Health and Social Care Committee

HSC(4)-08-12 paper 6

One Day Inquiry on wheelchair services in Wales – Evidence from the College of Occupational Therapists

Introduction

The College of Occupational Therapists is the professional body for occupational therapists and represents around 28,000 occupational therapists, support workers and students from across the United Kingdom and 1,500 in Wales. Occupational therapists work in the NHS, Local Authority housing and social services departments, wheelchair and prosthetics services, schools, prisons, voluntary and independent sectors, and vocational and employment rehabilitation services.

Occupation, i.e. all the things that people do or participate in, is fundamental to the health and wellbeing of individuals. Occupational therapists work with wheelchair users and their families and carers to enable them to take control of their lives. Wheelchairs, specialist buggies and other assistive equipment are key in enabling people live full and independent lives and participate in their communities. 

Occupational therapists from all over Wales have contributed to this response.

General Comment

The College is aware that the posture and mobility service has undergone significant change. Much of this work has focused on developments in service priorities and in processes which will result in fundamental change as they are implemented but may take a while to show effect in practice. Occupational therapists are now beginning to report significant improvements and developments in wheelchair services across Wales and this review is occurring just as the all the changes are taking effect; in another few months the fundamental impact of change will be clearer. It will be important that the Welsh Health Specialist Services Committee (WHSSC) and host Local Health Boards continue to support the new posture and mobility service to sustain these improvements in the coming years.

Many occupational therapists report a significant reduction in waiting times for assessments and in the provision of children’s wheelchairs.

Specific comments

National Service Specification and Strategic Plan

The College understands that significant work has been undertaken to develop this and that strategic priorities for the service are being articulated. Occupational therapists have been included in the development of these priorities and in providing feedback to the service. These will now need to be implemented and communicated.

The College assumes these service priorities will be common for the whole service and that although remaining within two separate health boards, they and or WHSSC will be responsible for an overview to monitor performance against the priorities. This will help service users experience a common standard regardless of which centre provides that service.

Integration with community and other NHS services and with social services

Occupational therapists are beginning to see improvements in this area.  Regular meetings now occur with groups such as the paediatric occupational therapy managers. It is our understanding that the initial focus of ALAS’ work has been on reducing waiting times for assessments and wheelchairs. The required improved communication with social services and other agencies will be the next stage of work. This is a complex area and good communication and liaison systems will be needed to ensure that when an adaptation is required to facilitate the use of a wheelchair that concurrent referrals, for example to social services for adaptations, are made to reduce delays and maximise the effectiveness of outcomes. Not all referrers are aware of the need to do this and omissions may only become apparent once someone is seen by ALAS staff. As waiting times continue to reduce and communication is improved this should become less of a problem. Some referrer education may also help.  The College has discussed this with the wheelchair service and are pleased to learn that the intention is to develop clear pathways to create better integrated working.

Performance measures should focus on outcomes forusers, taking account of their wider needs

Some occupational therapists have reported that there are times when the complexity of the postural need results in a chair that does not facilitate good participation in activity. For example, it is difficult to transfer independently because of fixed footrests, or the chair is too big to use in the family car. However, the wheelchair service is developing new protocols to enable service users to prioritise their needs to find a solution to fit their lifestyle where those choices do not increase long term health problems. As this way of working develops and becomes more widespread there should be greater co-production of good solutions because service users, families and health professionals have been part of the decision making process.

Waiting times

Occupational therapists report a significant change within the last few months. The posture and mobility service report that 95% of standard chairs in South Wales are delivered within five days of ALAS receiving the item and 97% in 21 days in North Wales. Waiting times for assessment for children is within six weeks. There are still some long waits for complex solutions. However, where appropriate short term loans are used. For those whose needs cannot be met except by the complex solution, which can take a long time to produce, the service is beginning to communicate processes and options so that people understand reasons for decisions.

The additional money for children’s wheelchairs has been vital in increasing capacity. It will be important to sustain this. The service is also changing working patterns to create capacity and this has meant more timely assessments and the capacity to begin reviewing children’s needs.

Communication

Communication is improving so that people are beginning to see why they are waiting and when they might receive their chair. Therapists report that quicker responses to referrals are beginning to occur and ALAS report they invite community therapists to joint appointments. Some therapists would like to see the possibility of tracking requests online so that they are able to monitor where in the process they are, but priority so far has rightly been given to reducing waiting times over new communication developments.

The new service will need to effectively communicate its plans for change to the wider group of health and social care professionals as well as communicating specifically on the progress for delivering specific service users chairs. 

Number of community therapists trained to undertake Level 3 assessments

1,000 nurses and therapists have been trained to level 1 standard over the last two years. The use of year long rotations of staff into the service has also increased knowledge levels in community and hospital therapy services.  The increased capacity in the service has reduced waiting times for all assessments, which has released ALAS staff with specialist expertise to assess people with complex needs themselves. So although the number of community therapists trained to level three has not increased this alternative solution has provided a quality outcome for those previously waiting for an assessment. It will be important to ensure that this level of waiting time is maintained in the long term. The work on the service priorities and further change in referral, emergency responses, review and evaluation processes will embed these improvements in the new service.

Joint funding and working

The College understands from the posture and mobility service that this is being developed with charities and local authorities. Local protocols are being developed and individuals are now allowed to fund “extras” provided that ALAS staff are sure these do not compromise the effectiveness of the core provision. Joint funding with continuing care funding is already happening and that is making a difference for service users.

Maintenance and repair

The College received some mixed comments about this. Where therapists have experienced the new system they report that the changes to the maintenance and repair service are good. Not all therapists or clients have yet experienced the new system and thus awareness is lagging behind the new developments. Those who have not, still report concerns from their previous experience.

Regular reviews forusers are delivered, particularly for children

ALAS has told the College that from October 2011 every child will be reviewed annually. We welcome this development and support the changes made by the service to create this capacity. Because this is new, not all service users and therapists are yet aware of this process. As it becomes established, we expect satisfaction and confidence with the service to rise. It will be vital that this new capacity and quality of service is maintained and the investment in the service will need to be protected in the difficult times facing all public services.

Conclusion

The investment and strategic support for the new posture and mobility service will deliver high quality service improvements. Such fundamental change in service provision always takes time to implement and this review is occurring just as the service starts to implement real improvements. Therapists are beginning to see the effects of this change and their satisfaction is increasing and service user outcomes are improving. However, not everyone has yet experienced them. Another three or four months should see more widespread impact.

The danger is that in these difficult financial times the service will face reductions in resources that undermine the excellent work which is beginning to make such a difference