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7 Summary and final remarks
7.1.1 Those of us who have worked on this project are in little doubt that the majority of staff within the wheelchair and seating service in NHSScotland are struggling hard to give a good service. Despite being successful in many instances, there is demoralisation and frustration at the limitations of the service. The most telling comment came from a member of clerical staff in a wheelchair centre: "We can walk away at the end of the day, they can't".
7.1.2 The level of user dissatisfaction and growing frustration at the shortcomings of the service can almost be felt. Despite a series of reports clearly outlining the need for change, the same problems remain: delays in assessment, provision and repairs, individuals who are unable to get the equipment they need to fulfil quite basic needs, and staff shortages causing further delays and difficulties. There are two issues that underpin all of these symptoms:
- shortage of funds due, at least in part, to a low visibility and status, and
- lack of accountability to drive up standards.
7.1.3 The main findings of our report are summarised below.
The remit of the service
- Assessment should embrace social inclusion and be based on the needs of users and carers and should reflect their lifestyle. 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 and be agreed with the user/carer.
- 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.
- 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.
Resources
- 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.
- Additional funds will be needed to make significant and lasting improvements; many of the current problems with the service are directly linked to lack of money.
- 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.
- 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.
- The recommendations outlined by the Steering Group will cost approximately an additional £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.
- It should be noted that, even if funds were to be freely available, improvements will take some time to implement, due in large part to staffing constraints.
Delivery
- 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.
- 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.
- 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.
Accountability
- The lack of visibility and accountability for the wheelchair service is one of its primary problems, and this must be resolved. Clear targets, regular information about performance and managers who are held to account for delivery are essential. There are several ways in which this key goal could be delivered: whichever is chosen, a mechanism for ensuring involvement of both users' and carers' voices are incorporated.
- Information systems are needed to allow monitoring and delivery.
We hope that this report will lead to these issues being addressed.
March 2006
Frontline Consultants
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