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executive summary
This report has been prepared by an expert Steering Group, supported by staff from the Scottish Executive Health Department ( SEHD) and NHS Quality Improvement Scotland ( NHSQIS). Frontline Consultants were selected by the Steering Group to undertake an extensive, independent, consultation exercise with users, carers and service providers throughout Scotland.
The Steering Group has undertaken an in-depth analysis of all the information gathered in this exercise culminating in 40 recommendations for improvements in the delivery of NHS Wheelchair and Seating Services in Scotland. Central to the recommendations are five key points that emerged from the formal consultation and stakeholder discussions:
- The remit of the NHS Wheelchair and Seating Service should address the lifestyle requirements of users and carers ensuring maximum possible social inclusion.
- Service delivery should be based on holistic requirements and not coloured by available funding for equipment.
- The service should measure performance and demonstrate accountability.
- The service should be adequately funded to meet its core values - additional resources should be provided to fill large gaps that exist in current service provision.
- A multi-agency approach to deliver a seamless service, from the user and carer perspective, should be established at national level, delivered locally.
The expectations for the service have been clearly and unanimously stated by users, carers and professionals in the form of a 'Declaration of Independence' delivered to the national conference in Edinburgh on 12 September 2005. It states:
"The service should be a basic human right, accessible through self-referral. It should ensure individuals are given all appropriate aids necessary to fulfil the basic rights of all citizens to play an active part in society and their daily life, regardless of physical limitations or differences."
Previous reports produced over more than three decades have highlighted the need for changes in NHS Wheelchair and Seating Services. They too identified serious gaps in services. They were thorough, realistic and grounded in the requirements of users and carers, yet despite obvious barriers to social inclusion, other inequities, inefficiencies and injustices in the delivery of the service, resources have not only been limited for this service but actually redirected to support other funding priorities of the NHS Boards. A health economics analysis provided in Frontline Consultants' report (Appendix 1) shows clearly and objectively that the cost-benefits of providing an excellent wheelchair service will give outstandingly good value, measured against national norms.
This report comprises a summary of the recommendations of the Steering Group, with proposed timelines for implementation, background information that defines the context in which the report is submitted, a more detailed discussion of the recommendations, estimates for the cost of implementation of each main recommendation category and finally, extensive appendices, including the report prepared by Frontline Consultants that provides, in detail, the primary evidence that underpins the recommendations.
The summary recommendations of the Steering Group have been prepared in the form of charts providing information about the urgency, estimated time to complete and ease of implementation for each recommendation. Indicative costs have been prepared that account for the timing of the implementation of the recommendations. In revenue terms this amounts to an additional £8.7 million initially, building to an additional recurring requirement of £15.8 million after three years, above the current funding level of £14.2 million per annum.
These changes can only be brought about in partnership between the professionals with the expertise to provide top quality services and the users and carers who provide guidance that ensures that these improvements make real differences to quality of life. The high levels of participation and partnership that were shown in creating this report are a testament to the importance of these services and the passion for improvement shown by all involved.
The response to this consultation far exceeded any others that have been co-ordinated by NHSQIS in recent years. The message from users, carers and service staff is clear: action is needed now.
The Steering Group respectfully urges the Minister for Health and Community Care to accept these recommendations and establish an implementation process as a matter of urgency.
The following section of the report contains the 40 recommendations made by the Steering Group. The Steering Group has scored each recommendation in terms of urgency, implementation time and ease of implementation. These are illustrated in the charts for each section of recommendations. The charts provide an indication of:
- the urgency of a recommendation, represented by the practical start date
- the time to implement, represented by the columns, and
- the ease of implementation, colour coded according to a traffic light system.
redesign of service delivery
Recommendation 1 - establish an Implementation Team
An Implementation Team will be established to take forward delivery of the recommendations made in this report on behalf of the Minister for Health and Community Care.
Recommendation 2 - reorganise into a national, integrated, assistive technology service
The provision of all assistive technology services (including wheelchairs, seating, prosthetics, orthotics, augmentative communication, environmental controls) will be integrated into a single national service, funded centrally but delivered locally. The NHS Wheelchair and Seating Service will pilot this change. The NHS Wheelchair and Seating Service will be accountable for expenditure through a budgetary process. With guidance from an Advisory Group comprising representatives of users, carers, service professionals and appropriate government departments, the national service will establish minimum performance standards for the service.
Recommendation 3 - maximise social inclusion
The central ethos of the NHS Wheelchair and Seating Service will be to maximise social inclusion. At referral, assessment and provision, services will be led by the requirements of users and carers embracing individual lifestyles and aspirations, taking into account domestic, educational, vocational and environmental requirements.
Recommendation 4 - increase number of centres, local facilities and clinics
The number of centres, local facilities and clinics will increase in a manner to be determined by further consultation. There will be a substantial increase in the number of local facilities and clinics that will be staffed by centre staff. Suitably trained community staff will also support local facilities as they become available.
Recommendation 5 - provide support for privately purchased wheelchairs
The NHS Wheelchair and Seating Service will support assessment and maintenance for a defined range of privately purchased wheelchairs.
Recommendation 6 - establish evidence-based mobility pathways
Documented, evidence-based mobility pathways (similar to 'patient pathways') will underpin all stages of the service provided to users and carers.
Recommendation 7 - improve co-ordination with community services
A review in the context of recommendations made in this report will be undertaken to improve co-ordination between wheelchair and seating provision and community services responsible for making home, school and workplace adaptations to ensure compatible solutions are developed in an efficient and timely manner.
referral, assessment and provision
Recommendation 8 - self-referral for reassessment
Users and carers will be informed that they can self-refer to the service for reassessment and repairs when they feel they are required. Any healthcare professional will be able to make a referral to the NHS Wheelchair and Seating Service. Training will be established to improve communications between referring community-based staff and service staff.
Recommendation 9 - phased removal of eligibility criteria
Current eligibility criteria for NHS Wheelchair and Seating Services will be removed by phased implementation, unless they relate to safety.
Recommendation 10 - agreed mobility and seating plan for each user
An individual mobility and seating plan will be developed for each user assessed and should form an agreement that is signed by the user, carer and wheelchair service clinician. In the event that there is a failure to agree on the mobility and seating plan then an independent review group will be available to arbitrate an agreement.
Recommendation 11 - assessment to document optimum equipment specifications
The assessment process will clearly document the optimum specifications to meet user and carer goals and requirements. Financial considerations should not be a key issue.
Recommendation 12 - assessment and provision for those who need the service
Assessment and provision of equipment will be available to all with mobility and/or postural support needs, including those in care homes, bariatric users and carers, people with terminal illness and people with acute needs.
Recommendation 13 - users and carers to be offered more information about the service
All users and carers will be offered a simple introduction to the NHS Wheelchair and Seating Service so that they understand:
- the purpose of the assessment and associated individual mobility and seating plan
- their right to appeal the specifications of the equipment to be supplied
- how to provide feedback to the service, including the complaints process, and
- procedures for obtaining repairs and preventive maintenance.
Recommendation 14 - assessment to be integrated, multi-disciplinary and multi-agency
Assessment leading to provision of equipment will be an integrated, multi-disciplinary and multi-agency approach. Deployment of staff will be flexible, with medical staff available when needed but reserved for assessment of those with complex, multi-factorial needs.
Recommendation 15 - assessment to ensure compatibility with carer requirements
The assessment will include review of the particular requirements of carers ensuring that any equipment provided is compatible with their requirements.
Recommendation 16 - equipment to be delivered within known timeframes
Systems will be established to ensure that equipment is available within a known timeframe following the assessment process. Agreed timescales and lead-times will be stated following the assessment, and a commitment will be made to communicate any unexpected delays.
management
Recommendation 17 - establish as a national service delivered locally
The national service (as proposed in Recommendation 2) will be operated by a Management Group comprising members of the user and carer working groups (Recommendation 18) and representatives of other relevant stakeholders.
Recommendation 18 - each centre will establish user and carer working groups
User and carer working groups will be established in association with each centre. The groups will provide advice to the centre and will be supported with basic secretarial services to enable them to confer with other users and carers.
Recommendation 19 - governance and complaints overseen by national service
Governance and complaints processes will be specific to the wheelchair service and linked to the national service's governance system.
Recommendation 20 - services available to users and carers at any centre in Scotland
Users and carers will be able to obtain services from any centre in Scotland.
Recommendation 21 - services to support more effectively life-change transitions
Services will be provided so that critical life-change transitions affecting users and/or carers (child to adult service user, loss of key carer ( e.g. parent), university to workplace) are continuous and driven by the wishes of the user and carer.
information management and systems
Recommendation 22 - national IT system to support management
A robust national IT system allowing management of waiting lists and equipment, and facilitating performance comparisons will be established. This will have the facility to link to the electronic patient record and record comprehensive information about each user and the equipment they use.
Recommendation 23 - communication links between centres and staff working locally
Appropriate communication links will be established to ensure that staff working remotely from the centre can lead assessments, and access information and advice. Experienced staff in specialist centres ( e.g. spinal injury/head injury, multiple sclerosis, stroke units) may wish to directly assess the requirements of the user and carer who may be based in their facility. They will need to seek approval for supply of the equipment based on the assessment and an agreed mobility and seating plan.
training
Recommendation 24 - improvements to infrastructure
The infrastructure to provide training on wheelchair and seating needs to be established and accredited. All staff, including reception, administration and technical staff, will receive training in 'customer relations' with an emphasis on the specific requirements of people with disabilities and their carers.
Recommendation 25 - review career structure for service staff
A review should be undertaken by NHS Education for Scotland ( NES) to ensure that an appropriate career structure exists for clinicians and technicians delivering wheelchair services.
Recommendation 26 - review staffing levels throughout the service
A review will be undertaken to determine whether current staffing levels are adequate and whether the most appropriate skill-mixes are in place.
Recommendation 27 - appropriate training for service staff
Staff referring to the service should receive appropriate training.
repair, maintenance and support
Recommendation 28 - agreed response times for repair and maintenance
The NHS, at all levels in the service, will provide repair and maintenance support. It should have response times that are determined through the national service consultation process involving users and carers.
Recommendation 29 - provision of out-of-hours support
Out-of-hours support, including weekends and holidays, will be provided. The feasibility of using NHS 24 as a means for users and carers to contact centres and obtain emergency response outside normal business hours will be considered.
Recommendation 30 - review of in-house refurbishment practices
A review of using in-house workshops to refurbish and customise chairs will be carried out.
Recommendation 31 - provide mobile service
To provide dedicated area technician support for preventive maintenance and minor repairs, centres will consider provision of a suitably qualified mobile service.
Recommendation 32 - establish planned preventive maintenance programmes
Planned preventive maintenance ( PPM) programmes should be established. Inventory management systems should include measures to remove obsolete equipment from use to ensure that stocks keep pace with currently available technology.
facilities
Recommendation 33 - ensure facilities are fully accessible to people with disabilities
All wheelchair service facilities must be fully accessible to people with disabilities and their carers.
Recommendation 34 - ensure facilities have adequate space for clinical assessment
All facilities should be provided with appropriate space for clinical assessment, storage and the equipment needed to support effective assessment.
Recommendation 35 - facilities will be family-friendly
All facilities will ensure that they are family-friendly with dedicated waiting areas and clinical facilities for children.
particular considerations for children's services
In addition to the above recommendations, the following particular considerations should be given to the provision of services for children.
Recommendation 36 - children to have access to a multi-disciplinary team
Children should have comprehensive access to a multi-disciplinary team when being assessed or reviewed for wheelchair and seating systems.
Recommendation 37 - all services for children provided in child-oriented facilities
All services for children will be undertaken in family-friendly, child-oriented facilities by staff specially trained in the assessment of children with requirements for wheelchairs and seating.
Recommendation 38 - provide access to specialist paediatric clinicians
Clinics will provide access to specialist paediatric clinical expertise as needed.
Recommendation 39 - extended equipment loan programmes
Extended equipment loan programmes will be introduced to provide longer periods of time for children to be trained so that they can learn to use equipment during the assessment process, prior to making a decision for its provision.
Recommendation 40 - establish multi-agency links
Centres will establish properly functioning multi-agency links.
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