Field notes from Malvern, year 40. With thanks to @FranGame for the slide that should hang in every multidisciplinary clinic in the world.
I came in this morning expecting another graceful walk through the National Diabetes Foot Care Audit dashboard. What I got instead was the most useful reframe I have heard in a long time.
The line, more or less verbatim: 98.4% of people with a wound presenting to a multidisciplinary clinic in England and Wales will NOT undergo a major amputation within 6 months of first expert assessment.
Read that sentence again. Then read it the way every patient, every commissioner, and every primary care colleague should hear it: the MDT is the closest thing in modern medicine to a leg-saving machine.
We have spent a generation quoting the 5-year mortality of a diabetic foot ulcer being worse than most cancers — and we should keep quoting it, because it is true. But somewhere along the way we let the gloom narrative crowd out the win. Fran’s slide is the win.
Where the 98.4% comes from
The NDFA — now stewarded under the National Diabetes Audit dashboard at NHS Digital — has been registering new diabetic foot ulcer episodes since July 2014. The current State of the Nation report covers April 2018 through March 2023 and sits on top of well over 100,000 ulcer episodes.
Two numbers, side by side, tell the whole story:
- Less-severe ulcers (SINBAD 0–2) at the time of first expert assessment: major amputation within 6 months runs about 0.5–0.6%.
- Severe ulcers (SINBAD 3–6) at first expert assessment: major amputation within 6 months runs about 2.5–2.7%.
Pool that across the population presenting to specialist MDT services and you land at roughly 1.6%. The complementary number — 98.4% — is the one I want on the wall.
The lever we collectively may actually own
The single most actionable signal in the audit is not a new biologic, a new device, or a new molecule. It is the calendar.
Time to first expert assessment (FEA) is the variable the MDT controls and the variable that moves outcomes most reliably:
- 0–13 days from presentation to FEA: roughly 54% alive and ulcer-free (AAUF) at 12 weeks in the most recent audit year.
- 14 days to 2 months: meaningfully worse.
- More than 2 months: down around 34% AAUF at 12 weeks.
The audit period also showed AAUF in the fastest-access cohort climbing from 46% to 54% from 2018-19 to 2022-23. That is the curve of a system that knows how to learn when it is allowed to measure itself.
So when someone asks what we should be doing to drive amputation rates down further, the honest answer is: shrink the door-to-MDT interval. It is free, it is local, and it works.
The undertow (undertoe) nobody wants to talk about
Here is where the 98.4% reframe earns its keep — by being honest about what it is not saying.
Hurst, Young, Jeffcoate, Valabhji and Game’s 2024 Diabetologia paper on 71,000 NDFA registrants reported mortality at 12, 26 and 52 weeks of 4.2%, 8.2%, and 14.4% respectively. In other words: by one year, roughly 1 in 7 people who walked into a specialist diabetic foot service is dead. Of all the patients who fail “major amputation-free survival at one year,” about 87% of that failure is death, and only about 13% is the amputation itself.
Collectively, we are very, very good at saving limbs. We are still not good enough at saving the people those limbs belong to. The ulcer is the herald, not the disease. The disease (in addition to the DFU) is multi-territory atherosclerosis, neuropathy, renal failure, heart failure, and frailty.
Which brings us to the most important slide nobody made today, but should have: the limb you save is wearing a sick person. SGLT2 inhibitors, GLP-1 receptor agonists, statins, blood pressure control, smoking cessation, structured exercise, and aggressive cardiovascular risk modification belong in the diabetic foot clinic in 2026 as surely as a doppler probe and a debridement tray. That is the “Flow” in Toe, Flow, and Go — not just the artery in the leg, but the artery in the heart.
Major amputation-free survival is the metric we should carry
If your service still benchmarks itself only on major amputation rate, you are measuring 13% of the problem.
Major-amputation-free survival at 1 year — alive, with both legs — is the composite that matters. The NDFA puts it at roughly 90% for less-severe and 82% for severe ulcer episodes. That is the number to put in your annual report, your grant aims, and your patient brochure. It is the only outcome that simultaneously tells you whether the MDT is doing its job and whether the rest of the medical home is doing theirs.
Three things I am taking back from Malvern this year
One. Lead with the 98.4%. When you brief a patient or a referrer the first sentence is “you almost certainly keep your leg.” The cardiovascular conversation goes second, but it does go.
Two. Audit your door-to-MDT interval. Every minute you trim off it is worth roughly a percentage point of AAUF, in aggregate. Cheapest intervention in the building.
Three. Stop running an amputation clinic. Run a survival clinic that happens to also save limbs. Collectively bring the cardiologist, the nephrologist, and the diabetologist into the same hallway — figuratively, and where possible literally.
Huge thanks to Fran Game and the NDFA team — Bob Young (in memoriam), William Jeffcoate, Jonathan Valabhji, and colleagues — for a generation of disciplined measurement that has quietly become one of the most consequential pieces of audit work in vascular and metabolic medicine anywhere in the world. Thirty years coming to Malvern, and the audit is still teaching me how to think.
Selected sources: NDFA State of the Nation 2018-2023, NHS Digital, May 2024 · Hurst NH, Young B, Jeffcoate W, Valabhji J, Game F et al. Mortality rates in people presenting with a new diabetes-related foot ulcer: a cohort study with implications for management. Diabetologia 2024;67:2691-2701 · NDFA Interval Review 2014-2021 · Game F. 2022 Update on the National Diabetes Foot Care Audit. Diabetic Foot Journal 2022;25(4):12-15 · IWGDF 2023 Classification Guideline · NDFA dashboard at digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-footcare-audit
#DiabeticFoot #Malvern2026 #DFCon #NDFA #FootCareAudit #LimbPreservation #ToeFlowGo #MDT #PodiatricSurgery #VascularSurgery #DiabetesUK #FranGame #DiabetesCare #PAD #CLTI
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