Background
Methodology
Ethics
Sampling, recruitment, and data collection
Participant Pseudonym and highest qualification | Age | Years registered as a podiatrist | Current practice |
---|---|---|---|
Alice (BSc) | 55 | 20 | 100% private practice from 2001 – General podiatry |
Beryl (BSc) | 40 | 19 | 50% private: 50% NHS – General podiatry and musculoskeletal speciality |
Cathy (BSc) | 52 | 31 | 100% private practice between 2 shared clinics – General podiatry |
Donna (BSc) | 39 | 18 | 40% Private: 60% NHS – General podiatry and diabetes speciality |
Eddie (BSc) | 52 | 23 | 60% private: 40% NHS – general podiatry and musculoskeletal speciality |
Fran (MSc) | 37 | 16 | 20% private practice: 40% any qualified provider (AQP) podiatry service: 40% NHS management. General podiatry and high-risk podiatry speciality and research |
Georgina (BSc) | 31 | 10 | 100% NHS – general podiatry |
Heather (BSc) | 55 | 34 | 100% NHS – general podiatry |
India (BSc) | 48 | 27 | 100% NHS – new patient assessments and health promotion speciality |
James (BSc) | 28 | 7 | 100% NHS – general podiatry and musculoskeletal speciality |
Participant Pseudonym | Age | Years registered as Chiropodist/podiatrist | Current practice |
---|---|---|---|
Kate | 50 | 25 (hands on practice) 5 years 100% management | 100% NHS podiatry management. Clinical background in paediatric biomechanics |
Leonard (MSc, PhD) | 57 | 36 | 70% NHS management 15% academic role 15% other consultancy work and research |
Martin (MA) | Un-disclosed | Un- disclosed | 100% academic management and lecturing with a history of high risk and general podiatry |
Naomi | 22 | Pre-practice | |
Olivia | 25 | Pre-practice | |
Paul | 42 | Pre-practice | |
Queenie | 35 | Pre-practice | |
Rachael | 33 | 5 | 100% podiatry lecturing after 3 years 100% NHS practice – general podiatry |
Participant pseudonym | Professional role |
---|---|
Viv (BSc) | Band 6 district nurse |
Yvonne (BSc) | Band 6 district nurse |
Steve (MSc) | Band 7 High-Risk podiatrist and NHS podiatry team leader |
Alexa (BSc) | Pre-practice podiatry graduate |
Zena (BSc) | Pre-practice podiatry graduate |
Trevor (BSc) | NHS podiatry services manager |
Warren (MSc, PhD) | Professional association representative with history in high-risk podiatry specialism |
Ursula (MSc, PhD) | Vascular Nurse Specialist and Academic |
Data analysis
Results
Main Themes | Current practice | Identity | Time |
Sub themes | Talking the talk Venous disease is not in the podiatry veins | Foot focussed Life and sole Inter-professional identity Priorities | Constraint or opportunity? Time is routine |
Main Themes | Autonomy | Education | Venous disease in health care |
Sub themes | Money is power Follow the guidelines | Undergraduate education Waiting for champions Theory–practice mis-match | Who does what and when |
Current practice
We don’t do any tests for that as such but if they’ve got bad skin or venous changes I still give them advice, (Georgina, NHS podiatrist)I mean obviously if there’s a potential problem developing then (I) usually give advice, even things like maybe suggest they ask about the support stockings, things like that (Alice, private podiatrist).
I think from the advice that I’ve heard, like put your legs up, but no, nothing that’s structured that I could take away and think “oh that, that were really good” (Naomi, pre-practice podiatry graduate).
Beryl palpated the pulses of patients whilst asking about current foot problems and preparing to start treatment. For many patients there were signs of venous disease in the form of telangiectasia and oedema yet this was not commented on or apparently investigated any further. (Beryl, private podiatrist, observation notes).
They’ve [podiatrists] done a fantastic movement in the line of solving, or helping to solve a problem of peripheral arterial disease. Well that’s tiny numbers compared to venous disease and soft oedema. (Ursula, vascular nurse specialist and academic, focus group).This is the sleeping giant and actually proportionately, it is probably a major amount of our patients, but it’s not being reviewed, looked at or otherwise. (Martin, podiatry academic).
I would ask the nurse to do the venous assessment, but I don’t even know if that’s their role, I’m not sure on that one. It’s a grey area. Hmm. I’m not sure. (Donna, private podiatrist).…we’ve got a problem when you get to management but we’ve got a bigger problem in terms of awareness and prevention… nobody treats soft oedema of a lower leg, everybody goes, “ooh that’s nice and soft isn’t it?” and walks away from it and waits for it to ulcerate. (Ursula, vascular nurse specialist and academic).
Identity
…it seems to be as well that other people leave it to podiatrists, other healthcare professionals, if it’s anything below the knee, even though we cover further up but, “oh podiatrist’ll sort that out” (Paul, pre-practice podiatry graduate).…we just associate podiatrists with feet, we don’t see what other skills you’ve got. (Yvonne, district nurse)
…sometimes if they needed some stockings or anything, I might tell them to see their nurse. So I still look at venous, and still be aware of them. (Georgina, NHS podiatrist).…but it’s like when you’re faced with a patient with venous problems, I think, other than observational signs, and referrals, what are we doing? (Rachel, podiatry academic).
(I am) The counsellor (Beryl, private podiatrist)
In between appointments Fran told me, "the other nice thing in private practice is that patients come for a chat and are coming for counselling really." (Fran, private podiatrist, observation notes).Sometimes some patients come in and pour everything out to us and you do end up talking more about different things (Georgina, NHS podiatrist)
Time
What I found when I worked in the NHS was I never really looked above the knee. I never looked at them [Patients]… I never really took any notice, because I didn’t care, I didn’t have enough time to care. I was just doing my job. (Cathy, private podiatrist).
… it’s probably three times longer in time than a GP consultation that a podiatrist gets with a patient, so the opportunity to discuss your long-term conditions, your actual general medical health that impact on your foot health is a great opportunity but I don’t think it’s used at all. (Fran, private podiatrist).
I think the podiatrist’s got a big role to play in terms of health promotion and education and I don’t think we do that, I think the patient sits down, people pick clippers up and cut their nails even if they don’t need doing. (Fran, private podiatrist).
Autonomy
I think they feel that they’re paying so they come in and they’ll tell you what they want and you’ll do what they want (Fran, private podiatrist)Because ultimately we’re paid to do things that the Commissioners tell us to do, either via a block contract or an add-on, and if it lies outside of that we don’t get paid, and I suppose that, that in itself is a big driver… (Kate, NHS podiatry services manager).
The diabetes pathway is promoted strongly by NICE (National Institute for Health and Care Excellence) and there’s so much to go wrong that deviating from that pathway, you are putting your future career at risk (Leonard, NHS podiatry services manager and academic).Is it not all NICE guidelines and stuff like that, we have to meet NICE guidance with regard to certain side of our profession and certain things have been thrust upon us…(India, NHS podiatrist).
(there is a) lack of pathway or an assessment or a pathway that would prompt you. We’ve got pathways for claudication, all the ischemic pathways, all the foot ulcer pathway, but there’s no venous escalation methods that I know of. (Donna, private podiatrist).I can see the benefit in doing that to prevent problems further down the line. It’s not there at the moment, and I think if we had enough evidence and I think if it came in a more directed way through our Commissioners then we probably would be going down that route. (Kate, NHS podiatry services manager).
Education
I did physiology within the system. Causes of venous problems, I got that. The usual sort of DVT, pregnancy, that sort of thing. it wasn’t a huge part of the syllabus, it was in there…(Eddie, private podiatrist).
I think they [students] lack the ability to have a good general medical knowledge and I think that sometimes that can affect our profession. That’s where the, “oh you only cut nails”, comes from or the view or the vision of what a podiatrist does and I think there should be more core medical training as an undergraduate. (Fran, private podiatrist).How they train students now is different to how they trained students when I was training which was thirty years ago this year and I do think students tend to kind of cut off at the feet and not think much more than the feet sometimes, they don’t think about the patient…(Heather, NHS podiatrist).
You need the right champions pushing it forward, you need the right enthused person to keep pushing it. (Steve, high risk specialist podiatrist and NHS podiatry team leader, focus group).So maybe it’s because I’ve not read around it, I’ve not ever seen anything as an article about venous supply and the complications of it so it’s not ignited my imagination much (Beryl, private podiatrist).
It was covered but I think then because notoriously…it’s like you don’t use it you lose it…. We have actually put an update on, on peripheral arterial disease and we were questioned on the veins and we all struggled as a department. We could all label all the arteries but not the veins (Donna, private podiatrist).