Our feet are invaluable to us if we want to be able to be active, mobile, and healthy. If they go wrong, then they can seriously affect our quality of life. Those who have suffered from foot-related problems such as plantar fasciitis (heel pain), Achilles tendonitis, neuromas, ingrowing toenails, corns etc. will know how each painful step can impact on their happiness, their mood, and their interactions with others. Not being able to play your favourite sport, or take part in your favourite activity, or even carry out your job, is both frustrating and depressing.
It may not even be due to pain though. The appearance of feet is significant for many, and when they don’t look right aesthetically, then it can have an effect on mental health. Just knowing that you have a verruca or fungal infection or smelly feet can lead people to feel contaminated in some way, choosing to hide their feet away from others out of embarrassment. The impact of this is often felt when it comes to holidays when feet may be more on show.
So if we applied all that to teeth, we know exactly where we would go for solutions. Our first port of call would be to see a Dentist. The reason for that is because Dentistry has been legally afforded “Protection of Function” and “Protected Titles”. The Dentists Act 1984 sets out the law in relation to the provision of dental treatments and advice in the UK. By law, all dental professionals in the UK must be registered with the General Dental Council (GDC) in order to work legally and safely. The specific protections come in the form of unlimited fines in England & Wales, and are detailed on the GDC website:
- Section 38 of the Act makes it a criminal offence for anyone who is not registered with GDC to practise dentistry or to offer or imply they are prepared to practise dentistry.
- Section 37 of the Act explains that practising dentistry means providing or offering to provide the treatment, advice or attendance that would usually be given or performed by a dentist.
- Section 39 of the Act makes it a criminal offence for anyone who is not registered with GDC to take or use various protected dental titles, such as ‘dentist’, ‘dental nurse’, ‘dental hygienist’, ‘dental technician’ or to imply that they are a registered dental professional.
- Sections 40 and 41 of the Act sets out that it is a criminal offence for an individual who is not registered with GDC to receive payment for dental treatments or advice.
- Section 43 of the Act sets out that if a company is going to receive payment for dental treatment or advice, the majority of its directors must be registered with us or it will be committing a criminal offence.
- Tooth whitening is the practice of dentistry and can only safely and legally be offered by registered dental professionals
They seem most comprehensive as protections for your teeth and tooth-health don’t they? And you would think that the same should or even does exist for the protection of your feet and foot-health. After all, they are both important aspects of our health & wellbeing. But alas, your feet are not afforded anywhere near the same protection. In fact, they are not given hardly any protection in Law at all. There is no “Protection of Function” or “Protected Titles” for who is and who is not allowed to treat feet. Anyone can treat feet, with no training whatsoever. Let me repeat that:
ANYONE CAN TREAT FEET WITH NO TRAINING WHATSOEVER!
How different is that to Dentistry? It doesn’t seem possible in 2020 that our feet are left at risk to be treated by anyone. That could be by those with no or poor training, no qualification (or a made-up one), and no criminal or DBS checks. Our feet (and therefore us) could even be at the mercy of criminals such as paedophiles, rapists, murderers etc. But “What about Chiropodists or Podiatrists?” I hear you say. Well, you are correct that there is technically some protection in Law when it comes to those professionals, but in practice, the protection leaves a lot to be desired. I hope the following explanatory list of those involved in the treatment of feet will help to clarify things for you:
Of course it is not legally possible to stop you from doing whatever you want to your own feet, even if you may cause yourself harm.
- Untrained helpers:
Asking a friend or relative to help with the treatment of your feet is also impossible to legally stop, even if they may cause you harm.
- Toenail Cutters/Trimmers or Nail Technicians:
This could be your hairdresser who has chosen to diversify with only the experience of cutting their own nails, or it may be a diversification of service by Nail Technicians at your local Nail Bar. It could be volunteers or someone appointed by a charity such as Age Concern who may have received some (minimal) unregulated training, that may even have been provided by the NHS. They may even use the following logo on letterheads / correspondence / marketing material (including websites):
Either way, they may or may not have the knowledge or be insured to treat or even give advice on whatever foot-related issue you present them with.
- Reflexologists, Sports Therapists, Masseurs, or Beauticians / Beauty Therapists:
These are allowed to make your feet look and/or feel nice (with possible mental & physical beneficial effects), and should be insured to do so. That doesn’t mean treating foot pathologies though, such as corns, verrucas, fungal infections, ingrowing toenails. They may choose to provide treatments and/or advice on such conditions, but they may or may not be insured or trained to do so.
- Podiatry Assistants or Hygienists:
These are not trained or insured to be fully-autonomous practitioners but instead work under the supervision of a Podiatrist (see section 9 below) either directly or indirectly. In the NHS they may be known as Assistant Podiatry Practitioners or Foot Care Assistants.
- Student or Apprentice Podiatrists:
These are those being trained to be fully-autonomous practitioners but who are currently under the supervision of a Podiatrist (see section 9 below) either directly or indirectly during their training.
Whilst in the eyes of the Law, there is no difference these days between Chiropodists and Podiatrists, the public perception of these Foot professions together with their history creates a difference in practical usage. “Chiropody” is often seen as “Foot Care”, whereas “Podiatry” is seen as “Foot Specialism”. So they are listed here as a separate entity even though it has not been possible to qualify as a “Chiropodist” in the UK for many years.
“Chiropody” is defined as “the treatment of feet and its ailments”, so it is understandable that those who seek such treatment would think that those who provide it (such as Foot Health Professionals / Practitioners detailed in section 8 below ) are “Chiropodists”, or perhaps they just use that terminology for simplicity even though they are aware of the difference, or maybe they have been misled by their own foot care provider. Either way, it leads to confusion for the public in the same way that some still refer to “Chemists” (who aren’t allowed to dispense certain medicines) whereas the modern correct term is “Pharmacists” (who are allowed to dispense Pharmacy-only items).
Prior to 2003, anyone could call themselves a Chiropodist (or Podiatrist). There was no protection in Law at the time. Only those who were “State-Registered” (having achieved the standard of education as specified by the Government at the time that they qualified) were allowed to provide Chiropody/Podiatry services for NHS patients. Other Non-State Registered (eg Surgical Chiropodists) were not allowed to work for the NHS in that role as they had non-standardised training. After 2003, only those registered with the Health and Care Professions Council (HCPC) could call themselves HCPC-registered Chiropodists / Podiatrists, and there is an (incorrect) assumption that this means the terms Chiropodist or Podiatrist are “Protected Titles”.
- Foot Health Professionals / Practitioners (FHPs):
These are a more recent development having been a transition from the Non-State Registered Chiropodists with the formation of the HCPC and the evolution of the previous private Schools of Chiropody. In the eyes of the public, all too often FHPs are seen as “Chiropodists” yet they are not the same.
It is at this level in the list where, in the author’s opinion, the Law really lets the Public down. There is no entry criteria, prior medical experience, nor academic ability required for FHP courses, just the ability to pay the private course provider for the period of study & qualification. There is a perceived trust in the title that FHPs are able to deal with all things “Foot Health”, and indeed they are allowed to be fully-autonomous practitioners with no supervision or monitoring required. Yet the variation in training & knowledge is immense, with course lengths ranging from less than a month to generally less than one year. Some will have done an extensive initial course with lots of accurate and up-to-date information in the care of feet, together with some hands-on supervised experience. Some will have done a course affiliated to a University (earning credits towards higher qualifications) yet still via a private school rather than a Government-funded establishment. Some will have done less training, or with less accuracy, or the trainers will have less up-to-date knowledge. Some will even have had no hands-on supervised experience yet have still been awarded a qualification to treat feet.
There is no mandatory regulation of FHPs or safety checks for the public, but there are privately-maintained registers available albeit with no ability to be “struck-off” for any reason that leaves the public at risk. Indeed, those Chiropodists/Podiatrists who have been “struck-off” (see section 9 below) for whatever reason they were deemed to be unsafe to treat the public, can still continue to work as an FHP and be on one of those registers! However, the Government (via the Professional Standards Authority for Health and Social Care – the PSA) do approve of the Accredited Register of Foot Health Practitioners in accordance with the Health and Social Care Act 2012: http://foothealthpractitionerregister.co.uk/. You may, therefore, see the following logo on letterheads / correspondence / marketing material (including websites):
The PSA approval, in theory, may afford some level of protection for those who don’t want to be “struck-off” that register, but alas any disgraced FHP could just continue to treat the public as “unregistered” or on a different register.
An FHP ideally should be trained, qualified and insured to treat foot problems within their “scope of practice”. A good FHP will refer on anything beyond that scope and/or will do further training / mentorship to be competent to deal with such things. They will not just ask their equally untrained / unqualified colleagues for advice on managing foot conditions that are out-of-scope. There are many supplemental courses that FHPs can do to increase their knowledge, in order to be able to help the public better, more safely, and more effectively. However those courses may be non-standardised / unregulated, and there are many FHPs who choose not to do them nor seek appropriate mentorship / support. Conversely, there are some very good, safe, responsible & knowledgeable FHPs in the private sector, who have good referral links to Podiatrists (see 9 below).
This is the modern term for “Chiropodists” with technically the same definition. They are autonomous practitioners allowed to treat feet and its related structures without any further supervision after graduation. The Law ideally should see Podiatry as a “Protected Title”, however it doesn’t (although it thinks it does!). The Law actually defines “Chiropodists” and “Podiatrists” as “Designated Titles” which is a very different kettle of fish.
The Health Professions Order 2001 provides the legislation, with the HCPC regulating that (overseen by the previously-mentioned PSA). The regulation extends to standards of education for Chiropodists/Podiatrists (as the HCPC refers to them), currently as a University-based Batchelor of Science (with Honours) 3-4 year degree course. You might expect this course to be enough to produce true “Foot Specialists” upon graduation, but alas it isn’t as comprehensive as really required to make that claim. This may partly be due to NHS bursary funding in recent years influencing the content of the course (as the NHS don’t provide comprehensive Podiatry services), together with a lack of mandatory post-graduate clinical mentorship/rotations that other Health Care Professionals (HCPs) benefit from. However, the level of training during the degree course is currently the highest level of graduate “Foot” training available in the UK with specific academic entry criteria, encouragement of critical thinking, assessment against national benchmarks, and many more hours of clinical experience than given by any other training provider. The course length is at least 3 times that of any current FHP course (and in many cases significantly more times that), with technically a wider “scope of practice”, more indepth knowledge, and more standardised qualification criteria.
Note that in 2003, those Foot professionals who wanted it could apply to be registered with the HCPC irrespective of their previous qualification. So the State-Registered and Non-State Registered sectors came together without standardisation of previous training, so there are some (but not all) Chiropodists/Podiatrists without a degree, some with advanced skills (eg use of local anaesthetics, nail surgery, access to some prescription-only medicines) like their Degree-trained colleagues have. Diplomas in Chiropody or Podiatry or Podiatric Medicine were historically the qualification achieved before the first Degree course came in the early 1990s. Since then, Masters and Professional Doctorate qualifications have also been available to Podiatrists.
The HCPC regulatory system isn’t as comprehensive or effective as the possibly wider-known Care Quality Commission (CQC), the latter not being a requirement for any “Foot” services (apart from where diagnostic ultrasound is undertaken). The HCPC does not inspect everyone or every clinic and does not have the power to close down a sub-standard facility or practitioner. It encourages reflective practice and relies on whistleblowing by the public or other professionals to bring to their attention anyone who may be in breach of their standards. It regulates other Health Care Professionals (and some Social Workers), some post-graduate qualifications, disciplinary matters, and it maintains a register of its registrants at https://www.hcpc-uk.org/. The HCPC will allow the use of their logo by those who are registered with them, so you may see the following on letterheads / correspondence / marketing material (including websites):
However, you can be a Podiatrist or Chiropodist providing Podiatry or Chiropody Services without being “HCPC-registered” as long as you have a Chiropody or Podiatry qualification and you have made it clear to the public there is no affiliation to or regulation by the HCPC. So in theory, if you are “struck-off” as a Podiatrist through the HCPC disciplinary procedure, you could carry on working with your previous title (or choose to call yourself an FHP instead) providing you were transparent with the public regarding your lack of HCPC regulation.
Just like the FHPs, a Podiatrist should be trained, qualified and insured to treat foot problems within their “scope of practice”. A good Podiatrist will refer on anything beyond that scope and/or will do further training / mentorship to be competent to deal with such things. There are many supplemental courses that Podiatrists can do to increase their knowledge, in order to be able to help the public better, more safely, and more effectively. Indeed there is an obligation for HCPC-Registered Chiropodists/Podiatrists to undertake mandatory continuing professional development (CPD), but this is only monitored through a random selection process.
- Other Health Care Professionals:
Doctors, Nurses, Surgeons, Physiotherapists, Orthotists, Chiropractors, Osteopaths etc. all have their own regulations and legislation that allows them to treat feet and their related structures. However, they are also allowed to treat the rest of the body and will be insured to do so. Some of these will have had minimal training in the management of foot problems, yet others may choose to specialise in feet and/or use the “Consultant” prefix eg Consultant Orthopaedic Foot & Ankle Surgeon. Of particular note, it is not unusual for a nurse to go on to train as an FHP. However their professional nursing registration / qualification may not confer to their FHP training & work, and whilst regulated as a nurse, that won’t mean they are regulated as an FHP as that regulation does not currently exist (see 8 above).
- Foot Doctor or Foot Doc:
These are colloquial titles used by some who treat feet or used by the public to describe them. They could be used by any of the above and do not distinguish differences in qualification, knowledge, or experience. Some private practitioners use the term for marketing / promotion purposes.
FHPs, Chiropodists, Podiatrists will generally (but not always) be members of a Professional organisation that supports them with services, benefits, information, CPD and possibly insurance (although there are many other independent insurers). These organisations will not be available to all in the above list. Membership may infer the lawful use of their logo by the member, so you may see the following on letterheads / correspondence / marketing material (including websites):
In addition to the above starting points for those who treat feet, Podiatrists can go on to complete further training or be promoted (eg in the NHS) to achieve titles such as:
- Independent Prescriber – Additional regulated training and qualification is required to allow access to the same medicines as GPs
- Graduate / Senior / Specialist / Advanced / Principal / Lead Podiatrist – Outside of the NHS, these are non-standardised, unregulated additions to the title Podiatrist irrespective of other terms used alongside them eg musculoskeletal (MSK), diabetes, high-risk foot, rheumatology, dermatology, sports medicine, wound care etc.
- Extended Scope or First Contact Practitioners – The NHS use these terms and define them, but they are non-standardised and unregulated outside of the NHS
- (Consultant) Podiatric Surgeons – They undergo several years of additional regulated & supervised training to be able to carry out surgical procedures on the feet, additional to those that Podiatrists are legally allowed to perform
Alas, it’s all very complicated for the public, and whilst the above information is aimed to be comprehensive, there will no doubt be gaps and exceptions. One important thing to appreciate is that each of the above have different scopes of practice, training, knowledge, and understanding of the management of feet and foot-related problems. Some will be strongly regulated, others won’t be regulated at all. Their “title” may give limited information as a whether they are working within their “scope of practice” and whether they are best-suited to manage your needs & expectations safely & effectively. Whatever the level of their training/qualification, some will act responsibly and refer onwards anything that is beyond their scope of practice. Others will give potentially dangerous advice or treatment for a foot problem which they don’t have the necessary skills, information or tools to deal with. Some will be monitored and regulated, others will not. But most importantly is NOT to assume that the Law is there to protect your health and that in each of the numbered list above, you can get good & bad care, good & bad treatments and good & bad practitioners.
Remember you only get one pair of feet, so look after them and be careful who you allow / trust to manage any problems you may have with them. Don’t become a statistic or sufferer of sub-optimal care – there is plenty of good help available for you to access. This may be more readily available privately than on NHS depending on where you live. Your feet deserve the best so help them find the best possible care to keep you mobile, active, healthy and happy.
The purpose of this article is to educate and inform. It is based on the facts currently available and is not intended to promote or denigrate any particular service provider. In particular, it does not support the non-registration of Chiropodists / Podiatrists with the HCPC, whose purpose is to protect the designated titles.