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  • Writer's picturePeak Health Coaching

The 90:10 Split to Save a Diabetic Foot



The 90:10 split, to save a diabetic foot. 


This week I was involved in talking to a diabetes foot clinic about the possibility of using Patient Activation levels to tailor the care delivered in the clinic. I was talking with commissioners and experienced clinicians who work in the clinic. 


They told us how treatment in the clinic involves a combination of treating infections, dressing wounds, offloading weight from wound sites, and encouraging tighter diabetes control. They described the heavy burden of treatment this places on the individual, requiring them to adapt their life significantly. They told of people swearing that they had been using their leg casts, only for them to observe very little wear on the cast, suggesting they’d hardly been used. 


What was really interesting to me was that the clinic staff reflected that in their opinion 90% of the outcome rested with what the person did (or did not do). They could use their expertise to set up the treatment, but success is heavily dependent on the person sticking to it. 


Diabetic foot wounds often last months or years. The complications of poor management often result in significant cost to the patient and the system, with long stays in hospital on IV antibiotics, surgical interventions and amputations. If feet are not looked after properly longterm the problems often reoccur. 


It made me reflect that if 90% of the outcomes in such a high cost area of health is related to what the person does, why aren’t we pouring more resource into supporting this better. When you compare the technology and expense that goes into wound dressings and medication, development and fitting of casts, and the professional consideration of medical factors, it doesn’t make sense that we apply less sophistication to what contributes most to the outcome. It would seem that so much energy and resource are being wasted. 


So why don’t we focus more on the 90%? What is it that drives the attention of patients and professionals to the minority 10%. We invest all our faith and commitment to an area that even if we get perfect, plays a relatively minor role. 


Is it that people don’t want to take responsibility? Do they fear the recrimination of being blamed? Do we want to protect people from this harsh reality, by inflating the relative value of modern medicine? Is this a collusion of compassion?


Is it that our modern life, and the context for people make it just too hard to play an active role in health care? Life is so busy, with so many other pressures, health gets pushed down the list of priorities.


Are we bombarded with ‘quick fixes’ and lured by passive solutions that offer a psychologically easier path to take? Many of these ‘offers’ are driven hard by corporations that stand to profit from consumption of these ‘solutions’. 


I’m sure people living in these situations have the best idea of the reality for them. I’m sure we don’t ask them enough. I am also sure that we know enough about better ways to support people in coping with this 90% and have a better chance of achieving better outcomes. Behaviour science and health coaching techniques are evolving fast. We are learning how to apply them in different situations and how tailoring these to the individual’s context and capabilities creates a personalised care plan. Certainly, if people are low in skills, knowledge of confidence in what they need to do, it makes it much harder. But we are developing the skills as health systems to nurture these at the right pace. 


The final question I ask is how much we should invest in the 90% and how much are we wasting in the 10%? Well intentioned staff working so hard, but until we are confident that the 90% is supported properly and working well, so frustrating to see the waste.

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