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3. Strategic Direction
3.1 Pilot National Service
Recommendations Covered
Recommendation 1 - establish an implementation team
An Implementation Team will be established to take forward delivery of the recommendations made in this report on behalf of the Minister for Health and Community Care.
Recommendation 2 - reorganise into a national, integrated, assistive technology service
The provision of all assistive technology services (including wheelchairs, seating, prosthetics, orthotics, augmentative communication, environmental controls) will be integrated into a single national service, funded centrally but delivered locally. The NHS Wheelchair and Seating Service will be accountable for expenditure through a budgetary process. With guidance from an Advisory Group comprising representatives of users, carers, service professionals and appropriate government departments, the national service will establish minimum performance standards for the service.
Executive's response
A Project Board, reporting to the Executive, should be established to drive the transformational change identified by the Review. Advice on the composition, remit and tenure of the Project Board should be sought from the NHS Rehabilitation Technology Advisory Group ( ReTSAG.), the advisory group established under NHSMEL(1997)47.
The Project Board, led by a senior NHS manager, should address the recommendations in the Review and develop a national Action Plan within the first 12 months for delivering change, for consideration by the Executive. The Board should provide appropriate leadership to drive forward change leading to improvements within the service.
An Advisory Group, consisting of professional experts in the field of rehabilitation and representatives from users, carers and the voluntary sector, should be established to advise the Executive, specifically, on progressing the recommendations. This Group should provide strategic direction and influence policy towards excellence in the delivery of Scotland's Wheelchair and Seating service.
The Advisory Group should establish national guidelines, within the same timescale as the Project Board, on minimum performance standards for the service to complement the Action Plan. In the longer term, it should examine how the goal of an integrated national service, encompassing all aspects of rehabilitation and assistive technology could be delivered locally in partnership with other agencies in accordance with the principles of Delivering for Health. It is vital that this group be aware of, and integrate, cross cutting policy developments which affect service delivery, into its recommendations.
(Example: Currently the Health Department is developing a Rehabilitation Framework as an outcome from Delivering for Health. This framework is designed to support services for older people, people with long term conditions and people returning to work after a period of ill health. It promotes a co-ordinated approach to delivering integrated care in community settings, focusing on developing the roles of nurses and of Allied Health Professionals. The Advisory Group should consider how the Review recommendations fit within this framework.
(Example: Changing Lives: Report of the 21 st Century Social Work Review (2006))
3.2 Embrace Social Inclusion
Recommendations Covered
Recommendation 3 - maximise social inclusion
The central ethos of the NHS Wheelchair and Seating Service will be to maximise social inclusion. At referral, assessment and provision, services will be led by the requirements of users and carers embracing individual lifestyles and aspirations, taking into account domestic, educational, vocational and environmental requirements.
Executive's response
It will require significant change to transfer services towards a more integrated approach which meets individual and social needs. However there is a strong argument that a holistic approach in assessing needs should take into account the wider health benefits of ensuring and sustaining adequate mobility. This then assists an individual to access services, employment, and social networks, all of which will contribute to improved health and wellbeing and, in turn, reduce demand on health and social services. There should be long term benefits to individuals, and to service providers, in ensuring rapid and appropriate provision of Wheelchair and Seating Services.
Recommendation 3 is in line with the Joint Future position on referral, assessment and provision. We agree, in particular, that the user and carer requirements are an essential part of the assessment process.
The Executive understands that eligibility criteria can, at times, be difficult to accept for those users and carers who wish to access the service. However, it is important to have clear, transparent criteria which reflect local and national priorities, and are developed in partnership with users and carers.
The Executive believes that, in easing the burden on service-users, by improving the range of services and support, more people dependent upon Wheelchair and Seating Services would have greater opportunities to participate more fully within their communities and within society generally.
Through its "Closing the Opportunity Gap" policy approach to tackling poverty and disadvantage, the Executive is looking at ways to improve access to enhanced services for people who could otherwise face barriers to full participation in society.
The Executive recommends that local partnership agreements between Local Authorities and NHS Boards consider joint funding arrangements for the provision of wheelchairs in certain situations. The development of local Community Health Partnerships should facilitate this process.
3.3 Life-change Transitions
Recommendations Covered
Recommendation 21 - services to support more effectively life-change transitions
Services will be provided so that critical life-change transitions affecting users and/or carers (child to adult service user, loss of key carer ( e.g. parent), university to workplace) are continuous and driven by the wishes of the user and carer.
Executive's response
The Executive supports this recommendation and understands that, in some parts of NHSScotland trained volunteers already provide support, particularly during the transition from children to adults services. Joint Future is identifying examples of good practice in, for example, Glasgow and addressing, with Social Work colleagues, whether involving the voluntary sector more actively in this support/advocacy role to users and carers can be delivered in the wider NHS.
3.4 Removal of Criteria
Recommendations Covered
Recommendation 9 - phased removal of eligibility criteria
Current eligibility criteria for NHS Wheelchair and Seating Services will be removed by phased implementation, unless they relate to safety.
Executive's response
The Executive acknowledges that the service is working within narrow parameters. The Executive is aware that phased implementation of this recommendation would be resource intensive. Changes in criteria should, therefore, be suitably phased in over time; should be developed in partnership with users and carers; should be open and transparent; and should be regularly reviewed. NHS Boards should aim to provide the most appropriate support possible to users and carers within their general allocations.
"Policies and criteria should genuinely contain the possibility of flexibility, based on the individual needs and circumstances of particular clients or patients"
(to avoid the courts reacting against public bodies which impose rigid policies or rules that are incapable of considering exceptions. This is known as "Fettering of discretion").
Extract from "Using the Law to develop and improve equipment and adaptation provision" Executive, 2003
To achieve this goal, the Advisory Group should work with the Executive, service providers, users and carers, in setting criteria for the future service delivery within the resources available.
Criteria in relation to safety would remain paramount, but be clearly defined and explained. Users and carers should be involved in defining the level of risk on a case by case basis.
3.5 Agreed Mobility Plan
Recommendations Covered
Recommendation 10 - agreed mobility and seating plan for each user
An individual mobility and seating plan will be developed for each user assessed and should form an agreement that is signed by the user, carer and wheelchair service clinician. In the event that there is a failure to agree on the mobility and seating plan then an independent review group will be available to arbitrate an agreement.
Executive's response
The Executive supports the recommendation that an individual mobility and seating plan be developed for each user assessed, and that NHS Boards should encourage service providers to develop and implement the use of such plans as an ongoing needs assessment tool. While it is acknowledged that this may increase the patient journey at assessment stage, it is considered an important aspect of service delivery.
It is a similar recommendation to that contained in "Care Management" and a National Training Framework and Resource Pack was developed by the Executive to support partnerships who have been asked to implement "Care Management" by June 2007. The Wheelchair and Seating Service could adapt this to suit service needs.
The Executive has noted the second part of the recommendation that an independent review group be established. However, there are already mechanisms in place to obtain a second opinion from another clinician or another regional service if that is thought to be necessary. There is also a formal NHS Complaints Procedure in place, and a right of appeal for individuals to the Scottish Public Services Ombudsman. It is acknowledged, however, that the importance of highlighting people's rights and providing them with appropriate information on the various stages and options available to them is a necessary strand in implementing this recommendation. This is an area where voluntary organisations could be asked to play a role in the dissemination of information.
3.6 Assessment
Recommendations Covered
Recommendation 5 - provide support for privately purchased wheelchairs
The NHS Wheelchair and Seating Service will support assessment and maintenance for a defined range of privately purchased wheelchairs.
Recommendation 8 - self-referral for reassessment
Users and carers will be informed that they can self-refer to the service for reassessment and repairs when they feel they are required. Any healthcare professional will be able to make a referral to the NHS Wheelchair and Seating Service. Training will be established to improve communications between referring community-based staff and service staff.
Recommendation 11 - assessment to document optimum equipment specifications
The assessment process will clearly document the optimum specifications to meet user and carer goals and requirements. Financial considerations should not be a key issue.
Recommendation 12 - assessment and provision for those who need the service
Assessment and provision of equipment will be available to all with mobility and/or postural support needs, including those in care homes, bariatric users and carers, people with terminal illness and people with acute needs.
Recommendation 14 - assessment to be integrated, multi-disciplinary and multi-agency
Assessment leading to provision of equipment will be an integrated, multi-disciplinary and multi-agency approach. Deployment of staff will be flexible, with medical staff available when needed but reserved for assessment of those with complex, multi-factoral needs.
Recommendation 15 - assessment to ensure compatibility with carer requirements
The assessment will include review of the particular requirements of carers ensuring that any equipment provided is compatible with requirements.
Executive's response
It is acknowledged by the Executive that patients should be given choices with regard to the services and equipment that is available, so that they can make informed decisions on the options that best meet their particular needs. By doing so, individuals are simply exercising their right to enhance their quality of life.
Feedback from the consultation exercise indicated that users generally have a high regard for the advice and support given to them by the staff within the Wheelchair and Seating service, and it is this professional advice that they wish to be able to access when choosing a privately sourced wheelchair. They are also aware that the range of NHS equipment available will always have financial limitations. The, Executive will, however, enter into discussions with NSS National Procurement about the range of wheelchair provision currently available and whether there is a case for this to be extended.
The Project Board would be expected to examine and quantify the potential for increasing the range to better address the needs of clients, the attendant impact on repair and maintenance, and the legal implications of doing so.
Self referral is already happening in some NHS Board areas and the service has agreed to roll it out across all regions. There is a desire, however, to recognise: (a) that healthcare professionals making referrals should be state registered; and (b) there would be a need for sufficient, appropriately trained, staff within the service if the referral rate increased the pressures on the service.
The Project Board should consider how best to achieve the balance between self referral, referral by a state registered healthcare professional and others such as local authority staff (occupational therapists for example), and service provision once a referral is made, which minimises the length of the patient journey. Although each local CHP will have its own Local Delivery Plans, the Project Board should give guidance on best practice.
It will be important to establish whether, and when, other partners in the mobility journey may allocate a wheelchair as an alternative to referral to the service, and at what point referral to the service is necessary. This should be an integral element of any training package for service providers. The resource issues require attention. For example, Local Authorities required to install ramps to enable wheelchair use, should be part of the decision making process at the Single Shared Assessment ( SSA). This will enhance their awareness of the importance of their role in the provision process; alert them to the financial implications; and that they can sign up to the mobility plan.
Appropriate training packages - including distance learning - should be designed to achieve the level of knowledge required to inform the decision to make a referral. There is also a recognised need to raise the profile of the Wheelchair Service within the NHS, with more commitment to AHP clinical placements.
The Executive is aware of the resource implications of recommendation 11, and while it is clearly the desired outcome for users and carers, the need to manage the service within available resources will require careful consideration to be given as to how this recommendation may be best delivered. In this respect partnership working within CHPs will be essential.
It is suggested that optimum equipment specifications should be documented at the SSA stage, at local level, on the basis of need, and the mobility plan should reflect agreement from all partners as to the best way to adequately meet that need, both in practical and resource terms.
Consideration should be given to the user's lifestyle, including whether they wish to undertake outdoor activities, or are in employment or education, and the appropriate partners should be involved in the SSA.
The Executive supports the principle of the provision of a wheelchair to anyone who needs one. As manufacturers have addressed the issue of very heavyweight users, unless it is on the grounds of safety, this is no longer an issue for the wheelchair service. Care home residents who have specific needs are entitled to access the local wheelchair service in the same way as any other individual living in the community.
The National Care Standards for care homes set out what the people using care home services can expect from the provider. The Standards specify that each resident will have a personal plan which details their needs and preferences and sets out how these will be met. This includes any special furniture, equipment and adaptations requirements.
The Executive is aware that service delivery can vary in different areas and locations, although in producing national standards for the wheelchair and seating service, it is hoped that any anomalies would be eliminated.
Patients with acute conditions linked to their mobility will have different needs, which should be met by appropriate provision within the Acute sector.
The establishment of Community Health Partnerships should facilitate the delivery of recommendation 14. The Executive agrees that wheelchair services should be provided through a whole system/multi agency approach. A skills mix from various agencies are required to co-ordinate, not just assessment, but a range of supporting provision. Local Joint Future Partnerships should include the Wheelchair and Seating Services in developing joint care pathways for these services and in working with users and carers to develop Local Improvement Targets, based to improve outcomes for service users, as part of the Joint Performance Information and Assessment Framework.
The Joint Performance Information and Assessment Framework ( JPIAF) is being extended beyond services for Older People, to all client groups for adult community care. Consideration will be given to including wheelchair services as a target area for physical disability in the guidance for 2007-08.
The Executive acknowledges that training issues and guidelines around referral issues will need to be addressed appropriately.
Including the needs of carers in assessing wheelchair and mobility needs is to be welcomed, as the Executive believes that carers should have the right to their own assessment within this service, as is currently the case within Community Care. However, it is recognised that this would have significant resource implications due to the likely demand for equipment such as lighter weight or power propelled chairs.
Service providers have indicated that they would welcome the ability to deliver this wider service to carers. However, there is the potential for differences between the views of the user and the carer and any national guidelines would have to allow appropriate flexibility to address this. Local agreements around carers should take account of this recommendation.
The Executive's response to the Care 21 Report - "the future of unpaid care in Scotland", highlights carer training as one of the four priority areas that the Executive will deliver, along with improving carer health, better support for young carers and improved short breaks for carers. The Executive is currently working with stakeholders to assess capacity and resource issues in preparation for the 2007 Spending Review. The Executive is likely to focus on generic training for carers, for example on carers' rights, and stress management/coping strategies.
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