During my recent trip to England, I participated as a faculty member at two podiatry and physiotherapy meetings. This was my third trip to the country in the past five years, giving me the opportunity to lecture and interact with colleagues. My experiences this time ran the gamut from dismay about the healthcare system in the United Kingdom to awe and respect for the level of care many of our colleagues offer in this country.
The Division of Podiatry and Clinical Sciences sponsored the first meeting, which took place at the University of Huddersfield. This year, the second Annual Musculoskeletal Research Conference focused on adult-acquired flatfoot. Podiatrists from the U.K. provided excellent lectures and covered assessment, ultrasound imaging and even surgical intervention for the musculoskeletal disorder.
My experience in the workshops, however, revealed how the national healthcare system in the U.K. has failed to provide adequate care for patients. I evaluated two middle-aged women who both had progressive, debilitating adult acquired flatfoot. They had each received little to no care at all while their condition worsened to the point that they could barely ambulate. In both cases, they had received simple prefabricated foot orthoses and nothing more. The notion of prescribing custom ankle foot orthotic therapy for adult-acquired flatfoot is not well accepted in the U.K. Certainly, the national healthcare system will not cover this service.
Previously, I wrote a blog about the current standard of care in the United States (see http://bit.ly/iUQtm3  ). Generally, custom ankle foot orthotic therapy begins before surgical intervention for the adult-acquired flatfoot. The success and avoidance of surgery for this treatment is at a rate of approximately 70 percent.1 The U.K. has yet to institute the use of ankle foot orthotic treatment for adult-acquired flatfoot despite the fact that there are at least six studies published to support it.2-7 Ironically, the British healthcare system will offer its patients surgery, which is generally tenfold more expensive than preventive interventions.
My next seminar was the Podiatric Biomechanics Symposium at the Royal Society of Medicine in London. This meeting had a fantastic lineup of speakers. The podiatrists who presented were among the best I have ever heard in terms of quality of content and delivery of their subject. Hannah Yirrell, BSc (Hons), who is an attending podiatrist at the Defense Medical Rehabilitation Center at Headley Court, provided a particularly inspirational lecture. This facility offers care to wounded soldiers from the U.K., who have served in Iraq and Afghanistan.
Dr. Yirrell presented amazing case studies in which she had been able to restore mobility in young men who had been severely injured by improvised explosive devices (IEDs). In many cases, she used ankle foot orthotic therapy combined with physical therapy to make dramatic changes in the ambulatory status of these unfortunate victims. At this facility, the defense budget covers treatments. The level of care is far superior to what is available to citizens who rely on the national healthcare system in the U.K.
Upon returning home, I realized how fortunate I am to participate in a healthcare system in which I can offer numerous, superior treatment options, not available in the U.K., to my patients. I often listen to colleagues who bemoan our own healthcare system and vent frustration over reimbursement challenges in private practice. However, in comparison to the situation in the U.K., we do not have it so bad.
I worry about what changes may occur in the future if the U.S. institutes a more nationalized healthcare system. The result may be denial of treatment options that might actually save healthcare costs. The massive government sponsored healthcare system in the U.K. has certainly verified that this can be a reality, particularly for our podiatric colleagues practicing there.
1. Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Nonoperative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2011; 50(3):311-314.
2. Krause F, Bosshard A, Lehmann O, Weber M. Shell brace for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2008;29(11):1095–1100.
3. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured non-operative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006;27(1):2–8.
4. Augustin JF, Lin SS, Berberian WS, Johnson JE. Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003;8(3):637–645.
5. Bek N, Oznur A, Kaviak Y, Uygur F. The effect of orthotic treatment of posterior tibial tendon insufficiency on pain and disability. The Pain Clinic. 2003;15:345–350.
6. Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996;17(12):736–741.
7. Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009;89(1):26–37.