Health and Social Care Committee
HSC(4)-08-12 paper 5
One-day inquiry on wheelchair services in Wales – Evidence from the Chartered Society of Physiotherapy
CSP Wales Office
1 Cathedral Road
Cardiff CF11 9SD
029 2038 24289
Dear Chair and Committee Members
One-day Enquiry on Wheelchair Services in Wales
The Chartered Society of Physiotherapy (CSP) in Wales is pleased to provide a written contribution to this review.
General introduction
The profession provided written and oral evidence to the review in 2010. Views were sought from clinicians working in the NHS across Wales and in particular views and recommendations were made by physiotherapy staff working in paediatrics, neurosciences and older people’s services where clinicians had direct interaction with ALAS services.
To inform this review of progress on wheelchair services the profession has once again canvassed views from clinicians across Wales, responding with views on progress against the recommendations made by the committee.
Key points from the Chartered Society of Physiotherapy
Recommendation 1. We recommend that the Welsh Government ensures that a full, national service specification be prepared, including details on the service’s approach to joint working with other organisations; joint funding with organisations and individuals; and information on performance targets and monitoring systems.
CSP members did not report that they have had sight of a national service specification but the profession understands that the Posture and Mobility Partnership Board has developed it and it forms part of their terms of reference.
Recommendation 2. We recommend that the Welsh Government should draw up a strategic plan, to give direction to the service over the coming years. This should be done in conjunction with the service providers, users, stakeholders and other interested parties.
The CSP understands that the National Leadership and Innovation Agency for Healthcare (NLIAH) and the Delivery Service Unit (DSU) have been working with the service to put in place the strategic priorities for service development and delivery. Members from North Wales report an ‘ALAS Turnaround Team’ followed by meetings with NLIAH. One of the goals of these meetings was to improve the integration of the ALAS service with the community professionals and the ‘Team around the Child’. Improvement has been made but members consider more progress is needed. There has been a perception in the past of ‘disconnect’ between ALAS and the reality of community work with children with disabilities.
The CSP understands that the service priorities, which include Referral to Treatment Guidelines (RTT), are being monitored by ALAS on a 60 day cycle.
Recommendation 3. We recommend that the strategic plan should address the need for better integration of the service with community and other NHS services and with social services.
Members report that efforts have been made here. Since the publication of the first review the paediatric physiotherapy managers held a productive meeting with the manager of ALAS in South Wales to better understand the needs of their patients. This was seen as very useful and it is hoped that such meetings can continue to be a regular occurrence. The CSP understands that a range of joint clinics with paediatric therapists have been organised in the South and in increasingly varied venues in the community.
Members in the North report there has been some change in venues used which has shortened journey times for families and staff from North West Wales. There was praise for the use of the Children’s Development Centre in Bangor for joint consultations with local therapists. It was also hoped that the Llanwrst clinic could be used once more which would improve access from Gwynedd and Ynys Mon.
Recommendation 4. We recommend that the Welsh Government ensures that the arrangements for a restructured wheelchair service incorporate clear responsibilities and lines of accountability for service delivery.
At the time of the last review there was some confusion within the physiotherapy membership around responsibilities and lines of accountability. Physiotherapists now understand that the ALAC services have direct accountability to the Executive Board of the Cardiff and Vale (in the South) and Betsi Cadwaladr (in the North) Health Boards. The Welsh Health Specialist Service Committee (WHSSC) funds, and takes monthly reports from both ALACs and the Posture and Mobility Partnership Board meets quarterly.
The CSP would like to see more information in the public domain in relation to funding and decision making at WHSSC level. The profession understands that whilst additional money was provided by Welsh Government to ALAS, the service was expected to find, and make efficiency savings. Whilst efforts are being made to bring down waiting times it would appear counter-productive to take money away from ALAS.
Recommendation 5. We recommend that new performance measures should focus on outcomes for users, taking account of their wider needs.
Very few members who provided feedback had knowledge of performance measures that are being used by ALAS. Most commented on waiting times and others commented on communication with referrers and service users. The main performance indicators relate to the National Service Framework for Children (assessment and delivery) and the RTT target.
The CSP understands that new quality indicators have been agreed around:
· Provision of service information
· Providing a quality service (to include qualifications and CPD, assessment, delivery and maintenance and user feedback)
· The care pathway
In relation to taking account of a client’s wider needs, South Wales ALAS encourages referring therapists to undertake joint assessment with them so that lifestyle and particular needs can be addressed. The service does stress, however, they are only funded for essential health needs.
Recommendation 6. We recommend that the Minister should keep under review the planned performance measures and targets and should introduce sanctions for non-compliance.
No specific comment from the CSP.
Recommendation 7. We recommend that the service specification should include an action plan, including targets and milestones, for meeting the standards in the Children’s NSF on wheelchairs.
The CSP has not had sight of the service specification but does understand that both ALAC services aim to be meeting the Children’s NSF target on wheelchairs by the end of March 2012. The challenge for the service will be sustaining the ability to meet targets.
Recommendation 8. We recommend that the Welsh Government ensures that the service prepares a communication strategy to outline how it will improve communication with users and stakeholders. This communication strategy should be drawn up and introduced as a matter of urgency.
The CSP highlights this was an area of concern in the last review but from the feedback received from members in Wales there has been a perceived improvement in communication for referring therapists with ALAS. Physiotherapists in mental health services report improved dialogue with ALAS, providing them with photographs and additional information on possible usage of the wheelchair.
Although the CSP has not seen a communication strategy the profession understands the ALAS service has worked closely with NLIAH holding events with stakeholders (including community therapists) and are now involved in a Wales-wide Service User Engagement work stream with three year funding from Welsh Government.
In North Wales, a physiotherapist has been seconded to look specifically at communication with service users and with referrers to the service. A welcome pack has been developed for patients and referring therapists receive better information and access to training.
In South Wales, the CSP understands that a DVD has been developed, currently being trialled, that will provide improved support for the referring therapists.
Recommendation 9. We recommend that the communication strategy should include measures to provide better information to users generally, but in particular on progress within the system.
Members have not provided many examples or issues with this and it is considered that RTT process should mean that service users should have better information on timescales. ALAS will contact service users to confirm they are happy to accept appointments. Emergency call out service is in place and emergency repairs are carried out within 24 hours, according to ALAS.
Recommendation 10. We recommend that the Welsh Government should explore with the service, voluntary organisations and charities, options for providing the best possible interim solutions for users who will be waiting for significant periods for delivery or maintenance of a chair.
Members in North Wales were not aware of developments in this area. South Wales ALAS reported they had met with (British Red Cross) to review closer working opportunities. They have also developed a drop-in clinic to improve access to timely re-assessment and repairs.
Recommendation 11. We recommend that the Welsh Government should conduct an assessment of the long-term resource needs of the service, giving particular consideration to the resources required to sustain improved waiting times; provide regular reviews for some users; and to clear the waiting list backlog in North Wales. The Government should then make a clear statement setting out how it intends to meet these resource requirements for the current budget cycle.
The CSP has heard from members that waiting times have improved and it would appear that work done in North Wales has cleared the backlog. The CSP understands capacity and demand analysis has been undertaken and in both ALACs new systems have been put in place to bring about sustainable change.
RTT requires particular information on waiting times and North Wales ALAS now has a new information system that has been up and running since December 2011.
South Wales ALAS told the CSP it is undertaking work to introduce an off line working system which will enable staff to review and input data off site, releasing more clinical time.
Recommendation 12. We recommend that the Welsh Government should explore opportunities for joint working between ALAS and organisations, charities, community therapists and others, and that this should form a central part of the service’s strategic plan
Members report meetings with ALAS staff, training and joint clinics. The All Wales Paediatric Physiotherapy Service Managers met with the Head of South Wales ALAS and a senior staff member to discuss issues and ways to improve the experience for the referrer.
The CSP has not seen the service’s strategic plan so cannot comment further on this.
Recommendation 13. We recommend that the Welsh Government ensures that efforts are made to streamline the referrals process, possibly through the development of on-line resources.
Members report still using paper based referral systems at the moment but within the NLIAH 60 day review process there has been a referrals work stream which has had the aim of developing an improved referral form which will be consistent across South and North Wales.
It would appear that ALAS is concentrating on getting the referrals that come in to them to be of a better quality rather than moving to a web based resource. Time and effort, at this stage, has been spent on sharpening up the referral but the CSP understands ALAS will be moving on to look at electronic referrals.
Recommendation 14. We recommend that the Welsh Government should ensure that there is a sufficient number of community therapists trained to undertake Level 3 assessments.
The CSP is pleased to note that staffing levels in the ALAS has increased as a result of the investment made in the service. At the time of the original review, the CSP lobbied hard to increase the pool of therapists with level 3 assessment skills.
NLIAH has supported the service in conducting capacity and demand analysis and funding has also supported administrative posts which in turn have freed up clinical time. So, whilst there may not be an increased capacity of community therapists trained to level 3, the capacity overall has increased.
ALAS have explained to us that to be trained to level 3 is complex and requires detailed knowledge of a wide range of seating solutions, accessories and products. Assessors need to maintain their knowledge and be safe prescribers. Where they deal with community therapists regularly they have developed a ‘trusted assessor’ relationship and they will accept prescriptions from these therapists.
Trusted assessors may have worked in ALAS or have been in a rotational post based in ALAS and thus have built up the expertise and knowledge.
The ‘All-Wales’ training manager has trained over 1000 nurses and therapists to level 1 standard over the last 2 years. A neuro clinical specialist physiotherapist reported she had requested level 1 training for specialist nurses and this was delivered and has subsequently vastly improved the quality of referrals. It has also raised the awareness of multidisciplinary team members of when to refer for new wheelchairs and when review appointments are required.
The physiotherapists who work in South Wales ALAS tell the CSP that the amount of equipment specific information regarding the products on the contract is staggering. They comment that the recommendation needs careful consideration regarding the practicalities and possible clinical governance implications.
Recommendation 15. We recommend that, as a matter of urgency, the Welsh Government should clarify and make public the policies and arrangements for joint funding with organisations and individuals.
No specific comment from the CSP.
Recommendation 16. We recommend that the Welsh Government clarifies and makes public its policy and arrangements for the maintenance and repair of equipment bought by individuals.
The CSP does not know of any specific policy on this at the present time but understands that local agreements are being developed.
This is an area that will need further development and communication with service users and local referrers.
Recommendation 17. We recommend that the Welsh Government should explore further the possibility of pooling existing budgets, particularly education budgets, in relation to the provision of equipment for users.
No specific comment from the CSP.
Recommendation 18. We recommend that the Welsh Government should review arrangements for short-term loans of wheelchairs, which are not provided by ALAS, to ensure that this service provision is adequately resourced.
CSP members tell us that the British Red Cross take on short term loans. A Paediatric physiotherapist in North Wales noted that they usually have no children’s size chairs. South Wales ALAS reported to us that assessment training has been provided to the British Red Cross. The CSP cannot comment on whether it is adequately resourced.
Recommendation 19. We also recommend that the Welsh Government should ensure closer joint working between ALAS and those providing short-term loans of wheelchairs, particularly the British Red Cross.
No specific comment from the CSP.
Recommendation 20. We recommend that the Welsh Government should ensure that the arrangements for maintenance and repair in Cardiff ALAC, and Wrexham ALAC be kept under review, to ensure that the service is meeting the necessary standards.
South Wales ALAS has brought the approved repairer service in house and has made a range of changes such as ‘one stop’ clinics at the depot, weekend clinics at the depot, a delivery driver and a fitter based in West Wales.
Members in North Wales report that repair services are good but there is no regular maintenance.
Recommendation 21. We recommend that the Welsh Government should ensure that ALAS consults users and stakeholders on their needs in advance of any future tendering process for maintenance and repair contracts.
The CSP understands that ALAS has undertaken this and NLIAH are supporting a 3-year Welsh Government user engagement work stream which will provide a valuable opportunity for service users and their families to shape improvements in the future.
Recommendation 22. We recommend that the Welsh Government should ensure that regular reviews for users are delivered, particularly for children and other users with changing conditions.
Responses differ from around Wales. Members in the North suggest that regular reviews are not currently in place. Community paediatric therapists have to inform ALAS when they feel the child needs reviewing. The CSP understands that once the capacity and demand analysis in North Wales ALAC has been completed regular reviews for paediatric service users will be undertaken.
In the South, the CSP understands that regular reviews are in place for Rehabilitation Engineering Unit service users because of the complexity of the client’s condition. Adults are reviewed once a year and children are reviewed twice a year.
Recommendation 23. We recommend that the Welsh Government should ensure that ALAS explores joint working opportunities with charities to provide training for users.
The CSP understands that funding has been allocated to support training of some service users and a tender is being developed in conjunction with NLIAH to provide training across Wales.
Concluding comments
Overall, member feedback to the CSP reports improvements in services and dealings with ALAS for the referring physiotherapists. There still seem to be a few issues but opportunities exist to raise these with ALAS and look for solutions.
Communication remains the key area where continued development will improve the experience of those referring in to the service.
Re-assessment and review, particularly for children, is on the agenda for continued development and training for service users is also under consideration. These were areas of concern raised by the CSP in the previous review.
The CSP notes that both ALAS services expect to achieve the Children’s NSF target by the end of March 2012. The key issue then will be sustaining that target and continuing to make improvements in waiting times for adults. The profession hopes that the Committee will keep wheelchair services on the agenda and ask the Welsh Government and WHSSC for regular updates.
Philippa Ford MCSP
CSP Policy Officer for Wales
March 2012
About the CSP and Physiotherapy
The Chartered Society of Physiotherapy is the professional, educational and trade union body for the UK’s 50,000 chartered physiotherapists, physiotherapy students and support workers. The CSP represents over 2,000 members in Wales.
Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity. Physiotherapists and their teams work with a wide range of population groups (including children, those of working age and older people); across sectors; and in hospital, community and workplace settings. Physiotherapists facilitate early intervention, support self management and promote independence, helping to prevent episodes of ill health and disability developing into chronic conditions.
Physiotherapy delivers high quality, innovative services in accessible, responsive and timely ways. It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person centred professionalism. As an adaptable, engaged workforce, physiotherapy teams have the skills to address healthcare priorities, meet individual needs and to develop and deliver services in clinically and cost-effective ways. With a focus on quality and productivity, physiotherapy puts meeting patient and population needs, optimising clinical outcomes and the patient experience at the centre of all it does.
Philippa Ford MCSP
CSP Policy Officer for Wales
07990 542436
February 2012
This submission has been developed with contribution from:
The All Wales Physiotherapy Managers Committee
The All Wales Children and Young People’s Physiotherapy Service Managers Committee
The Welsh Neuro Physiotherapy Network
The Welsh Paediatric Physiotherapy Network
The Welsh Older People’s Physiotherapy Network