10. In the Trust’s complaint response, it said it does not provide ongoing, routine toenail cutting in most circumstances. This can only be offered where the patient has medical conditions that put them at significant risk of things like foot ulcers, unhealing wounds or amputation. It explained that there is nothing in Mr I’s referrals or in any of his medical information that would indicate he is in any greater risk of medical complications and therefore is not eligible for ongoing toenail care.
11. The Trust said Mr I’s GP confirms that he is not diabetic and has no medical conditions that place him at high risk. It makes no reference to arthritis, however even if it did, that would not make him eligible for NHS podiatry services. This is because nail cutting is not a medical condition that needs to be treated by specialists and there are other options for patients, even with reduced mobility to have their nails cut.
12. It explained that whilst previous referrals to the podiatry service have been rejected, a podiatrist saw Mr I in mid-July 2024 as a one-off new patient. This was a new patient assessment, to determine his level of need. The podiatrist recorded that Mr I wanted his nails cutting regularly and correctly informed him that in the absence of any medical condition or risk, he is not eligible for ongoing NHS nail cutting. The podiatrist recommended filing his nails weekly to keep them shorter. It then discharged him from its service.
13. We will address Mr I’s complaints separately below:
Rejected referrals
14. The medical records indicate there were several GP referrals to the Trust’s podiatry service which it rejected.
15. The Trust’s Clinical Acceptance Criteria sets out who is eligible for podiatry services. This includes patients who have specific health conditions, for example diabetes, and have a podiatric level of need, which includes active ulceration, acute/chronic biomechanical problems.
16. In rejecting the referrals, our adviser said the Trust was acting within its own Clinical Acceptance Criteria and other similar trusts’ guidelines.
17. NHS Podiatry services do not offer nail cutting for patients who have no eligible needs, for example someone who is not diabetic – as in Mr I’s case. Our adviser said Mr I was not at such a risk level which required the Trust’s podiatry service to cut his toenails.
18. Because Mr I did not meet the Trust’s Clinical Acceptance Criteria, our adviser said the referral should be rejected and the ‘patient should be discharged from the service’, in line with its own guidance. The Trust correctly signposted Mr I to other care alternatives to have his toenails trimmed and gave him a leaflet on how to look after his feet.
19. We recognise Mr I’s concerns on whether the Trust should have rejected referrals from his GP to have his toenails trimmed and the impact he says this has had on him. Informed by clinical advice, we consider the Trust rejected the referrals in line with its own Clinical Acceptance Criteria. There is no indication the Trust did anything wrong.
July 2024 consultation
20. The medical notes show that Mr I had a podiatry appointment booked for mid-July. The Trust saw him as a new patient.
21. Our adviser says in line with good clinical practice/experience when a podiatrist sees a new patient, they should consider their medical history, assess their medical needs and carry out an examination.
22. The notes from the July consultation are comprehensive. Our adviser said the Trust’s Podiatrist considered and assessed Mr I’s medical history and needs and carried out an examination of his feet.
23. Our adviser explained there is no relevant medical history which would require the Trust’s Podiatry Services to continue to cut Mr I’s toenails. For example, there is no evidence of him being diabetic, on blood thinners, high infection risk, serious leg or foot infections. There is no evidence of Mr I being on medication which would mean the podiatry service should reconsider and continue to cut his toenails.
24. In line with the Trust’s own guidance, our adviser said the podiatrist informed Mr I during the consultation that he was not eligible for ongoing nail care and discharged him. Most podiatry units in the NHS can only provide a nail trimming service to high-risk patients, these in general are diabetics. There is no capacity to provide a nail cutting service to the general population.
25. The podiatry service’s inclusion criteria is also documented on the Trust’s ICB’s website. This says:
‘Inclusions Patients registered with… [a GP practice within the Trust’s area] that have a podiatric need and a medical condition that puts their foot at risk - see service acceptance criteria (see Downloads), including: • Biomechanical problems, injection therapy and bespoke orthotic provision • Podiatric need e.g. callus/corns (must have medical condition that puts their feet at risk e.g. peripheral vascular disease) • Ulcers (not requiring MDT [multidisciplinary team] care) • Ingrown toenails requiring surgery • A limited housebound service is available for those that do not leave home for other medical/social reasons.’
26. The evidence from the medical notes confirms the podiatrist carried out an appropriate assessment of Mr I’s needs and he was not eligible for NHS treatment, as he did not meet the Trust’s inclusion criteria.
27. Our adviser explained that being in foot pain will affect mobility and could in some patients affect lifestyle and lead to depression or impact on existing depression. However, this outcome is not a reasonable reason to insist on nail care. The Trust appropriately assessed Mr I and due to his lack of specifically relevant medical history he had no priority as far as footcare is concerned. To reject his application was appropriate and in line with many other podiatry services across the country. The challenges on the service are high and priority has to be given to high-risk patients.
28. We acknowledge Mr I’s complaint on whether the podiatrist - during an appointment in July 2024 - assessed his medical needs on whether he should have his toenails trimmed. We have carefully considered his and the Trust’s account, his medical records and independent clinical advice. The weight of the evidence indicates the Trust’s Podiatrist considered and assessed Mr I’s medical history and needs, including an examination of his feet, in line with good clinical practice/experience. This is no indication of a failing.
29. We are sorry to learn of Mr I’s complaint about the Trust. Our decision is not made without recognition of the impact this had on him, and we are sorry if our decision causes any further upset. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.