Westminster

Primary Care Trust

Feet First
Foot Health & Podiatry for Homeless People

Alison A Gardiner BSc MChS HPC Reg Specialist Podiatrist for Homeless and Vulnerable People
Westminster PCT

Content
Westminster PCT health care provision for homeless people overview Westminster Homeless Podiatry service.

Foot facts
Common foot conditions Diabetes and Feet. Health inequalities Why are homeless people more prone to foot problems? Case studies Important considerations Conclusion

 The Homeless Health Team - GPs, nurses, CPN and podiatrist.

Westminster PCT Homeless Health Care

PCT leases premises in 3 charity run day centres. Also linked to 2 GP practices for homeless people with dentist, psychiatrist, benefits advice, legal advice, drug and alcohol worker, optician etc. Podiatry at 3 day centres & one GP surgery. Four podiatry sessions a week in total.
Day centre volunteers help with running of clinics Computer records kept. Vision. All sites linked.

Telephone interpreters. Language Line

Podiatry Service
60% of my post Funding by podiatry service and Homeless Health Team. Clinical provision in day centres. Occasional street visits. Hostel visits for housebound. Health promotion for service users in day centres/hostels. Training for hostel/day centre staff Promote access of vulnerable people to mainstream service. Training for colleagues mental health, drugs and alcohol, working with interpreters etc. Rotations for colleagues. Undergraduate placements and teaching. University of East London

 When your feet hurt you hurt all over. (Socrates) The foot is a masterpiece of engineering & a work of art. (Leonardo da Vinci)

Foot Facts
The foot contains 26 bones, 100 ligaments, 33 joints & 20 muscles.
The skin of the feet have 250,000 sweat glands releasing nearly a cup of moisture a day. The average person walks 4 miles every day.

What do Podiatrists treat? Foot Conditions

Corns. (Hard and Soft). (Heloma durum, heloma

molle) Cause. Pressure, (eg shoes, biomechanics, deformity) Treatment. Scalpel debridement, shoe and self care advice, not to use corn plasters, insoles, biomechanical assessment

Bunion
(Hallux abducto valgus) Description Medially deviated 1st toe with OA &
enlargement of 1st metatarsophalangeal joint, restricted ranger of motion, may push up 2nd toe which may become dislocated. Difficulty with shoe fitting. Cause. Biomechanics, footwear, RA, OA Treatment. Shoe advice, orthopaedic shoes, biomechanical assessment, orthoses, surgery.

Hammer Toes Clawed deformity of lesser toes.

Dorsal lesions can occur & difficulty with shoe fitting.

Cause and treatment. Similar to bunion

Verruca Cauliflower appearance with overlying

callus. May be painful if occurs on weight bearing
area of foot. Cause. Viral skin infection. Treatment . Acid, cryotherapy, laser, occlusion

Heel Fissures crack in heel. May be shallow or

deep. May become infected if open to deeper layers of skin Cause. Dry callused skin round perimeter of heel. Dermatitis, psoriasis. Treatment. Callus debridement, advice to use a foot file, emollient, shoe advice, dressings/antibiotics if open/infected.

Ingrown toenail - May be inflamed /infected.

Cause. Footwear, involuted nail, trauma, nail spicule left by poor nail cutting which has pierced skin. Treatment. Conservative. Antibiotics. Shoe advice. Surgery

Neglected Nails

Mycotic Infections infected nails

appear thickened & discoloured. Infected skin may appear inflamed, blistered & wet if between the toes. May have a dry, peeling, blistered appearance on other parts of the foot. Usually very itchy. Cause. Poor hygiene, sleeping in shoes

Treatment. Nail cutting, foot care advice, topical preparations. Oral medication or lacquer for nail infections

High arched, cavoid feet- A very rigid

foot type. High pressure loading to balls of feet & heels with may result in painful corns & callus. Lesser toes often clawed causing dorsal lesions. May be related to neurological conditions such as Charcot Marie Tooth disease. May need reduction of pressure lesions & insoles. Shoe advice

Pes Planus Flat feet- A very mobile

foot type. Thought to be related to development of bunions & other biomechanical foot problems. Orthotics may be helpful if symptomatic.

Biomechanical Problems
Heel, forefoot, knee, hip, back pain Cause. Acquired, congenital Treatment. Biomechanical assessment , Orthotics, exercises, shoe advice, NSAIDS

Trench Foot
Causes. Not removing shoes, sweaty feet, poor footwear often plastic Treatment. Advice to air feet, hygiene, provision shoes/socks

Diabetes
1.3 million diagnosed cases in the UK but can go undiagnosed for years

1 in 20 over age of 65
Most common cause of amputation of the lower limb in the UK

Health Inequalities & Diabetes

Men more likely to develop diabetes but women have higher rates of complications and mortality. Black and ethnic minority groups Social exclusion/ deprivation/ mental health problems/learning difficulties See National Service Framework for Diabetes, section on Health Inequalities.

Diabetes & Feet

Poor diabetic control can lead to

Peripheral neuropathy Peripheral vascular disease Ulceration, infection, gangrene and amputation. NB Ulcers may be painless if neuropathy is present.

AMPUTATION & INFECTION risks reduced by

Good diabetic control Foot care education Annual screening for neurovascular foot complications Podiatric treatment of any foot problems

Why are homeless and vulnerable people more prone to foot problems?

 Increased risk of diabetes & diabetic complications Walking long distances. Stress relief. No
choice! Blisters, biomechanical problems.

Mental health. Self neglect. Can border on self

harm.

Poor hygiene. Scabies, infections (fungal and

bacterial).

Exposure to elements. Cold/wet/heat Poor nutrition. Poor healing and infection. May
not get to food hand outs etc due to foot pain

 Finance. Lack of money for good well fitting shoes,

(ideal leather lace ups/trainers), socks & nail clippers. Pulling off nails, sharing clippers.

Not removing shoes/socks. Fear of theft, self

neglect, need move quickly. Trench foot. Fungal infections

Self treating with blades, knives. Ulceration.

Infection and scarring.

Smoking Sharing showers. Verrucae

 Alcohol. Peripheral neuropathy, increased

risk of diabetes, osteoporosis, poor immunity, assault, accidents. Self medication of foot pain

Sleeping with legs dependant on

buses/benches oedematous feet and legs.

Drugs. Infection of injection sites, thrombosis, HIV.

Self medication for foot pain.

Asylum seekers. Conditions rarely seen in UK

which can affect feet polio, TB, leprosy, rickets, polydactyly, industrial/agricultural accidents, torture

Difficulty accessing health care

Not registered with a GP
Forgetting appointments, frustration with making appointments, no mail address, waiting times.

Stressful waiting rooms, difficulty communicating with medical staff/receptionists due to mental health problems etc., perceived/actual insensitive treatment by medical staff. Embarrassment.
Language barriers, illiteracy, no glasses Lack of awareness of podiatry

No internet access

CASE STUDIES Westminster Homeless Podiatry Service

 57 year old
Rough sleeping white male

Alcoholism
Trench foot

Issued with socks and shoes, foot care advice.

 Age 45 black African male hostel resident Good health Bow legs - (childhood rickets?)

Heavy heel callus

Callus removed, advice on self care with foot file, emollient prescription, orthotics, shoe advice.

 Afro Caribbean 39 year old male rough sleeper

Alcohol, cannabis, cocaine, heroin, smoker

Fracture of left leg age 24 led to clawed toes & large painful corn under left foot Patient self treated Infection & hospitalisation. Corn removed, self care advice, physio/orthopaedic/podiatric surgery referral, orthopaedic shoes, insoles

 44 years old rough sleeper

Born Bombay. UK resident many years Crack & heroin Previous fracture right leg Painful corn & fungal nail infection Corn removed, self care advice, wider shoes

 White male rough sleeper, 63

Frequent hostel evictions. Revolving door prison/street/hostel Alcoholic, WernickeKorsakoff Syndrome, epilepsy. Poor circulation, heavy smoker Fracture right ankle age 15 not set. Walks on side of foot. Infected ulcer right foot. Trench foot

 Seen many times in day centre clinic but not able to self refer or follow advice due to Korsakoffs. Never takes off shoes/socks. Not suitable for surgery. Ulcer dressing and padding. Antibiotics. Orthopaedic shoe referral eventually!

Important considerations
Aim to provide a service which is equal to mainstream i.e. access to specialities, (diabetes specialist podiatrist, musculo skeletal specialist), equipment, infection control etc. Good links to mainstream helpful. Common podiatry problems may need a different approach e.g.. Verrucae, ingrown toenails. Less common problems trench foot, torture Annual diabetic foot check. How to achieve? Supplies of shoes and socks . Encourage day centre to provide. Supporting letter to benefit office.

 If in stable accommodation, can refer to the mainstream podiatry service if appropriate. Assertive promotion of service. Flyers, posters etc.

Challenges and opportunities of working alongside non NHS organisations and staff.
Safety! Room set up, alarms, client info, training, agreed policies, (seeing intoxicated patients etc.) Consent issues Inter-professional working /holistic approach. Signposting to counselling, other medical services etc., Other vulnerable groups prisoners, travellers Drop in versus appointments?

Mainstream medical services can benefit hugely from drawing on the expertise and experience of homeless services in providing health care to groups that are vulnerable and difficult to reach, thus helping to reduce health inequalities in the UK.

Thank you!
Podiatry Head Office Health at The Stowe 260 Harrow Road, London W2 Tel: 0207 316 6808
Alison.gardiner@westminster-pct.nhs.uk 07752 832539