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6 Conclusions

In November 2005, NHSQIS issued a consultation document to seek views on the provision of wheelchair services and how these might change to better serve the population. The final section of this document has been produced after full analysis and input from the consultation experience. Again, we have dealt with the issues identified as key to a successful future for the service:

• a local service structure
• accountability
• assessment
• provision of equipment
• maintenance of equipment
• gap analysis
• staffing, and
• funding.

6.1 Structuring the service, making it local

6.1.1 Throughout this document, the need for access to services to be as easy as possible for wheelchair users and carers has been emphasised. How could physical access to wheelchair services be improved?

• While there is no 'right size' for a wheelchair centre, there seem to be no clear benefits of scale from large Scottish centres, while very small centres may find it difficult to recruit.
• Outreach clinics provide valuable access to many patients, but are limited in the range of service they offer and consume scarce staff time in travelling.
• Innovative options are worth considering, such as the use of an equipped mobile van to extend the range of services at an outreach clinic, or the development of more local facilities by employing a therapist and administrator.
• Efficiency and users' experience can be optimised if whatever facility used is fit for purpose, has disabled facilities and appropriate workshop, storage and clinic space.

Future options

More outreach clinics and local facilities

6.1.2 Outreach clinics are currently provided by a mobile team of staff travelling from a wheelchair centre. The concept of expanding these received reasonably good levels of support at consultation.

6.1.3 Benefits:

• additional outreach clinics would probably be the quickest way of providing much improved access for many service users.
• recruitment to a centre, which then provides outreach clinics, may be a practical way of providing staff.
• the costs of running an outreach clinic will be about £16-£26k per annum for each location which has a basic monthly clinic staffed entirely by a team from the centre. Costs would be significantly less if existing facilities such as clinics and community centres could readily be used. Making some allowance for this, a total of 25 additional clinics across Scotland could cost <£400-£650k; this compares well with the costs of additional centres.
• a network of outreach clinics could be a good base for future integration with local authority services.

6.1.4 Drawbacks:

• outreach clinics take more staff time in travelling than fixed regional centres, and
• the clinic is unlikely to be able to offer a full range of skills, as there will usually not be a full complement of staff, and equipment will normally also be a limitation.

6.1.5 The possibility of a mobile clinic, using a fully equipped van or lorry, has been suggested: this would allow a wider range of assessments to be offered, for example. Costs could be in the region of an additional £10-£15k per annum for a single leased vehicle, perhaps £100k across the country, plus running costs.

6.1.6 More local contact and benefits to service users could be delivered by employing some permanent staff at outreach clinics. An administrator, based in a local clinic or similar location, and a mobile physio or occupational therapist, possibly part-time, could do much to provide a local service and get to know their clients. Such a model, with an administrator and part-time therapist, would cost about £1.3m for 25 outreach locations running fortnightly clinics (this might not be the ideal configuration, but it gives an indication of costs). It could potentially provide the best solution to staffing, giving flexibility to employ appropriate staff in a wider variety of locations.

Additional regional centres with outreach clinics

6.1.7 There was no clear consensus for any one of the options outlined at consultation, but good levels of support were received for this option, particularly from groups. Additional regional centres could be provided by splitting Glasgow and possibly Edinburgh. They would be located in a conurbation to be decided largely on the basis of demographics, giving maximum access benefits. This concept was well supported at consultation.

6.1.8 Benefits:

• the centres would be permanently staffed and, given funding, would also be able to provide local outreach clinics. Service users would be able to relate to staff who are less remote in location.
• setting up additional outreach clinics from this base will incur perhaps less than half the costs of an outreach clinic run from the current centres because travelling distances are reduced.
• there may be advantages, particularly in the medium to long term, in splitting bigger centres, which, at least in the case of Glasgow, do not seem to deliver benefits of scale, yet are remote from many of their clients.

6.1.9 Drawbacks:

• for many, the centre will still be some distance away.
• ideally, we would look to see staff at the existing centres redeployed to the new locations, but there may be only limited potential for this. If so, a recruitment and training scheme will be required: the ability to attract and retain staff may make it more difficult to deliver this option.
• we estimate that it may cost between £330-£400k per annum to run each additional centre, less if premises were already available, dependent on the level of new versus reallocated services.
• there will be additional costs associated with the transition from the current arrangements.
• this option is likely to take longer to deliver benefits than additional outreach clinics, while planning and delivery will need an investment of time and resource that could be spent on other priorities.

6.1.10 It has been suggested that this option could evolve over time, reflecting Glasgow's current working model which organises the service in a three-way geographic split: this is attractive in that it could potentially produce some local staffing fairly quickly, with minimal disruption and reduced cost. The danger could be that further changes are not driven through.

Radical restructuring

6.1.11 As outlined in the consultation document, it is not feasible to deliver this in the short term: it is more a target for gradual evolution over a period of years. There was good support for this option at consultation, although largely from individuals rather than groups. This is a model seen in other countries, pre-eminently Norway where significant funding is invested in local mobility centres which are to be found in most medium sized conurbations, lead by local authorities. Applying a similar pattern in Scotland would result in 15-22 service centres. This would undoubtedly produce very significant improvements in access and travelling for service users.

6.1.12 However, the difficulties of moving to this option in the short term are so great as to be almost insurmountable, with significant challenges to be overcome whenever introduced.

• Staffing - an integrated partnership between health and social care is the most likely way to success, given that the NHS already has problems with recruitment in smaller centres. A substantial training programme for local authority and health staff would be needed, as well as additional recruitment.
• Disruption - this would be a major change, needing planning and resources from integrated public services. We think that some disruption to a range of services could well follow.
• Cost and value for money - we estimate that this solution could cost as much as £5m-£8.8m plus training and transition costs. Our view is that there are other immediate priorities for such substantial expenditure within the wheelchair service. Further, we suggest that some, although certainly not all, of the access benefits can be achieved more rapidly by other more practical routes. Finally, the indications are that costs will be much lower with a gradual transition.

6.1.13 This could be a long-term goal, to be moved to gradually following ongoing assessment of other service changes, perhaps hand in hand with the Joint Future agenda within Scotland. The benefits could include:

• holistic and integrated services offering support in healthcare, home support, housing, adaptations and mobility aids, employment
• a service which is not based on responding to illness alone
• easy local access, and
• a more personal approach from local staff who know and are known to clients.

Status quo

6.1.14 As outlined above, the indications from the current situation in Scotland are that there are no obvious advantages to be gained from a large centre, although staffing may be a problem for the smallest centres. Large centres may have some disadvantages in terms of travel to access services. The status quo does not, therefore, appear a particularly attractive option, and responses to consultation support this. The only obvious reasons for retaining the current configuration are:

• no additional cost
• no disruption to services, and
• other changes are a higher priority.

6.1.15 The potential benefits of change may outweigh these disadvantages through:

• better access for service users
• improved value for money, and
• opportunities for further redesign.

Facility infrastructure

6.1.16 The efficiency of services and the experience of users can be much more positive if basic infrastructure is in place, such as disabled toilets, sufficient clinic space, a workshop facility, space to store a range of chairs.

It is of vital importance to service users that they can minimise travelling, and access a local service, with staff and systems that they get to know. This could be provided by more centres, more outreach services, innovation in extending the range of support available locally or a mixture of all of these. The local involvement of community staff should also be promoted. Costs could be minimised by making use of existing community premises, but all facilities should be fit for purpose.

6.2 Making the service accountable

6.2.1 It could be argued that one of the main disadvantages the service suffers from is the lack of visible accountability to service users.

• The wheelchair and seating service has not enjoyed a high profile: despite a series of reports (see appendix) recommending changes and improvements, at best only modest progress has been made in implementing these.
• The service is fragmented: it has no central body with a clear responsibility to drive performance: there is a lack of high profile champions agitating for more resources or for improved performance.
• There is no system for setting standards, monitoring performance and reporting results in public, so that when the NHS is under pressure, the wheelchair service may be the first to feel the effects.
• There is considerable variation in the service offered across the five centres.
• Funding levels are not scrutinised: the overall spend has not kept pace with inflationary uplifts since central funds were devolved to NHS Boards, giving apparent shortfalls against the original allocation.
• The lack of a standardised information system makes it difficult to compare performance, quantify issues and manage the caseload.
• The voice of service users is limited, certainly at a national level
• If additional funds are made available, there is no ready mechanism to scrutinise investment.

Future options

No change to current accountability arrangements

6.2.2 We would argue that unless the wheelchair service receives a higher profile, this report and recommendations will go the way of previous documents and very little will change. Service users and, indeed providers, will continue to struggle even to retain their existing share of resources and will remain a low priority. Given the benefits to be gained from improving the service, this cannot be acceptable.

6.2.3 We would strongly suggest that there is a need for more robust accountability arrangements, so that executives who have accountable officer status for wheelchair funds are incentivised to drive improvements in performance, and invest resources, whether time or money, in the service. This will not be achieved from the current arrangements. There was little support for the status quo at consultation.

Maintain regional management with measures to ensure equity

6.2.4 This option, which received most support at consultation, would involve nationally agreed standards and targets which would be monitored, made public, included in performance reviews of NHS Boards and their management teams, and in the national waiting times initiative. Performance measures should be designed with the input of service users, carers and staff. However, each NHS Board would continue to have the authority to design a service that met local needs, provided it also met national targets. Those NHS Boards who did not host a wheelchair centre would also have responsibility for ensuring that the service for their population met national standards, thus exerting further pressure on the provider NHS Board, or incentivising the set-up of a more local service.

6.2.5 Benefits:

• a raised profile, attracting more resources and higher priority
• the requirement to deliver common standards, thus driving improved performance
• little, if any, disruption to the service
• flexibility at a local level to cope with differences in staff availability, rurality etc
• minimal costs: a national users forum with support might cost £45k per annum
• this structure provides an incentive for NHS Boards to consider moving additional funds into wheelchair provision to help meet targets, and
• the prospect of rapid action and results.

6.2.6 Disadvantages:

• some benefits could be delayed due to the lack of a robust national data collection system (see below)
• less focus on the service than would be delivered from option 6.2.7 below
• no clear single voice to champion the wheelchair service nationally
• no ready vehicle to oversee allocation of any additional funds to the wheelchair service: this would probably need to be managed by SEHD, and
• unless there is a mechanism to keep reviewing standards and driving higher performance, priorities for the service could slip again with time.

A single co-ordinating body

6.2.7 This option, which also received significant support at consultation, would see a national body to focus on the service and co-ordinate provision. This would see the development of a single organisation for Scotland responsible for all wheelchair centres and funded directly by the SEHD, similar to the Scottish Ambulance Service. This would require a sum of money to be removed from each NHS Board's existing annual allocations and re-routed to the new organisation. The current centres would report to the central organisation and, once in place, a national body could be the fastest way to implement any subsequent changes across all wheelchair centres. Support services, such as human resources and payroll could continue to be provided locally or might, over time, become centralised.

6.2.8 Benefits:

• a single organisation could readily introduce common standards, policies and procedures
• elimination of the current regional variations in funding
• a clear focus on improving services with no distractions
• a voice for the future, which can continue to lobby for users, undeterred by complications in other aspects of the service, and
• a good vehicle for sharing out any additional funding.

6.2.9 Drawbacks:

• costs associated with setting up a central body could easily amount to £450k
• more short-term disruption to the service than option 6.2.2 above
• there would be no more money available purely as a result of this move and attempts to even out existing funding across centres would mean withdrawing money from those better off
• withdrawing funds from NHS Boards would present some problems as there would be several different ways in which the amount could be calculated: too high a level would put pressure on other services, the reverse would 'short-change' the new organisation
• once funds were removed, there would be no incentive for NHS Boards to put any additional resource or goodwill into the wheelchair service to deliver targets
• confusion for staff who may work both for the wheelchair and seating service, and in other areas such as rehabilitation
• a more robust national data collection system would be required to yield full benefits (see below), and
• this would be a very small organisation with a very modest budget, which could be in danger of being brought under another umbrella, whether a 'host' board or national services, for instance: this could be the worst of both worlds.

A national wheelchair network

6.2.10 A further alternative is a hybrid: this would see a wheelchair network being set up along similar lines to managed clinical networks for cancer, stroke or diabetes. Wheelchair centres could remain under the management of NHS Boards, but a national network, with a clinical champion, could provide leadership and a voice for the service. The network could embrace user and provider forum(s), which could input into the development of standards and priorities. This approach could have many of the advantages of both the above options, without significant drawbacks. It would be ideal in determining additional allocations and scrutinising business cases. Costs might be £150,000 per annum.

Information technology

6.2.11 The current system in use by several centres has been developed with very modest resources and due to the initiative of service staff. A more robust, fit-for-purpose system seems to us to be a priority, both to monitor performance and to assist with service delivery. This might be achieved by adopting the current system and extending it, or through an off the shelf package, several of which are available. The costs might be around £100k. Any such system should have the potential to be connected to an electronic patient record when it becomes available.

The lack of visibility and accountability for the wheelchair service is one of its primary problems, and this must be resolved. A user voice will be essential within any accountability framework. Information systems are needed to allow monitoring and delivery.

6.3 Assessment

6.3.1 As previously reported, assessment is currently heavily influenced by what the NHS can afford, and is controlled by wheelchair centres regardless of the complexity of an individual's case. Key issues that need to be addressed are:

• the use of eligibility criteria to restrict equipment offered results in user distrust, frustrated staff and, most importantly, unmet need
• assessment is seen as too focused on medical criteria, and is therefore perceived as unholistic, taking little account of users' aims or carers' situation
• not every centre has a core of staff with paediatric training and communication skills
• reassessment may not take place at an interval which addresses the individuals needs and wishes
• there is an element of double handling, in that a community therapist may carry out an assessment, this is then authorised by a GP before being sent to the wheelchair centre for screening, and
• an NHS assessment service for those buying equipment privately.

Future options: assessment of simple and complex needs

NHS services continue to be the sole assessor, but with assessment separated from provision

6.3.2 Consultation revealed only very modest support for this option, which would allow a transparent assessment not influenced by considerations of what could be afforded, or by eligibility criteria. The assessment could be discussed with users and carers and the options explored, including an understanding of what the NHS would provide and why, and recording unmet need. If wheelchair users could access additional funds, they would make a more informed choice about the equipment best suited to their needs. The costs of introducing this approach would be about £315k, largely due to additional staff time during assessment.

6.3.3 During consultation, service providers have emphasised that they see no need for different staff to take the decision about equipment provision: what would be needed would be more time for staff to have a full discussion with each individual wheelchair user during assessment. We accept this argument.

6.3.4 Benefits:

• easy to introduce
• minimal disruption
• wheelchair users would have a clear understanding of their assessment, allowing informed choice about further equipment options
• lessening of mistrust between staff and patients, and
• clarity about the level of unmet need, which could drive further change and/or funding.

6.3.5 Disadvantages:

• all referrals would still go to wheelchair centres, causing some delay and using up staff time, which is in short supply
• the possibility of increased dissatisfaction from wheelchair users as unmet need becomes more transparent
• a phased introduction could be necessary as additional staff time would be in short supply, and
• the possibility of a lost opportunity for further decentralisation.

NHS centres assess complex cases only

6.3.6 This option, which attracted very considerable support at consultation, would see service users with less complex needs assessed in the community by local professionals. In practice, we envisage that this would allow community physiotherapists, occupational therapists and nurses, many of whom currently refer to wheelchair centres, to carry out basic assessments themselves. This would require additional training for many staff involved. In due course, this approach could potentially be extended to appropriate local authority staff and to a wider group of wheelchair users. The costs involved would be around £200-£500k per annum dependent upon the additional time needed by community staff, less savings in wheelchair centres. These costs would be in addition to those above if the changes in assessment practice at wheelchair centres are also delivered.

6.3.7 During consultation, it has become clear that there would be benefit in seeing such an approach as an integrated service between the specialist centres and community staff. The centres would be best placed to provide training and guidance through standardised flow charts and advice. Indeed, for some services, this would only be an extension and formalisation of their current approach. There would be further opportunities for decentralisation and integration with other possibilities outlined in this paper, giving further benefits to users and carers, for instance, increased numbers of outreach clinics could provide additional support, and this could be a stepping stone towards gradual development of the model outlined in section 6.1.11.

6.3.8 Benefits:

• the potential to extend into further decentralisation and integration with local services over time
• time saved in processing straightforward referrals
• the release of some staff time in wheelchair centres
• more holistic assessment as it involves those who know the individual best, and may well take place in their home, and
• should be relatively quick to introduce, but there may be some disruption and delay if community staff cannot be released for training, for instance.

6.3.9 Disadvantages:

• an increased risk of inappropriate prescribing of equipment
• additional responsibilities and pressure for community staff
• it is unclear how much support this approach would receive from primary care services, and
• lack of clarity about funding and financial control.

No change

6.3.10 There was little support for this approach at consultation. Clearly, none of the above benefits would be delivered, and the difficulties of the current situation would remain as would the one obvious benefit: if funds are tight, the status quo is a reasonable way of sharing scarce resources. However, the picture would be very different if additional funding were made available, since many of the current difficulties relate to shortage of money.

Future options: follow-up and reassessment

The initial assessment should include a personal plan for follow-up

6.3.11 This suggestion produced overwhelming agreement at consultation. It would see the initial assessment process including a date for the next planned assessment or contact and should be based on the individual's own situation. For those with changing needs, this might mean reassessment in six or twelve months, for others, it might amount to an annual letter offering contact if required. The service, whether provided by a centre, outreach team, or community staff, should take responsibility for ensuring that this happens. The additional staff time associated with this will depend on how many users wish to take up the invitation for reassessment: our estimate of additional costs is £480,000.

6.3.12 Advantages:

• greater responsiveness to individual needs giving greater user satisfaction
• less unmet need
• more appropriate equipment
• reduced delays, and
• improved equipment adjustment and advice on use.

6.3.13 Disadvantages:

• additional costs of patient contact and equipment
• some delay in implementation if additional recruitment is required, and
• reduced prioritisation of staff time, which can be in short supply.

No change

6.3.14 There was little support for this at consultation, but some respondents made the point that a lot of staff time could be committed to follow-ups for users with less complex conditions: if staff time is a constraint, individuals with greater wheelchair dependency could suffer. It would therefore be important to introduce changes in a planned way. The pros and cons of the status quo are the opposite of those outlined above.

Paediatric assessment

6.3.15 It is clearly particularly important that children have access to an appropriately skilled team, when appropriate. Medical advice, for developmental and cognitive issues, will need to be sought more often than is the norm. Reassessment needs to be carried out on a planned and regular basis for some children. The assessment team need to be skilled in communicating with children, as well us understanding their mobility needs.

Assessment should be based on the needs of users and carers. While value for money must be a consideration, financial issues should be secondary: for this reason, assessment should be holistic, transparent and decoupled from affordability. Initial assessment should include a plan for follow up agreed with the individual. Paediatric assessment is particularly important and should be provided by staff with the relevant communication, technical and clinical training. Other therapists with appropriate backgrounds should be empowered and actively encouraged to assess and prescribe equipment: community staff in particular have a role here for less complex needs.

6.4 Provision of equipment

6.4.1 The current route for providing equipment is designed, in great part, to reduce costs, and appears to succeed well in so doing. The range of equipment purchased is controlled, allowing central bulk purchasing and significant savings on unit cost, and reducing the range of skills and spare parts needed to service and maintain equipment. There are, however, several issues which should be considered in designing the future of the service:

• increased choice
• a multiplicity of providers
• introducing new technology
• the cycle of refurbishing chairs
• the cycle of purchasing standard modular chairs and customising them in NHS workshops
• greater use of alternative supply routes direct from the manufacturer, and
• the impact on repair and maintenance.

Future options

The NHS continues to provide all wheelchairs following assessment

6.4.2 A modest majority of respondents supported this approach. It is worth emphasising that, were some financial constraints lifted, the NHS could provide a wider choice of chairs, yet retain much of its purchasing power. If community assessment is implemented, less complex chairs could be delivered direct to a service user from the warehouse or manufacturer and, indeed, this is only an extension of the practice already adopted by some centres.

6.4.3 Benefits:

• lower purchasing costs: the NHS would still be able to buy in bulk
• ready potential to save money through some refurbishment and customisation if appropriate
• lower cost and, in theory, faster repairs and maintenance, and
• given a will to improve choice, this could be delivered quickly.

6.4.4 Drawback:

• loss of an additional mechanism to drive down waiting times.

A number of providers including the NHS

6.4.5 This option was also well supported by a minority at consultation. Again, the range of models provided could be expanded to give more choice, but balanced with cost and repair issues. The more providers, potentially the greater the competitive effect, but the more serious the loss of bulk purchasing discounts.

6.4.6 Benefits:

• the element of competition should be a force to reduce waiting times, and
• increased drive for more choice.

6.4.7 Drawbacks:

• higher equipment purchase costs: our estimate is £600k, with no change in the functional specification of the equipment, and
• a commercial system will take some time to set up and change should the need arise.

Refurbishment and customisation

6.4.8 The issues of refurbishment and customisation have attracted much debate. We suggest that 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. There is further discussion of this issue in section 3.4.

Service users require equipment to be delivered promptly and the NHS has not always been reliable in this respect. There are significant cost advantages in the bulk purchase of wheelchairs via the NHS, but, if this continues to be standard practice, it is essential that long delays are eliminated. If this is not accomplished, a competitive route with multiple providers might well be preferable. The NHS should be flexible about equipment provision pathways, and review its practices with regard to customisation, refurbishment and the role of extensive central workshops.

6.5 Maintenance of equipment

6.5.1 This is another element of the service that can create frustration for service users and providers alike. Being without a functioning wheelchair has serious consequences for individuals who rely on their chair for their mobility. If a chair has to be taken away for repair, the NHS may not offer a replacement, and a substitute is in any event unlikely to be equivalent. Key issues are:

• most centres do not run a PPM programme, which can reduce breakdowns and promote user safety
• some centres have a mobile technician who can visit schools and homes to carry out a range of repairs, some centres take all repairs back to a central workshop
• several centres will refund basic repairs carried out at a local garage or cycle shop
• could other organisations be better placed to provide a breakdown service?
• determining the level of need for an out-of-hours service and how best to provide it, and
• maintenance of private chairs.

Future options

The wheelchair centres continue to run the maintenance and repair system, but with a programme of PPM introduced in all centres

6.5.2 This received equal support with option 6.5.5 below, with groups being particularly supportive of the introduction of PPM. Inverness is now providing a PPM service and other centres are keen to follow suit. Many centres operate a mobile technician scheme where many repairs can be carried out at home without the loss of a chair to a central workshop. The two approaches could be integrated.

6.5.3 Benefits:

• reduced breakdown rate so fewer problems for users
• lower costs in wheelchair centre workshops
• regular contact with the service, perhaps for minor adjustments or advice
• the potential to extend the PPM service to cover call outs in the case of breakdown, including out-of-hours emergencies
• NHS staff are keen to introduce a PPM system, and
• the opportunity to address health and safety issues and concerns.

6.5.4 Drawback:

• additional cost estimated to be <£1.2m-£2.4m.

All minor repairs to be contracted out to accredited local providers, for example, garages and bicycle repair shops, combined with PPM run by wheelchair centres

6.5.5 This option was equally well supported, but particularly by individuals. Some responses from organisations raised doubts about the practicalities of a local repair scheme, with concerns about the volume of work that could realistically be carried out and the costs of setting up accreditation.

6.5.6 Benefits:

• fast access to local repairs, and
• reduced workload on wheelchair services.

6.5.7 Drawbacks:

• small volumes of repairs involved, and
• costs, including setting up accreditation, could be £210k.

All maintenance and repairs contracted out

6.5.8 There was little support for this approach. Whilst it could yield benefits, the costs and practicalities are uncertain. This option should not be considered further at the moment.

No change to the current method of maintaining equipment

6.5.9 This received little support: in our view the only obvious benefit - no cost increase - is far outweighed by the potential improvements in the service which could be delivered through PPM.

Private chairs

6.5.10 An open commitment from the NHS to cover maintenance of any private chair could produce a number of problems:

• staff training and familiarisation with the product
• spare parts not held and potentially difficult to obtain
• delays for users due to the above
• warranty issues, and
• cost.

6.5.11 A more feasible alternative might be for the NHS to undertake maintenance where:

• the chair fits the NHS assessment
• it is within a range of chairs which the NHS has determined that it will support, or the wheelchair centre has agreed that it can accommodate a variant, and
• if an individual chooses to buy outside these parameters, the NHS will offer a voucher towards maintenance that is equivalent to in-house costs (it should be noted that this may only amount to perhaps £10-20 per annum).

Out of hours support

6.5.12 The options for this should be reviewed in the light of decisions over PPM. A network of mobile technicians, who provide PPM as well as a repair service from users homes, could potentially be used to provide support for emergencies out-of-hours. The knowledge of a prompt response the next working day may well alleviate much of the current concern. Risk assessment of individuals who live alone and are dependent on their chair for mobility could also be helpful in identifying urgent need. It might also be possible to link the wheelchair service to call-out alarms carried by many people with disabilities who live alone.

A PPM system should be established, with a frequency based on risk profiles. This will deliver major benefits by reducing breakdowns and the consequent cycle of repairs. PPM should be integrated with mobile repair technician schemes: this approach could be extended to deal with emergency and out-of-hours breakdowns.

6.6 Gap analysis

6.6.1 Many of the changes discussed in this paper could lead to improvements in the service currently offered, potentially giving faster responses, clearer assessments, easier access and more choice. However, broadly speaking, the equipment provided is not likely to significantly change for the better unless additional funding is made available. Unless the criteria currently used to determine what type of chair is prescribed are abolished, or relaxed, entitlement to some equipment will not improve.

Future options

6.6.2 Minimum common standards - due at least in part to the differential funding across Scottish centres, some are able to provide higher standards than others. We would suggest that the funding levels at Dundee should provide a benchmark standard: the centre has the highest budget per capita (outside the very small centre at Inverness serving a scattered population); a good level of service as assessed by users; a high ratio of staff to users; and higher levels of issue of powered chairs. There would then be no good reason for other centres not to deliver to the same standards. This would cost around £2.4m per annum recurrent.

6.6.3 Responses at consultation concurred with the gaps in equipment provision listed below, with costing information and additional comments now included. There seems little doubt that all the groups identified would benefit if extra funds were available. If not all can be afforded, health gain analysis could be useful in prioritisation.

6.6.4 Children - equipment needs change as they grow and they need new chairs and seating more frequently than most users. Several respondents at consultation took the view that insufficient importance was attached to the special needs of children throughout the whole process, and made the case for a specialist service with staff trained accordingly. We would endorse the need for such an approach and for staff interacting with children to be properly trained in both technical and communication skills. However, with the exception of some specific communication issues, the current shortfalls, in our view, come less from staff competence than from funding constraints.

Costs estimated at £1m-£1.8m.

6.6.5 Young adults - face similar difficulties to children, with the additional challenge of a reduced range of services available to them as adults. Costs estimated at £140-£280k.

6.6.6 People with progressive disease - two particular needs are not currently being addressed: first, the need for new equipment as needs change; secondly, powered chairs are not routinely prescribed for this group where there is self-mobility, even though this may vary from day to day. Costs may be duplicated in minimum common standards above, or could be < £360k additional to this.

6.6.7 People with limited functional mobility - if an individual can move around their own home, using furniture, sticks or a walking frame for support, they do not currently qualify for a powered chair for indoor use. Furthermore, in order to obtain a chair for outdoor use, the person must first qualify for an indoor powered chair. Outdoor chairs are not directly prescribed.

6.6.8 Older people with carers - carers' requirements should be included when assessing the needs of the wheelchair user and may drive the prescription of a power-assisted chair.

6.6.9 It has been difficult to separate costs for the two groups above, but it is clear that the constraints on powered chairs are particularly problematic. For example, eligibility criteria prevent an outdoor chair being issued unless an individual qualifies for an indoor powered chair - and this will not occur if they can walk a few steps around the house, regardless of the health of a carer, who may be frail themselves. Our estimate for the costs of issuing powered chairs in this situation are £4m-£5.6m.

6.6.10 Those with terminal illness - long waiting times for assessment and provision of equipment mean that it is difficult for the service to make a timely response to these individual's very immediate and often short-term needs.

6.6.11 Those with temporary disability - for example those with broken legs, may also be unable to readily access chairs.

6.6.12 Again, while 6.6.10 and 6.6.11 represent very different groups of people, they have in common the need for a fast response. In terms of assessing numbers of individuals involved it has been difficult to differentiate the statistics between these two groups. However, the costs of delivering a fast response for those who need it are estimated at up to £136k.

6.6.13 Many of the above costs are for equipment and this investment in wheelchairs could be spread over time, although centres will need to consider how this might be fairly accomplished. A three-year time line for investment might well be in pace with the additional staffing required to implement improvements. Once a new wheelchair fleet is established, annual investment in equipment can reduce somewhat, since replacement is likely to be needed on a three- to five-year cycle.

The mobility equipment provided by the NHS is currently based on eligibility criteria, which were designed with an underlying financial bias. As a result there are major gaps in the range of wheelchairs provided. The situation will not significantly change for the better unless additional funding is made available, and the criteria currently used in prescribing chairs are abolished or relaxed.

6.7 Staffing

6.7.1 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. In addition there are considerable differences in staffing levels and skill mix between centres.

6.7.2 Attracting and retaining staff is an important consideration, since the availability of key skills 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.

Future options

NHS Education for Scotland ( NES) should conduct a training needs analysis for wheelchair services

6.7.3 Not surprisingly, there was overwhelming support for this option. This could include the needs of community staff who may be empowered to prescribe 'basic' chairs, the needs of those staff who may wish to work in the wheelchair service for a short time - six months up to two years - and for those who wish to move their career forward within the wheelchair service. Courses to meet these needs should then be commissioned and funded. The costs of scoping this work would be about £25k: the costs of commissioning and providing the relevant courses would be dependent on the results of the training needs analysis.

6.7.4 Due attention should be paid to 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.

Staffing should be based on national agreement but should be flexible enough to allow local recruitment, with the input of medical staff reserved for assessment of those with complex needs.

6.7.5 Again, there was overwhelming support for this option. Wheelchair centres should move towards any required change at a speed which suits local circumstances. While a reasonable mixture of therapy and bioengineering/technical skills is necessary to provide balanced assessment, variations in skill mix could be accommodated.

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 delay them. The status of the service and lack of training and career progression are key issues. Unless this is addressed, NHS service providers will not be able to make the changes both they and service users want.

6.8 Funding

6.8.1 While some of the options presented in this paper will not need additional money to implement, others, such as the provision of more powered chairs, will. We need to consider how some of this finance might be sourced.

6.8.2 It should be noted that analysis of health gain suggests that additional funding for the wheelchair service would compare very well with investment in other parts of the NHS that we take for granted.

6.8.3 All permanent recurrent funds for the wheelchair service come from the public purse. Wheelchair centres may have access to some charitable or endowment funds, some at quite significant levels.

6.8.4 As has already been noted, there are a number of anomalies in funding between centres.

• Allocation per head of population served. The funds devolved to NHS Boards in 1996 were at historical levels, reflecting budgeted expenditure rather than need or population size. Since then, some NHS Boards have maintained levels, some have uplifted for inflation, and others have reduced the allocation in real terms.
• Considerable variation in the overheads charged to wheelchair centres to cover capital charges on building use, heat light and power, rates, etc and a share of support services such as payroll, personnel, financial support and possibly a share of management costs.
• Value for money. There could be merit in further attention to this issue, exploring the link between levels of income per capita and key deliverables, such as staffing or the ratio of chairs issued.

Social inclusion

6.8.5 There may be financial savings to be made across the public sector by providing people with the mobility equipment they need in a reasonable timeframe. For example, getting people back to work could lead to a reduction in benefit claims and increased economic output. Recent national initiatives around incapacity benefit could support this approach. One of the Scottish centres has obtained funding from local authorities to support a training programme for wheelchair users, and it is conceivable that initiatives such as Joint Future will open more opportunities of this sort.

6.8.6 It seems anomalous that, although much of the need for wheelchairs is not due to ongoing health or ill-health issues, often the entire cost is borne by the NHS; it could be argued that social services, education, housing and the DWP could play an increasing role in ensuring mobility needs are met, or at least funded. Applying a joined-up model of funding from a number of different agencies may be a way to secure additional funding for the service, while maintaining bulk purchasing power.

Future options

Flexible funding

6.8.7 Consultation revealed widespread support for such an option. This would, in principle, allow money from different sources to be used towards the cost of a chair. Funds could come from the NHS, the individual, charities, various local authority departments, DWP or from national initiatives such as 'back to work'. The details of how such a scheme could function would need to be worked out. They might, as in England, allow an individual to take a voucher equivalent to the sum of money the NHS would have spent on their chair, and use it towards the cost of a chair purchased privately. Perhaps more likely in Scotland would be a 'top-up' facility, where the NHS purchases the chair with the user 'topping-up' the cost difference between the chair the NHS would have bought and the one the user wishes to purchase.

6.8.8 Although these schemes are restricted to those who can access additional funds, the individuals will be better off, and, if other initiatives outlined in this paper are adopted, the chair they access could be selected with the guidance of an NHS assessment and covered by NHS repair and maintenance regimes.

Leasing schemes

6.8.9 This was acceptable to a little over half of all respondents at consultation, especially to those who replied as individuals. In order to offset the cost of providing a wider choice of complex equipment, the NHS could lease equipment through manufacturers or a finance house, with new chairs being replaced after an agreed period, for example five years. This would end the practice of repeated refurbishment and re-issue of chairs, a practice that uses a sizeable amount of NHS staff time and resources and can cause delays, and it may save money, or provide more up-to-date chairs without commensurate additional cost. Further research would be needed to fully understand the economic equation.

Hire purchase

6.8.10 A scheme like Motability (which is set up to provide cars for people with disabilities) could be developed for wheelchairs. The user pays (or has paid for them from their benefit allowance) a set amount every month towards equipment and when the agreed term is at an end, the equipment can be retained or a new agreement entered into. A minority of those responding to consultation found this attractive. Nevertheless, this option would, in our view, be worth further investigation, perhaps with Motability. It does allow a wide choice of wheelchairs and this can become the individual's property, but it does, of course, penalise them financially.

Funding of recommendations

6.8.11 The Wheelchair and Seating service has for many years been seriously constrained in the support and mobility equipment it can offer service users. As a result of the service having a relatively low profile to date, allocation of financial resources has been severely restricted. Further, since 1996 the funds available appear to have reduced in real terms, apparently to meet alternative priorities within the NHS Boards.

6.8.12 Having prepared recommendations, the Steering Group requested that Frontline prepare indicative costs for implementation of the main categories of their recommendations.The resulting costs are shown in the table below and indicate that a substantial increase in funding is required if users are to be provided with a service that delivers social inclusion and freedom from unacceptably restrictive eligibility criteria.

6.8.13 The costs give a broad indication of the support needed to deliver what we believe would be a world-class service. However it is important to note that the figures are very much an informed estimate, based on available information with some input from service providers. It will therefore be imperative that allocation of additional money to specific centres or projects is scrutinised through an appropriate business case process prior to release of funds, with fully costed proposals and implementation plans, setting out financial requirements from both capital and revenue streams, with the latter split between recurring and non-recurring revenue.

6.8.14 Table 13 summarises the estimated additional revenue consequences of the recommendations, including the recurring revenue effect of potential capital investments. It may be that capital rather than revenue will be required to fund specific elements of building development or expensive equipment, but pending detailed proposals, an assumption has been made for the sake of simplicity that all investment will be of a revenue nature. At this stage, what is important is not the source or nature of funding requirements, but the overall amount required.

6.8.15 The phasing suggested by the steering group for introducing improvements is ambitious, and we anticipate that it may be constrained by the ability to recruit staff. If implementation takes place at a slower pace, it will be important to ensure that total funds are not lost to the service.

Table 13 - Additional revenue funding required to support recommendations

Notes

1. The current NHS wheelchair and seating service has available recurrent annual funding of £14.2 million. In order to effect the implementation of the recommendations of the steering group, additional funding will be required. This would be in the order of an additional £8.7 million for the first 12 months of implementation, followed by a further additional £6.7 million each year in years 2 and 3. Thereafter, to maintain a steady state, with allowance for some increased demand after successful implementation of all recommendations, a recurrent £15.8 million would be required additional to the 2005/06 position, giving £30 million in total.

2. Contained within this additional £15.8 million is a funding stream of some £6.6 million per annum for additional wheelchairs and powered wheelchairs, plus a further £1.45 million for modernising the existing fleet.

3. The highest cost programmes comprise:

• Overarching principles: substantial increase in local access however provided - revenue costs of leasing facilities or the equivalent cost of building and owning them.
• Referral, Assessment and Provision: funding for equipment, based on significant increases to the wheelchair fleet in years 1-3 due to the removal of current restrictive eligibility criteria, followed by more frequent replacement and increased demand.
• Referral, Assessment and Provision: additional staff time for regular reassessment and full discussion of mobility plans with service users following assessment
• Repair Maintenance and Support: introduction of a PPM programme across Scotland, plus regular replacement of older stock currently in the wheelchair fleet.

4. It should be noted that while costed recommendations specific to the children's service are included, the costs relating to additional staffing and equipment are contained within the recommendations that relate to: Overarching Principles for the Service and Referral, Assessment and Provision.

To make significant and lasting improvements additional funds will be needed, in particular for equipment purchase.

Work on health gain clearly indicates that there are major improvements to be achieved for relatively modest additional costs when compared to other health investments.

Approaches to funding should be flexible in order to achieve maximum benefits as quickly as possible and value for money should be maximised through service redesign.

The recommendations outlined by the Steering Group will cost approximately an extra £15.8 million per annum to deliver, in addition to the current £14.2 million budget. Given that this figure is an informed estimate, any release of funds should be subject to a full business case analysis. This level of investment would deliver a world-class service.

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