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5 Lessons from Elsewhere
As part of the review, we examined models of service elsewhere in the world, to identify good practice and lessons that could be applied in Scotland. Our discussions with staff and managers of other wheelchair services revealed a range of interesting and potentially instructive experiences, highlighted below.
For example, services in the United States have adopted an off-the-shelf purchase model, to reduce in-house adaptation. They also have an innovative approach to providing equipment for users with progressive conditions. Services in Norway are based on a holistic, human rights based model that joins up social and healthcare provision to meet the totality of client need. We discuss the various service models in more detail below.
5.1 England
5.1.1 England does not have a single common model for the delivery of wheelchair services, but a variety of different service configurations across the country. There are 151 wheelchair services in England, a ratio of 1:300,000 of the population, in comparison with Scotland's current ratio of 1:1,000,000.
5.1.2 In 2002, the Department of Health, the Modernisation Agency and the Accounts Commission set up a collaboration with around one-third of wheelchair services in England and one of the two Welsh centres to look at:
- reducing delays
- maximising efficiency
- ensuring user and carer needs were addressed, and
- ensuring the outcome of contact with services was an enabling experience, promoting independence.
Selected reported improvements were:
- North Bristol - reduced wait for routine assessment from 120 to 50 days
- North Cumbria - reduced maximum wait from referral to assessment for a powered chair from 12 weeks to 6 weeks, and
- Brighton - reduced the wait from assessment to delivery of a powered chair from 47 days to 4 days.
Staff involved in the initiative have suggested that the improvements were achieved through:
- making small changes, for example streamlining processes like collecting and monitoring data
- taking time out to evaluate the use of resources, and
- sharing and learning from the experiences of others.
The initiative finished in May 2004 and it is not entirely clear how many of the improvements have had a lasting effect, or if any additional advances have been secured without the concentrated effort of the initiative being brought to bear. However, we understand that several of the improvements have not been sustained, for whatever reason.
5.1.3 The current situation in England continues to vary from area to area. The north of England has a 'super-centre' in Newcastle for complex cases, with smaller regional services dealing with less complex cases. Yorkshire has multiple centres each covering around 2,000 users; the general perception here is that the 'localness' of services is good, but that their 'smallness' means that no one has the critical mass of staff to deal with complex cases.
5.1.4 Chailey Heritage is an NHS-based assessment and treatment centre for children and young adults with complex physical disabilities. Chailey covers a range of services including rehabilitation engineering, clinics and assessment services, a head injury service, respite and outreach services. Referrals come from consultants and local therapists, with around 300 a year made to the rehabilitation engineering service. Funding comes from Primary Care Trusts through service level agreements and wheelchairs are then funded through local wheelchair services.
5.1.5 Chailey is also a specialist centre for research into children's postural needs and is able to offer robust assessment, multi-disciplinary working and continuity for service users. However, waiting times are currently around 5-6 months for assessment, and then a further four months 'post-Chailey' for the fitting and delivery of equipment.
5.2 Wales
5.2.1 Wales has a single wheelchair service with two centres, one each in the north and south of the country. There are in addition three rehabilitation centres each specialising in a different clinical area. Repairs, maintenance and refurbishments are contracted out on a three-year contract basis. Interestingly, Wales has no eligibility criteria for equipment, preferring instead that the individual's needs are assessed and met, including buying outside of the contract if necessary.
5.2.2 Funding of the service in Wales appears to be at a higher rate per capita with, for example, the service in north Wales receiving £3m for 17,000 service users as opposed to the £14.2m Scottish services receive for 100,000 service users. Waiting lists are however still long, with some users waiting up to two years for equipment. They do however achieve a delivery time of 21 days for standard equipment that does not require the user to be assessed face to face. There is a PPM programme - annually for powered chairs, but not for manual, as funding would not allow. Repairs are carried out on a basis of three days as standard, with a response within 24 hours for emergencies.
5.2.3 Wales has also developed a training programme for OTs, which is about to be accredited by the University of Wales, and all OTs have completed at least part of the programme available to them.
5.3 Netherlands
5.3.1 Responsibility for provision of wheelchairs and other mobility equipment lies with local authorities, with the onus on the person with disability or their carer submitting a written request to their local town hall. Following an equipment aid assessment, the selection of equipment is made between the authority and the client and the supplier. There is potentially no restriction on the specification of the chair. Waiting times from referral to delivery are commonly 4-6 months, but can be up to one year.
5.4 Norway
5.4.1 Norway has the most impressive of all the services we looked at. Their approach is based on the fact that access to assistive technology is seen as a basic right and is provided on the user's terms. The service incorporates all assistive technologies from wheelchairs to hearing aids and home adaptations. The service receives about £250m a year in funding with around £50m being spent on wheelchair services. This is for a population size comparable to Scotland. Norway has a total of 22 centres, 19 of which are in the 19 regions providing solutions to complex needs, with three national centres including a vehicle centre and two IT centres. Funding is allocated to the autonomous local centres, but if they have to overspend, more money is made available by local health authorities.
5.5 United States
5.5.1 As with England, there are various models of service delivery across the United States. The main difference between Scotland and the US seems to be that they purchase 98% of their equipment 'off the shelf' meaning minimal levels of local customisation, which they have found to be cost-neutral when all factors are taken into account. The practice in the United States is also to purchase a higher basic specification chair, leading to minimal repair and maintenance costs. Users with progressive disease are offered a 'lend-lease' service where the chair can be returned if and when needs change. Reassessment and renewal of equipment is automatic after five years and service users are then allowed to keep the old chair as back up.
5.5.2 PPM is done routinely on all products - annually for manual chairs and 3-monthly for powered chairs. Equipment is also checked at any patient appointment.
5.5.3 There is a separation of assessment and purchase, enabling mobility and seating professionals to act as advocates for the client's holistic need without reference to eligibility criteria. However, it must be noted that the insurance-based funding system in which the model operates is considerably different to Scotland's.
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