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3 Key Issues - Discussion and Alternatives

3.1.1 This review is an opportunity to revisit the ways in which we approach providing the wheelchair service in Scotland. This section of the report discusses options and alternatives for future service patterns. We have concentrated on a shortlist of key issues identified from the review described in section 2. These are:

• localising the service and infrastructure
• standards, performance monitoring and accountability
• assessment
• equipment provision pathway
• staff training and education
• gap analysis, and
• funding.

3.1 Infrastructure and localising the service

3.1.2 Earlier in this report we remarked on the disparity in size of service centre, with five wheelchair centres serving the total population of around five million people, and one centre serving around 2.5m of these. As the Kerr Report ( SEHD 2005) makes clear, 'localising' services where appropriate and feasible is the accepted way forward in health and community care in Scotland. People with mobility difficulty and their carers face not only the disruption and discomfort of long round trips to get to service centres, but also have to confront the added difficulties that mobility difficulty brings to travel by public transport. Wheelchair services should be organised in such a way that trips to distant centres happen only rarely and when unavoidable.

Hubs and spokes

3.1.3 The current model, with service centres operating as 'hubs' with outreach clinic 'spokes' has been tried and tested in other countries and can work well, but do we have the optimal balance between the numbers of hubs and spokes and their functionality? Factors to consider include:

• population centres and geography
• availability of appropriate facilities or cost of providing these
• gains in accessibility for patients
• staff availability
• efficiency
• equipment duplication or portability
• additional costs
• management arrangements, and
• other innovative ways of providing local access.

3.1.4 A formal review of the entire pattern of service centres and outreach clinics would be the most thorough method of ensuring that support is provided as close to population centres as possible. However, this would be time consuming and could arguably delay other changes that are more fundamental.

3.1.5 A more pragmatic approach would be to target the bigger centres, WESTMARC and perhaps Edinburgh. WESTMARC is doing much to improve its service, and in some respects user feedback was positive. However, given the size of the area it covers, it is probably no surprise that WESTMARC users expressed more concern than users at other centres about access to appointments. The area presently served by WESTMARC and possibly Edinburgh could be split into perhaps five service centres, giving a total of eight service centres for Scotland, determined by a mixture of population size, population density and geography. Purely as an illustrative example, we might then see a service which could be configured something like this:

Table 8

3.1.6 This is only an example of how more equitable coverage might be achieved. It could involve working across existing boundaries, allowing users to access the most convenient service, regardless of the NHS Board area they live in. There are several well-recognised contractual arrangements within the NHS which should allow this, for example 'cross-boundary flow' or 'out-of-area treatment' payments.

3.1.7 This type of model would reduce travelling time for users with complex needs who had to attend a wheelchair centre. We would expect an increase in cost, while recruitment in some areas could be a constraint, and there could be a continued need for some tertiary referrals out-of-area. An increased number of service centres should allow the development of yet more outreach services within reasonable travelling distance for service staff, thus making best use of a scarce resource. This could perhaps occur on a flexible basis dependent on users' needs.

3.1.8 Another option would be to retain the current service centres, but increase both the number of outreach services and the range of support they can offer, across all areas of Scotland. This would, in effect, be a speeding up of a trend already under way. From the user's perspective, this could be a good option in terms of physical access for many, although the likelihood would be that a small number of individuals requiring particularly comprehensive mobility aids would still need to travel to a service centre.

3.1.9 Costs of premises to provide additional outreach services could be kept to a minimum by using existing buildings, public or private. However, staff travel costs and, more importantly, lack of staff availability given additional travelling time might make this a more difficult option to deliver. We could envisage outreach clinics running for very small numbers of users leading to pressure for them to run at very infrequent intervals. This option may not readily address the closer affiliation with centres that some users wanted.

3.1.10 One way of addressing some of the limitations of outreach clinics as currently configured could be to develop some to give a more permanent presence: perhaps dedicated local administration support and a part-time therapist, linked to a local hospital or clinic. It could be possible to develop mobile assessment units, with equipment in a large van, which could travel round to local clinics and allow the provision of a wider range of local services. This approach could offer benefits to service users, including a local base with which they can develop contact, and might be a more pragmatic solution to staffing constraints.

Centre size

3.1.11 Given the wide variation in centre size, we have explored whether there is any evidence as to the 'right' size for a centre. The current performance of the wheelchair service in Scotland suggests no obvious benefit to be derived from having larger centres:

• there are quite marked differences between the two largest centres, making it difficult to draw conclusions about centre size
• access and travelling is generally perceived as more difficult
• users find it harder to develop a continuous relationship with remote centres
• there is no apparent correlation between centre size and waiting time experienced by service users
• there are no readily apparent economies of scale in the budgeted funds per head of population
• size does not apparently aid bigger centres in delivery of more comprehensive equipment, such as more powered chairs: levels of funding appear more closely linked, and
• there may be a modest inverse relationship between staff numbers and size of centre. This could indicate economies of scale, but it is likely to be related to other factors, including quality of service.

Smaller centres generally find it more difficult to attract and retain staff, while service users appear to be more supportive, however, both factors could well be related to rurality, rather than any intrinsic benefit within the operation of a smaller centre.

3.1.12 In conclusion, there is no evidence to suggest that there is any key reason why we should retain our larger centres, and some indication to the contrary from service users, although we should be cautious about creating more very small centres.

Functionality and facilities

3.1.13 During our research it became clear that the variation in facilities provided at wheelchair centres did hinder efficient services. For example, lack of space in centres may prevent a range of chairs being available, so that an individual attending a centre cannot readily try out a wheelchair. This could necessitate a further visit, or hinder the customisation of a wheelchair to best suit a user's needs. The shortlist of facilities identified in section 2.2.9. represents the ideal infrastructure of a centre and should be provided wherever possible: centres lacking any of this basic infrastructure should be working to achieve this.

3.2 Standards, performance monitoring and accountability

Service profile

3.2.1 The wheelchair and seating service has not enjoyed a high profile in Scotland or indeed in the UK generally. Despite a series of reports recommending changes and improvements, at best only modest progress has been made in implementing these. The service is fragmented: it has no central body such as the ambulance service does, with a clear responsibility to drive performance. There is a lack of high profile clinical champions agitating for more resources or for improved performance, in the way that senior consultants, Royal Colleges or 'Czars' do in other areas of the NHS. Wider public interest, whether from MSPs or the media, is generally restricted to local stories about individuals: there is no ready locus for a national interest story such as might arise from a public board meeting, formal annual report or similar.

Monitoring and standards

3.2.2 NHSScotland has a fairly comprehensive system for setting standards, monitoring performance and reporting results in public. These include waiting time guarantees, developing standards for clinical services, and annual performance reviews for NHS Boards with the Minister for Health and Community Care. However, these do not currently apply directly to the wheelchair service, although work has been done within the service in recent years to develop standards. Inevitably, this means that other services, subject to targets and formal review, receive a higher profile within the health service; these are the services that are likely to attract a greater investment of effort and resources. Chief executives of NHS Boards are likely to direct maximum attention to the issues for which they are held personally accountable through monitored targets and performance reviews. Further, we believe that, in some areas, the service is not seen as a priority by senior managers within NHS Boards, and therefore tends to suffer when the NHS as a whole is under pressure.

3.2.3 The wheelchair service has a dedicated group of managers who have, largely through their own initiative, worked towards some commonality across the country. A target benchmark specification has been developed, and this could constitute a useful basis from which to build standards that would be stretching, achievable, measurable and observable, that would be developed in conjunction with service users, staff and managers, that would be open and that would be subject to external measurement, the results of which would be reported publicly.

Variation

3.2.4 There is general consensus that our health service should offer equal access to individuals, free at the point of delivery on the basis of need. Yet there is considerable variation in a range of factors across the five wheelchair service centres in Scotland, including:

• funding levels received from NHS Boards
• amount charged for 'overheads' by the host NHS Board
• apparent 'shortfall' in funds against the allocation originally made by SEHD
• input from local NHS Boards to the way the service is run by the five centres
• number and mix of staff employed
• number of powered chairs issued
• length of wait for assessment, provision of equipment and repairs, and
• perceptions of the service from wheelchair users and carers.

Alternative accountability models

3.2.5 One way to ensure managerial attention and priority would be to revert to a single national service, which, although delivered regionally, would have a single dedicated management team. This would presumably need a 'top slice' of existing budgets, which would then be 'ring fenced'. The allocation of funds currently held by NHS Boards to a central entity would be problematic: there is no easy formula to determine how much money should be committed. This arrangement would achieve the necessary improvements in direct accountability and focus, and could be a rapid way of introducing national standards and processes. It would not, of course, automatically lead to any increase in funding: indeed it would add to management costs, as a central team would need to be set up to provide an accountable officer and a board. The structure would need to be reasonably flexible in order to deliver locally. Service users could readily have a voice in such an organisation.

3.2.6 Other services in Scotland are run in this manner, the ambulance service for instance. There could be particular difficulties in separating the wheelchair service from other components of the local NHS: for example, staff, support functions and premises are likely to be shared. This is not insoluble financially, but other aspects, such as loss of co-operation, reluctance to provide therapy support, etc, may be more problematic. The approach is also somewhat at odds with the trend towards devolution within NHSScotland, while services with modest budgets, such as the wheelchair service tend to become part of a bigger cohort, whether a host NHS Board or a central body, thus potentially losing their independent voice while saving money. Even if rehabilitation services as a whole were brought together into a central service, there would be some doubt as to their viability and value for money as a single entity with a top-heavy infrastructure.

3.2.7 It may be possible to achieve a similar national focus and drive through other arrangements such as a national network. This could have a lead clinical champion and a small supporting team, but management responsibility for wheelchair centres would remain with NHS Boards. This arrangement would be unlikely to have the same level of impact as an independent central entity, but would also avoid most of the problems involved in separating wheelchair services from their hosts. It would also be cheaper, as there would be no need to change accountability arrangements and set up a Board and an executive team.

3.2.8 There are other options: although it could be argued that performance targets can have disadvantages, they undoubtedly bring benefits too. For example, if NHS Board chief executives were held to account for the performance of local wheelchair services against agreed waiting times targets, they would arguably make it their business to ensure that attention is being paid to this aspect of the service. Conversely, if there are monitored targets for most other services and not for wheelchairs and seating, funding and attention for wheelchairs and seating is vulnerable. Giving wheelchairs higher priority may well be advantageous in persuading NHS Boards to change resource priorities and invest financially in the service from existing funding streams.

Voice of service users

3.2.9 It is to be expected that following the rise in profile of the wheelchair service and user expectations that this review has fuelled, stakeholders will want to be involved in the way that standards are set, monitored and reported. This would be consistent with developments in standard setting and monitoring in Scotland over the last six years and should be encouraged as the best way of continuing to bring the service closer to user needs. A national users forum would be one way of providing such an input, in hand with local users groups, which already exist in some areas.

3.2.10 Although there are active national bodies and user groups who meet regularly, their sphere of influence appears limited: they apparently have little power to lever comprehensive change or alter policy at a national level. Whatever the accountability framework for the future, the important concept of user involvement in standard setting and service direction should be taken into account.

Information

3.2.11 Despite the best efforts of centre managers, and the laudable development of the ReTIS annual report about the service across Scotland, there is not a standardised data collection system or common definitions of waiting times and similar matters. This makes it difficult to assess and compare performance. It is also difficult to quantify waiting list problems, to assess the scale of gaps in the service, or to plan for the future, as comprehensive data are not widely available.

3.2.12 Just as importantly, while service managers have made progress in developing IT systems, the lack of a standard, supported, fit-for-purpose system in every centre adds to the difficulties of managing the active caseload, expediting complex equipment delivery, and in recording, monitoring and reporting data about standards and service delivery.

3.2.13 There are a number of tailor-made wheelchair IT systems currently in use in the NHS in both England and Scotland, which could be reviewed.

Scrutinising investment

3.2.14 One of the questions arising from this project was how any additional funds should be managed. Assuming that additional money is made available, this should not merely be allocated to NHS Boards on a per capita basis without scrutiny of the benefits expected. Our cost estimates are not accurate enough to control the allocation of public funds: business cases should be produced when bidding for additional monies, and these should be assessed for optimum benefit to local populations. Accountability models should provide a solution regarding a transparent mechanism for the allocation of funds.

3.2.15 There is the added complication of shared funding between NHS Boards where a centre takes referrals across boundaries: there is no reason why any NHS Board should not be charged with delivering standards of care for its residents, regardless of whether it hosts a wheelchair centre or not: if the current out-of-area provider is not delivering, financial penalties can be applied, the service can be purchased from elsewhere or a local service can be established.

3.3 Assessment

Transparency

3.3.1 Assessment was one of the main concerns from service users. It was commonly viewed as being non-holistic and limited by what the service could provide as opposed to being a full exploration of users' needs in relation to their aspirations and individual circumstances. Our review of the service suggests that there is some excellent technical practice but, ultimately, the equipment prescribed as a result of any assessment is constrained by the eligibility criteria, which are widely seen as being tailored to fit the budget available. The entire assessment is consequently seen as being 'unfair' and 'unholistic'. One way of addressing this problem would be to separate assessment from the prescription and provision of equipment. The results of the assessment could be given direct to users.

3.3.2 Of course, greater clarity in the assessment process would not itself alter the equipment provided, but it would increase transparency between the service and users. It could also potentially open a wider range of equipment options and choice, albeit many of these would have funding implications. For those who wanted to source equipment other than that offered by the NHS, a professional NHS assessment would be of great value.

Assessment would also be an ideal opportunity for users and carers to be fully briefed on the service, its structure and how to access further information and support: this happens informally in many centres at the moment, but could be done in a structured way through a mobility plan or information about mobility pathways and links with local authority services.

Simple and complex assessment

3.3.3 Service users told us that they wanted to involve the health professionals who knew them, their needs and their personal circumstances best in referral and assessment; those people were most often occupational therapists, physiotherapists, district nurses and, on occasion, hospital consultants. Not all service users felt the need to have the assessment carried out in their home, but many service users wanted a process that took home, school, work and leisure environments into account.

3.3.4 There is no doubt that a relatively small percentage of wheelchair users have a very real need for intensive expert assessment. However, perhaps 70% of the less complex referrals currently made to the service are not seen at wheelchair centres, with equipment being provided based on information from the referring professional. Currently such referrals are received by the centres and screened by a member of the team, ensuring that no-one who needs a full assessment slips through the net.

However, with some training and the help of a well designed decision-tree flow chart, basic chairs could potentially be prescribed by community professionals, whether employed by the NHS or local authorities, fulfilling users' wishes as well as saving time for the referral to be sent to and processed by the centre, and releasing some much needed professional capacity at the centre. Most centres already have a good relationship with health professionals who are regular referrers, and some may provide training.

Ongoing assessment and review

3.3.5 Assessment may be a one-off process for a number of users whose needs do not change much from month to month or year to year. For service users with complex needs, those with progressive disease and children experiencing periods of growth, regular reviews are required. These service users need an individual ongoing management plan that includes forward planning. This should ensure that their needs are anticipated and/or responded to and met on a continuous basis and that avoidable complications of inadequate mobility or support do not occur.

3.3.6 Whilst all the centres we visited told us that existing wheelchair users were welcome to contact them directly with any concerns, in practice this may not be straightforward. Some centres contact all users annually to ask them if they have any issues, allowing follow-up arrangements to be made very easily. This could be a model for the future.

3.4 Equipment provision pathway

Procurement

3.4.1 Provision of chairs is currently solely the responsibility of the NHS, unless an individual chooses to buy a chair privately. Following assessment, a chair is resourced through one of several routes:

• from a national contract that is negotiated centrally at rates advantageous to the NHS: we are advised that the range of chairs procured in this way has been extended in recent years. It is significantly cheaper for the NHS to bulk buy chairs in this way than for an individual to buy direct from the manufacturer, despite these purchases being VAT exempt (surely NHS purchases are effectively VAT exempt also).
• direct from a supplier, especially if the chair is specialised and purchased in small numbers.
• from a wheelchair centre workshop where the chair has been refurbished having been returned from a previous user.
• in the case of any of the above, a chair may be modified by a wheelchair centre workshop to fit it specifically for a given individual: this is known as 'customisation'.

Refurbishment and customisation

3.4.2 The issues of refurbishment and customisation have attracted much debate. We note that:

• refurbishment to a high standard appears to produce chairs which are nearly indistinguishable from new, but this practice maintains a stock of chairs which only slowly gets replaced to reflect advances in technology.
• customisation may have a similar effect and also reduces choice by encouraging the use of modular, standardised chairs.
• some manufacturers argue that customisation does not represent value for money: they assert that they could produce a modern chair as quickly, tailored to the specification for an individual user, saving the NHS the costs of an extensive centre workshop, plus the chair would be covered by their guarantee, which the NHS voids when it alters a chair. Some manufacturers offer a facility where a chair can be ordered online, including precise specification of components to individual needs.
• wheelchair centres argue that both practices save money: although this looks logical with respect to refurbishment, we have seen insufficient evidence to convince us one way or another with regard to customisation.
• some services in England refurbish chairs via a private contractor, reducing the need for extensive NHS workshops.
• several suppliers and manufactures have told us that margins on the supply of wheelchairs to NHSScotland are so tight that they have ceased to invest here.

3.4.3 The NHS should review these practices particularly with regard to customisation and the value and role of extensive centre workshops. However, we have taken the approach that this issue is tangential to this review as it does not fundamentally affect the more strategic decisions considered here.

Multiple providers

3.4.4 The negative effect that waiting for equipment has on wheelchair users is a theme throughout this report. Yet there are other providers who could help reduce waiting times: is it appropriate for the NHS to provide all wheelchairs? NHS provision does have advantages, albeit these are largely financial:

• a good way to manage a tight budget and ration wheelchair issues
• bulk purchasing power
• a limited range of models and manufacturers reduces maintenance difficulties
• maximum refurbishment opportunities, and
• user feedback for professionals in the service who both assess and prescribe.

3.4.5 However, a multiplicity of providers could potentially provide significant benefits for users:

• competition could drive down waiting times - if one provider cannot let you have your chair quickly, maybe another can: a common feature of retail competition is the ability to get rapid delivery
• logistical difficulties such as sickness, staff shortages, lack of facilities, which slow down a single provider, would have less impact on the user if there are multiple providers
• basic chairs could be supplied by high street retailers, or delivered direct to home
• NHS staff would be freed to concentrate on complex patients
• competition could drive down costs, and
• more choice.

3.4.6 If we imagine a situation where assessment is done by the public sector, divorced from equipment provision, we could see a multiplicity of providers competing to give patients options in fulfilling their equipment prescription. Providers might include the NHS, and for complex chairs with seating systems, the NHS might very well be the provider of choice, even the sole provider.

A customer could take their NHS assessment to a dealer or specialist provider and order a chair direct from the manufacturer. Some manufacturers now boast a chair which can be computer-designed on screen with the detailed order transmitted direct to the factory: this system could work for basic chairs and potentially some with a higher degree of complexity.

3.4.7 What about the potential problems? We would need to consider quality control, whether in the form of spot checks, customer feedback, licensing, or kite marks, which could add to costs. The biggest drawback of this method of equipment provision is the increase in cost. The NHS will not be able to make the major cost savings it does now by bulk purchase of a limited range of chairs. Another potential cost pressure would come from the decrease in levels of refurbishment currently carried out by the NHS: changes in technology and reduced workshop costs will go some way to balance the savings from recycling chairs, but is unlikely to bridge the gap entirely.

Setting up a system of private providers would take some time, and would need a professional commercial approach. If the NHS wanted to make changes to the system, or bring it back in house, this could also take time.

3.4.8 Whilst, in theory, the NHS could offer more choice and reduce waiting times given the will, management attention and funding, the use of private sector providers would be an additional driver in this direction. The NHS is well placed to provide a wider range of models and manufacturers at an economical cost if additional funds are committed to this. However, the same advantages in speed of delivery that we would expect from private sector provision due to competition would not necessarily follow unless there was a mechanism to drive this.

3.4.9 We have considered whether individuals could buy their chairs direct with some type of refund arrangements from the public purse. While private purchasers do not have to pay VAT, even with this advantage the NHS purchasing power ensures that the service pays a significantly lower cost per chair than the individual wheelchair user. Although we would expect that if an increasing number of individual wheelchair users were purchasing equipment direct, prices would fall. The table below shows that there would need to be a very significant decrease to equal NHS purchase prices.

Table 9

Source: Lomax Wheelchairs, Dundee

3.4.10 We have also considered whether the advantages of bulk purchase could be retained by a single private sector provider. This is probably a more likely alternative, although the addition of a profit margin is likely to lead to an increase in costs even before we consider any increase in diversity of models and manufacturers. Further, even subject to regular competitive tendering, a single provider could decrease some of the benefits of competition.

Repair and maintenance considerations with multiple providers

3.4.11 A wider range of chairs would give individual users more choice, but the diversity of models and manufacturers would make fast maintenance and repair a greater challenge. A larger range of spare parts would need to be carried, and the skills required to carry out repairs and maintenance would be broader. This applies regardless of whether the NHS or another provider supplies the chairs. The range of equipment supported could be controlled to balance choice, cost and repair complexities.

3.5 Maintenance and repairs

Current provision

3.5.1 All maintenance/repair of equipment issued by the NHS is presently carried out by the NHS wheelchair service. In most centres this is done on a reactive basis: equipment is not routinely maintained or serviced but is repaired when a fault develops and is reported. Sometimes repairs are performed by a 'mobile technician' who comes out from the wheelchair centre to the users home or school, or, on occasion, minor repairs like tyre punctures are carried out by local garages or bicycle shops. However in some instances, repairs are carried out at the wheelchair centre and no matter where repairs are carried out, there can be long delays. Loss of a personal chair - particularly pronounced where chairs are removed for repair at a service centre - can be a serious matter for an individual who relies on it, regardless of whether a temporary replacement is offered and so a fast repair service is very important. Even better would be a system that minimised equipment failure in the first place.

Local repairs

3.5.2 Several centres offer users the option to take minor repairs (typically under £20 or so) to a local garage or bike shop, where they can be carried out quickly. We have had some mixed views about this approach with some centres telling us that they offer the facility but it is little used as repairs would be minor only: e.g. brake adjustments. Local repair outlets do not carry a stock of wheelchair specific replacement parts and therefore repairs requiring these need to be carried out by wheelchair centres. It has been suggested that local repair could be extended to all areas and given a broader base through the use of accredited suppliers. If a straightforward, easy to administer system could be set up, this would sound attractive: there is, however, a danger that it could develop a life of its own, becoming over complicated and expensive.

Other potential service providers

3.5.3 There are perhaps other organisations, in some respects, better placed to provide a breakdown service than the NHS, for example Mobility Scotland who already provide a repair service across central Scotland which the user pays for. National organisations that deal with car breakdowns, for example, might also be able to extend their services to repair faulty wheelchairs since they already operate 24/7 in an equipment maintenance market. It is important to recognise, however, that the spare parts and product knowledge required would be different. Response and return times could be improved through the contracting system and could potentially include a 6/12/24-hour response service for urgent circumstances, for example, older people living alone who are bed-bound or house-bound without their wheelchair. The costs of such a system are difficult to assess and would ultimately require a detailed specification and competitive tendering. However, we can assume that there will be a significant price tag attached, offset somewhat by savings in NHS workshops. It is important to understand that there will still be some repairs which cannot be dealt with at the user's home, and these chairs will presumably still need to be removed to a workshop for repair. NHS staff would also need to monitor a quality control system for any contracted-out service.

Planned preventive maintenance

3.5.4 Some parts of the NHS are now running a PPM service, with a technician visiting the user to check their chair. This has the major advantage of potentially preventing breakdowns and also giving contact with the wheelchair user who may welcome advice about minor adjustments. The investment required to start this programme should be offset by the expected reduction in breakdowns and therefore repairs: reports from the USA even suggest that it can be cost neutral in the long term.

3.5.5 PPM could potentially be extended and integrated into a mobile repairs service, visiting users both to address planned maintenance issues and to carry out repairs on site. A service that travels to the user and carries out a high proportion of repairs on site is greatly preferred to a system that uplifts chairs to return to a central depot for rectification. Although this currently happens on many occasions under NHS provision, it is not universal. PPM could potentially be extended to a mobile repairs service and/or an out-of-hours service for emergencies.

3.5.6 Various pressures, including Health and Safety legislation, fear of litigation, NHS advisories and manufacturers' recommendations have put pressure on the service to implement PPM uniformly for all chairs, regardless of the user's circumstance and type of chair. A risk assessment framework plus individual user preferences should be used to determine the frequency of PPM: it is unlikely to be necessary or cost effective to apply a one-size-fits-all approach: PPM should be concentrated on complex and/or much used equipment.

3.5.7 Again, it should be emphasised that, whatever new arrangements are made, some repairs will still require specialist parts and/or expertise and will need to be returned to a central depot. The wider the range of chairs and manufacturers, the more complex the range of spares and skills will be needed for a repair service, of whatever sort.

Private chairs

3.5.8 At the moment, anyone who buys a wheelchair privately cannot get it maintained or serviced by the NHS. This stems from concerns about taking on a wider range of wheelchairs, which will increase the challenges of any maintenance service with a greater variety of spare parts and skills being required, plus worries about the suitability of chairs for some individuals. Wheelchair users may argue that, having saved the cost of a chair, a private purchase should at least be maintained by the NHS.

3.5.9 A solution to this impasse might be to agree that the NHS would support a privately bought chair if:

• it fitted the individual needs determined at an open, holistic assessment (see section 2)
• it was part of an extended range of specific chairs which the NHS could support for servicing and repairs, and
• a voucher of equivalent cost could be offered towards maintenance costs if the chair was outside this range: however there could be complications to this approach. The sum involved would only be modest and the purchaser and NHS should, in theory, be able to reach agreement about a chair acceptable to both with regards to maintenance.

Out-of-hours and emergencies

3.5.10 There is normally no facility to have a chair repaired 'out-of-hours' (after 5.00pm, at weekends or on public holidays). There is no doubt that equipment failure out-of-hours can be a very serious situation for a wheelchair user, particularly one who lives alone. While we have received mixed views as to how such an emergency should be dealt with, not surprisingly there seems to be general support for access to an emergency repair service if this proved practical. The need for this should diminish if PPM were introduced, reducing breakdowns, and a rapid response to an emergency were provided the following day, including weekends and public holidays.

3.6 Staffing, staff training and education

3.6.1 The wheelchair service finds it difficult to recruit staff at present, and the commitment of existing staff can be strained. The underlying cause is the profile of the service, with few opportunities for further training or career progression, and staff, at all levels, feel demoralised and frustrated in a specialty that can fail to meet users' needs within a reasonable timeframe.

3.6.2 The numbers of staff employed in the service and the skill mix vary widely from centre to centre. In some cases, for instance, senior medical staff are centrally involved in the assessment process - particularly for powered chairs - in others the whole process is managed by bioengineers, technical officers and therapists, who involve medical staff in the small number of cases that require specialist advice. There are also differences in skill mix between those with technical, therapy and bioengineering backgrounds, perhaps due to historical factors or local availability. A reasonable mixture of therapy and bioengineering/ technical skills is necessary to provide balanced assessment, variations in skill mix could be accommodated. There are issues which particularly affect the paediatric service: assessment of children should involve a range of staff who have appropriate skills in communication as well as clinical and technical matters, and medical advice may be more frequently sought, particularly about developmental issues.

3.6.3 There are very few courses established to provide training in wheelchair and seating provision. This can be a problem not only in attracting permanent staff, but also in equipping staff who are willing to rotate into the service for a short period. For engineering and technical staff in particular, there is no easy route to becoming autonomous practitioners, a significant pre-requisite to career progression.

3.6.4 This issue could be tackled in several ways in parallel.

• Morale and recruitment will improve if this report leads to a service more focused on users' needs.
• Short-term courses, for example, five days in length, could be commissioned for qualified professionals on arrival in the service. This might be particularly useful for those who will be working in the wheelchair service for a limited time, perhaps on rotation.
• Commissioning longer courses, giving a professional qualification at the end should be considered and providing a career path for those who wish to stay in the service, encouraging retention and creating independent practitioners should be considered.
• Further support could be given to practical continuous professional development ( CPD) opportunities.
• Considerations of multiskilling could be designed into training, so that, for example, bioengineers have a basic understanding of physiotherapy issues and vice versa. As well as being good practice for almost any interaction with a wheelchair user, this could also increase the number of assessments that could be carried out by a single professional, bringing efficiencies and more opportunities for outreach work.
• There is a marked discrepancy in the involvement of consultants in routine assessment in provision. In most centres there is no routine medical involvement, whilst in others, medical staff are involved in assessing for provision of powered chairs. We would suggest that medical staff should be available for some complex consultations and to input to particular situations, for example, the need for a cognitive assessment. However, we do not see a need for consultants to be routinely involved in centre assessments, including assessment for powered chairs.
• Centres have considerable variation in skill mix. Some are in the process of changing this; others are constrained by ability to recruit. The best arrangement appears to be a team approach, with physiotherapy, occupational therapy and technical/engineering staff in the mix. However, given the difficulties of recruiting in some areas, we suggest that flexibility is needed over skill mix.
• This service may never be top of the list when staff have many options to choose from. This is another good reason to consider outsourcing and decentralisation of various sorts, thus minimising the workload for specialist staff.

Attracting and retaining staff is a key issue, which will undoubtedly constrain some of the developments outlined in this paper: indeed, it could prevent some improvements, not merely hold them up. Unless this is addressed, NHS service providers will not be able to make the changes both they and service users want.

3.7 Gap analysis of equipment provision

3.7.1 The NHS provides a limited range of equipment both in terms of stakeholder choice and in relation to the full range available from manufacturers. Eligibility criteria for some types of equipment are acknowledged to be limiting and are widely understood to have been driven by the need to stay within a limited budget. There can be no doubt, for example, that some individuals who would benefit in clinical and wider terms from the provision of a powered chair do not currently qualify for one and, consequently, the range of mobility and independence they have is more limited than it might be. Changing the range of providers, or the assessment process, as suggested above, will not automatically change the equipment provided to the user, unless funds are provided to support this.

3.7.2 During the course of the review and through our discussions with all the various stakeholder groups, we have identified several potential gaps in the service. These are primarily in the following areas:

• children
• young adults
• those with progressive disease
• people with limited functional mobility
• older people with carers
• people with terminal illness and those with temporary disability, and
• balancing capacity and demand: a minimum standard.

Additionally, individuals in any of these groups may be termed bariatric due to their heavy body/mass index and find it difficult to access equipment due to their weight.

Children

3.7.3 Children with disability are like any other child in that they need to interact with their environment as they grow and develop, sometimes predictably and sometimes in fits and starts. It follows then that their equipment requirements will also change along those lines. Since the service is currently not uniformly proactive in relation to users' needs, it may only react when children re-present because they have outgrown their equipment. Reassessment and re-provision takes time and so children may well spend longer than they should in uncomfortable chairs and outgrown seating, or worse, may be bed bound while waiting for new equipment, missing out on education and social interaction.

3.7.4 Older children making the transition from primary to secondary school face new difficulties in remaining in mainstream education. All secondary school children need the ability to move around easily, rapidly and frequently from class to class. This means that children who use wheelchairs have to be very proficient and able with a manual chair, or use a powered chair.

Young adults

3.7.5 Young adults may face further difficulties in relation to transition from children's to adult services. The range and choice of equipment available to children through the NHS can be better than for adults and support services are often more extensive. Studies such as SCAMP have shown that young adults may have an inappropriate chair and worsening access to support, at a time when they might expect to be very active, seeking work or moving into further education, etc. Targeted input can help, for example additional funds may be available from access to work schemes via the Department for Work and Pensions ( DWP).

People with progressive disease

3.7.6 Wheelchair users with progressive disease, for example multiple sclerosis, motor neurone disease, Duchenne muscular dystrophy, or even arthritis can find their physical abilities and postural support needs changing relatively slowly or over very short periods of time.

There are two particular issues with services for this group. Firstly, the lack of regular planned reassessment means that they can be subject to similar difficulties as children in relation to changing needs, although these are generally not as rapid. Secondly, people with multiple sclerosis and similar diseases, where abilities may vary over time, may not qualify for a powered chair because they can sometimes propel a manual chair, although they cannot do so reliably.

People with limited functional mobility

3.7.7 Under current assessment criteria, to qualify for a powered chair, the individual must be unable to walk or propel a manual chair at all. This excludes some people who can walk a very short distance, for example around their living room using furniture for support, or can propel a chair for 20 or 50 yards. However, this limited mobility does not necessarily allow them to get to the bus stop, the local shops, the library or their place of work. Many service providers told us that individuals in care homes were particularly penalised in provision of all chairs, but powered chairs in particular. Scooters, which are generally less expensive than powered outdoor chairs, could be an alternative for some individuals, but they are currently not routinely provided by the NHS.

Older people with carers

3.7.8 Many manual wheelchair users depend from time to time on carers to push their chair - uphill, up and down kerbs, over rough ground for example - or to lift a heavy chair into a car. This may present a hazard to even the most fit and able carer. A carer or care worker may be put in the invidious position where they have to choose whether to risk back injury or muscle strain in this way. Further, older people often have older carers who are not as able as they might be, or who have medical conditions themselves, angina for example, that preclude them from pushing a chair. However, the needs and requirements of carers are not routinely considered in the assessment process, which may leave the wheelchair user effectively unable to leave their home.

Those with terminal illness or temporary disability

3.7.9 Some individuals, such as those with terminal illnesses and those with temporary disability need a wheelchair quickly, often for a short period of time. While their situations are clearly very different in other respects, the requirement for a fast response is similar. At present, there is no easy way to circumvent waiting lists and no ready stock of wheelchairs to be given out at very short notice. People who may have only a few weeks to live, but who may gain enhanced quality of life for that time by having the use of a wheelchair, may not easily access one. People with temporary disability, for example a broken leg, may face similar difficulties: although theirs is a disability from which they will recover, they may face inconvenience and disruption to education or employment.

Balancing capacity and demand: opportunities for service re-engineering

3.7.10 The service currently has variable waiting times for assessment and for equipment provision. Some centres are very responsive in dispatching standard equipment, while most centres have longer waits for complex equipment such as powered chairs with seating systems. This may be due to several factors:

• lack of staff, inability to recruit, sickness or absence
• lack of funds for equipment
• poor organisation
• logistical problems
• backlog of orders or referrals, and
• minimal outsourcing.

Due to the complexity of obtaining reliable waiting list information, it is difficult to attribute cause and effect. Providing powered chairs with adaptations and seating, with the need perhaps for final adjustments with the user, is intrinsically more time consuming than issuing a simple manual chair. In such cases a prompt response will be dependent on well-designed logistical pathways bringing together the various equipment components.

3.7.11 The limited information we have suggests that in some centres the service could potentially cope fairly well with the number of current referrals in a timely manner, and has the funding to cope with demand accommodated under current eligibility criteria if the accumulated backlog of work was cleared. Clearing the backlog of equipment for which individuals have already been assessed and are waiting, would significantly improve their perception of the service. Once this backlog was addressed, the speed of equipment delivery should also be improved for new assessments. Some additional funds have already been provided to assist with clearing the backlog.

3.8 Funding

3.8.1 Some of the improvements in the service explored in this document should be deliverable without additional costs although they may, perhaps, require 'pump priming' to make the transition. Others, such as addressing the equipment gaps identified above, could cost comparatively large sums of money to address. If we do want to make changes, how will we finance them?

Equality of funding

3.8.2 Figures shown in section 2 indicate that the various wheelchair centres have considerable variation in the funds available to spend per head of population or per registered user, far more than can readily be accounted for on the basis of rurality etc. When funds for the service were devolved to NHS Boards, they were not 'ring fenced' - some NHS Boards appear to have moved funds out of the service, others seem to have left the revenues intact or uplifted for inflation. In any event, the funds allocated by the Scottish Executive seem to have been determined by historical spend, rather than on the basis of need or population: there has never been a formula to determine appropriate expenditure for this element of the NHS.

3.8.3 In theory, the total funding for all NHS Boards should be based on an allocation per capita adjusted for rurality and deprivation. An argument could therefore be made that NHS Boards should be asked to produce an action plan which would see them all moving towards a common level of funding for wheelchair services. Unless additional funding was made available, this could require money to be moved from another service. An alternative, perhaps more in line with current devolved management arrangements, might be to set and monitor realistic service standards and leave the details of funding these to the NHS Boards.

Efficiency and service redesign

3.8.4 We do not have direct productivity measures for the wheelchair service, however, the information we do have suggests some potential opportunities for efficiency gains through service redesign. For example:

• examining the range of funds allocated and comparing this with other variations, there appears, not surprisingly, to be a correlation between the numbers of powered chairs issued per head of population and the funding available
• examining this in more detail, there are some services that appear to provide above the average level of powered chairs for the funding they receive, some below
• the range of staffing per head of population and skill mix variation also appear to provide some interesting patterns which might merit investigation
• there are some parts of the service that appear to provide a more acceptable and timely service despite relatively low levels of funding and vice versa
• inefficient infrastructure in some services consumes staff time, suggesting that improvements could be made in productivity, and
• the variation in numbers of repairs between centres could also merit further investigation.

As discussed in further detail later in this document, the Modernisation Agency in England provided support to wheelchair providers to assist them in improving their services through process redesign. This initiative was very successful in a number of areas, although we understand that several have subsequently reverted to their original performance as resources were once again withdrawn. Nevertheless, this does indicate that there are opportunities in this area.

There is some potential for service redesign to improve service standards.

Joint working and flexible funding packages

3.8.5 Some studies have shown that equipment more closely matched to users' needs can be funded through a more flexible approach, accessing funds from a mixture of the NHS, DWP, social care, support organisations, charities, insurance, court settlements for injuries and private funding. An approach of this nature could help bridge some funding gaps. There could well be other service improvements that could be achieved by more joint working between health and other agencies. As a minimum, some of the difficulties we heard about could be resolved ( e.g. no house adaptations from the local authority until a wheelchair is delivered, but no wheelchair from health unless the house is modified).

3.8.6 The voucher scheme operating in England sees the NHS 'giving' service users a voucher equivalent to the sum that would have been spent on their individual equipment by the NHS to be used towards the cost of the equipment the user chooses. Evidence from England shows mixed success. The scheme may - not surprisingly - work best in affluent areas where people have money to add to the vouchers, however, there are signs that the concept is gaining in popularity as confidence grows over its application to powered chairs.

3.8.7 A 'top-up' scheme allows individual users to add their own funds to those of the NHS and obtain the chair they want. Some Scottish centres may occasionally operate this system already on an ad hoc basis, in which case choice is restricted to models that the NHS is willing to maintain.

3.8.8 The best approach could be a compromise, where funding from several sources can be used to bridge any gap between the chair the NHS is funded to provide, and the one the user wants, presumably in keeping with the professional assessment provided by the public sector.

Leasing schemes

3.8.9 A major constraint to the current service pattern is the lack of funds to purchase higher priced equipment: standard powered chairs cost approximately £1,000 and a complex version can cost £5,000. An alternative might be for the NHS to set up a leasing scheme whereby instead of paying the capital cost, the NHS leases the chair, probably from the manufacturer through a central contract (there could be variations on this including the NHS holding the capital centrally). There would be savings in the early years, although the cost of capital might make it more expensive by, say year five.

3.8.10 However, the income flow would allow a new chair to be issued at year five for example, for no additional cost. Refurbishment of chairs funded in this way would become a thing of the past for the NHS - but there might well be additional costs if the chair is not used for its full lease period - five years in the illustration below. These arrangements would be invisible to the user. Information about life expectancy of chairs would be needed for a full assessment of the viability of this concept.

Table 10

There are a number of issues here that would need to be clarified and worked through. For example, the above illustration assumes that a third party will fund the original capital purchase and that the NHS will pay 5% interest on this sum. This may not be a commercially viable proposition for manufacturers or banks/finance companies.

We should therefore emphasise that this is an outline suggestion that will require a substantial amount of investigation to assess its practicality.

Hire purchase schemes

3.8.11 The Motability scheme whereby people with disabilities can use their disability allowance to buy a car through a hire purchase scheme could be replicated in relation to wheelchairs. This scheme is run by a government-sponsored organisation with close links to motor manufacturers. The end result is a car modified for a driver with disabilities, which can be purchased, over a period of several years, for the cost of the disability allowance. For interest, the scheme also offers cars suitable for wheelchair users, but for additional cost.

3.8.12 Such a scheme also readily allows purchase of a wheelchair through monthly payments. Involvement could be attractive to wheelchair manufacturers in the same way as motor manufacturers if they believe that additional or higher priced sales might result, also driving down costs to the user. In theory, this could be run in parallel with concepts like the voucher scheme and other flexible funding arrangements.

A high proportion of the cost of the service (40-60%+) is attributable to equipment purchase. We therefore suggest that to make significant and lasting improvement in the current service will require additional funds for equipment, although this should be supported by service redesign.

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