National Diabetes Foot Care Report
National Cardiovascular Intelligence Network
1 Introduction
The National Cardiovascular Intelligence Network (NCVIN) has published information on diabetes-related foot care since it’s inception in 2013, via the diabetes foot care profile reports. These reports have provided NHS Clinical Commission Groups with tailored information regarding people with diabetes admitted to hospital for foot disease in their area. The reports have been updated annually, with content and format altering slightly each year. This report is the latest edition in this series.
Taking a population health perspective, this report includes analysis assessing the disparities in the risk of complications among patients with diabetes, recent trends in admissions and an evaluation of the geographical variation in foot disease and amputations. It also presents analysis on how the COVID-19 pandemic has impacted hospital admissions for foot disease in patients with diabetes.
It is intended that the data presented in this report, and the variation they highlight, will be useful in guiding equitable commissioning of foot care services and other preventative interventions.
The information in Sections 2-4 is compiled from Hospital Episode Statistics (HES) and this release focuses on the latest update to the diabetes foot care profile indicators. This includes admissions and procedures between 2017/18 and 2019/20. Data are presented for England, NHS Regions and Clinical Commissioning Groups. For Section 5, an initial analysis of the admissions data for 2020/21 is included.
The data is also available through Fingertips, which includes data for all different geographies.
Key Information
During the three-year period of 2017/18 to 2019/20:
There were 171,759 foot disease-related hospital admissions for patients with diabetes.
97,175 individual patients had a hospital admission for foot disease and 34% had more than one admission over the three years.
There were 7,957 major amputations with a directly standardised rate of 8.1 major amputations per 10,000 population with diabetes per year.
There were 21,738 minor amputations with a directly standardised rate of 22.1 minor amputations per 10,000 population with diabetes per year.
Patients with diabetes that are male, from the most deprived areas, aged over 65 or of white ethnicity had greater risk of amputation.
2 Background
The prevalence of diabetes is increasing, with nearly 3.5 million people registered as having the disease with general practices in England [1]. Lower-limb complications, such as ulceration or amputation, are common among the population with diabetes and have a substantial human cost due to the impact they can have on how an individual can live their life. In 2014/15, the total expenditure on health care related to foot disease for patients with diabetes was close to 1% of NHS spending [2]. The impacts to individual’s income and welfare and the wider impact on the economy may also be significant.
Many foot-related complications are preventable if identified and treated early. The guidance from the National Institute for Health and Care Excellence (NICE) [3] suggests this can be achieved in several ways:
- Improving and speeding up the care pathways, including minimising the delay for the first expert assessment within a dedicated foot protection service
- Annual foot checks are made available and encouraged for adults
- Educating patients and their family members or carers on foot problems and care pathways
3 Lower-limb amputations in patients with diabetes
A major lower-limb amputation (above the ankle) can be an adverse outcome of diabetes. The rate at which major amputations occur in a population with diabetes can be used as a good overall proxy measure of the effectiveness of health care and the foot care system for patients with diabetes. Survival rates have been found to be poor following a major amputation [4,5]. Unlike a major amputation, a minor amputation can be considered a preventative treatment. For example, the removal of dead tissue with the expectation that healing will follow.
This section provides information on the rate of lower-limb amputations in England for patients with diabetes. Crude rates are presented in Section 3.1. In Sections 3.2 and 3.3, directly standardised rates (DSR) of amputations per 10,000 population with diabetes per year have been produced, controlling for the age and ethnicity of the patients with diabetes. This allows for more robust comparisons of the number of amputations being carried out between areas. Evidence suggests the risk of amputation in South Asian and Black populations is typically lower than in White European populations and that the risk of amputation increases with age [6,7]. For further details on the methodology and technicalities of standardising, please see the accompanying technical document. For further information on how patient management and ulcer severity impact on the rates of amputation please see the National Diabetes Foot Care Audit, available through our partners at NHS Digital.
3.1 Disparities in the rate of amputation
The following descriptive statistics show the England distribution of both major and minor lower-limb amputation procedures that occurred between 2017/18 and 2019/20. Category-specific rates per 10,000 population with diabetes per year have been calculated for deprivation, sex, ethnicity and age separately and are presented in Figures 3.1A and 3.1B. It should be noted that, because each demographic category has been examined separately, the other demographic categories have not been controlled for. The following information may be useful in increasing awareness of which groups in the population with diabetes are most at risk of amputation and informing public health and clinical approaches to reducing variation.
Figures 3.1A and 3.1B show that there is a higher risk of amputation among males, patients of white ethnicity and patients aged over 65. This is true for both major and minor amputations. In addition, patients from the most deprived areas had the highest risk of amputation. The rate of major amputations in the most deprived areas was 1.82 times higher and 1.47 times higher for minor amputations when compared to the least deprived areas.
Figure 3.1A - Crude rate of major lower-limb amputation rates for particular groups compared to England, 2017/18 - 2019/20
Deprivation
Sex
Ethnicity
Age
Data table
| Category | Sub-category | Crude rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| Deprivation | Most deprived quintile | 10.6 | 10.2 | 11.1 |
| 2nd most deprived quintile | 8.2 | 7.8 | 8.6 | |
| Middle quintile | 7.4 | 7.0 | 7.7 | |
| 2nd least deprived quintile | 6.1 | 5.7 | 6.4 | |
| Least deprived quintile | 5.9 | 5.5 | 6.3 | |
| Age | Under 65 | 6.7 | 6.5 | 6.9 |
| 65 to 79 | 9.5 | 9.2 | 9.8 | |
| 80 and over | 8.6 | 8.1 | 9.1 | |
| Sex | Male | 10.6 | 10.3 | 10.8 |
| Female | 4.7 | 4.5 | 4.9 | |
| Ethnicity | White | 9.5 | 9.3 | 9.8 |
| Asian, Black, Mixed and Other | 2.7 | 2.5 | 2.9 |
Figure 3.1B - Crude rate of minor lower-limb amputation rates for particular groups compared to England, 2017/18 - 2019/20
Deprivation
Sex
Ethnicity
Age
Data table
| Category | Sub-category | Crude rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| Deprivation | Most deprived quintile | 25.1 | 24.5 | 25.7 |
| 2nd most deprived quintile | 22.5 | 21.8 | 23.1 | |
| Middle quintile | 21.8 | 21.2 | 22.5 | |
| 2nd least deprived quintile | 19.2 | 18.6 | 19.8 | |
| Least deprived quintile | 17.1 | 16.5 | 17.8 | |
| Age | Under 65 | 20.3 | 19.9 | 20.7 |
| 65 to 79 | 23.2 | 22.7 | 23.7 | |
| 80 and over | 23.5 | 22.7 | 24.3 | |
| Sex | Male | 30.8 | 30.3 | 31.2 |
| Female | 10.4 | 10.1 | 10.7 | |
| Ethnicity | White | 26.0 | 25.6 | 26.3 |
| Asian, Black, Mixed and Other | 7.7 | 7.4 | 8.1 |
3.2 Major lower-limb amputations in patients with diabetes
There were 7,957 major lower-limb amputation procedures for patients with diabetes in England between 2017/18 and 2019/20. This equates to a directly standardised rate (DSR) of 8.1. In the same period, there was a total of 15,663 major lower-limb amputations carried out on all patients aged 18 and over in England. Major lower-limb amputations for patients with diabetes therefore made up 51% of all major lower-limb amputations that occurred during this period.
In Figure 3.2A, the trend of DSRs for major amputations in England from 2012/13-2014/15 to 2017/18 - 2019/20 is shown. Nationally, there was an increase in the number of major amputations carried out in 2017/18 - 2019/20 compared to previous periods. However, when accounting for the increasing at-risk population with diabetes, there has been no change in the rate of major amputations in England between 2012/13 - 2014/15 and the latest period.
The DSRs of major amputations for England and NHS regions are displayed in Figure 3.2B. This shows that only the North West had amputation rates significantly higher than England. London and East of England had rates significantly lower than England. Figure 3.2C shows the geographical variation in the DSRs of major amputations across Clinical Commissioning Groups and whether each is statistically significantly different to the DSR for England. These range from 3.5 to 16.8 (a 4.8-fold difference). Of the 135 Clinical Commissioning Groups in England, there were 13 with a DSR statistically significantly higher than the DSR for England and 20 statistically significantly lower.
The geographical distribution of the Clinical Commissioning Groups with the highest and lowest rates are displayed in Figure 3.2D.
Figure 3.2A - Directly standardised rates of major lower-limb amputation rates for England, 2012/13 - 2014/15 to 2017/18 - 2019/20
Chart
Data table
| Analysis period | Count of major amputation procedures | Directly standardised rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| 2012/13 - 2014/15 | 6,957 | 8.25 | 8.06 | 8.45 |
| 2013/14 - 2015/16 | 7,119 | 8.13 | 7.94 | 8.32 |
| 2014/15 - 2016/17 | 7,305 | 8.17 | 7.98 | 8.36 |
| 2015/16 - 2017/18 | 7,545 | 8.19 | 8.01 | 8.38 |
| 2016/17 - 2018/19 | 7,809 | 8.23 | 8.05 | 8.42 |
| 2017/18 - 2019/20 | 7,957 | 8.14 | 7.96 | 8.32 |
Figure 3.2B - Directly standardised rates of major lower-limb amputations for England and regions, 2017/18 - 2019/20
Chart
Data table
| Area | Count of major amputation procedures | Directly standardised rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| England | 7,957 | 8.1 | 8.0 | 8.3 |
| North West | 1,210 | 8.8 | 8.4 | 9.4 |
| North East and Yorkshire | 1,500 | 8.8 | 8.3 | 9.2 |
| South West | 860 | 8.1 | 7.5 | 8.7 |
| Midlands | 1,640 | 8.1 | 7.7 | 8.5 |
| South East | 1,150 | 7.8 | 7.3 | 8.2 |
| East of England | 835 | 7.2 | 6.7 | 7.7 |
| London | 765 | 6.7 | 6.1 | 7.2 |
Figure 3.2C - Directly standardised rates of major lower-limb amputations for Clinical Commissioning Groups compared to England, 2017/18 - 2019/20
Chart
Data table
| CCG | Count of major amputations | Directly standardised rate | Lower 95% confidence interval | Upper 95% confidence interval | England comparison |
|---|---|---|---|---|---|
| NHS Blackpool CCG | 70 | 16.8 | 13.1 | 21.2 | Significantly higher |
| NHS Tower Hamlets CCG | 35 | 16.2 | 10.2 | 23.9 | Significantly higher |
| NHS Redbridge CCG | 50 | 14.8 | 10.2 | 20.4 | Significantly higher |
| NHS Cannock Chase CCG | 35 | 13.8 | 6.9 | 22.8 | Not statisitcally different |
| NHS Southport and Formby CCG | 20 | 13.1 | 5.0 | 24.4 | Not statisitcally different |
| NHS Liverpool CCG | 120 | 13.0 | 10.8 | 15.6 | Significantly higher |
| NHS Telford and Wrekin CCG | 45 | 13.0 | 9.2 | 17.8 | Significantly higher |
| NHS County Durham CCG | 125 | 12.3 | 7.7 | 17.5 | Not statisitcally different |
| NHS Southend CCG | 40 | 12.2 | 8.6 | 16.8 | Significantly higher |
| NHS Northumberland CCG | 100 | 12.2 | 9.9 | 14.8 | Significantly higher |
| NHS Barking and Dagenham CCG | 30 | 12.1 | 7.9 | 17.7 | Not statisitcally different |
| NHS Stoke On Trent CCG | 75 | 11.9 | 9.4 | 14.9 | Significantly higher |
| NHS Portsmouth CCG | 45 | 11.9 | 8.5 | 16.1 | Significantly higher |
| NHS Newcastle Gateshead CCG | 100 | 11.8 | 9.5 | 14.5 | Significantly higher |
| NHS Brighton and Hove CCG | 40 | 11.4 | 8.0 | 15.8 | Not statisitcally different |
| NHS North Cumbria CCG | 90 | 11.2 | 9.0 | 13.8 | Significantly higher |
| NHS Luton CCG | 35 | 11.0 | 7.2 | 16.0 | Not statisitcally different |
| NHS Shropshire CCG | 55 | 11.0 | 6.1 | 17.0 | Not statisitcally different |
| NHS Fylde and Wyre CCG | 45 | 10.8 | 7.8 | 14.5 | Not statisitcally different |
| NHS Kernow CCG | 120 | 10.7 | 8.8 | 12.9 | Significantly higher |
| NHS Castle Point and Rochford CCG | 45 | 10.7 | 7.8 | 14.5 | Not statisitcally different |
| NHS Bolton CCG | 60 | 10.7 | 8.2 | 13.8 | Not statisitcally different |
| NHS East Staffordshire CCG | 30 | 10.3 | 6.9 | 14.8 | Not statisitcally different |
| NHS Newham CCG | 35 | 10.1 | 5.6 | 15.8 | Not statisitcally different |
| NHS Nottingham and Nottinghamshire CCG | 185 | 10.1 | 8.6 | 11.6 | Significantly higher |
| NHS Hull CCG | 65 | 10.0 | 7.7 | 12.7 | Not statisitcally different |
| NHS South East Staffordshire and Seisdon Peninsula CCG | 40 | 9.9 | 6.4 | 14.4 | Not statisitcally different |
| NHS Havering CCG | 45 | 9.7 | 7.1 | 12.9 | Not statisitcally different |
| NHS Dudley CCG | 65 | 9.7 | 7.4 | 12.4 | Not statisitcally different |
| NHS Sandwell and West Birmingham CCG | 75 | 9.6 | 7.5 | 12.2 | Not statisitcally different |
| NHS North Hampshire CCG | 35 | 9.6 | 6.7 | 13.4 | Not statisitcally different |
| NHS Manchester CCG | 75 | 9.6 | 7.4 | 12.2 | Not statisitcally different |
| NHS Southampton CCG | 40 | 9.6 | 6.8 | 13.1 | Not statisitcally different |
| NHS Wolverhampton CCG | 50 | 9.6 | 7.0 | 12.8 | Not statisitcally different |
| NHS Stafford and Surrounds CCG | 30 | 9.5 | 6.4 | 13.7 | Not statisitcally different |
| NHS Bury CCG | 35 | 9.5 | 6.6 | 13.2 | Not statisitcally different |
| NHS Ipswich and East Suffolk CCG | 65 | 9.5 | 7.1 | 12.4 | Not statisitcally different |
| NHS Wirral CCG | 60 | 9.4 | 6.5 | 13.0 | Not statisitcally different |
| NHS Oldham CCG | 40 | 9.4 | 6.7 | 12.9 | Not statisitcally different |
| NHS Wigan Borough CCG | 70 | 9.3 | 7.2 | 11.8 | Not statisitcally different |
| NHS Doncaster CCG | 65 | 9.3 | 6.9 | 12.2 | Not statisitcally different |
| NHS Heywood Middleton and Rochdale CCG | 40 | 9.2 | 6.5 | 12.5 | Not statisitcally different |
| NHS Rotherham CCG | 45 | 9.1 | 6.6 | 12.3 | Not statisitcally different |
| NHS Chorley and South Ribble CCG | 30 | 9.1 | 4.9 | 14.7 | Not statisitcally different |
| NHS Salford CCG | 40 | 9.1 | 6.3 | 12.6 | Not statisitcally different |
| NHS Gloucestershire CCG | 105 | 9.1 | 7.2 | 11.3 | Not statisitcally different |
| NHS Bassetlaw CCG | 25 | 9.1 | 5.9 | 13.3 | Not statisitcally different |
| NHS Tees Valley CCG | 125 | 9.0 | 7.4 | 10.9 | Not statisitcally different |
| NHS Hammersmith and Fulham CCG | 20 | 8.9 | 4.8 | 14.8 | Not statisitcally different |
| NHS North East Lincolnshire CCG | 30 | 8.9 | 5.9 | 12.9 | Not statisitcally different |
| NHS North East Hampshire and Farnham CCG | 30 | 8.8 | 6.0 | 12.5 | Not statisitcally different |
| NHS Sunderland CCG | 55 | 8.8 | 6.6 | 11.4 | Not statisitcally different |
| NHS Walsall CCG | 50 | 8.8 | 6.5 | 11.6 | Not statisitcally different |
| NHS Kent and Medway CCG | 300 | 8.8 | 7.8 | 9.9 | Not statisitcally different |
| NHS North Tyneside CCG | 45 | 8.7 | 6.3 | 11.8 | Not statisitcally different |
| NHS St Helens CCG | 40 | 8.7 | 6.2 | 11.8 | Not statisitcally different |
| NHS Bradford District | 85 | 8.6 | 6.8 | 10.8 | Not statisitcally different |
| NHS East Lancashire CCG | 60 | 8.6 | 6.6 | 11.1 | Not statisitcally different |
| NHS South Sefton CCG | 30 | 8.6 | 5.7 | 12.4 | Not statisitcally different |
| NHS Blackburn With Darwen CCG | 25 | 8.6 | 5.5 | 12.7 | Not statisitcally different |
| NHS Lincolnshire CCG | 145 | 8.5 | 6.9 | 10.4 | Not statisitcally different |
| NHS Sheffield CCG | 85 | 8.5 | 6.8 | 10.5 | Not statisitcally different |
| NHS Waltham Forest CCG | 35 | 8.5 | 5.1 | 12.7 | Not statisitcally different |
| NHS West Hampshire CCG | 75 | 8.5 | 6.4 | 10.9 | Not statisitcally different |
| NHS Devon Clinical Commissioning Group | 215 | 8.5 | 7.4 | 9.7 | Not statisitcally different |
| NHS Hounslow CCG | 25 | 8.4 | 5.1 | 12.9 | Not statisitcally different |
| NHS North Staffordshire CCG | 45 | 8.4 | 6.0 | 11.3 | Not statisitcally different |
| NHS Morecambe Bay CCG | 60 | 8.3 | 6.3 | 10.6 | Not statisitcally different |
| NHS Bristol North Somerset and South Gloucestershire CCG | 130 | 8.2 | 6.9 | 9.8 | Not statisitcally different |
| NHS Greater Huddersfield CCG | 30 | 8.2 | 5.6 | 11.7 | Not statisitcally different |
| NHS Oxfordshire CCG | 75 | 8.1 | 6.4 | 10.1 | Not statisitcally different |
| NHS North Lincolnshire CCG | 30 | 8.0 | 5.3 | 11.6 | Not statisitcally different |
| NHS Leeds CCG | 110 | 8.0 | 6.5 | 9.6 | Not statisitcally different |
| NHS Leicester City CCG | 40 | 8.0 | 5.4 | 11.2 | Not statisitcally different |
| NHS Cheshire CCG | 100 | 7.9 | 5.8 | 10.3 | Not statisitcally different |
| NHS Warwickshire North CCG | 30 | 7.9 | 5.4 | 11.2 | Not statisitcally different |
| NHS Fareham and Gosport CCG | 35 | 7.9 | 5.5 | 10.9 | Not statisitcally different |
| NHS Calderdale CCG | 30 | 7.8 | 5.2 | 11.1 | Not statisitcally different |
| NHS Herts Valleys CCG | 70 | 7.8 | 6.0 | 9.8 | Not statisitcally different |
| NHS Birmingham and Solihull CCG | 165 | 7.7 | 6.5 | 9.0 | Not statisitcally different |
| NHS Derby and Derbyshire Clinical Commissioning Group | 160 | 7.7 | 6.5 | 9.0 | Not statisitcally different |
| NHS Milton Keynes CCG | 30 | 7.6 | 5.0 | 11.0 | Not statisitcally different |
| NHS East Sussex | 75 | 7.6 | 5.8 | 9.7 | Not statisitcally different |
| NHS South Tyneside CCG | 25 | 7.5 | 4.9 | 11.0 | Not statisitcally different |
| NHS Bath and North East Somerset Swindon and Wiltshire CCG | 120 | 7.4 | 6.1 | 8.9 | Not statisitcally different |
| NHS Dorset CCG | 110 | 7.3 | 5.9 | 8.9 | Not statisitcally different |
| NHS Surrey Heartlands CCG | 110 | 7.3 | 6.0 | 8.8 | Not statisitcally different |
| NHS West Suffolk CCG | 40 | 7.3 | 5.2 | 9.9 | Not statisitcally different |
| NHS Greater Preston CCG | 25 | 7.2 | 4.6 | 10.7 | Not statisitcally different |
| NHS Coventry and Rugby CCG | 50 | 7.2 | 5.4 | 9.4 | Not statisitcally different |
| NHS North East Essex CCG | 50 | 7.2 | 5.2 | 9.6 | Not statisitcally different |
| NHS West Leicestershire CCG | 50 | 7.1 | 5.2 | 9.4 | Not statisitcally different |
| NHS South Eastern Hampshire CCG | 35 | 6.9 | 4.8 | 9.7 | Not statisitcally different |
| NHS West London CCG | 20 | 6.9 | 3.6 | 11.5 | Not statisitcally different |
| NHS City and Hackney CCG | 30 | 6.9 | 3.2 | 11.7 | Not statisitcally different |
| NHS Halton CCG | 25 | 6.9 | 4.4 | 10.4 | Not statisitcally different |
| NHS Barnsley CCG | 40 | 6.9 | 4.9 | 9.4 | Not statisitcally different |
| NHS Norfolk and Waveney CCG | 155 | 6.9 | 5.8 | 8.2 | Not statisitcally different |
| NHS Tameside and Glossop CCG | 35 | 6.8 | 4.7 | 9.6 | Not statisitcally different |
| NHS East Riding of Yorkshire CCG | 50 | 6.8 | 5.1 | 9.0 | Not statisitcally different |
| NHS Bedfordshire CCG | 50 | 6.6 | 4.9 | 8.7 | Not statisitcally different |
| NHS Mid Essex CCG | 45 | 6.6 | 4.8 | 8.9 | Not statisitcally different |
| NHS East Berkshire CCG | 35 | 6.6 | 4.6 | 9.1 | Not statisitcally different |
| NHS Wakefield CCG | 45 | 6.3 | 4.4 | 8.8 | Not statisitcally different |
| NHS Cambridgeshire and Peterborough CCG | 95 | 6.3 | 5.1 | 7.8 | Significantly lower |
| NHS Herefordshire and Worcestershire CCG | 100 | 6.3 | 4.9 | 8.0 | Not statisitcally different |
| NHS Warrington CCG | 25 | 6.3 | 4.1 | 9.2 | Not statisitcally different |
| NHS West Sussex CCG | 105 | 6.3 | 5.1 | 7.6 | Significantly lower |
| NHS Thurrock CCG | 15 | 6.2 | 3.5 | 9.9 | Not statisitcally different |
| NHS Brent CCG | 25 | 6.1 | 3.1 | 10.0 | Not statisitcally different |
| NHS Basildon and Brentwood CCG | 25 | 5.9 | 3.8 | 8.7 | Not statisitcally different |
| NHS South West London CCG | 110 | 5.9 | 4.7 | 7.2 | Significantly lower |
| NHS Hillingdon CCG | 25 | 5.9 | 3.6 | 9.0 | Not statisitcally different |
| NHS Northamptonshire CCG | 70 | 5.8 | 4.5 | 7.4 | Significantly lower |
| NHS East and North Hertfordshire CCG | 55 | 5.8 | 4.3 | 7.6 | Significantly lower |
| NHS Somerset CCG | 55 | 5.8 | 3.3 | 8.8 | Not statisitcally different |
| NHS North Yorkshire CCG | 50 | 5.8 | 4.3 | 7.6 | Significantly lower |
| NHS Berkshire West CCG | 40 | 5.8 | 4.1 | 7.9 | Significantly lower |
| NHS Trafford CCG | 20 | 5.7 | 3.5 | 8.7 | Not statisitcally different |
| NHS Vale of York CCG | 35 | 5.7 | 4.0 | 7.9 | Significantly lower |
| NHS East Leicestershire and Rutland CCG | 35 | 5.7 | 3.9 | 7.9 | Significantly lower |
| NHS West Lancashire CCG | 15 | 5.7 | 3.1 | 9.5 | Not statisitcally different |
| NHS Stockport CCG | 30 | 5.4 | 3.6 | 7.9 | Significantly lower |
| NHS North Central London CCG | 110 | 5.3 | 4.2 | 6.6 | Significantly lower |
| NHS Buckinghamshire CCG | 45 | 5.3 | 3.8 | 7.2 | Significantly lower |
| NHS South East London | 130 | 5.2 | 4.3 | 6.3 | Significantly lower |
| NHS North Kirklees CCG | 15 | 4.9 | 2.8 | 7.9 | Significantly lower |
| NHS Isle of Wight CCG | 15 | 4.8 | 2.7 | 7.8 | Significantly lower |
| NHS Ealing CCG | 20 | 4.7 | 2.5 | 8.0 | Not statisitcally different |
| NHS West Essex CCG | 25 | 4.7 | 3.0 | 7.0 | Significantly lower |
| NHS Knowsley CCG | 15 | 4.3 | 2.4 | 7.1 | Significantly lower |
| NHS Central London (Westminster) CCG | 10 | 3.8 | 1.3 | 7.9 | Significantly lower |
| NHS South Warwickshire CCG | 15 | 3.7 | 2.1 | 5.8 | Significantly lower |
| NHS Harrow CCG | 10 | 3.5 | 1.3 | 6.9 | Significantly lower |
| NHS Surrey Heath CCG | 10 | NA | NA | NA | Count too small |
Figure 3.2D - Directly standardised rates of major lower-limb amputations for Clinical Commissioning Groups in England, 2017/18 - 2019/20
3.3 Minor lower-limb amputations in patients with diabetes
There were 21,738 minor lower-limb amputation procedures for patients with diabetes in England between 2017/18 and 2019/20. This equates to a directly standardised rate (DSR) of 22.1. In the same period, there were a total of 31,581 minor lower-limb amputations carried out on those aged 18 and over in England. Minor lower-limb amputations for patients with diabetes therefore make up 69% of all minor lower-limb amputations that occurred during this period.
In Figure 3.3A, the trend of DSRs of minor amputations in England from 2012/13 - 2014/15 to 2017/18 - 2019/20 is shown. Nationally, there has been an increase in the number of minor amputations carried out in the current analysis period compared to previous periods. When accounting for the increasing at-risk population with diabetes, this increase in minor amputations in England between 2012/13 - 2014/15 and the latest period is statistically significant.
The DSRs of major amputations for England and NHS regions are displayed in Figure 3.3B. This shows that the regions with amputation rates significantly higher than England are South East and South West. East of England, North East and Yorkshire and North West had rates significantly lower than England. Figure 3.3C shows there is substantial geographical variation in the DSRs of minor amputations across Clinical Commissioning Groups and whether each is statistically significantly different to the DSR for England. These range from 7.7 to 44.6 (a 5.8-fold difference). Of the 135 Clinical Commissioning Groups in England, there were 28 with a DSR statistically significantly higher than the DSR for England and 38 statistically significantly lower.
The geographical distribution of the areas with the highest and lowest rates are displayed in Figure 3.3D.
Figure 3.3A - Directly standardised rates of minor lower-limb amputation rates for England, 2012/13-2014/15 to 2017/18 - 2019/20
Chart
Data table
| Analysis period | Count of minor amputation procedures | Directly standardised rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| 2012/13 - 2014/15 | 17,224 | 20.43 | 20.13 | 20.74 |
| 2013/14 - 2015/16 | 18,408 | 21.01 | 20.71 | 21.32 |
| 2014/15 - 2016/17 | 19,073 | 21.17 | 20.87 | 21.47 |
| 2015/16 - 2017/18 | 19,920 | 21.49 | 21.20 | 21.80 |
| 2016/17 - 2018/19 | 20,973 | 22.01 | 21.71 | 22.31 |
| 2017/18 - 2019/20 | 21,738 | 22.14 | 21.85 | 22.44 |
Figure 3.3B - Directly standardised rates of minor lower-limb amputations for England and regions, 2017/18 - 2019/20
Chart
Data table
| Area | Count of minor amputation procedures | Directly standardised rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| England | 21,738 | 22.1 | 21.8 | 22.4 |
| South West | 2,785 | 26.7 | 25.7 | 27.8 |
| South East | 3,655 | 24.5 | 23.7 | 25.3 |
| London | 2,520 | 22.2 | 21.2 | 23.2 |
| Midlands | 4,320 | 21.2 | 20.6 | 21.9 |
| North East and Yorkshire | 3,635 | 21.0 | 20.3 | 21.7 |
| North West | 2,820 | 20.5 | 19.7 | 21.3 |
| East of England | 2,000 | 17.2 | 16.5 | 18.0 |
Figure 3.3C - Directly standardised rate of minor lower-limb amputations for Clinical Commissioning Groups compared to England, 2017/18 - 2019/20
Chart
Data table
| CCG | Count of minor amputations | Directly standardised rate | Lower 95% confidence interval | Upper 95% confidence interval | England comparison |
|---|---|---|---|---|---|
| NHS Somerset CCG | 420 | 44.6 | 37.9 | 51.9 | Significantly higher |
| NHS Southampton CCG | 175 | 42.5 | 36.3 | 49.3 | Significantly higher |
| NHS Bassetlaw CCG | 70 | 40.7 | 26.3 | 57.9 | Significantly higher |
| NHS Barking and Dagenham CCG | 100 | 38.8 | 31.1 | 47.6 | Significantly higher |
| NHS Southend CCG | 120 | 38.0 | 31.4 | 45.5 | Significantly higher |
| NHS Isle of Wight CCG | 95 | 37.1 | 26.0 | 50.0 | Significantly higher |
| NHS City and Hackney CCG | 95 | 36.8 | 27.8 | 47.4 | Significantly higher |
| NHS Telford and Wrekin CCG | 135 | 35.3 | 29.4 | 42.0 | Significantly higher |
| NHS Calderdale CCG | 130 | 33.8 | 28.2 | 40.2 | Significantly higher |
| NHS South Eastern Hampshire CCG | 150 | 33.5 | 26.9 | 40.9 | Significantly higher |
| NHS North East Hampshire and Farnham CCG | 115 | 33.2 | 27.4 | 39.8 | Significantly higher |
| NHS Kernow CCG | 350 | 32.3 | 28.3 | 36.6 | Significantly higher |
| NHS Bristol North Somerset and South Gloucestershire CCG | 490 | 32.1 | 29.2 | 35.1 | Significantly higher |
| NHS Shropshire CCG | 210 | 31.4 | 27.3 | 35.9 | Significantly higher |
| NHS Newham CCG | 95 | 31.1 | 22.9 | 40.7 | Significantly higher |
| NHS Blackpool CCG | 125 | 29.8 | 23.7 | 36.8 | Significantly higher |
| NHS South Warwickshire CCG | 135 | 29.6 | 24.8 | 35.1 | Significantly higher |
| NHS Tower Hamlets CCG | 65 | 29.5 | 21.5 | 39.2 | Not statisitcally different |
| NHS Liverpool CCG | 270 | 29.4 | 25.8 | 33.2 | Significantly higher |
| NHS Bolton CCG | 165 | 29.0 | 24.7 | 33.9 | Significantly higher |
| NHS Wolverhampton CCG | 145 | 29.0 | 24.3 | 34.4 | Significantly higher |
| NHS Portsmouth CCG | 115 | 28.9 | 23.7 | 34.8 | Significantly higher |
| NHS Havering CCG | 135 | 28.3 | 23.7 | 33.5 | Significantly higher |
| NHS North Lincolnshire CCG | 105 | 28.1 | 22.8 | 34.1 | Significantly higher |
| NHS Stoke On Trent CCG | 180 | 27.6 | 23.7 | 32.0 | Significantly higher |
| NHS Brighton and Hove CCG | 100 | 27.6 | 22.3 | 33.7 | Not statisitcally different |
| NHS Sandwell and West Birmingham CCG | 240 | 27.1 | 23.4 | 31.1 | Significantly higher |
| NHS Stafford and Surrounds CCG | 80 | 27.0 | 21.5 | 33.6 | Not statisitcally different |
| NHS Fareham and Gosport CCG | 120 | 26.9 | 22.4 | 32.2 | Not statisitcally different |
| NHS North Staffordshire CCG | 125 | 26.5 | 20.8 | 33.0 | Not statisitcally different |
| NHS Cannock Chase CCG | 75 | 26.5 | 17.6 | 37.1 | Not statisitcally different |
| NHS Kent and Medway CCG | 900 | 26.2 | 24.5 | 28.1 | Significantly higher |
| NHS Devon Clinical Commissioning Group | 660 | 26.2 | 24.2 | 28.4 | Significantly higher |
| NHS Redbridge CCG | 100 | 26.0 | 19.9 | 33.1 | Not statisitcally different |
| NHS West Hampshire CCG | 245 | 26.0 | 22.5 | 29.7 | Significantly higher |
| NHS North Cumbria CCG | 190 | 25.8 | 20.7 | 31.6 | Not statisitcally different |
| NHS Hull CCG | 160 | 25.6 | 21.5 | 30.2 | Not statisitcally different |
| NHS Wirral CCG | 175 | 25.5 | 21.4 | 30.0 | Not statisitcally different |
| NHS Manchester CCG | 195 | 25.3 | 21.7 | 29.3 | Not statisitcally different |
| NHS Doncaster CCG | 190 | 25.2 | 21.7 | 29.2 | Not statisitcally different |
| NHS Vale of York CCG | 155 | 25.2 | 21.4 | 29.5 | Not statisitcally different |
| NHS Hounslow CCG | 90 | 24.9 | 19.2 | 31.6 | Not statisitcally different |
| NHS Blackburn With Darwen CCG | 70 | 24.7 | 19.2 | 31.4 | Not statisitcally different |
| NHS Surrey Heartlands CCG | 380 | 24.6 | 22.2 | 27.3 | Not statisitcally different |
| NHS South Sefton CCG | 80 | 24.4 | 19.4 | 30.2 | Not statisitcally different |
| NHS South East London | 600 | 24.3 | 22.2 | 26.5 | Not statisitcally different |
| NHS North Yorkshire CCG | 200 | 24.3 | 20.7 | 28.3 | Not statisitcally different |
| NHS Coventry and Rugby CCG | 185 | 24.2 | 20.8 | 28.0 | Not statisitcally different |
| NHS Mid Essex CCG | 170 | 23.8 | 20.2 | 27.8 | Not statisitcally different |
| NHS North Hampshire CCG | 85 | 23.5 | 18.5 | 29.4 | Not statisitcally different |
| NHS Dudley CCG | 155 | 23.3 | 19.8 | 27.3 | Not statisitcally different |
| NHS East Lancashire CCG | 160 | 23.2 | 19.8 | 27.1 | Not statisitcally different |
| NHS Herts Valleys CCG | 205 | 22.9 | 19.9 | 26.3 | Not statisitcally different |
| NHS East Riding of Yorkshire CCG | 165 | 22.8 | 19.5 | 26.6 | Not statisitcally different |
| NHS Buckinghamshire CCG | 180 | 22.7 | 19.5 | 26.2 | Not statisitcally different |
| NHS Walsall CCG | 130 | 22.5 | 18.8 | 26.7 | Not statisitcally different |
| NHS Gloucestershire CCG | 270 | 22.4 | 19.7 | 25.4 | Not statisitcally different |
| NHS Sheffield CCG | 220 | 22.4 | 19.5 | 25.6 | Not statisitcally different |
| NHS East Berkshire CCG | 135 | 22.3 | 18.5 | 26.6 | Not statisitcally different |
| NHS Leeds CCG | 305 | 22.2 | 19.8 | 24.9 | Not statisitcally different |
| NHS Oldham CCG | 95 | 22.2 | 17.9 | 27.1 | Not statisitcally different |
| NHS North Tyneside CCG | 95 | 22.1 | 16.8 | 28.3 | Not statisitcally different |
| NHS Ipswich and East Suffolk CCG | 145 | 22.1 | 18.3 | 26.4 | Not statisitcally different |
| NHS Leicester City CCG | 125 | 22.0 | 17.7 | 27.0 | Not statisitcally different |
| NHS Barnsley CCG | 135 | 22.0 | 18.4 | 26.1 | Not statisitcally different |
| NHS Hammersmith and Fulham CCG | 45 | 22.0 | 15.2 | 30.4 | Not statisitcally different |
| NHS Luton CCG | 65 | 22.0 | 16.3 | 28.8 | Not statisitcally different |
| NHS Newcastle Gateshead CCG | 205 | 21.9 | 18.9 | 25.3 | Not statisitcally different |
| NHS Greater Preston CCG | 70 | 21.7 | 16.9 | 27.4 | Not statisitcally different |
| NHS South West London CCG | 390 | 21.6 | 19.4 | 24.1 | Not statisitcally different |
| NHS Greater Huddersfield CCG | 80 | 21.4 | 17.0 | 26.7 | Not statisitcally different |
| NHS East Leicestershire and Rutland CCG | 120 | 20.8 | 17.2 | 24.9 | Not statisitcally different |
| NHS Oxfordshire CCG | 200 | 20.7 | 17.9 | 23.8 | Not statisitcally different |
| NHS Rotherham CCG | 105 | 20.6 | 16.7 | 25.2 | Not statisitcally different |
| NHS Halton CCG | 70 | 20.6 | 16.0 | 26.1 | Not statisitcally different |
| NHS Bath and North East Somerset Swindon and Wiltshire CCG | 345 | 20.5 | 18.3 | 22.9 | Not statisitcally different |
| NHS Herefordshire and Worcestershire CCG | 335 | 20.2 | 17.9 | 22.6 | Not statisitcally different |
| NHS Nottingham and Nottinghamshire CCG | 375 | 19.9 | 17.9 | 22.0 | Not statisitcally different |
| NHS Birmingham and Solihull CCG | 440 | 19.9 | 18.0 | 21.9 | Not statisitcally different |
| NHS Northumberland CCG | 160 | 19.7 | 16.7 | 23.0 | Not statisitcally different |
| NHS Fylde and Wyre CCG | 80 | 19.6 | 15.6 | 24.5 | Not statisitcally different |
| NHS North East Lincolnshire CCG | 65 | 19.5 | 15.0 | 24.9 | Not statisitcally different |
| NHS Berkshire West CCG | 135 | 19.5 | 16.3 | 23.1 | Not statisitcally different |
| NHS Castle Point and Rochford CCG | 75 | 19.4 | 15.3 | 24.2 | Not statisitcally different |
| NHS East Staffordshire CCG | 55 | 19.4 | 14.4 | 25.5 | Not statisitcally different |
| NHS West Sussex CCG | 330 | 19.3 | 17.3 | 21.5 | Significantly lower |
| NHS North Central London CCG | 375 | 19.2 | 17.1 | 21.5 | Significantly lower |
| NHS Bury CCG | 75 | 19.2 | 14.9 | 24.2 | Not statisitcally different |
| NHS East and North Hertfordshire CCG | 175 | 19.1 | 16.3 | 22.2 | Not statisitcally different |
| NHS Sunderland CCG | 110 | 19.1 | 15.1 | 23.7 | Not statisitcally different |
| NHS Heywood Middleton and Rochdale CCG | 85 | 18.9 | 15.1 | 23.4 | Not statisitcally different |
| NHS Harrow CCG | 60 | 18.8 | 13.2 | 25.6 | Not statisitcally different |
| NHS Warwickshire North CCG | 75 | 18.3 | 14.4 | 22.9 | Not statisitcally different |
| NHS County Durham CCG | 190 | 18.3 | 13.1 | 24.1 | Not statisitcally different |
| NHS Cheshire CCG | 255 | 18.1 | 15.4 | 21.1 | Significantly lower |
| NHS St Helens CCG | 85 | 18.0 | 14.4 | 22.2 | Not statisitcally different |
| NHS Bradford District | 170 | 18.0 | 15.3 | 21.0 | Significantly lower |
| NHS Morecambe Bay CCG | 130 | 17.8 | 14.8 | 21.1 | Significantly lower |
| NHS Salford CCG | 85 | 17.7 | 14.1 | 22.0 | Not statisitcally different |
| NHS South East Staffordshire and Seisdon Peninsula CCG | 85 | 17.6 | 14.0 | 21.8 | Significantly lower |
| NHS Chorley and South Ribble CCG | 55 | 17.5 | 11.5 | 24.9 | Not statisitcally different |
| NHS West London CCG | 50 | 17.4 | 12.0 | 24.1 | Not statisitcally different |
| NHS West Suffolk CCG | 95 | 17.4 | 14.0 | 21.2 | Significantly lower |
| NHS Southport and Formby CCG | 50 | 17.1 | 12.6 | 22.7 | Not statisitcally different |
| NHS Northamptonshire CCG | 225 | 16.9 | 14.7 | 19.3 | Significantly lower |
| NHS North East Essex CCG | 115 | 16.8 | 13.7 | 20.4 | Significantly lower |
| NHS East Sussex | 175 | 16.4 | 13.9 | 19.1 | Significantly lower |
| NHS Lincolnshire CCG | 285 | 16.2 | 14.1 | 18.5 | Significantly lower |
| NHS South Tyneside CCG | 60 | 16.1 | 12.3 | 20.8 | Significantly lower |
| NHS Brent CCG | 80 | 15.8 | 10.7 | 21.8 | Significantly lower |
| NHS Tees Valley CCG | 225 | 15.8 | 13.7 | 18.1 | Significantly lower |
| NHS West Essex CCG | 80 | 15.7 | 12.4 | 19.5 | Significantly lower |
| NHS Waltham Forest CCG | 70 | 15.7 | 11.3 | 20.9 | Significantly lower |
| NHS West Leicestershire CCG | 110 | 15.6 | 12.8 | 18.9 | Significantly lower |
| NHS Dorset CCG | 250 | 15.5 | 13.6 | 17.5 | Significantly lower |
| NHS Hillingdon CCG | 65 | 15.4 | 11.6 | 20.0 | Significantly lower |
| NHS North Kirklees CCG | 50 | 15.3 | 11.3 | 20.2 | Significantly lower |
| NHS Stockport CCG | 80 | 15.1 | 12.0 | 18.9 | Significantly lower |
| NHS Tameside and Glossop CCG | 75 | 15.1 | 11.8 | 19.0 | Significantly lower |
| NHS Knowsley CCG | 60 | 15.0 | 11.4 | 19.4 | Significantly lower |
| NHS Bedfordshire CCG | 120 | 14.9 | 12.4 | 17.9 | Significantly lower |
| NHS Norfolk and Waveney CCG | 340 | 14.8 | 13.2 | 16.6 | Significantly lower |
| NHS Milton Keynes CCG | 60 | 14.8 | 11.2 | 19.2 | Significantly lower |
| NHS Warrington CCG | 65 | 14.7 | 11.3 | 18.7 | Significantly lower |
| NHS Central London (Westminster) CCG | 30 | 14.3 | 8.8 | 21.5 | Significantly lower |
| NHS Derby and Derbyshire Clinical Commissioning Group | 290 | 13.9 | 12.3 | 15.6 | Significantly lower |
| NHS Wigan Borough CCG | 95 | 13.7 | 10.9 | 17.1 | Significantly lower |
| NHS Surrey Heath CCG | 20 | 13.6 | 8.3 | 21.0 | Significantly lower |
| NHS West Lancashire CCG | 30 | 12.1 | 8.2 | 17.3 | Significantly lower |
| NHS Ealing CCG | 75 | 12.0 | 8.3 | 16.3 | Significantly lower |
| NHS Cambridgeshire and Peterborough CCG | 185 | 11.6 | 9.9 | 13.4 | Significantly lower |
| NHS Wakefield CCG | 90 | 10.9 | 8.6 | 13.5 | Significantly lower |
| NHS Trafford CCG | 35 | 9.0 | 6.2 | 12.6 | Significantly lower |
| NHS Thurrock CCG | 25 | 8.4 | 5.4 | 12.4 | Significantly lower |
| NHS Basildon and Brentwood CCG | 35 | 7.7 | 5.3 | 10.8 | Significantly lower |
Figure 3.3D - Directly standardised rate of minor lower-limb amputations for Clinical Commissioning Groups in England, 2017/18 - 2019/20
4 Hospital admissions for diabetes-related foot disease
The information below relates to spells of care in hospital that were predominately for inpatient management of diabetes-related foot disease. One spell of care was taken as a proxy for a single admission for foot disease. The rates in this section have not been standardised due to the heterogeneous nature of the conditions included under the definition of foot disease, meaning the demographic profiles across different conditions are not necessarily uniform. Full details of the criteria used for defining diabetes-related foot disease can be found in the accompanying technical document.
The 171,759 admissions for diabetes-related foot disease during 2017/18 - 2019/20 are equivalent to 171.8 admissions for every 10,000 population with diabetes per year.
Figure 4A shows the trend of crude rates of hospital admissions for diabetes-related foot disease in England from 2012/13 - 2014/15 to 2017/18 - 2019/20. There has been a statistically significant increase in the rate of admissions between 2012/13 - 2014/15 and the latest period.
Figure 4B displays the admission rate for England and NHS regions. The regions with rates statistically significantly higher than England are South East and East of England. London and North West had rates significantly lower than England. Figure 4C shows the geographical variation in rates of hospital admissions across Clinical Commissioning Groups and whether each is statistically significantly different to the rate for England. These range from 109.3 to 297.2 (a 2.7-fold difference). This demonstrates the varying need for foot care services throughout the country. The lack of standardisation may impair comparisons due to the different age distribution of the population with diabetes in different areas.
The geographical distribution of the areas with the highest and lowest rates of hospital admissions are displayed in Figure 4D.
Figure 4A - Crude rates of hospital admissions for foot disease for England, 2012/13 - 2014/15 to 2017/18 - 2019/20
Chart
Data table
| Analysis period | Number of admissions | Number of patient | Crude rate |
|---|---|---|---|
| 2012/13 - 2014/15 | 109,211 | 68,395 | 129.5 |
| 2013/14 - 2015/16 | 121,067 | 73,388 | 138.2 |
| 2014/15 - 2016/17 | 132,114 | 78,792 | 145.5 |
| 2015/16 - 2017/18 | 147,067 | 85,837 | 156.6 |
| 2016/17 - 2018/19 | 157,886 | 90,955 | 163.2 |
| 2017/18 - 2019/20 | 171,759 | 97,175 | 171.8 |
Figure 4B - Crude rate of hospital admissions for foot disease for England and regions, 2017/18 - 2019/20
Chart
Data table
| Area | Admission count | Crude rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|
| England | 171,759 | 171.8 | 171.0 | 172.6 |
| East of England | 20,520 | 186.6 | 184.0 | 189.1 |
| South East | 25,495 | 181.0 | 178.8 | 183.2 |
| South West | 16,275 | 171.4 | 168.8 | 174.1 |
| Midlands | 34,760 | 170.3 | 168.5 | 172.1 |
| North East and Yorkshire | 27,200 | 169.8 | 167.8 | 171.8 |
| North West | 21,990 | 168.2 | 166.0 | 170.5 |
| London | 25,525 | 158.9 | 157.0 | 160.9 |
Figure 4C - Crude rate of hospital admissions for foot disease for Clinical Commissioning Groups compared to England, 2017/18 - 2019/20
Chart
Data table
| Area | Admission count | Crude rate | Lower 95% confidence interval | Upper 95% confidence interval | England comparison |
|---|---|---|---|---|---|
| NHS Southend CCG | 925 | 297.2 | 278.7 | 317.3 | Significantly higher |
| NHS Brent CCG | 2,490 | 290.4 | 279.3 | 302.3 | Significantly higher |
| NHS Northamptonshire CCG | 3,420 | 271.0 | 262.0 | 280.3 | Significantly higher |
| NHS Norfolk and Waveney CCG | 4,570 | 235.6 | 228.9 | 242.6 | Significantly higher |
| NHS Barnsley CCG | 1,135 | 233.9 | 220.1 | 247.5 | Significantly higher |
| NHS South Sefton CCG | 640 | 233.7 | 215.6 | 252.1 | Significantly higher |
| NHS Vale of York CCG | 1,170 | 231.5 | 218.8 | 245.5 | Significantly higher |
| NHS Knowsley CCG | 700 | 223.9 | 207.0 | 240.4 | Significantly higher |
| NHS Sheffield CCG | 2,120 | 220.1 | 211.0 | 229.9 | Significantly higher |
| NHS Somerset CCG | 2,205 | 218.1 | 209.1 | 227.4 | Significantly higher |
| NHS Blackpool CCG | 750 | 216.3 | 201.4 | 232.6 | Significantly higher |
| NHS Liverpool CCG | 1,810 | 209.9 | 200.3 | 219.7 | Significantly higher |
| NHS North Tyneside CCG | 845 | 209.8 | 195.9 | 224.4 | Significantly higher |
| NHS South Tyneside CCG | 615 | 209.3 | 193.7 | 227.2 | Significantly higher |
| NHS Derby and Derbyshire Clinical Commissioning Group | 4,045 | 209.0 | 202.6 | 215.5 | Significantly higher |
| NHS St Helens CCG | 785 | 207.0 | 192.5 | 221.7 | Significantly higher |
| NHS Wirral CCG | 1,235 | 206.0 | 194.9 | 218.0 | Significantly higher |
| NHS Buckinghamshire CCG | 1,675 | 205.3 | 195.4 | 215.2 | Significantly higher |
| NHS Castle Point and Rochford CCG | 690 | 204.9 | 190.2 | 221.1 | Significantly higher |
| NHS South East London | 6,060 | 203.7 | 198.6 | 208.9 | Significantly higher |
| NHS Rotherham CCG | 970 | 202.4 | 190.1 | 215.8 | Significantly higher |
| NHS Herts Valleys CCG | 1,855 | 202.2 | 193.4 | 211.9 | Significantly higher |
| NHS Chorley and South Ribble CCG | 620 | 201.6 | 186.3 | 218.4 | Significantly higher |
| NHS Stoke On Trent CCG | 1,175 | 201.3 | 190.1 | 213.3 | Significantly higher |
| NHS Nottingham and Nottinghamshire CCG | 3,585 | 200.7 | 194.2 | 207.4 | Significantly higher |
| NHS Kent and Medway CCG | 6,260 | 199.9 | 195.0 | 204.9 | Significantly higher |
| NHS Halton CCG | 525 | 199.8 | 183.1 | 217.7 | Significantly higher |
| NHS Northumberland CCG | 1,270 | 192.6 | 182.5 | 203.8 | Significantly higher |
| NHS Hammersmith and Fulham CCG | 525 | 191.5 | 176.1 | 209.3 | Significantly higher |
| NHS North Yorkshire CCG | 1,345 | 191.3 | 181.4 | 202.0 | Significantly higher |
| NHS Brighton and Hove CCG | 635 | 190.6 | 175.7 | 205.7 | Significantly higher |
| NHS Calderdale CCG | 705 | 190.2 | 176.4 | 204.8 | Significantly higher |
| NHS Basildon and Brentwood CCG | 825 | 190.0 | 176.8 | 203.0 | Significantly higher |
| NHS Surrey Heartlands CCG | 2,755 | 187.6 | 180.7 | 194.8 | Significantly higher |
| NHS Bristol North Somerset and South Gloucestershire CCG | 2,800 | 187.3 | 180.3 | 194.2 | Significantly higher |
| NHS Salford CCG | 810 | 186.7 | 173.9 | 199.8 | Significantly higher |
| NHS Southport and Formby CCG | 425 | 186.0 | 168.8 | 204.6 | Not statisitcally different |
| NHS North Hampshire CCG | 620 | 185.1 | 171.1 | 200.5 | Not statisitcally different |
| NHS Isle of Wight CCG | 495 | 184.1 | 168.2 | 201.1 | Not statisitcally different |
| NHS Hull CCG | 980 | 183.8 | 172.7 | 195.9 | Significantly higher |
| NHS South Eastern Hampshire CCG | 730 | 183.0 | 170.2 | 197.0 | Not statisitcally different |
| NHS Shropshire CCG | 975 | 182.2 | 171.3 | 194.4 | Not statisitcally different |
| NHS Greater Preston CCG | 605 | 182.1 | 168.2 | 197.5 | Not statisitcally different |
| NHS Mid Essex CCG | 1,155 | 181.4 | 170.9 | 192.0 | Not statisitcally different |
| NHS Morecambe Bay CCG | 1,075 | 179.7 | 168.8 | 190.4 | Not statisitcally different |
| NHS North Staffordshire CCG | 755 | 179.6 | 166.8 | 192.6 | Not statisitcally different |
| NHS Thurrock CCG | 500 | 179.4 | 163.7 | 195.5 | Not statisitcally different |
| NHS Oxfordshire CCG | 1,670 | 179.1 | 170.4 | 187.7 | Not statisitcally different |
| NHS Doncaster CCG | 1,145 | 179.0 | 168.9 | 189.8 | Not statisitcally different |
| NHS South Warwickshire CCG | 750 | 178.2 | 165.7 | 191.5 | Not statisitcally different |
| NHS Telford and Wrekin CCG | 620 | 178.2 | 164.4 | 192.8 | Not statisitcally different |
| NHS Bedfordshire CCG | 1,380 | 177.6 | 168.1 | 186.9 | Not statisitcally different |
| NHS Southampton CCG | 730 | 176.2 | 163.4 | 189.2 | Not statisitcally different |
| NHS East Riding of Yorkshire CCG | 1,055 | 175.3 | 165.2 | 186.5 | Not statisitcally different |
| NHS Portsmouth CCG | 615 | 174.9 | 161.9 | 189.9 | Not statisitcally different |
| NHS Tameside and Glossop CCG | 830 | 174.2 | 162.4 | 186.3 | Not statisitcally different |
| NHS West Suffolk CCG | 775 | 174.0 | 161.7 | 186.5 | Not statisitcally different |
| NHS Fareham and Gosport CCG | 650 | 174.0 | 160.3 | 187.3 | Not statisitcally different |
| NHS East Leicestershire and Rutland CCG | 975 | 173.7 | 163.4 | 185.4 | Not statisitcally different |
| NHS North Lincolnshire CCG | 605 | 172.3 | 158.8 | 186.6 | Not statisitcally different |
| NHS Cambridgeshire and Peterborough CCG | 2,505 | 171.9 | 165.2 | 178.7 | Not statisitcally different |
| NHS Havering CCG | 830 | 171.9 | 160.6 | 184.2 | Not statisitcally different |
| NHS Hillingdon CCG | 990 | 171.0 | 160.3 | 181.8 | Not statisitcally different |
| NHS West Hampshire CCG | 1,395 | 170.9 | 162.2 | 180.3 | Not statisitcally different |
| NHS Fylde and Wyre CCG | 555 | 170.5 | 156.9 | 185.6 | Not statisitcally different |
| NHS North East Essex CCG | 1,010 | 168.9 | 158.5 | 179.5 | Not statisitcally different |
| NHS West Sussex CCG | 2,630 | 168.7 | 162.5 | 175.4 | Not statisitcally different |
| NHS Newcastle Gateshead CCG | 1,440 | 168.2 | 159.6 | 177.1 | Not statisitcally different |
| NHS East Berkshire CCG | 1,250 | 168.2 | 158.8 | 177.6 | Not statisitcally different |
| NHS Bath and North East Somerset Swindon and Wiltshire CCG | 2,565 | 168.1 | 161.5 | 174.6 | Not statisitcally different |
| NHS Kernow CCG | 1,615 | 167.8 | 159.8 | 176.3 | Not statisitcally different |
| NHS South East Staffordshire and Seisdon Peninsula CCG | 645 | 167.0 | 154.1 | 180.1 | Not statisitcally different |
| NHS Tees Valley CCG | 2,070 | 166.1 | 159.2 | 173.6 | Not statisitcally different |
| NHS North Cumbria CCG | 1,050 | 165.9 | 155.7 | 175.9 | Not statisitcally different |
| NHS Warrington CCG | 600 | 165.3 | 152.6 | 179.4 | Not statisitcally different |
| NHS Devon Clinical Commissioning Group | 3,470 | 165.3 | 159.8 | 170.9 | Significantly lower |
| NHS West Leicestershire CCG | 1,105 | 164.7 | 155.1 | 174.7 | Not statisitcally different |
| NHS Bassetlaw CCG | 385 | 164.4 | 148.4 | 181.7 | Not statisitcally different |
| NHS East Staffordshire CCG | 425 | 164.1 | 149.6 | 181.3 | Not statisitcally different |
| NHS West Essex CCG | 790 | 163.7 | 152.5 | 175.6 | Not statisitcally different |
| NHS East Sussex | 1,540 | 162.4 | 154.5 | 170.9 | Significantly lower |
| NHS Oldham CCG | 805 | 162.1 | 150.7 | 173.3 | Not statisitcally different |
| NHS East and North Hertfordshire CCG | 1,410 | 161.9 | 153.6 | 170.7 | Significantly lower |
| NHS North East Hampshire and Farnham CCG | 570 | 161.8 | 148.5 | 175.3 | Not statisitcally different |
| NHS Barking and Dagenham CCG | 670 | 161.4 | 149.9 | 174.6 | Not statisitcally different |
| NHS South West London CCG | 3,645 | 160.5 | 155.4 | 165.9 | Significantly lower |
| NHS Dudley CCG | 980 | 158.1 | 148.4 | 168.4 | Significantly lower |
| NHS Lincolnshire CCG | 2,375 | 156.1 | 149.7 | 162.4 | Significantly lower |
| NHS Dorset CCG | 2,065 | 155.4 | 148.9 | 162.4 | Significantly lower |
| NHS Heywood Middleton and Rochdale CCG | 735 | 155.3 | 144.1 | 166.8 | Significantly lower |
| NHS Bury CCG | 565 | 155.0 | 142.2 | 168.0 | Significantly lower |
| NHS Ipswich and East Suffolk CCG | 975 | 154.3 | 144.8 | 164.3 | Significantly lower |
| NHS Herefordshire and Worcestershire CCG | 2,190 | 153.1 | 146.8 | 159.7 | Significantly lower |
| NHS Leeds CCG | 2,070 | 152.7 | 146.3 | 159.6 | Significantly lower |
| NHS Warwickshire North CCG | 555 | 152.6 | 140.2 | 165.8 | Significantly lower |
| NHS Berkshire West CCG | 1,070 | 152.5 | 143.7 | 162.2 | Significantly lower |
| NHS Manchester CCG | 1,515 | 151.1 | 143.6 | 159.0 | Significantly lower |
| NHS Cannock Chase CCG | 395 | 150.8 | 135.6 | 165.7 | Significantly lower |
| NHS Sunderland CCG | 790 | 150.3 | 140.0 | 161.2 | Significantly lower |
| NHS Stockport CCG | 755 | 150.1 | 139.6 | 161.2 | Significantly lower |
| NHS Ealing CCG | 1,370 | 149.6 | 141.6 | 157.5 | Significantly lower |
| NHS Trafford CCG | 555 | 147.8 | 135.5 | 160.3 | Significantly lower |
| NHS West London CCG | 465 | 147.2 | 134.7 | 161.9 | Significantly lower |
| NHS Surrey Heath CCG | 205 | 146.6 | 125.8 | 166.5 | Significantly lower |
| NHS Greater Huddersfield CCG | 590 | 145.7 | 134.2 | 157.9 | Significantly lower |
| NHS Walsall CCG | 895 | 145.6 | 136.5 | 155.8 | Significantly lower |
| NHS Gloucestershire CCG | 1,555 | 145.0 | 138.1 | 152.6 | Significantly lower |
| NHS Stafford and Surrounds CCG | 365 | 144.2 | 130.2 | 160.2 | Significantly lower |
| NHS City and Hackney CCG | 645 | 141.8 | 130.9 | 153.0 | Significantly lower |
| NHS Harrow CCG | 895 | 140.9 | 131.9 | 150.6 | Significantly lower |
| NHS Birmingham and Solihull CCG | 3,655 | 140.6 | 136.2 | 145.3 | Significantly lower |
| NHS Wigan Borough CCG | 865 | 140.4 | 131.4 | 150.3 | Significantly lower |
| NHS Cheshire CCG | 1,765 | 139.2 | 132.9 | 146.0 | Significantly lower |
| NHS Central London (Westminster) CCG | 345 | 139.0 | 125.4 | 155.3 | Significantly lower |
| NHS East Lancashire CCG | 965 | 137.7 | 129.3 | 146.8 | Significantly lower |
| NHS Wolverhampton CCG | 775 | 137.2 | 127.5 | 147.0 | Significantly lower |
| NHS Coventry and Rugby CCG | 1,160 | 137.1 | 129.6 | 145.5 | Significantly lower |
| NHS Sandwell and West Birmingham CCG | 1,705 | 136.4 | 130.1 | 143.2 | Significantly lower |
| NHS Wakefield CCG | 945 | 135.0 | 126.3 | 143.6 | Significantly lower |
| NHS West Lancashire CCG | 270 | 135.0 | 120.3 | 153.2 | Significantly lower |
| NHS Leicester City CCG | 1,225 | 134.2 | 126.6 | 141.7 | Significantly lower |
| NHS Luton CCG | 590 | 133.8 | 123.0 | 144.8 | Significantly lower |
| NHS North East Lincolnshire CCG | 420 | 133.6 | 120.8 | 146.7 | Significantly lower |
| NHS Bolton CCG | 795 | 129.8 | 121.1 | 139.3 | Significantly lower |
| NHS Milton Keynes CCG | 565 | 128.3 | 118.2 | 139.6 | Significantly lower |
| NHS Waltham Forest CCG | 650 | 126.9 | 117.7 | 137.4 | Significantly lower |
| NHS County Durham CCG | 1,370 | 126.7 | 120.2 | 133.7 | Significantly lower |
| NHS Newham CCG | 1,030 | 125.8 | 118.1 | 133.6 | Significantly lower |
| NHS Bradford District | 1,600 | 125.0 | 119.0 | 131.3 | Significantly lower |
| NHS Hounslow CCG | 790 | 124.3 | 116.1 | 133.6 | Significantly lower |
| NHS North Kirklees CCG | 495 | 123.7 | 113.3 | 135.4 | Significantly lower |
| NHS Blackburn With Darwen CCG | 435 | 122.1 | 110.6 | 133.8 | Significantly lower |
| NHS North Central London CCG | 2,785 | 113.5 | 109.3 | 117.8 | Significantly lower |
| NHS Tower Hamlets CCG | 595 | 109.5 | 101.0 | 118.8 | Significantly lower |
| NHS Redbridge CCG | 735 | 109.3 | 101.5 | 117.5 | Significantly lower |
Figure 4D - Crude rates of hospital admissions for foot disease for Clinical Commissioning Groups in England, 2017/18 - 2019/20
5 The impact of the COVID-19 pandemic on foot care
During the early period of the COVID-19 pandemic in the UK access to healthcare was substantially impacted. Reductions to both emergency and elective admissions were identified during the Spring of 2020. In both the Spring and Winter of 2020, high COVID-19 infection rates led to the redistribution of resources within the NHS, including to support the vaccination campaign in December 2020 and into 2021.
Figure 5A1 displays the monthly crude rate of foot disease-related admissions between 2017/18 and 2020/21 per 10,000 population registered with diabetes in that year. This indicates that there was a substantial drop in admissions from March 2020, with the lowest admission rate occurring in April 2020 - a 48% decrease compared to 2019. There was a month-on-month increase up until August 2020, after which admissions drop off again towards the end of the year and into 2021. There is an indication that admissions began to return to normal levels by March 2021.
A recent study commissioned by NHS England demonstrated that, during the first wave in March to June 2020, rates of major and minor amputations were significantly lower than the equivalent period from 2017 to 2019 [8]. This was true after controlling for age, sex, ethnicity, deprivation and geographical region.
It is currently unclear whether the reductions in admissions identified here reflected an actual reduction in complications in the population or patients’ treatment having been delayed, patients themselves actively reduced accessing care or an artifact of data recording issues during periods of high demand on the NHS.
The next update of this report will assess further how rates of hospital admissions and amputations were affected during the pandemic, once all the necessary data for 2020/21 is available.
Figure 5A - Crude rate of hospital admissions for foot disease per month in England, 2017/18 to 2020/21
Chart
Data table
| Year | Month | Admission count | Crude rate | Lower 95% confidence interval | Upper 95% confidence interval |
|---|---|---|---|---|---|
| 2017/18 | April | 4,052 | 12.7 | 12.3 | 13.1 |
| May | 4,479 | 14.0 | 13.6 | 14.4 | |
| June | 4,658 | 14.6 | 14.2 | 15.0 | |
| July | 4,440 | 13.9 | 13.5 | 14.3 | |
| August | 4,602 | 14.4 | 14.0 | 14.8 | |
| September | 4,348 | 13.6 | 13.2 | 14.0 | |
| October | 4,466 | 14.0 | 13.6 | 14.4 | |
| November | 4,403 | 13.8 | 13.4 | 14.2 | |
| December | 4,401 | 13.8 | 13.4 | 14.2 | |
| January | 4,528 | 14.2 | 13.8 | 14.6 | |
| February | 4,087 | 12.8 | 12.4 | 13.2 | |
| March | 4,913 | 15.4 | 14.9 | 15.8 | |
| 2018/19 | April | 4,460 | 13.4 | 13.0 | 13.8 |
| May | 5,032 | 15.2 | 14.7 | 15.6 | |
| June | 5,058 | 15.2 | 14.8 | 15.7 | |
| July | 5,324 | 16.0 | 15.6 | 16.5 | |
| August | 5,033 | 15.2 | 14.7 | 15.6 | |
| September | 4,578 | 13.8 | 13.4 | 14.2 | |
| October | 4,821 | 14.5 | 14.1 | 14.9 | |
| November | 4,709 | 14.2 | 13.8 | 14.6 | |
| December | 4,484 | 13.5 | 13.1 | 13.9 | |
| January | 4,778 | 14.4 | 14.0 | 14.8 | |
| February | 4,334 | 13.1 | 12.7 | 13.5 | |
| March | 5,046 | 15.2 | 14.8 | 15.6 | |
| 2019/20 | April | 5,054 | 14.6 | 14.2 | 15.0 |
| May | 5,278 | 15.3 | 14.9 | 15.7 | |
| June | 5,122 | 14.8 | 14.4 | 15.2 | |
| July | 5,732 | 16.6 | 16.2 | 17.0 | |
| August | 5,420 | 15.7 | 15.3 | 16.1 | |
| September | 5,180 | 15.0 | 14.6 | 15.4 | |
| October | 5,147 | 14.9 | 14.5 | 15.3 | |
| November | 4,919 | 14.2 | 13.8 | 14.6 | |
| December | 4,783 | 13.8 | 13.5 | 14.2 | |
| January | 5,013 | 14.5 | 14.1 | 14.9 | |
| February | 4,427 | 12.8 | 12.4 | 13.2 | |
| March | 3,784 | 11.0 | 10.6 | 11.3 | |
| 2020/21 | April | 2,653 | 7.6 | 7.3 | 7.9 |
| May | 3,604 | 10.3 | 10.0 | 10.7 | |
| June | 4,108 | 11.8 | 11.4 | 12.1 | |
| July | 4,372 | 12.5 | 12.2 | 12.9 | |
| August | 4,501 | 12.9 | 12.5 | 13.3 | |
| September | 4,476 | 12.8 | 12.4 | 13.2 | |
| October | 4,231 | 12.1 | 11.8 | 12.5 | |
| November | 4,024 | 11.5 | 11.2 | 11.9 | |
| December | 3,945 | 11.3 | 10.9 | 11.7 | |
| January | 3,671 | 10.5 | 10.2 | 10.9 | |
| February | 3,848 | 11.0 | 10.7 | 11.4 | |
| March | 4,841 | 13.9 | 13.5 | 14.3 |
Source: Hospital Episode Statistics, Quality Outcomes Framework.
Footnotes
6 Resources for foot care
Below are helpful resources for understanding diabetic foot care both nationally and at a local level, including preventing complications:
Diabetes foot care profiles: This profile presents statistics on people with diabetes in England, who were admitted to hospital for foot disease. The profile includes a range of analysis covering treatment and outcomes relating to foot disease. The data are presented at NHS Clinical Commissioning Group, Sustainability and Transformation Partnerships and NHS Region geographies.
National Diabetes Core Audit: A major clinical audit of patients with diabetes in England and Wales, assessing healthcare processes and treatment targets against NICE guidelines, including the percentage of patients that have received a foot check. The audit also reports data from the Diabetes Prevention Programme, which delivers evidence-based behavioural interventions aiming to prevent or delay the onset of Type 2 diabetes among those with non-diabetic hyperglycemia.
National Diabetes Foot Care Audit: This is an audit of specialist foot care services for patients with diabetes, measuring the performance against NICE guidelines. It also reports on outcomes and complications that develop from foot disease.
NICE Guidelines for diabetic foot care: Guidance for healthcare professionals, commissioners and providers of foot care services and patients with diabetes and their carers. It aims to reduce variation in care by recommending a structured and dedicated care pathway for foot disease that prevents the development of foot problems as well as managing them.
References
- NHS Digital. Quality and Outcomes Framework, 2020-21. https://digital.nhs.uk/pubs/qof2021.
- Kerr M, Barron E, Chadwick P, Evans T, Kong WM, Rayman G, Sutton-Smith M, Todd G, Young B, Jeffcoate WJ. The cost of diabetic foot ulcers and amputations to the National Health Service in England. Diabet Med. 2019; 36(8): 995-1002; https://doi.org/10.1111/dme.13973.
- NICE guideline [NG19]. Diabetic foot problems: prevention and management; http://www.nice.org.uk/guidance/ng19.
- Icks A, Scheer M, Morbach S, Genz J, Haastert B, Giani G et al. Time-dependent impact of diabetes on mortality in patients after major lower extremity amputation: survival in a population-based 5-year cohort in Germany. Diabetes Care. 2011; 34: 1350–1354; https://doi.org/10.2337/dc10-2341.
- Ikonen TS, Sund R, Venermo M, Winell K. Fewer major amputations among individuals with diabetes in Finland in 1997–2007: a population-based study. Diabetes Care. 2010; 33: 2598–2603; https://doi.org/10.2337/dc10-0462.
- Leggetter S, Chaturvedi N, Fuller JH, Edmonds ME. Ethnicity and risk of diabetes-related lower extremity amputation: a population-based, case-control study of African Caribbeans and Europeans in the United Kingdom. Archives of internal medicine. 2002; 162(1): 73-78; https://doi.org/10.1001/archinte.162.1.73.
- Chaturvedi N, Abbott CA, Whalley A, Widdows P, Leggetter SY, Boulton AJ. Risk of diabetes‐related amputation in South Asians vs. Europeans in the UK. Diabetic Medicine. 2002; 19(2): 99-104; https://doi.org/10.1046/j.1464-5491.2002.00583.x.
- Valabhji J, Barron E, Vamos EP, Dhatariya K, Game F, Kar P, Weaver A, Verma S, Young B, Khunti K. Temporal trends in lower-limb major and minor amputation and revascularization procedures in people with diabetes in England during the COVID-19 pandemic. Diabetes Care. 2021; 44: e133–e135; https://doi.org/10.2337/dc20-2852.
Data Sources
Hospital Episode Statistics (HES) Copyright © 2010/11 - 2020/21, Re-used with the permission of NHS Digital. All rights reserved; National Diabetes Audit (NDA) 2015/16 - 2019/20, Healthcare Quality Improvement Partnership, All rights reserved; Quality and Outcomes Framework (QOF) 2010/11 - 2020/21, NHS Digital.
© Crown copyright 2022 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL or email psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.
Due to the method of assigning spells to months, the sum of the counts for the months of 2017/18 - 2019/20 may not equal the counts reported for the indicators above.↩︎