The Scottish Government

« Previous | Contents | Next »

Listen

recommendations and rationales

The recommendations and rationales presented here have been developed by the Steering Group based on the evidence gathered by Frontline Consultants. Evidence quoted in the rationales has been cross-referenced to the Frontline Consultants' report which is in Appendix 1.

redesign of service delivery

Recommendation 1

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.

Rationale

The recommendations of this report will require, in many cases, detailed development, the preparation of business cases and ongoing project management. Implementation will be best undertaken through a co-ordinated planning process and project management with the oversight of an Implementation Team.

Recommendation 2

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.

Rationale

At present there are five wheelchair centres that are managed by geographically associated NHS Boards. Evidence gathered in this review has shown that there is a lack of co-ordinated provision with wide variation in the scope of services provided, funding allocation per user and staff to user ratios across Scotland. ⁵ In 1996/7 funding was devolved to NHS Boards and was not ring-fenced, the funding therefore forming part of each NHS Board's annual allocation. Evidence shows that there has been an apparent shortfall in allocation using 1996/7 as a basis for 2004/5. ⁶ There is little evidence to suggest that these differences can be explained by regional differences in need, but instead is a consequence of differences in priority given to these services by each NHS Board.

This recommendation seeks to ensure that given a long history of under-resourcing, these services should receive nationally protected funding.

At present the service is not routinely included in any of the monitoring systems common to NHSScotland. ⁷ The framework for delivering a national service should support an approach where services are delivered locally but are accountable to nationally agreed minimum standards of scope and quality. A target benchmark specification has been developed which could constitute a useful basis from which to build standards. ⁸

A review of these services in other countries has shown that NHS Wheelchair and Seating Services can be integrated into a more comprehensive service encompassing many other assistive technologies. ⁹

In the long term a national, integrated assistive technology service should be established and it is proposed that the NHS Wheelchair and Seating Service should pilot this approach. The Steering Group discussed how a national focus would be organised and proposes that the details of this recommendation should be investigated in depth by the Implementation Team (Recommendation 1).

The suggested structure for the national service is illustrated below.

Recommendation 3

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.

Rationale

At present NHS Wheelchair and Seating Services are constrained by eligibility criteria based solely on medical need and lack of funding, rather than wider social requirements, and currently fail to recognise the requirements of carers. This narrow interpretation of how wheelchairs are provided is deeply resented by users ¹⁰ because wheelchair services fail to provide equipment that enables full social inclusion. Users have reported that the assessment process is too limited, is rarely perceived to be holistic and appears to be too heavily orientated towards what equipment is available rather than what is required. ¹¹ These concerns were at the centre of the 'Declaration of Independence' which was written and unanimously supported by users, carers and professionals at the national conference.

Users and carers emphasised that assessment should take account of:

• medical condition and needs around posture and seating, including neck/back support and extension
• lifestyle, leisure, environmental and employment requirements
• carer requirements
• accommodation, environment and car type, and
• likely future requirements. ¹²

Recommendation 4

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.

Rationale

Improved access for users could be achieved if there was a more local service they could identify with and access for most of their needs. This could be delivered by developing more local outreach facilities and empowering community staff to prescribe chairs for those with less complex needs. Enhancing the response to complex needs at the centres will provide the centre with a service which integrates local, outreach and community services and provides training and support for all staff.

Recommendation 5

The NHS Wheelchair and Seating Service will support assessment and maintenance for a defined range of privately purchased wheelchairs.

Rationale

NHSScotland does not currently repair privately purchased equipment. This is, in part, due to the diversity of makes and models that they might be required to deal with. ¹³ However, many users who have purchased their equipment privately state that they would welcome advice from the NHS on private purchase and, importantly, professional assessment prior to making the purchase. ¹⁴ In order to meet this need, a consultation should take place between the wheelchair service providers, users and the commercial sector to establish the most effective way to support service providers in giving appropriate assessment advice on a defined range of privately available chairs. This consultation should also explore whether it would be feasible for the NHS to stock parts for maintenance of that defined range of privately available chairs or merely issue a maintenance voucher. These options will be clearly stated in the mobility plan (Recommendation 10).

Recommendation 6

Documented, evidence-based mobility pathways (similar to 'patient pathways') will underpin all stages of the service provided to users and carers.

Rationale

At present, although referral pathways are similar between centres, ¹⁵ practices vary considerably in detail in addressing the specific requirements of users and carers. As part of the recommendation to establish minimum quality standards, it is proposed that 'mobility pathways' be established for different groups of users and carers based on best practice. Although there are many examples of best practice in current wheelchair centres, there is a great deal of scope to adopt excellent practices used outside Scotland and also improvements in practice resulting from research and development in this field. One of the goals for the national service should be to develop consensus on a wide range of current best practices.

Recommendation 7

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.

Rationale

Significant delays occur when community services implement home or workplace modifications, but staff are unclear about the type of wheelchair being proposed by wheelchair services ( e.g. power versus manual). Equally, wheelchair services are unclear about how to specify the wheelchair if they do not have adequate information about the proposed home/workplace modifications. Users have expressed frustration with poor communication and co-ordination between different services. ¹⁶

referral, assessment and provision

Recommendation 8

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.

Rationale

Users do not feel that they should have to return to the original referral pathway if they are uncomfortable or their wheelchair or seating system is not meeting their requirements. They should be able to approach the service directly to make an appointment so that these issues can be resolved. ¹⁷ The referral process for healthcare professionals working with users and carers in the community should be direct to the NHS Wheelchair and Seating Service to expedite and simplify meeting their requirements.

Recommendation 9

Current eligibility criteria for NHS Wheelchair and Seating Services will be removed by phased implementation, unless they relate to safety.

Rationale

The current eligibility criteria are not driven by user or carer requirements and fail to support social inclusion. The criteria for powered wheelchairs in particular are reported as unfair and unrealistic. ¹⁸ To avoid the service being overwhelmed by user demand at the outset, the removal of the current eligibility criteria will require to be undertaken in a controlled and phased manner as it will have major implications for existing service provider staff and on the provision of equipment.

Recommendation 10

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.

Rationale

To support a requirements-led approach (Recommendation 3) the mobility plan provides documentation that is agreed by the user, carer and clinician. The mobility plan will include details of:

• the outcomes of the needs assessment
• assessment process
• technology specification, and
• proposed programme for follow-up/review of user/carer requirements and equipment.

If, for financial reasons, the specified equipment cannot be provided, the mobility plan will provide a record of unmet need.

Users and carers have stated that there is no routine follow-up and that regular follow-up should identify problems and changing needs before they begin to impact upon the usefulness of the equipment. ¹⁹ Furthermore, review should ensure that the equipment supplied keeps pace with advances in technology.

Recommendation 11

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.

Rationale

Users feel that current assessment for equipment is constrained by financial resources. ²⁰ If these constraints are removed, the final decision to provide a specific wheelchair and seating system to meet the goals of the user may still require a compromise on optimal specifications. This compromise should be explained clearly to the user and carer and whether it is based on value for money, lack of funds, clinical or other considerations.

Recommendation 12

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.

Rationale

The consultation identified a wide range of circumstances where assessment and provision of equipment was either inadequate or non-existent for certain groups of users and carers. ²¹ Considerable concern was expressed about the limited support provided to users in care homes, despite significant need to provide postural support, pressure relieving cushions and lighter weight adjustable wheelchairs that could be used by frail elderly people. ²² Services for people with terminal and progressive conditions were also reported to be inadequate with equipment being provided too late to meet the user's requirements, particularly in retaining dignity and comfort. ²³ Obesity presents particular technical problems in providing an extensive selection of equipment whilst accommodating bariatric requirements in terms of structural strength, ample dimensions and operational safety. The role of the carer for bariatric wheelchair users also requires expert support in assisting with propulsion and transfers.

Recommendation 13

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.

Rationale

An introduction to the wheelchair service should be offered to all new users and carers to ensure that they understand the level of service they should expect to receive and their role in identifying their requirements to specify their equipment.

The introduction should explain the goal setting process, role of professionals and the procedures used in selecting the best available solution for their requirements, and the appeals and complaints procedures of the centre.

Currently users and carers do not know how to make the most of the service, how they can obtain information about their assessment and the equipment they receive or how to obtain further information about wheelchair and seating products. ²⁴

Recommendation 14

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.

Rationale

Many service users and carers want to involve healthcare professionals who know them, their needs and personal circumstances best. ²⁵ Many service users want a process that takes home, school, leisure and work environments into account. ²⁶

The Scottish NHS Wheelchair and Seating Services should be included in local partnership arrangements for the NHS and local authorities and the Joint Performance Information and Assessment Framework.

Wheelchair centres should also review how best to include equipment suppliers in the assessment of users and carers with complex needs. In many services outside Scotland the supplier undertakes an active role in the assessment process by giving detailed technical expertise about their products. It could be considered in complex cases to ask suppliers to assist with, for example, trialling chairs.

Recommendation 15

The assessment will include review of the particular requirements of carers ensuring that any equipment provided is compatible with their requirements.

Rationale

The assessment will take into account any limitations or concerns that affect the carer ( e.g. strength, risk of falls or injury, ability to assist with transfers) in supporting the user with the proposed equipment. In addition carers may face challenges due to their own health requirements, living environment or geographical location. Users have reported that they consider this to be an important part of the assessment. ²⁷

Recommendation 16

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.

Rationale

Systems need to be developed to expedite the delivery of equipment once an assessment has been completed. Users have expressed concern about the delays between assessment and delivery of the equipment. ²⁸ Audit systems should be put in place to monitor performance.

management

Recommendation 17

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.

Rationale

To ensure that the service is in touch with the requirements and priorities of users and carers, working in partnership with service providers, the national service will rely upon co-operative management principles. Each of the centres will support user and carer working groups and will provide a representative to the national service Management Group together with a representative of the service providers. Representatives of other relevant stakeholders will also be involved in the Management Group.

Recommendation 18

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.

Rationale

Each wheelchair centre should establish a user and carer working group to assist in providing representation of user and carer views in the development and management of the national service. The national service will be supported by a Management Group to manage funding and to monitor standards. The Steering Group emphasise that this is not intended to add another layer of bureaucracy to the service but to ensure equity of provision and to provide stronger advocacy for resources to support the requirements of wheelchair users and carers in Scotland.

Recommendation 19

Governance and complaints processes will be specific to the wheelchair service and linked to the national service's governance system.

Rationale

Currently, complaints are dealt with by the complaints office of the appropriate NHS Board. Users complained of having to take the initiative, a lack of information, no easy-access telephone number, poor response to queries and difficulties accessing an appropriate person on the telephone. ²⁹ If complaints are managed by wheelchair services directly, resolution will be quicker and should result in future service improvements. In addition, wheelchair services are more likely to understand the consequences of complications associated with concerns expressed by users and carers.

Recommendation 20

Users and carers will be able to obtain services from any centre in Scotland.

Rationale

The artificial boundaries of individual NHS Boards should not dictate where a user goes to access services, especially given the key importance of easy access. Further, when equipment problems develop they should be able to access the closest service. The NHS should ensure that there is no barrier to this occurring, through the use of an appropriate mechanism such as out-of-area treatment charges, cross-boundary flow or a similar arrangement.

Recommendation 21

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.

Rationale

Young adults face difficulties in relation to transition from children to adult services. At this crucial time in their lives, young people often lose the influence of advocates (parents, teachers and specialist paediatric clinicians) to support and represent their case for equipment that meets their changing requirements. The range in choice of equipment available to children through the NHS can be better than for adults, and support services are often more extensive. Young adults may have inappropriate equipment and worsening access to support at a time when they might expect to be very actively seeking work etc. ³⁰

Other transitions include: changes in clinical condition, changes in personal circumstances, moving house, and progression to powered mobility.

information management and systems

Recommendation 22

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.

Rationale

Although some progress has been made with the development of databases for rehabilitation technology by the Rehabilitation Technology Information Service ( ReTIS), there are limitations in the capabilities of these systems and there is substantial potential for further development. ³¹ In particular, databases are required that are accessible from all centres, local facilities and clinics. They should be accessible to all appropriately authorised staff involved in supporting users and carers (technical, clerical, clinical - including community staff). They should be linked to the electronic patient record.

Existing IT infrastructure does not support easy and accurate reporting of waiting times and waiting lists. Each centre interprets the phases of waiting differently and may well have several queues for different services or pieces of equipment. ³² Current IT systems fail to keep reliable information about registered users and do not have consistent and clear definitions of user and equipment characteristics. Inter-centre comparisons of service characteristics have proved to be difficult and the review was weighed down by lack of accurate, easy to access performance and activity information. ³³

Recommendation 23

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.

Rationale

Consistent with the proposal to increase the delivery of services more locally in local facilities and clinics, enhanced communication links will be required to provide support from the centres. Support should include the means to use video-links involving users, carers and clinicians. These systems will also provide important links between specialist clinical settings (such as spinal injury units) where improved communication links will support the effective handover of responsibility for the user and carer requirements to wheelchair services.

training

Recommendation 24

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.

Rationale

At present, training of service staff is often ad hoc, poorly resourced, infrequently accredited and no norms have been established that are associated with staff member responsibilities and roles. Training may also be neglected due to staff shortages. As a result of these constraints, the difficulties of recruitment and service quality can only be exacerbated. ³⁴ Training is an important component in generating the culture of the service and to reinforce values. Training in this field is important due to rapid changes in technology. All staff and relevant community staff must receive accredited training, supported by appropriate continuing professional development opportunities.

Recommendation 25

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.

Rationale

Failure to offer career structures fails to attract and retain the best staff into the field and demoralises those who join. ³⁵ Staff from professions such as bioengineering and occupational therapy are not keen to come into what is seen as a 'cinderella' service. For bioengineers there are reported limited places on specialist courses and considerable problems with the time taken to become state registered and therefore an autonomous practitioner. Continuing professional development opportunities are largely ad hoc with formal training opportunities thin on the ground. There is no planned programme of post-qualification training in Scotland, unlike the provision for orthotists and prosthetists. There is seen to be little opportunity for career progression in the wheelchair service, which also affects recruitment. ³⁶ Incentives should exist for staff to increase skills and knowledge and obtain higher level qualifications.

Recommendation 26

A review will be undertaken to determine whether current staffing levels are adequate and whether the most appropriate skill-mixes are in place.

Rationale

Many of the staff involved in delivering services at the centres come from hard to recruit professions, or technicians with highly specialised skills. It will be necessary in implementing the recommendations of this report to increase staffing levels, however the skill mix required should not be assumed to be the same as that in place at present.

Recommendation 27

Staff referring to the service should receive appropriate training.

Rationale

Training is required to ensure that people who work outside the wheelchair service, but have responsibilities to users and carers who use it, understand how best to make referrals to the service. This will help avoid duplication of some aspects of the assessment conducted when the user first makes contact with the service. This training could be combined with other training offered.

repair, maintenance and support

Recommendation 28

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.

Rationale

Centralisation of repairs and maintenance, although providing some advantages in terms of efficiencies of service create major difficulties for users and carers who seek more local support. The National Service Management Group will establish methods of delivering Planned Preventive Maintenance ( PPM) and repairs more locally in association with the development of the local facilities and mobile technicians.

Recommendation 29

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.

Rationale

Many respondents to the consultation highlighted frustration at the lack of support for equipment failure outside business hours, particularly at weekends and during holidays. Furthermore, they reported difficulties in making contact with NHS Wheelchair and Seating Services by telephone outside business hours. ³⁷ In some cases, users reported that they could be housebound as a result of unresolved equipment failures. ³⁸ Respondents highlighted the potential for reducing equipment failure through improved PPM and the need for appropriate levels of back-up in the event failure occurs. ³⁹ The need for equipment to provide equivalent function whilst equipment was taken away for repair was also emphasised. ⁴⁰ There should be clearly defined response times so that users and carers can plan accordingly. These should be defined by the national service Management Group in conjunction with users and carers.

Recommendation 30

A review of using in-house workshops to refurbish and customise chairs will be carried out.

Rationale

Workshops at wheelchair centres traditionally carry out refurbishment of chairs and customise standard chairs to individual requirements. These practices should be reviewed, taking into account technological changes, user satisfaction and overall costs.

Recommendation 31

To provide dedicated area technician support for preventive maintenance and minor repairs, centres will consider provision of a suitably qualified mobile service.

Rationale

Following a successful pilot, Inverness has now rolled out a PPM programme providing a mobile technician who visits users to check the set-up and maintenance of their equipment. This has been very well received. ⁴¹ This service will reduce equipment failure and therefore the need for repairs and associated loss of use if the wheelchair has to be returned to a central workshop to conduct simple repairs.

Recommendation 32

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.

Rationale

Preventive maintenance is intended to reduce the occurrence of equipment failure. However, it is thought that excessive minor repairs may result in a stock of outdated wheelchairs. Parts will become scarce and delays will occur while parts are acquired. This can also divert technicians from addressing more complex priorities. A balanced approach to PPM is likely to reduce equipment failure whilst it is in use and help to maintain an inventory of up-to-date equipment. This balanced approach will also help to reflect possible changes in the requirements of users and carers.

facilities

Recommendation 33

All wheelchair service facilities must be fully accessible to people with disabilities and their carers.

Rationale

There is evidence that some wheelchair centres are not fully accessible to users and their carers. ⁴²

Recommendation 34

All facilities should be provided with appropriate space for clinical assessment, storage and the equipment needed to support effective assessment.

Rationale

Services have failed to invest in equipment needed to provide assessment services using up-to-date objective tools. ⁴³ All facilities should have access to the following:

• moving and handling equipment
• plinths
• assessment and simulation equipment (including objective and outcome measurement tools) and procedures for their use (including calibration)
• weighing scales for wheelchair users
• an adequate stock of equipment to trial, and
• accessible facilities for users and carers to obtain product information (including web access).

Lack of adequate stock for trialling often means users and carers have not had a chance to see and test the equipment that is to be provided to them. Adequate product information ensures that users and carers are fully aware of the options and accessories available. This also supports professionals in researching product options.

Recommendation 35

All facilities will ensure that they are family-friendly with dedicated waiting areas and clinical facilities for children.

Rationale

NHSScotland guidelines for services for children specify that clinical facilities should provide dedicated areas for children. These guidelines have not been fully implemented in all facilities delivering NHS Wheelchair and Seating Services. For children with disabilities and their carers it is important that their experience in receiving these services is positive and enabling.

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 should have comprehensive access to a multi-disciplinary team when being assessed or reviewed for wheelchair and seating systems.

Rationale

To ensure that all the developmental needs of children are fully co-ordinated, all team members, including the child's family should be aware of decisions made by service staff and should participate in the process as necessary.

Recommendation 37

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.

Rationale

To be consistent with policy elsewhere in the NHS, children should be seen in a dedicated, family-friendly and child-friendly environment.

Recommendation 38

Clinics will provide access to specialist paediatric clinical expertise as needed.

Rationale

The skills required for the assessment of children differ from adults in some key respects, notably:

• staff should be trained to work with children
• the multi-disciplinary and multi-agency aspects of children's needs are generally more complex than adults, requiring links to different networks of expertise, and
• expertise in the developmental aspects of children is required.

Recommendation 39

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.

Rationale

Many children and their carers find that they need an extended trial period with equipment that is proposed for their use so that they develop basic skills before it is possible to confirm that the proposed equipment will meet their requirements. This is also true for children with complex postural support needs where sitting stability, ability to control systems and comfort are all more accurately assessed after a period of extended use.

Recommendation 40

Centres will establish properly functioning multi-agency links.

Rationale

To ensure that all of the dimensions of the developing child are represented in the planning, delivery and follow-up of services, strong systematic links with these services are required. These links are important to ensure that people who work with the child in the multiplicity of environments that they are in ( e.g. school, home, community activities) are able to provide advice and perspectives on the specification of equipment.

« Previous | Contents | Next »