Change in the podiatry workforce of the English National Health Service

INTRODUCTION

Foot disorders place a substantial and rising burden on the National Health Service in England. Diabetes-related foot disease accounts for a large share of lower-limb amputations, and people who present with a first diabetes-related foot ulcer have high rates of hospital admission and mortality that have persisted over time.(1,2) Because most major amputations are preceded by ulceration, the prevention and early management of foot disease are central to reducing limb loss. The complications of diabetes, including foot ulceration and amputation, have been described as a toll that remains too high despite improvements in glycaemic control.(3) The direct costs of diabetic foot ulcer care are considerable, spanning wound care products, specialist clinics, inpatient treatment and limb salvage.(4) Beyond diabetes, chronic foot pain is common in older people and restricts mobility, independence and quality of life.(5) The prevalence of diabetes in England has risen over recent decades, which enlarges the population at risk of foot ulceration and therefore the volume of preventive foot care that services must deliver.(2,3) As the population ages, the demand for foot health services is expected to rise further, and modelling has shown that foot health deteriorates after older people are discharged from podiatry services.(6)

The National Health Service delivers podiatry through community clinics, high-risk foot services and multidisciplinary diabetic foot teams. The demand for these services is driven by the ageing of the population and by the volume of diabetes-related foot disease, both of which have increased pressure on community and specialist foot care, and foot health inequities mean that the burden is not evenly distributed across the population.(7)

Podiatrists deliver much of this care within the National Health Service, providing prevention, wound management, offloading, vascular assessment and musculoskeletal foot care, and they work within multidisciplinary teams that coordinate the management of complex foot disease. Podiatry involvement in limb salvage programmes has been associated with economic value through the avoidance of major amputation.(8) Podiatrists are also central to the multidisciplinary management of diabetes-related foot disease and to the detection and management of peripheral arterial disease in people with diabetes, where a national survey has documented the breadth of podiatry practice.(9) The professional scope has widened over the past decade through independent prescribing and extended clinical roles, developments that were expected to increase service capacity and reduce pressure on medical colleagues.(10,11)

Despite this expanding role, workforce supply has remained a recurring concern. Reports describe a podiatry workforce crisis in parts of the United Kingdom, illustrated by a novel recruitment project in Glasgow, and comparable health systems have described the podiatry profession as in crisis or under strain in New Zealand and Australia.(12-14) These concerns matter because a workforce that cannot keep pace with demand may delay the very preventive care that podiatry is designed to provide. Burnout has been documented among podiatrists in the United Kingdom and elsewhere, and the wider National Health Service workforce has been reported to be under severe strain from shortages and workload.(15,16) Workforce planning for allied health professions has repeatedly been identified as less developed than planning for medicine and nursing, and career motivation and placement supply for these professions remain unevenly understood.(17-20) The NHS Long Term Workforce Plan has set out ambitions for the growth of the health workforce, including allied health professions, yet such ambitions require profession-specific data on current trends to be translated into training and recruitment targets.(21)

Quantitative evidence on the size of the podiatry workforce has largely relied on cross-sectional registrations or single-year workforce snapshots. Studies in Australia have quantified the podiatry workforce and its geographic distribution, and comparable work in England modelled the deterioration of foot health after discharge from podiatry services, but a recent decade-long quantification of the English National Health Service podiatry workforce alongside comparable professions is not available.(6,14,22)

What remains unclear is how the podiatry workforce of the English National Health Service has actually changed over a full recent decade, and whether podiatry has moved in line with, or diverged from, other allied health professions and from one region to another. The objective of this study was to quantify the change in podiatry full-time equivalents in the English National Health Service between 2015 and 2024, and to compare that change with six comparator allied health professions and across the seven NHS England regions. Three hypotheses were tested. H1: podiatry full-time equivalents declined between 2015 and 2024. H2: the change in podiatry was less favourable than the change in the combined comparator allied health professions. H3: the change in podiatry full-time equivalents differed across NHS England regions.

METHODS

RESULTS

Between September 2015 and September 2024 total Hospital and Community Health Services full-time equivalents in England increased from 1,014,217.70 to 1,359,357.90, a rise of 34.0%. The Scientific, therapeutic & technical staff group, which contains the therapy professions, increased from 127,921.20 to 174,922.90 (36.7%), and the combined comparator professions rose from 32,939 to 33,303.30 full-time equivalents. Podiatry moved against this trend, and its share of the Scientific, therapeutic & technical staff group fell from 1.9% to 1.1%.

H1

Between September 2015 and September 2024, podiatry full-time equivalents in England fell from 2,394.20 to 1,872.60, an absolute change of −521.60 full-time equivalents and a relative change of −21.8% (Figure 1). The series declined in every year except a brief plateau in 2020 and 2021, reached its lowest recorded value in 2023, and recovered slightly in 2024 (Table 1). The linear trend was estimated at −65.80 full-time equivalents per year (95% CI −90.5 to −41.0; p <0.001) (Table 2). On a relative scale, the average annual change was −3.1%. The decline predated the study window, with 2,794.20 full-time equivalents recorded in 2009, so the 2015-2024 reduction was part of a longer trajectory rather than a recent interruption.

Year	FTE
2015	2394.2
2016	2376.8
2017	2335.6
2018	2289.7
2019	2224.8
2020	2259.1
2021	2237.1
2022	1869.9
2023	1847.9
2024	1872.6

Note: FTE = full-time equivalent. England totals sum the seven NHS England regions. Source: Elaboration from NHS England HCHS workforce statistics, December 2024 release.

Estimate	Value
Podiatry FTE, September 2015	2394.2
Podiatry FTE, September 2024	1872.6
Absolute change (FTE)	-521.6
Relative change (%)	-21.8
Linear trend (FTE per year)	-65.8
95% CI (FTE per year)	-90.5 to -41.0
p value	<0.001

Note: CI = confidence interval. Trend estimated by ordinary least squares of annual FTE on year. Source: Elaboration from NHS England HCHS workforce statistics, December 2024 release.

H2

The podiatry total decreased by −21.8%, whereas the combined full-time equivalents of the six comparator professions increased by 1.1% (Table 3). The comparator group was larger than podiatry at both censuses, and physiotherapy was the largest comparator profession throughout the period. The comparator professions changed heterogeneously. Physiotherapy increased by 3.5%, dietetics by 15.6%, speech and language therapy by 5.2% and orthoptics by 1.6%, whereas occupational therapy decreased by −10.2% and prosthetics and orthotics by −5.9% (Figure 2). Dietetics recorded the largest relative increase and occupational therapy the largest relative decrease among the comparator professions, and podiatry decreased more than any comparator. The log-linear interaction model estimated a between-group difference in annual change of −2.70 percentage points per year (95% CI −4.4 to −1.1; p = 0.003). In the sensitivity analysis expressed as a simple percentage change, podiatry decreased by −21.8% while the combined comparator professions increased by 1.1%, a conclusion consistent with the interaction model.

Profession	FTE 2015	FTE 2024	Change (%)
Podiatry	2394.2	1872.6	-21.8
Physiotherapy	14453.0	14960.6	3.5
Occupational therapy	9214.1	8274.6	-10.2
Speech and language therapy	4635.6	4875.0	5.2
Dietetics	3564.9	4121.5	15.6
Orthoptics	840.7	854.5	1.6
Prosthetics and orthotics	230.7	217.0	-5.9
Combined other AHPs	32939.0	33303.3	1.1

Note: AHP = allied health professions. Combined other AHPs excludes podiatry. Source: Elaboration from NHS England HCHS workforce statistics, December 2024 release.

H3

All seven NHS England regions recorded fewer podiatry full-time equivalents in 2024 than in 2015 (Table 4). The North West held the largest podiatry workforce in 2015 and North East and Yorkshire the largest in 2024, while the South West held the smallest in both years. The relative change ranged from −4.7% in the South West to −34.5% in the Midlands, with reductions of −24.8% in the North West, −28.9% in the East of England, −22.2% in London, −17.6% in the South East and −12.9% in North East and Yorkshire (Figure 3). The year-by-region interaction was not statistically significant (p = 0.052).

Region	FTE 2015	FTE 2024	Change (%)
East of England	169.0	120.1	-28.9
London	306.9	238.7	-22.2
Midlands	443.9	290.8	-34.5
North East and Yorkshire	515.4	448.8	-12.9
North West	537.2	404.1	-24.8
South East	247.7	204.2	-17.6
South West	174.1	165.9	-4.7

Note: Percentage change between September 2015 and September 2024. Source: Elaboration from NHS England HCHS workforce statistics, December 2024 release.

DISCUSSION

The main finding of this study is that the podiatry workforce of the English National Health Service contracted by roughly one fifth over a decade in which the wider hospital and community workforce grew by one third. The divergence was specific to podiatry among the therapy professions examined, and the contraction occurred in every English region. In absolute terms, more than five hundred full-time equivalent podiatry posts disappeared from the Hospital and Community Health Services between 2015 and 2024.

The observed decline is consistent with accounts of a podiatry workforce crisis in Glasgow and with a profession described as in crisis in New Zealand.(12,13) Burnout and low job satisfaction have been documented among United Kingdom podiatrists and may contribute to attrition, and workplace characteristics have been linked to burnout in national surveys.(15) Recruitment also appears constrained, with student surveys describing financial and career barriers to entering the profession, and retention difficulties have been described in rural settings in Australia and New Zealand.(26-28) In line with these accounts, career motivation for allied health professions has been described as unevenly understood, which complicates recruitment planning and the design of student placements.(19,20)

Contrary to expectations from the international literature, the Australian podiatry workforce has been described as growing, and the distribution of registered podiatrists, physiotherapists and occupational therapists in Australia shows a different balance of supply.(14,22) These differences may reflect distinct funding, training and service delivery models rather than a universal decline in the profession. In England, workforce redesign policies have historically shifted the boundaries of generalist podiatry practice, and the profession's scope has expanded through independent prescribing, which changed the expectations placed on the workforce and may have redistributed activity across roles.(11,29,30) The evolution of professional practice has been proposed as both an opportunity and a barrier to change, and this tension may have contributed to the divergence from professions with a more stable service model.(10)

The divergence between podiatry and the comparator professions is notable because allied health professions in England have generally been prioritised for expansion. Physiotherapy and dietetics grew over the study period, and even occupational therapy, which declined, did so at less than half the podiatry rate, which suggests that the factors driving the podiatry contraction were not shared equally across the therapy professions. The prosthetic and orthotic workforce, a further comparator, has also been reported to face an uncertain future, indicating that some smaller allied health professions may be vulnerable even when the wider group grows.(31) Workforce planning for allied health professions has repeatedly been weaker than for medicine and nursing, and planning assumptions have historically shifted between under-supply and over-supply, with earlier analyses warning of both.(17,18,32,33) Consistent with this, the contrasting trajectories within a single staff group suggest that aggregate allied health profession targets may conceal profession-specific decline, and that satisfaction, wages and retention, which are associated with staying in the National Health Service, warrant profession-specific attention.(34,35)

Several mechanisms may explain the contraction. The supply of newly qualified podiatrists depends on a small number of training programmes, and placement supply has been identified as a constraint on allied health profession growth.(19,20) At the same time, the reconfiguration of community services and the extension of prescribing and extended roles may have redistributed podiatry activity across providers.(10,29) If some services were transferred to providers outside the Hospital and Community Health Services, the published counts would fall even when total activity did not. The brief plateau in 2020 and 2021 followed by a further fall in 2022 is also consistent with a delayed effect of the COVID-19 pandemic on recruitment and retention, a pattern that appeared in the comparator professions as well. Whereas the comparator professions recovered after 2022, podiatry did not, which suggests that the pandemic disruption was superimposed on a longer-running podiatry-specific decline.

The clinical implications of a contracting podiatry workforce are most direct in diabetes-related foot care, where podiatrists provide the offloading, wound management and risk stratification that underpin limb salvage. A reduced workforce may lengthen intervals between foot checks, delay access to high-risk foot clinics and shift work onto other members of the multidisciplinary team, with potential consequences for ulcer healing and major amputation.(1,9) The economic case for podiatry in limb salvage has been made explicitly, which makes the observed contraction difficult to reconcile with the expected return on podiatry staffing.(8) For musculoskeletal and biomechanical podiatry, the same staffing constraint may extend waiting times for assessment, orthoses and rehabilitation, although the present data do not measure activity or waiting times directly. Service commissioners who rely on podiatry to deliver preventive foot care will therefore need to weigh the observed staffing trajectory against the rising demand from an ageing population and a growing population with diabetes.

For podiatry education and the professional body, the findings reinforce the case for stable student intake, adequate clinical placement capacity and support for newly qualified podiatrists, because a decade of decline cannot be reversed quickly once training pipelines have contracted.(20,26) The motivations and barriers described among podiatry students suggest that recruitment messages and financial support may need to be profession-specific rather than generic to allied health professions.(19) Independent prescribing and extended roles have increased the clinical contribution of podiatrists, and a shrinking workforce would place these expanded responsibilities on fewer individuals, with implications for burnout and retention that national surveys have already flagged.(15,30)

The scale of the reduction deserves emphasis. A loss of one fifth of the podiatry workforce over nine years is a large change for a profession of this size, and it is not explained by an overall contraction of the health service, which grew substantially. In the wider workforce planning literature, such sustained divergence between a profession and its comparators has been interpreted as a signal of structural rather than cyclical change.(32,33) The present data cannot distinguish cyclical from structural causes, but the monotonic decline before, during and after the pandemic is more consistent with a structural contraction than with a temporary disruption.

Regional differences in the magnitude of contraction, although not statistically significant in the interaction test, echo the regional variation reported for the community nursing and support workforce in England.(36) Geographic inequities in foot health have been described, and the uneven distribution of allied health professions is a recognised challenge in other settings, including the rural-urban divide reported for surgical and allied workforces.(7,37,38) The absence of a significant interaction indicates that the decline was broadly national rather than driven by a small number of regions, and that regional monitoring should not assume that local variation explains the national trend. The largest relative declines in the Midlands and the East of England, and the smallest in the South West, further show that the geography of the contraction was not uniform even though the overall trend was national. From a policy perspective, this means that measures confined to the most affected regions would be unlikely to reverse a contraction that is occurring across the country.

The findings are likely to be informative beyond England. Comparable declines and workforce crises have been reported in New Zealand, and the Australian experience shows that growth is possible when training and funding models differ.(13,14) The methods used here, based on publicly available workforce statistics, could be applied to other health systems that publish profession-level workforce series, and the hypothesis-driven design offers a template for monitoring allied health professions over time.

The strengths of this study include the use of a complete national census rather than a sample, a ten-year annual series, a predefined hypothesis-testing framework and region-level disaggregation. The analysis was restricted to a single, stable definition of podiatry, which reduces the risk of misclassification, and the same definition was applied uniformly across all years and regions. The use of full-time equivalents accounts for changes in part-time working, and the comparator group was drawn from the same classification and source, so the comparison between podiatry and the other professions is internally consistent. The use of a single source file for all professions and years also avoids the inconsistencies that can arise when combining data from multiple publications. The results were reproducible from a publicly available file, and the pre-registration of the three decision rules reduced the risk of selective reporting.

CONCLUSIONS

Podiatry full-time equivalents in the English National Health Service declined between 2015 and 2024. The decline contrasted with the trajectory of the combined comparator allied health professions, which increased over the same period. The contraction occurred across all seven NHS England regions, with no statistically significant regional interaction.

References

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