National Diabetes Foot Care Audit 2020 to 2025

Healing is documented at 12 weeks following the first expert assessment (FEA) and is said to have occurred if the person is alive and ulcer free (AAUF) (i.e. all ulcers present during the ulcer episode have fully healed).

Being ulcer free also includes those who have had surgery – including minor amputation (below the ankle) and major amputation (above the ankle) – provided all wounds have healed.

The ulcer episode is still active if any ulcers persist unhealed. Active ulcers are ulcers that have not healed. The ulcer episode is still regarded as active if the original index ulcer has healed but if other foot ulcers remain active.

In this instance, 12 weeks following the FEA is defined as between 10 weeks (70 days) and 14 weeks (98 days) but as close as possible to 12 weeks (84 days).

Amputation, or surgical removal, of part of the foot or leg may be required when a diabetic foot ulcer cannot otherwise be successfully treated. When this is the case then an operation is needed to surgically excise bone and soft tissue in order to allow healing.

This may be a minor amputation (below the ankle) in which toes or part of the foot are removed in an attempt to save the leg. When this is not possible, major amputation (above the ankle) may be required.

Lower limb amputation is a life-changing event, with significant physical and psychological effects. Long hospital stays and periods of rehabilitation can result.
For reporting purposes, amputation must occur within 6 months of first expert assessment (FEA) by the specialist foot care service.

Runs from 1 April in year 1 to 31 March the following year.

Commissioners decide what health services are needed and ensure that they are provided. Integrated care boards (ICB) in England and local health boards (LHBs) in Wales are responsible for commissioning healthcare services.

The first expert assessment (FEA) of the ulcer is that undertaken by a member of the team registering the ulcer episode. 

Time to FEA is the interval between first presentation to any health professional (e.g. a GP or in A&E) and first assessment by the specialist foot care service. People with foot ulcers may also self-refer to a specialist foot care service (self-referral).

The number/proportion of ulcers (excluding self-referrals) that are assessed by the specialist foot care team between 0 and 13 days after referral from a healthcare professional.

Healing is documented at 12 weeks following the first expert assessment (FEA) and is said to have occurred if the person is alive and ulcer free (AAUF) (i.e. all ulcers present during the ulcer episode have fully healed). For more information, see the AAUF entry above.

For this analysis, person years are calculated using the following logic with the cohort being everyone who is alive on 1st April with a diagnosis of diabetes.  

Each person is assigned a 1, representing a whole year at risk of experiencing the event for the first time in the stated period e.g. ulcer registration during 2024-25.

A person is no longer at risk if they die, therefore if they die halfway through the year, the period at risk is set to 0.5.

Similarly if the event occurred a quarter of the way through the year, the person is no longer at risk of the event occurring for the first time, so the period at risk would be set to 0.25.

The numerator is set to 1 if the event occurred, else it's kept as 0. Only the first instance of the event per person is counted.

A healthcare provider is a legal entity, or sub-set of a legal entity, which may contract for the provision of healthcare; it may operate on 1 or more sites and outside hospitals. 

Healthcare providers (typically NHS trusts in England, local health boards (LHBs) in Wales or independent healthcare providers (IHPs) are the parent organisations of the specialist foot care services. 

People seen by the specialist foot care service are generally referred to this service by a health professional.

This will often be by a general practitioner (GP) who has identified a foot ulcer. Less often it will be by a hospital consultant – where a patient is referred after attending an A&E department, or after they have been seen by a specialist in another department (such as orthopaedics, renal services or dermatology). People may also be referred by community nurses, or another part of the specialist diabetes service.

Some people are seen by the specialist foot care service after they have ‘self-referred’. These people have usually had an earlier foot ulcer and know the foot care team, or may have been identified as high-risk and attend a foot protection service.  They will have been encouraged to contact the specialist foot care service at the first sign of trouble.

Most people with diabetes that develop a new foot ulcer do not and cannot refer themselves directly to a specialist foot care service and must be referred by a health professional – usually their GP.

Results in this report are split by audit year, which run from April to March (e.g. 2022-23 is from 1 April 2022 to 31 March 2023).

A direct provider of care, for example, a specialist foot care service.

The specialist foot care service is a team of diabetes foot care specialists (also known as a multi-disciplinary foot care team or service, MDFT/MDFS) that perform the first expert assessment (FEA) of the foot ulcer.

The NDFA collects information on diabetes related foot ulcers (DFUs).

An ulcer episode refers to the period during which a person has 1 or more DFUs. A person may have more than 1 ulcer episode if separated by a period of being ulcer free, no matter how short.

Ulcer severity is documented by the specialist foot care service at the first expert assessment (FEA). It is defined using the SINBAD classification (Ince et al. 2008) which scores an ulcer between 0 and 6 depending on how many of the 6 SINBAD adverse elements are present: Site (on hindfoot), Ischaemia, Neuropathy, Bacterial infection, Area (≥ 1cm²), Depth (to tendon or bone).

Ulcers with a score of 0 to 2 are defined as less severe; scores of 3 to 6 are defined as severe. If a person has more than 1 ulcer at FEA, 1 (usually the most severe or clinically significant) is selected as the index ulcer for the purpose of classification.