Feet that were On The Street

Providing NHS Podiatry Services to Rough Sleepers

in Central London

How it was and reflections on the new normal

Healthy Feet for All!

Alison Gardiner BSc MChS HCPC RegSpecialist Podiatrist for Homeless and Vulnerable PeopleCentral London Community Healthcare.

• Introduction

• Foot Facts

• Common foot problems

• Rarer foot conditions

• Diabetes and Feet

• Central London Community Healthcare homeless podiatry service

• Why are homeless people prone to foot problems?

• Case Studies

• The new normal ????....

• Take home messages

• Contact details

• Useful links

Foot Facts• The foot contains 26

bones, 100 ligaments, 33 joints & 20 muscles

• The average person walks 4 miles every day

• Feet produce an eggcup full of sweat every day…

Some common foot conditions...

Corns and calluses (plantar, interdigital , dorsal)

Toe deformitiesClawed, hammer, mallet, overriding, burrowing,polydactyly, syndactyly

Verruca

Bunion

Fungal skin infection

Fungal nail infection

Cracked heels

Infected ingrowing toenail

Flat Feet

High arched feet

Trench FootAdvise to air feet, leather shoes, change socks

Blisters

Less common foot conditions Malignant melanoma and tuberculosis

Diabetes and Feet• 3.9 million people are currently living with a

diagnosis of diabetes. In addition, there are almost a million undiagnosed bringing the total number up to more than 4.8 million. (Diabetes UK)

• Black and ethnic minority groups higher rates

• Social exclusion/ deprivation/ mental health problems/learning difficulties higher rates

• Most common cause of amputation of the lower limb in the UK

• 169 amputations a week in UK (2018) Diabetes UK

Diabetes can cause• Peripheral neuropathy• Peripheral artery disease• Ulceration, infection, gangrene

and amputation

This can be PREVENTED by• Good diabetic control• Diabetic foot health education• Yearly neurovascular foot

assessment by nurse, gp, podiatrist

• Quick access to podiatry/healthcare

Diabetic foot ulcers

May be painless if feet are numb

Central London Community Health Care

Homeless Podiatry Service

• Alongside nurse led CLCH Homeless Health Team provision

• Easy access. Drop in• 5 sessions a week in homeless day centres• Good links with specialist pods in mainstream• Westminster and Hammersmith & Fulham• Hostel visits for housebound• Foot health promotion/screening in day

centres/hostels• Training for hostel/day centre staff• Promote access of vulnerable people to mainstream

service. Training for pods in mental health, working with interpreters etc. Undergraduate placements and teaching University of East London

• Vulnerable Podiatry SOP (Standard Operating Procedure)

Why are homeless peopleso prone to foot problems?

• Alcohol. Peripheral neuropathy, increased risk of diabetes and osteoporosis, poor immunity, assault, accidents. Wernicke Korsakoff Syndrome

• Drugs. Infection of injection sites, thrombosis, HIV, mishits into femoral artery/vein, chaotic lifestyle

• Sleeping on buses/benches. Peripheral dependent oedema

• Asylum seekers. Conditions rarely seen in UK. Polio, TB, leprosy, rickets, polydactyly, untreated talipes(club foot), industrial/agricultural accidents, torture

• Carrying heavy bags• Increased risk of diabetes & diabetic complications.

• Finance. Lack of money for well fitting shoes, socks and clippers, cheap shoes man made materials. Pulling off nails, sharing clippers.

• Not removing shoes/socks at night. Fear of theft, self neglect, need move quickly, constantly ‘on the go’. Trench foot. Fungal infection, blisters

• Self treating due to lack of podiatry access with blades, knives, acid based corn plasters. Ulceration. Infection and scarring

• Smoking• Sharing showers. Verrucae• Walking long distances. Stress. No choice! Blisters,

biomechanical problems

• Mental health issues resulting in self neglect. Difficulty engaging with workers.

• Difficulty in maintaining good hygiene. Scabies, infections (fungal, bacterial and viral)

• Exposure to elements. Cold/wet/heat• Poor nutrition. Poor healing and infection• Difficulty accessing healthcare and podiatry

• Non referral • Support to attend appointments not in place.

Discharged• Banned from services due to behavior• Perceived or actual insensitive treatment by

medical staff / receptionists• Embarrassment, Language barriers• Illiteracy . No glasses• No internet access• Maslow’s Hierarchy of Need

CASE STUDIES

CLCHHomeless Podiatry Service

• 39 year old male

• Alcoholic, multiple drug user

• Fracture left leg at 24, no physio, led to clawed toes & plantar corn

• Self treated corn with razor blade

• Infection & hospitalisation

• Corn removed, advice, physio/orthopaedic/podiatric surgery referral, orthopaedic shoes, insoles?

• 50 year old male

• NIDDM, peripheral neuropathy, heart disease

• Neuropathic foot ulcer, Charcot foot . MRSA infection

• Dressings, deflective padding, swabs, specialist advice, post op sandals.

• Now under specialist diabetic podiatry team and housed.

• Foot healed

• 50 year old male

• Mycotic thick toenails could not cut

• Intravenous drug user now on methadone

• Now stable on methadone in hostel

• Nails later treated with Terbinafine tablets. Now able to self care

• Alcoholic male 55

• Poor memory

• Shoes and socks not removed for 8 months

• Trench foot got worse when in hostel! Refused to go into hospital for IV antibiotics

• Deceased- pneumonia

• Also hand dressed

• New stick

• New shoes!

• Male 63• Frequent hostel

evictions. Revolving door prison/street/hostel

• Alcoholic, Wernicke-Korsakoff Syndrome, epilepsy. PVD, heavy smoker

• Fracture right ankle age 15, not set at time!!!! Walks on side of foot

• Infected ulcer right foot. Trench foot

• Not able to attend appointments or follow advice due to Korsakoff’s. Never took off shoes/socks. Not suitable for surgery. Ulcer dressing and redistributive padding. Antibiotics. Orthopaedic shoe referral difficult. Now in a home

• Elderly male• Diabetic, schizophrenia• Slept rough in Hyde

Park many years • MDT work with Joint

Homeless Team and nurse from Great Chapel Street

• Shoes/socks never removed

• Very flexible podiatry• Leg ulcers with

maggots• Hospitalised• Now in a home

What lies ahead?...• Pandemic – Day Centre closed and reduced community

podiatry service currently in CLCH. Emergencies only and telephone consultations but moving towards opening clinics. Probably the same pan London.

• Possible covid related foot conditions? ‘Covid Toe’

• I am on call for homeless in CLCH any time. • Be alert for serious foot complications for high risk patients.

Immunocompromised, peripheral artery disease, peripheral neuropathy

• How will ex rough sleepers in hotels/hostels access podiatry?• Role of homeless podiatrist from August?

TAKE HOME MESSAGES!• THINK FEET. What could be going on in my

clients shoes?

• Be DIABETES AWARE. Is my diabetic client getting annual neurovascular foot checks? If you are a nurse consider updating skills to perform a diabetic foot assessment and give diabetic foot care advice, ensure access to the necessary testing equipment.

• Provide SUPPORT FOR SELF CARE AND PREVENTION– socks, shoes, nail clippers, bathing, attending appointments

Contact Details

Alison GardinerSpecialist Podiatrist for Homeless and

Vulnerable People

Central London Community Healthcare

agardiner@nhs.net

Tel: 07789777498

From 21.8.20 contact - Trusha Coward CLCH Podiatry

Service Diabetes Clinical Lead trusha.coward@nhs.net

Useful links• Society of Chiropodists and Podiatrists (Common foot

problems) http://www.scpod.org/foot-health/common-foot-problems/

• Diabetes UK https://www.diabetes.org.uk/Guide-to-diabetes/Complications/Feet/Taking-care-of-your-feet/

• CLCH Podiatry Service (Mainstream) www.clch.nhs.uk/services/podiatry-(foot-health)

• QNI guidance – New guidance about to be published. More detailed information on prevention and treatment of the conditions discussed in this presentation.

• Pathway, https://www.pathway.org.uk/faculty/standards/

And finally…..I’d like to take this opportunity to shamelessly promote the next phase of my life….as an artist! (But thanks for

all the feet – as Douglas Adams would say)Do keep in touch via Instagram - alison.gardiner.art