Is the Foot Health Practitioner Really a Contentious Issue?

Introduction

An organisation formed by Chief Chiropodists in the 1970s merged into the Association of Chief Chiropody Officers (ACCO). This organisation introduced the concept of Footcare Assistants (FCA) into the NHS and formalised their in-house training from 1977 onwards. As a recently qualified chiropodist (1978), I was tasked with the educational side of the sterilisation process.  

The FCA started as a chiropody surgery assistant (CSA) with the idea that chiropodists could benefit from dental surgery assistants as dentists benefitted from them. Understandably, resistance to the FCA as an infiltrator into the NHS, undertaking work the chiropodist could carry out, was strong. The leading professional body, the Society of Chiropodists, objected but could not change the natural course of events.

SMAE (Swedish Massage & Electrolysis) and Scholl were pioneers in correspondent courses, but soon, other organisations set up training. Chiropodists changed their names once undergraduate degree courses were introduced to podiatrists. By 1 April 2002, the Health Professions Council had replaced the Council for Professions Supplementary to Medicine (CPSM), which was established in 1960. Chiropody and Podiatry were now protected in the title and mandated to be registered with the Health & Care Professions Council (HCPC).

All Professionals Face Challenges

From time to time, those who have trained and established foot health services have faced challenges because, outside the HCPC, there is no register other than a submission to a voluntary FHP register RFHP. As a parallel argument for accountability, foot surgery developed by podiatrists caused an equal sense of rebellion from traditional medics, largely orthopaedic surgeons. When podiatrists felt an equal sense of injustice that a less rigorous course mimicked their three-year training and hard work, there was a certain irony. In the case of those known as podiatric surgeons, the HCPC provided a register of those annotated, affording not only standards that needed to be met but also accountability post-2015. The comparison between surgery, surgeons and FHPs ends there because the scope and risks are not in the same league.

Today, there are a number of FHP training programmes, and outside of this, some doubtless provide foot care without formal training. One of the poignant statements made by ACCO nearly fifty years earlier was that FCAs could perform the type of care that an able-bodied person could undertake, viz a vis nail and skin care. The safety of the methods of reducing callus, once reliant on unsafe blades or simple pumice, have been replaced by battery-operated hard skin reducers and safer self-aids. Nonetheless, an FHP can use a surgical scalpel to perform a similar task as a podiatrist—that of superficial debridement.

The key elements that make someone unsafe are more prosaic than an emotional charge. Why bother to train in podiatry if FHPs can undertake the same role? In any argument, facts must be considered rather than ideals. The practical training hours are many times greater with access to experienced professionals through a three-year full-time course.[1]

Podiatrists have wider access to medical procedures and can focus on higher-risk elements of foot disease through respected and well-defined procedures and protocols. Graduates have the option to progress within formal medical teams and expand their roles[2].

A Case for Foot Health Practitioners

NHS Services are shrinking

(Click over the heading to review the position of podiatry from Health Education England.)

(NHS England, 2020). The working party reviewing the need for more foot health care professionals has become less transparent than intended if indeed it still exists. So, those invited initially to examine the subject have, to some extent, continued to run their own programmes.

All patients are susceptible to foot conditions, and many require first aid or simple advice. The lack of access will always produce demand. Once where the NHS provided management for a broader range of clients, primarily those of pensionable age, the nation’s health service could no longer afford such provision without identifying a critical condition that affects life expectancy. In addition, NHS podiatry is split into four of five distinctive groups—

• Diabetic and high-risk care.
• Podiatric Surgery.
• MSK provision as a triage to orthopaedic service (including orthoses)
• Nail surgery.

This is not to suggest that some provision for general care (the fifth group) is not offered, but like many parts of the UK, services are not uniformly distributed. Podiatric surgery is undoubtedly only provided in some parts of England, while Scotland, Northern Ireland and Wales are poorly served and rely on orthopaedics. Independent podiatry practices have taken up the slack and often cannot meet the demand, so the FHP has become prominent because of demand. Many independent practices have seen the benefit and employ FHPs as a benefit to their business, while others actively offer training. Given the benefits the FHP can offer both to podiatry and the community, derogatory comments seem both unprofessional and ignorant. It is the right of any podiatrist to undertake foot care or advancement, but all professionals eventually expand, being a natural progression.  

What should be the minimum standards for FHP, and what risks should be flagged?

To understand and recognise what foot health risk means. This should include:

• Essential vascular and neurological assessment.
• Recognition of skin and nail conditions that are infected or might have healing defects.
• Understand medical pathologies that could lead to poor healing or provide complications.
• Recognition of when and who to refer to and how to refer onwards.

A certain amount of theoretical training is essential in achieving these aims, but this must be supported by practical training. The question is how much training is required and how long it should be considered necessary. The flaw is having enough exposure, and yet, when guided, FHPs understand their limitations, as do podiatrists. All professionals appreciate that the acquisition of real learning only arrives when actual contact practice exists. Of course, failing to use actual patients would disadvantage safe practice.

 

A minimum standard must be applied to all who practice. Tollafield 2024.

Safety in modern society means learning about

• cross-infection
• preparing instrumentation
• ensuring safe environments.

If FHP practice needs to be regulated, the elements above should ideally be ensured. To do this, any course that trains an FHP should meet standards acceptable to a similar process offered by the HCPC. The HCPC would be the best place for such administration, as the system has existed since 1960 and has access to expertise. However, without an HM Government mandate, there will be no change in the current registration requirements. Benefits outweigh risks because had this been applied to advanced podiatry with significant added risks, the profession would have been limited years ago to what was chiropody. Podiatry is not the new chiropody as the latter has no degree underpinning the scope of the modern course. Chiropody is a foot health profession, and many podiatry practitioners do not hold a degree. In the same vein, podiatrists practice orthopaedic surgery, so the distinctions become blurred.

As current practice stands, few organisations openly discuss their FHP training. The Royal College of Podiatry covers training for assistant podiatrists who work within the NHS framework but could work outside. One organisation that trains FHPs has expanded its curriculum to make the university transfer to podiatry more attractive for FHPs wishing to undertake graduate training in podiatry. The argument for academic training can always be justified if it is proportional and fits the remit required by the nation. 

FHP’s provision is different from that of podiatry because modern podiatry delivers a broader service and responsibility. And yet, without doubt, some podiatrists offer a similar service on the high street out of choice. In a democratic society, choice and freedom are hallmarks that found their routes in the earliest charters dating back to 1115AD and improved upon as emancipation expanded seven hundred years later with wider voting. This concept extends to the freedom to provide any service in a way where demand exists and no risks are evidenced harming the public.

Considering the features above, it is unlikely that much will change as long as care is provided at an essential level. As podiatry meets more medical needs, FHPs will fill gaps in the market that have always been assumed to be the domain of the podiatrist. 

Inevitably, responsible training will follow the model of podiatry for some clinical aspects—permission Institute of Podiatrists.

Evidence of Quality & Reflection of Attitudes

In 2024, I was tasked with reviewing the course for the Institute of Podiatrists (IOP). Over twelve months, which included reviewing all past documentation, examining and marking methods, practising practical skills, and interviewing FHP students, three significant observations were made.

• Much of the theory was overly curated and needed more focus to ensure that clear goals associated with risk and relevant practice were implemented.
• The standard of training, student support, awareness of clinical risks, and equipment preparation was consistent with the traditions observed in university-based podiatry clinics and the NHS.
• FHPs were highly motivated, intelligent individuals seeking to change careers. Many were already qualified in other areas of healthcare.

 

The fact that this article is open to broader review and scrutiny through the IOP demonstrates their probity about making changes. As a former podiatrist and university senior lecturer, I was pleased to address the inaccuracies that I held in regard to being against FHP practice. I am glad that I now have a better understanding of FHPs and their practice. Like everything else in life, we have to move forward not only with the times but be prepared to adjust our mindset, for without such mental change, we will remain in a vacuous circle based on ill-founded prejudices.

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David R. Tollafield is an educationalist and author who specialises in patient-led clinical information. As a former podiatric surgeon, he has over forty years of clinical experience and has published extensively. His books can be found on his website – davidtollafieldauthor.com. This article was produced as an independent review, and no organisation provided inducement during the production of this article.

(Opinions stated in this article are those of the author alone. It should be noted that the lead person implementing the proposed standards failed to respond to questions about the current position regarding standards and training—personal correspondence between the author and NHS England.)

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[1] Note that apprenticeship schemes will alter the balance of practical and didactic training but will still provide many more hours than under an FCA-limited training course.
[2] Guttormsen, K. Ed. Tollafield DR.  A Career in Podiatric Medicine. 2023. New Models of advancement in health care. Pp165-6

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