December 2024

“POCUS is the use of limited ultrasound (US) protocols performed at the patients bedside to assess a wide range of clinical conditions. This is distinctly different to the Sonographer and Radiologist delivered departmental studies which require many years of training and experience to provide a systematic structured assessment” ( Clare 2022)

In line with the statement above by Dr Sarbjit Clare MBE, Consultant in Acute Medicine and Deputy Medical Director, Sandwell and  West Birmingham Hospitals NHS Trust, in her seminal publication Ultrasound for the Generalist (Clare S and Duncan C., 2022), the Institute of Podiatrists recognises the enormous potential that POCUS has to aid the Podiatrist in point of care clinical decision making. In this respect the IoP view POCUS in the same category as other clinical point-of-care practitioner information tools such as using a vascular doppler, a 10g monofilament, a stethoscope or a 128Hz tuning fork (for example).

The tools that podiatrists use in their day to day practice have evolved over the years and continue to evolve. With every evolution the requirement for a podiatrist to understand their tools is a given and must be taken as an obligation, not least in respect of the necessity to be fully compliant with the legal standards laid out by the Health and Care Professions Council , which is the sole UK legal arbiter and regulator of podiatry standards. (see resources) In particular (but not exclusively) the following – standard 1. ‘Practice safely and effectively within their scope of practice’, standard 4. ‘Practice as an autonomous professional, exercising their own professional judgement’, standard 11 . ‘Assure the quality of their practice’ and standard 13. ‘Draw on appropriate knowledge and skills to inform practice’.

This clearly lays the responsibility for ensuring that such practice is safe upon the individual autonomous professional, and that responsibility is identical in respect of whatever tool the practitioner uses, be it a POCUS device or a 128Hz tuning fork. In the view of the IoP it is the practitioners duty to understand and internalise the following 7 key areas in respect of POCUS:

• What is US and specifically POCUS.
• Safety considerations of its use, including its necessary limitations.
• The medical context of US.
• Safe and effective operation of typical POCUS devices.
• The recognition and identification of US generated images.
• Physiological images vis-à-vis pathological images.
• Treatment and referral decisions made in respect of images viewed.

Again, the IoP applauds and endorses the declared view of Professor Dan Lasserson MA  MD  MRCGP  FRCP (Edin) Professor of Acute Ambulatory Care, Warwick University and Clinical Lead, Hospital at Home, Oxford University Hospitals NHS Foundation Trust, as follows : “Point of care ultrasound (POCUS) has become an essential tool within acute specialties to enhance bedside diagnostics, facilitate safe interventional procedures and guide referral to specialist services. It is vital for this tool to be expanded to community and prehospital settings where access to definitive investigations is limited. With the evolution of technology, ultrasound is becoming increasingly available due to reducing costs, machine size and remote image review for quality assurance purposes. This skill is invaluable for clinicians at all levels of training from medical school through to consultancy and allied healthcare professionals in any discipline” (Clare S, Duncan C  (eds) 2022).

Furthermore, the IoP recognises that some established diagnostic services and providers may believe that POCUS is a ‘disruptor’ to their own models of business (and profit?) and seek to either control or eliminate it – viz: “Is point-of-care ultrasound disruptive innovation? Formulating why POCUS is different from conventional comprehensive ultrasound”  (Weile J, et al 2018). In respect of the foregoing, the IoP believes unequivocally that POCUS is indeed firmly and clearly outwith the purview of traditional imaging services as Weil J and colleagues maintain: “The perspective of this paper is mutual understanding of similarities and differences between conventional and point-of-care ultrasound. Only with this understanding can the stakeholders collaborate and use the full spectrum of ultrasound for the benefit of the patient”.  This leads on to our declared position that when practiced by legally regulated and highly qualified healthcare specialists such as podiatrists, POCUS can be practiced safely and responsibly within the framework of the 7 mandatory key points previously identified to the considerable benefit of the patients to whom it is applied.

In respect of training for POCUS, the IoP recognise that there is no single defined standard syllabus, although many parties (who in some cases offer such training on a fee basis) lay claim to one, as is often the case in many areas of Healthcare. We therefore hold to reliance upon the HCPC standards of practice previously quoted, plus the 7 key requirements above, and use that as guidance in respect of Continuing Professional Development learning events concerning POCUS designed and laid on by the IoP.

Much of the necessary background knowledge appropriate to POCUS is available to registered podiatrists via self-directed learning, utilising our  recommended publications from recognised experts in POCUS and, most importantly, clinical human anatomy without which no ultrasonography at any level can be competently comprehended; ( Clare 2022, Loukas and Burns 2024, Loukas and Tubbs 2024). Nowadays, in the 21^st century there are also truly vast resources specifically in respect of POCUS online from highly respected practitioners and institutions widely available by both subscription from such as the New York School of Regional Anaesthesia (see resources)  and Wolters Kluwers digital and hybrid human anatomy (see resources), as well as a plethora of detailed public domain videos on YouTube from sonographers, specialists, physicians and academic institutions.

Once a viable standard of background knowledge has been acquired this should then be complimented by sufficient hands-on practice to acquaint the practitioner with practical device use, this can usually be acquired by attending an introductory  practical ‘hands on’ CPD event and will give a base for the practitioner to build their advancing knowledge upon. In respect of IoP members wishing to enjoy IoP level four  insurance for POCUS use, the foregoing is a mandatory requirement, together with ongoing continuing learning which is in any event a requirement of HCPC standards of practice in all areas of a podiatrists professional practice.

The Health and Social Care Act (2008) lays out clearly the requirements for registration with the Care Quality Commission for what it terms ‘captured’ activities. Paragraph 7 of that act and associated sub paragraphs deal with captured activities that are provided as ‘a service’ , so if a practitioner set up a ‘diagnostic and reporting service’ that would be clearly captured by the act and require CQC registration. Using  clinical tools at point of care by a clinician to audit the homeostasis of a patient, be that by using a stethoscope, a 128Hz tuning fork, a vascular doppler or a POCUS  ultrasound device is not in the view of the IoP ‘providing a specific service’,  it is simply part of the practitioner gathering information to enable safe, responsible and effective clinical decisions to be made by the practitioner to the benefit of the patient.

In line with the HCPC standards previously quoted, the use of any clinical tool, or any clinical decision made by a practitioner as ‘an autonomous professional’, should be  line with their ‘own professional judgement’ with the practitioner recognising that they are responsible for such clinical decisions and tool use. Practitioners are reminded that they are responsible for keeping appropriate records, so that should they be called to account for their clinical activities and clinical decisions they can clearly lay out the foregoing for interested parties and stakeholders.

References

Dr Sarb Clare, Dr. Chris Duncan (eds) Ultrasound for the Generalist 1pp: A Guide to Point of Care Imaging. Cambridge University Press, 2022.

Weile J,  Brix J, Moellekaer AB, . Crit Ultrasound J. 2018 Oct 1;10:25.

Loukas M, Burns D. Essential Ultrasound Anatomy. (2^nd Edn) Wolters Kluwers (pub) 2024

Loukas M, Tubbs RS, Grays Clinical Photographic Dissector of the Human Body. Elsevier (pub) 2024.

Resources

Wolters Kluwer online portal : https://www.lww.co.uk/

New York School of Regional Anaesthesia: https://www.nysora.com/

(IoP V1. Rev 1. 2024)

Injections of medicines including  intra and peri – articular injection therapies

 by HCPC registered Podiatrists with POM-A annotation

Qualified podiatrists who are awarded licences in POM-A (prescription only medicine- administration), as either part of their undergraduate degree or as stand-alone qualifications are given statutory permission to administer medicines by injection that they may lawfully access**. The POM-A licence also contains a specific permission to obtain (without the usually required prescription) :  a range of injectables which include various local anaesthetics, adrenaline (epinephrine) and the anti-inflammatory synthetic steroid methylprednisolone. This permission continues whilst said podiatrist remains on the statutory register of the Health and Care Professions Council, and ceases should they leave, or be removed from, the stated register.

Whilst so registered they can legally obtain**all of the medicines above, including the steroid, and administer** them, without further training or permission.

However, it is a requirement of safe and responsible practice that podiatrists with POM-A  must ensure that they a) have a full and detailed understanding of the pharmacology of said medicines including their pharmacokinetics and pharmacodynamics (essentially how the body affects the drugs and the drugs affect the body) and b) they have suitable medical indemnity insurance for use of the items above. In respect of the local anaesthetics, a) is included in the approved courses which grants POM-A ,  so b) is included in most malpractice policies. In respect of the licensed steroid however, the Institute requires the completion of an approved course which explains, in substantial detail, the action of when TO use, and perhaps even more importantly when NOT to use the permitted steroid.  By virtue of the holding of a POM-A licence it is clear that the holders are already trained and safe injectors and the simple techniques of safe administration will already be known, but nonetheless, these are specifically restated (with some practical tips and information pearls) during the course and delegates to the course will readily grasp the analogy between  local anaesthetics and steroids.

To this end, the Institute’s course is designed by, and taught by, highly qualified podiatrist independent prescribers and due to its carefully designed structure permits the Institute’s insurers to offer insurance cover to allow members who have successfully attended the Institute’s approved course to commence its use independently without requiring further permission or ‘mentoring’. **Prescription-only-medicines that usually require prescription by a recognised prescriber can, where defined by law, be made available to defined members of certain legally regulated professions under statutory ‘exemptions’ to the 1968 Medicines act and its numerous subsequent amendments. The exempted substances may be purchased at retail or wholesale from regulated pharmacies or other legal UK sources. Note that ‘administration’ in the context of the above must be within the professional activities of the aforesaid practitioner with the said ‘exemption’.  The exemption is not in law a ‘prescription’ and does not permit mixing of medicines,  nor does it permit the holder of said exemption to direct  others to mix and or administer them (a patient specific direction from a registered prescriber is required for directing others to mix/administer) The position of epinephrine is less well determined by the above, as this falls within the parameters applying to medicine identified as being within schedule 19 of the 1968 medicines act (and amendments) wherein its legal category is relaxed when used with the provable intent of saving or preserving life in an emergency situation.

18th October 2023

An official statement regarding Platelet Rich Plasma has been issued by the Medicines & Healthcare products Regulatory Agency.

MHRA Platelet Rich Plasma

Recommended titles for practitioners and students

The Institute of Podiatrists are excited and proud to have commissioned 2 dynamic and important handbooks written specifically by way of an introduction to the foot and as a supportive learning companion. Written by David R Tollafield, a highly experienced podiatry professional and renowned podiatric author.

An introduction to the foot & its common problems in the adult

The challenging subject of foot and lower limb mechanics is admirably clarified and easy to follow in this 180-page paperback, Pocket sized book. Well- illustrated, clear and informative, this book will appeal to podiatrists and foot health practitioners at all levels, whether you are new to the anatomy and workings of the foot or as a reference for reminder. This book will also appeal to other professions and healthcare professionals who have an interest in the foot.

The Foot – a professional learning companion

This companion course, sets out different styles of questions, offering tips for open and closed methods, especially multi-choice options.

Divided into two parts: questions in the first and detailed explanations in the second part. Supporting self-assessment for foot health practitioners and students on university courses, this handy aid helps understand the finer parts of foot health science in eight study areas.

Understanding the Human Foot: An Illustrated Guide to Form and Function for Practitioners by James Earls

Understanding the Human Foot is a full-colour, up-to-date overview of the structure and function of the foot, written for physical therapists and movement practitioners looking to deepen their understanding of holistic anatomy. Readers will gain perspective on the impacts of foot shape; the interdependence of form and function; and the cellular processes that determine how our tissue is designed. Most importantly, author James Earls demonstrates how the foot relates to and interacts with the rest of the body during movement, laying the groundwork for a comprehensive holistic approach to assessing, troubleshooting, and addressing functional and structural foot issues.

Written by Helen Rawse

To read this article please click here https://iop-uk.org/wp-content/uploads/2023/07/Bullous-Pephigoid.pdf

Case Notes is a regular feature in the IoCP quarterly publication – Podiatry Review. Every member will have seen unusual patients and/or will have unusual conditions which will be of interest to the readership, colleagues and peers.

Case Notes is an expansion on your own medical notes ensuring you do not identify the patient, unless you have written consent.

We welcome all submissions of your findings to be featured in our Podiatry Review, please contact media@iop-uk.org for more information or to submit your case!

Health Education England is launching the standards for the foot health support workforce.

The Foot Health Standards are part of work which aims to increase the supply of podiatrists in the NHS, while expanding the role of the support workforce. The Standards will ensure that the NHS recognises the knowledge and skills of the wider foot health support workforce.

The Standards were open to consultation in late 2020. The responses of stakeholders have been used to further develop the Standards and to better understand the issues and challenges around this topic.

The Standards are intended to support the NHS in utilising the full skills mix of the foot health workforce to meet demand, by providing a clear understanding of the footcare treatments that the NHS podiatry support workforce and foot health practitioners can safely perform. The needs and safety of patients is central in this work. Employers and managers can use the Standards to effectively plan, develop, and deploy their support workforce.

From our work with support workers and services across the country we know there is wide variation in their education and training, and how they are deployed. This work will ensure that:

1. Patients and service users have access to skilled and consistently well-trained support workers who have a defined role within their team
2. support workers have access to development structures that provide opportunities to follow a richer and more rewarding career pathway
3. services can address the current variation in support worker roles, banding and progression
4. support worker roles can be at the heart of improvements in service delivery and transformation, including new models of care.

The main objective is to increase the supply into podiatry and ensure that the NHS recognises the knowledge and skills of the support workforce.

How to use the Standards

NHS managers can use the Standards to understand the treatments that different parts of their foot health support workforces can safely deliver. This will support them in ensuring that they have in place workforces with the skills mix they need to care for patients. This will help managers design services to meet increased patient demand.

Education providers can use the Standards to underpin the development of educational pathways into the NHS podiatry support workforce and onto pre-registration education and training programmes in podiatry. This will support the development and growth of the support and podiatrist workforce

The development of the Standards was overseen by a Consortium of Foot Health Leaders who gathered to address the problem of the falling recruitment numbers on traditional routes into podiatry. The priority of the Consortium was to develop a foot health career ladder and educational resources that will support and increase the number of podiatrists and podiatry support workers working in the NHS.

The work of the Consortium has enabled a better understanding of the workforce that provides foot care, with the aim of optimising this workforce for the benefit of those who use the services of any practitioner, in England, who work in this arena.

To view the standards visit Standards for the Foot Health Workforce | Health Education England (hee.nhs.uk)

8th September 2021,

Health Education England have today launched The First Contact Practitioners and Advanced Practitioners in Primary Care: (Podiatry)

A Roadmap to Practice is a supportive document that provides a clear educational pathway from undergraduate to advanced practice for clinicians wishing to pursue a career in primary care.

For more information or to download the document please click the link below

First Contact Practitioners & Advanced Practitioners – Podiatry | Health Education England (hee.nhs.uk)

A national patient safety alert has been issued for the use of Liquefied Phenol 80%.

Please click the below image to read the full alert.

We are delighted to announce we have signed a memorandum of understanding with the Motor Neurone Disease (MND) Association. This establishes a solid partnership setting out the intention of our two organisations to work together to ensure good care for people living with and affected by MND.

Six people per day in the UK are diagnosed with motor neurone disease (MND). MND is a rapidly progressive and terminal disease that attacks the motor neurones in the brain and spinal cord.[1] It can leave people locked in a failing body, unable to move, talk and eventually breathe. It affects people from all communities and a person’s lifetime risk of developing MND is around 1 in 300. It kills a third of people within a year and more than half within two years of diagnosis. There is, currently, no cure for MND and whilst research into one continues, other research and therapeutic efforts are firmly focussed on managing symptoms and maximising the quality of life for people living with it.

We will be working with the Association as a therapy group that may be in a position to sign post patients to their GP if we suspect there is an underlying cause to the symptoms we are presented with

[1] 1 Bäumer D, Talbot K and Turner MR. Advances in motor neurone disease. Journal of the Royal Society of Medicine. 2014; 107:14.

If you have any questions or would like to know more about the Association please visit their website www.mndassociation.org which holds excellent information resources, information about current research and contact information MND Connect helpline. Alternatively contact Jennifer Bedford at Jennifer.bedford@mndassociation.org.

Additionally, if you are a Podiatrist and have any experience of Motor Neurone Disease we’d love to hear from you. Email our team media@iop-uk.org

Today, the Health and Care Professions Council (HCPC) has launched its annual Diversity Data Survey to increase its understanding of equality, diversity and inclusion (EDI) among its registrants. The survey will help the HCPC create and develop strategies, policies and regulatory processes that are inclusive and fair.

Jacqueline Ladds, Executive Director, Policy and External Relations comments:

“We’re committed to being an inclusive and diverse regulator and ensuring that our services are accessible and free from discrimination. We’ve launched this survey so that we can get a better understanding of equality, diversity and inclusion across our professions and use it to inform our improvement work in these key areas.

“We’ll use the findings to help create and develop policies, regulatory processes and strategies, which accurately reflect the diversity of our registrants. That’s why we are asking all our registrants to get involved, to ensure they complete the survey and to spread the word using #HCPCMyEDI.”

As part of HCPC’s commitment to enhancing equality, diversity and inclusion across the professions, the regulator hopes to hear from all HCPC registrants in this survey, which will be open from 15 December 2020 – 14 March 2021.

Since last year, HCPC has pushed for a stronger focus on EDI, with the development of a strategy to engage all stakeholders on these issues. The organisation has also created an EDI Forum, which guides HCPC on a range of relevant issues and concerns. The Forum also provides advice on the development of HCPC policies and procedures. The HCPC also routinely undertakes equality impact assessments for all major pieces of work.

Jacqueline Ladds, Executive Director, Policy and External Relations continues:

“We want to understand the issues that our registrants face and identify the measures that can be put in place to support them better. Our first Diversity Data Survey last year provided a good starting point, but this year we want more registrants to get involved to help create a deeper understanding. We know that sharing this kind of data is incredibly personal, and can feel daunting, but doing so will help us implement the best regulatory policies and processes for registrants and for service users and patients.

“As well as increasing our understanding of the equality, diversity and inclusion issues and challenges faced by our registrants, it will also create a picture of HCPC registered allied health professionals, healthcare scientists and practitioner psychologists in all four countries of the UK, working across health and care settings. This could help address wider workforce planning issues, and boost the understanding of equality, diversity and inclusion issues across the sectors.”

IOCP Midland Regional Director David Ayres has represented The Institute of Chiropodists and Podiatrists and our membership at the HCPC’s EDI development meetings.

Notes to editors

The Health and Care Professions Council is an independent regulator set up by the Health and Social Work Professions Order 2001. The HCPC keeps a register for 15 different health and care professions and only registers people who meet the standards it sets for their training, professional skills, behaviour and health. The HCPC will take action against professionals who do not meet these standards or who use a protected title illegally.

The HCPC currently regulates 15 health and care professions. Each of these professions has one or more ‘protected titles’. Anyone who uses one of these titles must register with the HCPC. The full list of protected titles can be found here.

Requests for interview should be made through the HCPC Press Office on 07585 992 942 or press@hcpc-uk.org.