely for granted don’t we. But I think it really can have a huge impact.” (Commissioner – code-5).
‘I think your point about social elements of healthcare is really important, because we do see that in some services. That actually, there’s a significant social element to what we’re paying for, as it were. So, I think where health and social care has been so divided over such a long period of time; that real kind of, that’s your money. That’s our money. The whole pooling of budgets has never really worked.” (Commissioner – code- 4).
“Podiatrists have got the complicated stuff. I rely on them to tell me what they think is the most important things they have to do.” (Commissioner-code-1).
Theme two: finance
“For me, everything has a spectrum and I think it’s about outcome, it’s not about service. So I don’t think for me, it’s less about what you buy; it’s more about the outcome that you’ve bought for the patient. So, in that instance, if the outcome was the patient needs to be able to walk to the shops, because it’s really important. And actually, that’s a big part of loneliness and isolation and that gets into that bit around actually, what’s the health and wellbeing objective for this person?” (Commissioner-code – 4).
“One of our providers is more cost effective than the other. Using their podiatrists, a lot more productively than the other.” (Commissioner – code-3).
“I will chat with them (patients who have arthritis) and not routinely refer due to the limited resource of podiatry.” (GP-code-1).
“I don’t know if it’s good value for money. I wouldn’t say the relief was enormous. It is just more comfortable.” (Patient-code-SP4).
“I would rather have more nail care appointments rather than shoes that don’t fit” (Patient-code -LP18).
Theme three: understanding what podiatry services have to offer
“… someone who was qualified. If you got somebody who is not, you might as well do it yourself.” (Patient-code -LP2).
“I suppose it looks as though I’ve been very fortunate in the way I’ve been treated. I started in 1961 so it’s a long time and in that time I have seen consultants and when they felt I was ready for something to be done with my feet I was referred to podiatry and orthotics so I feel I’ve been well cared for even though the problem of making the shoes takes the time but in the end I get them but I do see having a one stop”. (Patient-code-LP5).
“They’re very skilled professionals in dealing with foot problems I suppose. But they cover a wide variety of things. I mean obviously there is the medical stuff, the diabetics and there’s the more mundane stuff, such as toenail care and things like that and surgery for ingrown toenails. And then there’s all the way through to management of fungus and toenail, toe deformities and management of things like toe fasciitis at the same time designing custom orthotics. So, the bio-mechanical problems, bio-mechanical assessments in patients …. that sort of thing”. (GP-code-1).
“I think they’ve [podiatrists] got the complicated stuff. And I’m not a podiatrist so I wouldn’t be able to say to you that’s that and that’s that, I rely on them to tell what they think is the most important things that they have to do”. (Commissioner-code-1).
“… well after listening to everybody today [talking about who they access for foot pain] I’m not so sure because I am confused in my own mind who does what, for what reason and what purpose. So, I would have to say I’m totally unclear.” (Patient-code LP13).
“… a lot of us don’t know the difference between the names of people have because before we would have seen a chiropodist, now chiropodists don’t exist but if you don’t know who you’re supposed to be seen for what is wrong with your feet, how do you even start. The terminology is very confusing”. Patient-code-LP7).
Theme four: person factors of foot pain
“if you’ve got a problem with your feet, it’s awful if you can’t walk. There’s so much you can’t do.” (Patient-code SP3).
“If your feet don’t work or they are painful it impacts on the whole quality of your life from what you do recreationally, socially, work if you are still working. It impacts on everything. NEW SPEAKER: It’s a psychological impact not being able to wear a nice pair of shoes”. (Patient -code-LP6 &7).
“If your feet don’t work or they are painful it impacts on the whole quality of your life from what you do recreationally, socially, work – if you are still working. It impacts on everything.” (Patient-code-SP1).
“Nobody understood because they can’t see it [foot pain/arthritis], the broken leg can be seen”. (Patient-code LP4).
“What you were saying, one thing that I don’t think people that don’t have arthritis realise is the pain you can be in. They don’t appreciate the excruciating pain you can have and how debilitating it and tiring it, if you’re taking tablets it can make you sleepy or woozy or upset stomachs. People that don’t have arthritis don’t realise what you have to go through sometimes on a daily basis … .. when I go to the golf course my friends think it’s funny I’ve got a pocket full of tablets … .they have got a headache I’ve got drugs. I never leave the house without pain killers. And I don’t think they appreciate the amount of pain they [people with arthritis] can be in. She’s a bit grumpy this morning; I can’t move I’ve got pain”. (Patient-code-SP3).
“The pathway service is monitored through the level of complaints … no complaints from people with arthritis … therefore the arthritis foot doesn’t get anywhere near as much support because we’re never asked to.” (Commissioner-code-1).
Theme Five: facilitators of foot care
“We’re struggling to buy new things that are about lifesaving cancer drugs, let alone preventative healthcare. Even though it’s ridiculous because that’s where we should be investing, but when you’ve got the immediate problem in front of you for this year; it’s that burning platform issue isn’t it? I’ve got to put this fire out, I haven’t got a choice. But actually, it wouldn’t have even started if we’d have invested further up the pathway.” (Commissioner-code-2).
“it’s a big shock particularly for people who have had very paternal relationships with clinicians, you know, where, you know “tell me what to do, oh its lovely to see you again, how’s your mum” you know all this sort of thing, as opposed to actually, “Well, what did you do? How are you going to get out of this? What are your options? What do you think of these options I’m giving you?” (Commissioner-code-1)
“Everybody. We’ve had multiple stakeholder events, patients, carers, clinicians, all come together, some separately and sometimes together. Our partner organisations like Age UK … , we’ve run public forums where they’re talking next time about the acute service redesign, so everybody has an input. It takes it slower, but it gives people longer to think about things. We’ve been working on ‘my life, a full life’ now for … quite a few years.” (Commissioner-code-1).