National Diabetes Foot Care Audit 2020 to 2025

NDFA patient-level information on care processes and outcomes is collected through the NHS England Clinical Audit Platform (CAP) and covers patients in England and Wales with foot ulcers that underwent first expert assessment (FEA) by a specialist foot care service from 14 July 2014 onwards. Data collection began in December 2014.

The Audit also measures the provision of foot care services using the NDA Integrated Specialist Services Survey (ISS survey, abbreviated to ISS), a questionnaire based on National Institute for Health and Care Excellence (NICE) and Getting it Right First Time (GIRFT) recommended structures and systems for delivery of care to people with diabetes. 

2024 ISS data was collected by the NHS England Strategic Data Collection Service (SDCS). The survey was distributed to healthcare providers in England and Wales in October 2024, requesting data on how services were structured as of 1 October 2024. The foot care section of the questionnaire comprised 11 questions on aspects of care delivery which were selected by clinical members of the former NDFA Advisory Group.

This report uses ulcer episodes with a date of FEA between 01 April 2020 and 31 March 2025. Results have been split by audit years running from April to March, based on FEA (e.g. 01 April 2020 to 31 March 2021, abbreviated to 2020-21).

In some cases, additional filters were applied during cohort selection, e.g. to ensure an essential data item was available or that sufficient episodes were present.

It is difficult to assess the level of participation in the NDFA, as there is no definitive list of organisations that provide specialist diabetes foot care services in England and Wales.

279 specialist foot care services from 158 healthcare providers have submitted to the Audit between 01 April 2020 and 31 March 2025. The organisation types of the 158 healthcare providers are listed below:

• 103 acute NHS trusts
• 31 non-acute NHS trusts
• 17 independent healthcare providers (IHP)
• 6 Welsh local health boards (LHB)
• 1 NHS care trust

For context, there were 208 NHS trusts in England at the end of the audit period (31 March 2025), which includes acute, mental health, ambulance, community and care trusts. There were 7 LHBs in Wales. As noted, it is not known how many healthcare providers have specialist diabetes foot care services, so provider participation cannot be accurately calculated.

During the audit period assessed in this report, the mean number of ulcer episodes submitted to the NDFA by the 158 healthcare providers who submitted is 863.6 per healthcare provider (median 678), ranging from 5 to 4,875 with an interquartile range (IQR) of 241 - 1,231. 8.9% of healthcare providers submitted fewer than 100 ulcer episodes to the NDFA. 

79.1% of healthcare providers submitted to all 5 audit years between 2020-21 and 2024-25. On average, healthcare providers submitted in 4.5 of 5 NDFA audit years.

125 providers responded to the 2024 ISS: 105 NHS trust sites, 1 independent sector provider, 4 NHS trusts, 1 LHB, 9 LHB sites, 2 branch surgeries, 2 prescribing cost centres and 1 primary care network.

For comparison, there were 207 NHS trusts and 7 LHBs in England and Wales on 1 October 2024 (the date of ISS assessment), although some healthcare providers (e.g. mental health or ambulance trusts) would not be expected to contribute to the ISS.

A total of 136,410 ulcer episodes in 92,010 people with diabetes have been registered with the NDFA during the 2020-21 to 2024-25 audit period. There was a slight decrease in ulcer episodes registered in 2022-21, to around 22,000, coinciding with the COVID-19 pandemic however, there have been more than 30,000 ulcer episodes per year for 2023-24 and 2024-25.

Using the annual caseload estimates provided by NDFA submitters in the 2018 NDFA Provider Survey, the NDFA 4th Annual Report estimated 2017-18 case ascertainment to be 20% (slide 14), with a lower percentage in earlier collection years. By 2019-20 the number of patients submitted to the NDFA had risen by 50% since 2017-18, so case ascertainment is estimated to be around 30% in later audit years.

Probable low case ascertainment should be considered when interpreting NDFA findings, with acknowledgement that:

• The patients submitted to the NDFA may not be representative of the entire population of people with diabetic foot ulcers, though there is not presently any evidence to suggest that this is an issue.
• Counts presented in the NDFA are likely to underestimate the true national figure.

Data collected via the Clinical Audit Platform (CAP) and Strategic Data Collection Service (SDCS) systems was subject to validation checks on upload, preventing erroneous values from being entered.

The publication has now been updated to include HES and PEDW data which are used to identify complications.

HES and PEDW are databases containing details of all admissions, outpatient appointments and accident and emergency (A&E) attendances at NHS hospitals in England (HES) and Wales (PEDW). NDFA patients were linked to hospital admissions data in HES and PEDW.

Linkage to Welsh hospital data (PEDW) involved only Welsh patients, derived from the location of the foot care services which had registered the patient's FEA in the NDFA. Therefore, Welsh hospital admissions were only available for people assessed at foot care services in Wales, and any Welsh hospital admissions of people seen by an English foot care service were not included in the audit analyses.

NDFA processes and outcome collection data was extracted from CAP on 5 August 2025, following the 4 August 2025 submission deadline. The 2024 ISS survey was open between 14 October and 8 November 2024, but later the submission deadline was extended to 6 December 2024 to allow for more submissions.

The NDFA report for the period 01 April 2020 to 31 March 2025 was published on 13 November 2025. The time lag to publication was therefore 7 months after the end of the audit period, 3 months after the submission deadline.  2024 ISS data was first published in March 2025.

This report is presented in HTML format on the NHS England website. Supplementary materials are published in Excel format. 

In November 2025 an updated dashboard was made available to enable interrogation of the data: National Diabetes Audit dashboards

Further information about the audit can be found:

https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-foot-care-audit

This release is an update to the existing detailed analysis file and dashboard reporting on diabetes related foot disease in England and Wales. All NDFA reports can be found here:

National Diabetes Footcare Audit

The reports all cover multiple years and consequently, data from many of the same patients and ulcer episodes will have been included in earlier reports.

Please note that data relating to renal replacement therapy (RRT) in Table 13 of the detailed analysis file should not be compared with data from previous publications due to an update in the clinical codes which we use to identify RRT related hospital admissions. Following updated clinical advice we have removed a sub-set of ICD-10 and OPCS4 codes which has resulted in fewer admissions, therefore this should be bourne in mind when interpreting the data.

Disclosure control

Disclosure control has been used for numbers derived from patient / ulcer records to reduce the risk of patient identification; numbers 1-7 are shown as 5, while all other numbers are rounded to the nearest 5. Means and percentages have been be calculated using rounded numerators and denominators and are shown to 1 decimal place. The calculated value will not be shown in cases where the denominator is less than or equal to 20.

The most pronounced differences caused by rounding are a result of percentages derived from small denominators (e.g. 20) with small numerators (e.g. 1), with the numerator rounded-up to 5. This scenario is most likely with a low frequency event (e.g. major amputation) in a small cohort (e.g. split by organisation).

ISS survey

The ISS survey was first undertaken in 2020 and first used in the NDFA in 2021.

NDA Core collection

The core NDA reports on foot assessments for people with diabetes, but does not cover the process and outcomes information collected in the NDFA. 97.0% of NDFA patients were found in the core NDA demographics table for 2023-24.

Other data sources

The use of other data sources to identify specialist foot care services is limited. In HES/PEDW there is not the specificity of coding necessary to identify specialist foot care services from other diabetes related outpatient clinics or community podiatry services. The National Diabetes Inpatient Safety Audit (NDISA) includes information about foot care services, initiatives and multi-disciplinary foot teams (MDFTs) in hospitals, but is focussed on inpatient care only, not the specialist foot care services of interest to this audit.

Efforts have been made to reduce the burden on participating teams by the inclusion of linked data from other available data sources. By linking NDFA to the core NDA, a reduced number of data items are required from audit participants, and linking to HES and PEDW data enables further analysis of patient outcomes without increasing the data collection requirements. 

However, it is acknowledged that participation in the audit does involve costs in time and organisation for the providers that participated, and the NDFA continues to look at ways in which this might be reduced in later collection periods.

The NDA advisory group consists of clinicians, patient representatives, Diabetes UK and analysts from NHS England. The group provides advice on the direction and development of the audit. 

NHS England is keen to gain a better understanding of the users of this publication and of their needs. Your feedback is welcome and may be sent to [email protected] (please include 'National Diabetes Foot Care Audit' in the subject line).

Alternatively, you can call our contact centre on 0300 303 5678 or write to NHS England, 7 and 8 Wellington Place, Leeds, West Yorkshire, LS1 4AP.

Patient identifiable information – NHS number – has been collected in order to link information collected by the NDFA to other information about the patients’ diabetes care. Identifiable data is only released by NHS England where the release meets NHS England Information Governance procedures. More information on how NHS England uses patient data as part of the audit can be found in the National Diabetes Audit (England): Transparency Notice and National Diabetes Audit (Wales): Transparency Notice

It is expected that through the audit collection, all organisations will continue to follow existing NHS codes of practice in regard to patient confidentiality, information security management, record management and other legal obligations.

Risk assessment

A risk assessment has been carried out on the audit publication, and disclosure control has been applied. Please see the Coherence and comparability section for further detail.