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Equipped for Inclusion: Report of the Strategy Forum: Equipment and Adaptations

Chapter 5
Assuring quality and innovation

We have already made recommendations for standards in information provision, for advice and demonstration services, and for accreditation of assessors. Promoting and encouraging change, and maintaining the impetus are essential. There are a number of ways in which this can be achieved:

5.1 Resource use

Existing spending on equipment and adaptations needs to be identified as a matter of urgency.

Recommendation 26: the Scottish Executive should commission work to identify the current annual expenditure on equipment and adaptations across all sectors, itemised to compare the cost of providing equipment and adaptations and the cost of the equipment and adaptations themselves.

To demonstrate that services are being provided in accordance with the principles of Best Value, information on resource use on equipment and adaptations is essential. There are some examples of helpful activity:

• Audit Scotland is carrying out a review of established baseline information on how [selected] community equipment and adaptation services are managed by the statutory agencies. The review aims to capture data on organisational structure, activity levels, expenditure, staffing, policies and procedures, management and performance information, as well as some basic information on joint working between local authorities and the NHS. The review will provide useful comparative information across Scotland, and will facilitate the change towards more seamless and person-centred care, and more effective and efficient services through joint resourcing and joint management.
• the new single regulatory framework operated by Communities Scotland includes performance management for the provision of adaptations in registered social landlords [RSL] including local authorities. An audit of the new self-assessment process is being piloted in five authorities this year.
• the Rehabilitation Technology Information System [ReTIS] is working to improve the information available for wheelchair and seating services, which together with the work of the Scottish Rehabilitation Technology Providers Forum [SCOTReT] aims to provide information to assist in the commissioning of these services.
• the national Social Work Information Review Group [SWIRG] was set up in 1998 to address longstanding concerns about the quality and availability of social work performance and management information. A data standards project, funded by the Modernising Government fund was set up to produce data definitions and standards to improve the consistency and quality of social care information, both locally and nationally.

Recommendation 27: the Data Standards Project should work with existing initiatives and relevant partners to develop standard definitions for data relating to equipment and adaptations, in consultation with the Implementation Steering Group.

The targeting of resources including priorities and eligibility criteria should be explicit. Traditionally the greater the perceived need in terms of cost or dependency, the higher priority it will receive for provision. There are however other factors to consider:

• the cheapest option may not always be the most cost-effective, when taking in to consideration the frequency of use and the need to service, maintain, and replace. The service and back up support included in the manufacturer price may be an important consideration. An alternative basis for resource allocation could include a 'cost utility' approach, where a range of such factors is considered.
• safety can be compromised by incorrect installation, and usage can be improved by spending time with the person. Visits to check the installation, demonstrate use and evaluate effectiveness are important, as is challenging traditional demarcations between delivery, installation and demonstration so that the number of people involved is kept to a minimum.
• supporting autonomy and independence in routine activities of daily life may encourage greater participation in the local community and in employment. This whole life cost of equipment and adaptations includes Value for Money [VFM], durability, and 'recyclability'.
• having the right piece of equipment or the right adaptation at the right time may delay or negate the need for other health and care services.

Mechanisms such as the Community Dependency Index appear to allow resources to be targeted to where they have the greatest impact, while the Resource Use Measure [RUM] is being developed as a tool linked to SSA to validate the process of resource allocation across Scotland.

Recommendation 28: the Implementation Steering Group should commission work to explore approaches to the allocation of resources for equipment and adaptations. Specific attention should be paid to those that capture the dynamic relationship between equipment and adaptations, rehabilitation and care.

5.2 Waiting times

The report 'Equipment and Adaptation Services in Scotland: A Survey of Waiting Times for Social Work Provision' [Scottish Executive Central Research Unit, 2001] highlighted the wide variation in ability to gather the data required, both in terms of quality and quantity. It noted that: "the improvement of data collection and the use of data to manage the demand and supply of equipment and adaptations could play a major role in improving provision. Until this is achieved, the measurement of the effectiveness of provision and outcomes for people using services cannot be contemplated".

The introduction of a standardised system of recording the component parts of waiting times for equipment and adaptation services will support measurable minimum waiting times across a wide range of service perspectives, that can be included within existing national waiting times reports.

Recommendation 29: the Implementation Steering Group should advise on minimum waiting times to be achieved across the equipment and adaptation spectrum.

5.3 Recycling

People want to be able to return items on loan for others to use, and mechanisms for selling on purchased items would be useful. The latter could potentially be assisted by the development of information and advice services, and also mechanisms such as the web based resource in the Scottish Borders.

Better use could be made of existing resources if the recycling of equipment and adaptations was more effective and widespread. Some areas of equipment provision rely on rigorous recycling for the service to survive, whilst in others there is considerable potential to extend available resources by establishing the facilities required to achieve this. Matching special and adapted housing to people who require the facilities is just as important as cleaning and repairing equipment.

Recommendation 30: the Implementation Steering Group should set targets for the recycling of equipment and adaptations [including those to capture the impact of registers of special and adapted properties].

5.4 Standards of care in equipment and adaptation services

The way in which equipment and adaptations are delivered, either from the commercial or statutory sector will have a bearing on the outcome for the person. A good experience will support, and a poor experience may undermine the success of equipment and adaptation use.

Routine servicing and maintenance, particularly where there are mechanical and electrical components, ensure effective operation and can reduce the need for costly and unpredictable repair and replacement. Assistance for unforeseen events and emergencies should be available at all times.

There are some mechanisms in place that seek to influence delivery and aftercare in a positive way, such as the standards required for membership of the British Health Trades Association, or those of the Association of Alarm Providers.

The Scottish Commission for the Regulation of Care [the 'Care Commission'] is a new, independent non-departmental government body, set up under the Regulation of Care [Scotland] Act 2001, to regulate care services throughout Scotland. Its purpose is to put in place a new, unified and effective system of regulation, which puts the safety and wellbeing of users at its heart. It aims to ensure improvement in the quality of care services in Scotland, respecting the rights of people who use those services to dignity, choice and safety.

In the same way that a wide range of care services are to be regulated by the Care Commission, the provision of equipment and adaptations should also be subject to scrutiny. Where provision is easily identifiable from the assessment process, such as an equipment store or a technician's service, this should be straightforward. However, some consideration of the implications of this for certain areas of provision is required, for example where the specialist assessor also provides the service.

Recommendation 31: The Implementation Steering Group should review the way in which equipment and adaptation services [statutory and commercial] are currently regulated to see if and how essential 'care components' are captured, and consider the action required to address any gaps. All local partners involved in the provision of equipment and adaptation services should ensure that requirements for routine maintenance and repair are met, and that systems are in place for any unforeseen events, including emergencies.

5.5 Developing competence

Professionals have acquired and developed specific and overlapping expertise in equipment and/or adaptations. Whilst we seek to acknowledge this within the SSA framework, consideration of the demands of the future are also required.

For example, the Centre of Rehabilitation Engineering [CORE] at Kings College London offers a MSc in Assistive Technology [AT]. The need for this grew from:

• the continuing growth of demand in the field of AT, from an ageing population and the increasing expectations of people with disabilities
• the increasing sophistication of AT equipment and the legislation surrounding it
• the demands of occupational standards now being introduced into the health service and elsewhere
• the repeated call for an integrated multidisciplinary approach to the provision of AT for disabled and older people

A new distance learning course, accredited by the University of Greenwich, has been designed for practitioners who inform and advise disabled and older people and their carers on matters relating to 'assistive technology' but as yet do not hold any formal qualification.

Recommendation 32: the Implementation Steering Group should advise on the development of the competency framework required in response to the Joint Future agenda [recommendation 21] and to meet the needs of the future.

5.6 Innovation and development

There would not appear to be any current links between the design, manufacture and construction of equipment and adaptations, and their provision, nor any formal links to people who use them. Partnership with all sectors is critical for research and development to improve the quality and range of products available.

The Audit Commission update 'Fully Equipped 2002: assisting independence' noted the lack of any national service focus within England and Wales, designed to support independence. Such a focus could bring together all stakeholders to "promote shared learning, improve standards and establish collaborative practice in services designed to promote independence. Such a body could contribute to establishing national standards and competencies, as well as examining important issues, such as the health economics arguments underpinning these services".

In Sweden the Swedish Handicap Institute works towards full participation and equality for disabled and older people by ensuring access to high quality assistive technology and an accessible environment. The Institute's work includes stimulation of research and development, analysis of needs and testing of assistive technology. It also gives out information and provides training to professionals regarding assistive technology for different categories of disabilities. The Institute is also involved in international research and co-operation projects, demonstrating the health economics of, and providing inspiration in, the field of assistive technology and accessibility.

Recommendation 33: the Scottish Executive should establish a 'Scottish Centre of Excellence and Development for Equipment and Adaptations', to support innovation and development and provide a national service focus.

5.7 Orthotics and Prosthetics

It may be that the work of the Strategy Forum is transferable to the assessment for and delivery of artificial limbs and devices such as splints. Orthotics are currently provided from over one hundred sites across Scotland, and prosthetics from five sites. Consideration of this by the current multi-agency review of orthotics services would be helpful.

Recommendation 34: the Rehabilitation Technology Services Advisory Group and relevant partners should consider the applications of the equipment and adaptation strategy for orthotic and prosthetic services, outlining the benefits of this approach.

5.8 Evidencing impact and effectiveness

To achieve a balance between the needs of the person and the most effective use of statutory resources, we need know as much as possible about the factors that influence the effectiveness of equipment and adaptations, and the resulting impact of equipment and adaptations on people's lives.

This will inform decision making in resource use and will evidence the contribution that equipment and adaptations can make to the delivery of national and local priorities such as more care at home. It will also inform future policy development, and provide a baseline against which new innovations and designs can be evaluated.

Factors that influence the use of equipment [and adaptations] include:

• medical related: impact of diagnosis
• client related: age, preferences, coping mechanisms
• equipment related: safety, fitness for purpose
• environmental factors
• assessment related: value of home visits, involvement [person and family]
• training related: extent of instruction received

  [Dr. Gail Mountain, DLCC conference 2002]

To establish the impact that equipment and adaptations can have we need to know:

• the impact of a particular product or design
• the relative impact of particular combinations of equipment and adaptations
• the wider benefits to the person: occupation, participation, social inclusion
• the impact on other health and care services

Products that support and maintain the independence and autonomy of the person can also be associated with habilitation and rehabilitation. These distinctions are not always clear cut but are important factors within the matrix of health and social care services. For example, the Victoria Project in London provided a community assessment and rehabilitation service for people aged 65 and over. It demonstrated a reduction in unnecessary domiciliary care packages, providing savings to social services of £65,000 in respect of the 27 clients included in the first intake, and a further £14,000 saving on a reduced need for equipment due to a problem solving rehabilitative approach.

Recommendation 35: The Scottish Executive should commission a review of the evidence available on the effectiveness of equipment and adaptations, the impact they have on people's lives, and the relative impact of equipment and adaptations in terms of costs and effectiveness in relation to other health and care services. This should inform the commissioning of subsequent work to fill any gaps.

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