By Mark Hinkes, DPM.
Patient throughput is a pain point for many health care systems worldwide. In the US, when a patient with diabetes wants an appointment for foot care, they merely call the podiatrist’s office and ask for an appointment. Those patients who pay cash, have Medicare or PPO insurance (assuming the provider participates) usually have no problem with coverage. Those patients who have HMO insurance may not have the luxury to go “out of network,” and therefore may not be able to receive your care. Not only are there constraints on access by payor, but the time frame in which a patient may get access to care can vary. Several other questions for practices arise even after addressing payor issues. Is the patient new to the practice or requesting a follow-up appointment? When is the next available appointment? Is the nature of the visit emergent? In any case, access to care is usually achieved in a reasonable time frame.
In the US, we often take the ease of scheduling an appointment with a podiatrist for diabetic foot health care for granted. But scheduling an appointment in health care systems in other countries can be lengthy, complex, frustrating, and can result in unintentional tragedies. Some health care systems are not fine-tuned for patient throughput and patients with diabetes may become subject to a series of what might seem unreasonable bureaucratic steps that delay care. All too often, the delay in accessing care means that a problem that was at one time non-acute becomes critical and may require hospitalization or even result in an amputation.
Challenges to Foot Care in the UK: One Patient’s Story
Here is a story about a typical experience of a patient in a bureaucratic single-payor system that has a pain point with the issue of patient throughput. James is a 65-year-old male with type 2 diabetes and obesity. His blood sugars ran slightly elevated over many years and despite the recommendations of his primary care physician, he pretty much ate what he liked and used tobacco without regard to the long-term effects on his health. His attitude was quite cavalier. “Whatever it is, it won’t happen to me,” was his mantra. He lived a life of denial.
He recently developed a “sore” on the bottom of his right foot and only realized he had developed an ulcer when he saw blood and some exudate on his sock. Thinking the problem would heal itself in due time, he opted not to go to his primary physician, but instead to “give it some time to heal on its own.”
After waiting for a month, he realized the ulcer was not going to heal and in fact, a wound that was the size of a dime a month ago was now the size of a quarter and much deeper than he remembered. The development of redness and tenderness in his foot was the catalyst that made him ask for an appointment with his physician.
James lives in England and his health insurance is paid for in his taxes, so he, along with an avalanche of people, receive their health care from NHS England with no charges, deductible, or co-pay. Often times the demand for care is higher than the system is able to support and this is where patient throughput becomes an issue.
It is important to understand the cycle of events that James went through for an appointment to see a podiatrist. James first needed to get an appointment with his primary physician for an evaluation. That could take up to 14 days. If the primary physician felt unable to treat his ulcer, a consultation referral would be made by an acknowledgement letter (no phone call, no email, but by a letter!) to a podiatrist. Another 14 days could pass before acknowledgement of the consult request. Once identified as needing podiatric care, the actual appointment could be delayed for another 4 to 6 weeks. So, James could wait/in the queue for 8 to 10 weeks before he gets access to care. The longest a patient will wait from the time they are referred to the primary physician and before starting any podiatric treatment could be 18 weeks, or well over 4 months! (1)
James was eventually seen by a podiatrist and later hospitalized for treatment of his infected ulcer, which led to a below-knee amputation of his right leg.
The Pain Point: Where Can Change Begin in Patient Throughput?
The scenario James experienced has likely played out for thousands of people needing foot health care from NHS England. James was not alone. The most frustrating result of throughput issues is that patients are stranded in the queue and care is delayed. It is quite likely that had these patients been seen more promptly, their foot health issues may not have required treatment of complications requiring hospitalization, and in some cases amputations, both of which generate increased expenses.
The facts are that around 2 to 2.5 percent or around 60,000 to 75,000 patients with diabetes in England have an ulcer in any given week. There are over 7,000 lower limb amputations in people with diabetes in England each year, and the likelihood that someone with diabetes will have a leg, foot, or toe amputation is around 23 times that of a person without diabetes. Every year, approximately 8 out of every 10,000 people with diabetes undergo major lower extremity amputation (above ankle), and 18 out of 10,000 have a minor amputation (below ankle). (2)
A Partial Solution – Facilitating Patient Throughput Using a Digital Health Tool
While there has been significant progress in identifying at-risk patients and facilitating their entry into the system for medical care, NHS is working with one company who has led the way with a unique digital tool to facilitate patients’ throughput and more prompt access to foot health care. Their efforts have accelerated a change from using 19th century methods to a 21st century solution to one aspect of the problem of patient throughput.
To address the patient throughput issue to podiatry services that would lead to better access to care, NHS is working diligently to resolve the problem with Infotex, a London based digital health company. Infotex designed a digital self-referral tool for patients who would like an appointment with an NHS podiatrist that literally lets them skip the process of an appointment with their primary physician, saving 28 days of waiting time in the queue. The tool prompts patients to answer a series of questions and asks for a photo of their foot. A podiatrist at NHS reviews the documentation and decides on the nature of the foot problem, the immediacy / necessity of care, the type of care needed, and the location of the care.
The Infotex tool thus facilitates patient throughput by removing one time-consuming step in access to care. It expedites care by directing the patient’s request for foot care directly to a podiatrist who evaluates the request and refers the patient to the appropriate provider. It will be interesting to see how this tool impacts patient outcomes in England and what other countries, like the US, can learn from its results.
Dr. Mark Hinkes is a Doctor of Podiatric Medicine who recently retired from clinical care after 40 years’ service. 20 years in private practice in Miami, FL and 20 years at the Veterans Affairs Medical Centers. In Nashville, Tennessee he served as the Chief of Podiatry Services and Director of Podiatric Medical Education. He has been the Chairman of the Preservation Amputation Care and Treatment (PACT) Program for over a decade.
1. Personal communication with Deborah Keating, Head of Sales, Infotex
2. Improving footcare for people with diabetes and saving money: an economic study in England (PDF) Diabetes UK. Available here . Published January 2017. Accessed April 20, 2022.