This study has revealed some crucial aspects about podiatrists’ engagement in guidelines of relevance to the management of people who present with foot problems related to RA, in particular the NWCEG guidelines . It has demonstrated that, in relation to both the knowledge of and use of RA guidelines there is a notable difference in that the UK specialist podiatrists are far more likely to use the guidelines than UK non-specialist podiatrists. This is of concern as the NWCEG guidelines were intended for all podiatrists to ensure the appropriate and timely management of RA related foot problems.
Additionally, there were differences in responses in relation to barriers to the implementation of guidelines into clinical practice, with the non-specialist podiatrists more frequently reporting difficulties in interpreting guidelines (cognitive barriers) and had less favourable opinions about guidelines (affective barriers) than specialist podiatrists.
The few non-specialists recognising benefits commented more on how they support appropriate referrals to the rheumatology team for foot health management, rather than guiding them through their own management of the patient. However, this is beneficial in relation to the patient receiving the right intervention in the right setting. A few did identify that adhering to the guidelines supported defensible practice but it is of concern that some thought they were not relevant to their practice as their treatment of people with RA was very simple, such as toe nail cutting. This perhaps indicates a lack of knowledge about the implications of even simple foot care for those patients who are immunologically suppressed and/or receiving biological therapy for their systemic disease, and in whom skin and soft tissue infections occur more frequently and can develop rapidly . Indeed the non-specialist podiatrists were less likely to have undertaken postgraduate qualifications in this area.
Some non-specialist podiatrists considered that the guidelines detracted from their professional autonomy and hence they did not use them. Nancarrow and Borthwick  have proposed that perceptions such as these arise from professional isolation and may be linked to avoidance of medical hierarchies. This may indicate that, for those podiatrists, their practice is not defendable in terms of new paradigms of management of people with early RA disease , as advocated within the guidelines. As such, the ‘window of opportunity’ to ensure early detection and management of foot problems for these patients may be missed.
In contrast, to the non-specialist podiatrists, the specialist podiatrists were using the guidelines. However, they were hampered by external barriers such as a lack of agreement about their roles and responsibilities within rheumatology, particularly in relation to interventions that have traditionally been carried out by the medical profession. This is consistent with Redmond et al.  who identified wide variation in the UK in the provision of foot health services and training for specialist podiatry rheumatology services.
A positive perspective from our study was that the ‘specialist’ podiatrists stated that guidelines helped them to identify their professional development needs, specifically in relation to advanced skills and also helped them provide evidence for the provision of a specialist foot health service for people who have RA. A further development from this would be the embedding of foot health care algorithms in clinical practice as well as the design and implementation of an audit tool based on the foot health guidelines in order to formally evaluate services.
In relation to usability of guidelines, there were some comments by the specialist podiatrists as to how this could be improved. Solutions to the cognitive barriers may be simple in relation to the presentation and format of the guidelines. The specifics that were suggested were having a summary of the key aspects of the management guidelines in a separate document and also a summary of all relevant guidelines with an indication as to who they are relevant to (managers, patients, podiatrists). Also, it was suggested that a way of auditing the standards would be useful in order to identify gaps in training and service provision.
Dodek et al.  identified the influences on the implementation of guidelines as being the quality of evidence and the credibility of the guidelines development group. However, these were not identified as a barrier in this survey. One of the contextual factors that seem to be implicit in the results of this survey is the influence of the type of service. Dodek et al.  further identified that shared beliefs about guidelines and adherence to guideline recommendations may be more evident within teams. Therefore, one of the ways to improve the use of guidelines is to ensure peer support where non-specialist podiatrists are working in isolation. A ‘peer support and review scheme’ as recommended by Piper et al.  may help to support links between the specialist and non-specialist services. Further, a service that provides seamless care between specialist and non-specialist services could provide opportunity for support and education . Lineker and Husted  concluded that it is difficult to change behavior and noted that recent graduates may be more receptive to guideline implementation. Therefore, it would be pertinent to reinforce the benefits of using the guidelines during the undergraduate training of podiatrists.
There are some limitations to this study in that it was delivered at the UK Society of Chiropodists and Podiatrist’s annual conference and so may not reflect the opinions of all podiatrists practising within the UK. Further, there may be potential bias in the survey such as acquiescent responses, particularly from the specialist podiatrists. It was also impossible to ensure that the survey was not completed more than once by each participant or that a non-podiatrist could have completed it. Also it was impossible to ensure that it was completed by equal numbers of private, non-specialist NHS podiatrists and specialist podiatrists and so it was a pragmatic and convenient sample. However, the proportions of non-specialist (93.5%) to specialist (6.5%) podiatrists who completed the survey reflect the national profile as identified by Redmond et al. .