The background to this debate is a meeting I had with a number of local podiatrists representing the Royal College of Podiatry, so let me thank them for the briefing that the royal college has sent me. I want to talk about the development of a workforce strategy for podiatry.
To explain for those who may take an interest in the debate, podiatrists are highly skilled healthcare professionals. They are trained to assess, diagnose, prevent, treat and rehabilitate complications of the foot and lower limbs. They manage foot, ankle and lower-limb musculoskeletal pain, and skin conditions of the legs and feet. They treat infection, and assess and manage lower-limb neurological and circulatory disorders. They are unique in working across conditions and across the life course, rather than on a disease of a specific area.
A podiatrist’s training and expertise extends across population groups to those who have multiple chronic, long-term conditions, which place a high burden on NHS resources. The conditions largely relate to diabetes, arthritis, obesity and cardiovascular disease. In addition to delivering wider public health messages in order to minimise isolation, promote physical activity and support weight-loss strategies and healthy lifestyle choices, podiatrists keep people mobile, in work and active throughout their life. They contribute to the wellbeing of our economy and workforce.
Podiatry is intrinsic to multiple care pathways too, and podiatrists liaise between community, residential, domiciliary, secondary care and primary care settings. They specialise in being flexible and responsive, ensuring focused patient care, irrespective of the clinical setting. Podiatrists are at the forefront of delivering innovation in integrated care. They deliver high-quality and timely care, as well as embracing safe and effective technologies that lead to improved patient outcomes.
The role of podiatrists in managing diabetic foot complications is key. They play a vital role in the prevention and management of diabetic foot complications, which, at the last estimate, cost the NHS in England £1 billion a year. In the three-year period from 2017-18 to 2019-20, there were over 190 minor and major amputations per week in England. Of the people affected, 79% will be confined to one room within a year, with 80% tragically dying within five years. That is a shocking outcome for patients, and it is even worse than the outcomes for the majority of cancers we seek to deal with.
The impact of lower-limb amputations on patients’ quality of life and chances of survival are shocking, so we must do everything we can to prevent diabetic foot complications. We have to act in a timely and targeted manner to ensure that people have the best possible chance of living long and fulfilled lives.
It is estimated that by 2025, 1.2 million people with diabetes in the UK will require regular podiatry appointments if they are to remain ulcer, infection and amputation free.
What I have discovered on my journey of finding out about podiatry, which I knew very little about before I met podiatrists in my constituency, is that of course people need professional care, and that care needs to be properly funded. There are volunteers, but we should not have to rely solely on volunteers; we need professionals leading the way. Podiatrists are skilled and trained in the prevention and management of diabetes-related foot complications. That is why many of us believe that they must be at the heart of the NHS plan to eliminate unnecessary amputations and the consequent avoidable deaths.
As I said, the broader cost of diabetic foot ulcers to the NHS is more than £1 billion per year—the equivalent of just under 1% of the entire NHS budget. Effective and early intervention for diabetic foot complications prior to ulceration could save thousands of lives and millions of pounds each year.
The situation in my area in Hillingdon exemplifies what is happening elsewhere in the country, which the hon. Member for Strangford (Jim Shannon) has mentioned. Hillingdon’s community podiatry service is part of the Central and North West London NHS Foundation Trust. It is suffering from severe workforce issues, which is having a detrimental effect on the people delivering the service and those suffering from foot ulceration, infection and amputation.
The service is currently failing to meet its timescales for seeing patients at high risk of developing a foot ulcer. What should be a team of 13 clinical podiatrists is now just 3.5 full-time equivalents and three support workers. The immediate concern is the pressure that puts on the staff who remain and the impact it has on the patients who need a minimum of weekly wound re-dressings to enable healing and prevent infection and life-changing amputation. The opportunities to prevent life-changing and life-threatening complications are minimised by the shortage of staff.
We also have concerns that support workers are being asked to triage and treat people beyond their scope of practice due to the staff shortage. That is not a criticism of them, but it is the reality. We should be filling the service with professionals who are fully trained to deal with the range of complications that they might come across. The workforce challenge facing podiatry is the real issue.
There is a need for focused recruitment. As I said, it is estimated that by 2025, 1.2 million people with diabetes in the UK will require regular podiatry appointments if they are to remain ulcer and amputation free. In the absence of that, there will be a greater risk of premature disability and death. There are currently just under 10,000 podiatrists registered with the Health and Care Professions Council. That is just one per 5,500 residents in England, and that number is due to decline as a result of demographics.
Following the removal of NHS bursaries for student podiatrists in 2016, the number of undergraduates studying podiatry has declined by 38%. Prior to that, the student bursary was set at £9,000 a year and it covered the cost of tuition for a year. In 2020, in a welcome move, the Government reintroduced student bursaries, but at £5,000. That has caused a slight improvement in recruitment to the profession, but it falls far short of ensuring the future of the podiatry workforce that will be required to deal with the oncoming wave of severe diabetic complications coming out of the pandemic.
Another issue is that the average age of podiatry students on graduation is 32. The majority of students are pursuing a second degree, and the need for a second student loan is having a damaging impact on universities’ ability to recruit undergraduates to train as podiatrists. By leaving it up to the market, we face the prospect of not training the workforce required to meet the needs of an ageing population.
The other issue raised with me is the limited career progression in NHS settings. Of the podiatrists currently qualified in England, approximately 40% work in the national health service. It is projected that many of those podiatrists not heading for retirement are likely to move to work in the private sector in the next five years. The reasons cited for that include lack of career development opportunities; repetitive workloads, with limited skill mix; and high demand and low capacity to meet it, leading to what people consider are unsafe staffing levels and to staff burnout.
Expansion of the podiatric workforce across primary, community and secondary services may address some but not all of those issues. Support for workforce growth is critical, but support for those already qualified to progress to advanced clinical practice and consultancy is also critical to workforce retention and ensuring adequate capability in senior clinical, leadership, education and research roles.
We need policy to ensure closer working across providers and the delivery of a foot health strategy. There is significant opportunity to expand the foot health workforce to include non-registered roles, supported by qualified, expert podiatrists. There is also opportunity to consider alternative workforce models that are inclusive of podiatrists working in private practice or the wider foot health workforce in the third and voluntary sectors, for example. A clear workforce strategy is desperately needed now. It needs to explicitly underpin how the foot health workforce is optimally configured, funded, implemented and trained and what the core outcomes of foot health services must be to meet the needs of our future population.
Currently, there is no workforce strategy, no clear statement of aim, and no standardised set of core outcome measures informed by public health or policy. Clear foot health policy is urgently needed to maximise all the benefits that podiatry can offer across an integrated care system, before the profession becomes—as we predict it will—unsustainable, with staffing levels even more unsafe and avoidable patient harms, amputations and deaths relating to lower-limb disease rising dramatically.
I therefore have three key asks. First, I ask the Government to reinstate the £9,000 bursary for student podiatrists. If podiatrists are to be able to support the millions of people who will require their expertise, the Government must reinstate the full podiatry student bursary of £9,000 a year. That is essential if the workforce is to be secured and expanded for future generations. In the absence of long-term funding confidence, allied health professions such as podiatry are unable to commit substantial and consistent investment towards maximising recruitment and retention, both of which will be crucial in securing the future viability of this vital profession.
My second ask is for national collection of podiatry vacancy rates and inclusion of podiatry in workforce planning. Publishing a national workforce plan that considers future need for allied health professionals such as podiatrists must be a priority for the Government. That plan must take into account current trends in recruitment and retention and, for future needs-based public health, comorbidities and their impact on disease prevalence. A national workforce plan will also act as a crucial evidence base for the allocation of long-term workforce funding.
My third ask is for the guidance on integrated care system membership to be strengthened to include allied health professionals. The absence of national guidance or recommendations regarding which organisations and individuals should be included in integrated care partnerships has resulted in a patchwork of involvement for allied health professionals, including podiatrists, in integrated care decision making. Without their meaningful engagement in those discussions, there is a danger that the invaluable contribution podiatrists can make to the delivery of care might simply be overlooked. Strengthened national guidance on the make-up of integrated care partnerships, to include representation of allied health professionals such as podiatrists, should be developed and implemented at the earliest opportunity.
I conclude by thanking the professionals who work in my constituency, as well as those who work nationally. I recognise the pressures they are under and the valiant way that they cope with them.