Health and Social Care Committee

HSC(4)-09-12 paper 1

One-day inquiry on wheelchair services in Wales – Evidence from the Artificial Limb and Appliance Service, Cardiff

 

 

Background

Health Commission Wales [HCW], now Welsh Health Specialist Services Committee (WHSSC) is responsible for commissioning Assistive Technology from the Artificial Limb and Appliance Services [ALAS] for people resident, or who are registered with a GP in Wales. In line with NHS criteria, ALAS is resourced to provide essential equipment whilst striving to meet lifestyle needs within allocated resource constraints. ALAS offers a consistent and equitable service to people in Wales who have a permanent or long-term impairment. Short term disability needs are met through alternative sources.

 

ALAS is essentially a community service providing services for the whole of Wales. Clinical assessments and the delivery and repair of equipment are largely done at the user’s home, school or local hospital site. Users do attend ALAS for specialist assessment or because of the specialist facilities such as workshops, computer aided design technologies and equipment, casting rooms, physiotherapy gym, and walking training facilities.

 

ALAS is provided by a unique collaboration between three Local Health Boards. The three ALAS centres [ALAC] are situated in Cardiff (Cardiff and Vale UHB), Wrexham ( Betsi Cadwalladr UHB)and Swansea(Abertawe Bro Morgannwg UHB), working together to provide an All-Wales service.

 

 

 

Service

Cardiff 10

Area

Posture and Mobility [Wheelchair]

49,693

S Wales

Prosthetic

1,734

SE Wales

Orbital Prosthetic

2,483

All Wales

Electronic Assistive Technology Service (EAT).

563

All Wales

War Veterans Service

34*

SE Wales

Communication assessments

Orthotics

117

 

10,000

S Wales

 

Cardiff and Vale

Total

64,624

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*included in Prosthetic total

 

 

ALAS service profile:

 

Service

Cardiff

Wrexham

Swansea

Posture mobility /wheelchair service

√

√

 

Rehabilitation Engineering

√

√

√ equipment funded by Cardiff

Prosthetics

√

√

√

Orbital prosthetics

√

 

 

EAT

√

 

 

Orthotics local not WHSSC

√

√

√

 

 

 

The Cardiff posture and mobility services are supported by Rehabilitation Engineering services based respectively at Cardiff and Swansea who provide bespoke solutions for the most complex cases. Funding for these cases comes from the ALAS WHSSC budget.

 

ALAS currently receives an average of 800 referrals per month, broken down as follows:

 

 

Approx Total referrals a year = 9340

Per month = 779

of which 58% are new referrals

 

 

 

By Pathway Type

Standard

Per Year Approx = 4280

per month 357

46% of all referrals

 

Complex Postural

Per Year Approx = 2438

per month = 203

26% of all referrals

 

Technical

Per Year Approx = 1511

per month = 125

16% of all referrals

 

EPIOC (Electric powered indoor /outdoor)

Per Year Approx = 569

per month = 47

6% of all referrals

 

BER (Beyond economic repair)

Per Year Approx = 545

per month = 45

6% of all referrals

 

Following the period of the 2009 posture mobility review, the Minister for Health and Social care reported that:

 

The majority of wheelchair users are satisfied with the service.  Over 70% then received their wheelchairs within three weeks.  Some people with complex needs experienced longer waits. The approach to service delivery was not uniform across Wales.

 

She noted that there were currently variable (and sometimes significant) bottlenecks in the supply chain process resulting in delays between the raising of a wheelchair prescription and its delivery to the client. Also that across the four home nations, Wales provides its service users with the largest range of equipment, acknowledging that this is a deliberate strategy which enables clinical needs to be met to best effect, and maximising independence for service users.

 

The Artificial Limb and Appliance Service provide a wheelchair service that principally meets “health needs”, that is essential posture and mobility needs. Service users often need to have their wider requirements taken into account during the assessment process and every effort is made to accommodate these requirements, for example an increasing number of clients who live in local authority accommodation require mid wheel drive power chairs because it gives a smaller turning circle therefore it can be used in more compact settings.

 

A quality repair and maintenance service is an intrinsic and critical part of the wheelchair service, and is vital for all clients. The maintenance service in South Wales was then outsourced and had been subject to criticism. It was subsequently brought in-house in February 2010.

 

Short-term wheelchair loans (less than 6 months) are not funded through the Artificial Limb and Appliance Service. Currently, most clients, carers and practitioners rely on voluntary agencies for this service.

 

The Rehabilitation Engineering Units have been responsible for much development and innovation in this field, both locally and nationally. They are a crucial part of the wheelchair service and look after some of the most complex clients.

 

From this Ministerial response came a series of recommendations that are noted and updated below.

 

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 and individuals; and information on performance targets and monitoring systems.

 

The Partnership Board has been established and 3 meetings have so far taken place. The Board membership reflects the range of individuals and organisations involved in service delivery and use. The development of a service specification and robust key performance indicators, to support performance improvement, are specified in the Terms of Reference and reported to each Board meeting. Prior to the establishment of the Board, work was undertaken in conjunction with HCW, service user representatives and managers to agree the service specification and eligibility criteria.

 

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.

 

Work led by NLIAH and DSU in conjunction with service users and representatives as well as a broad range of clinical referrers have over the last 18 months developed service priorities which are being monitored on a 60 day cycle. These objectives have been adopted in both the North and South services to ensure equity of service improvement across Wales.

These include reporting Referral to Treatment Guidelines (RTT), capacity and demand assessment, a new referral form and new and more efficient ways of working.

 

Recommendation 3 

We recommend that the strategic plan should address the need for better integration of the service with the community and other NHS services and with social services.

 

A range of initiatives have taken place with more planned for the future. Currently ALAS senior clinical staff meet with All Wales professional groups to help us gain a greater understanding of their needs. This includes paediatric Occupational and Physiotherapy managers, Tissue Viability nurses, District Nurse managers. Training for referrers is delivered to a range of disciplines and students across Wales – over 1000 to date. Joint clinics with paediatric therapists are organised in Cardiff, Brecon and other centres. The number and range of venues for community clinics has been increased.

Band 6 occupational therapists rotate into the service for year long secondments which trains them to a high level of expertise.

 

 

Recommendation 4

We recommend that the Welsh Government ensures that the arrangements for a restructured wheelchair service incorporates clear responsibilities and lines of accountability for service delivery.

 

The Cardiff service has clear lines of responsibility to the Executive Board of Directors in Cardiff and Vale UHB with direct line management to the Executive Director of Therapies and Health Sciences. Service delivery for all specialities is reported via monthly meetings with Welsh Health Specialist Services Committee(WHSSC) and quarterly meetings with the Partnership Board. Every specialist professional section has a clinical/technical or engineering lead.  

 

Recommendation 5

We recommend that new performance measures should focus on outcomes for users, taking account of their wider needs.

 

Quality indicators have been agreed and are reported to the Partnership Board. These come under the headings of

 

1   Staff qualifications and CPD

2   Assessment

3   Delivery and maintenance

4   User feedback

·    Care pathway

 

Key performance indicators link to the National Service Framework for Children, waiting times for delivery of equipment and Referral to Treatment Guidelines(RTT) etc When the original review was undertaken our percentage compliance for the delivery of standard chairs within 21 days was 70%. This now stand at 95% compliance for delivery within 5 days. 

Work begun as a pilot scheme in which “Rea Assist” chairs are provided for spinal/head injury patients in ITU initially in Cardiff and now rolled out to include Swansea has saved hundreds of bed days by providing a specialist chair within 48hours. The patients are able to sit out earlier , improving posture, access to physio and rehabilitation.

 

Recommendation 6

We recommend that the Minister should keep under review the planned performance measures and targets and should introduce sanctions for non-compliance.

 

See response to recommendation number 5. NLIAH and DSU have been supporting ALAS to ensure waiting times are measured in accordance with Referral to Treatment process measures.  DSU are conducting assessments in both centres to ensure this is in place and have supported the service in implementing a capacity and demand review for clinical interventions. This model will now be rolled out across all services.

 

 

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.

 

A comprehensive assessment has been undertaken in conjunction with NLIAH and DSU to ensure compliance. The technical team at Cardiff have further developed the BEST(Bringing Equipment Services Together) IT system to ensure we are compliant with and reporting to NSF standards. We are currently in shadow format but will go live on 1st April.  

 

Recommendation 8 

We recommend that the Welsh Government ensure 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 service has worked closely with NLIAH to improve communication with service users. This will be taken forward in a number of ways.

As part of the 60 Day Review process, a Wales-wide Service User Engagement Work stream has been established with three years funding from Welsh Government. The working group consisting of ALAS, a community therapist and service user members with the express remit to:

 

1. Identify effective ways to capture service users’ views and experiences

2. Actively gather a baseline of the views and experiences of users using both quantitative and qualitative means

3. Prepare & implement a three year service user engagement strategy using the baseline information gathered, to target continuous improvement in service user engagement

 

4. Following a competitive tendering process an external consultancy, the “Kafka Brigade” were appointed to support the workgroup in developing an in-depth understanding of the user experience during year one of the strategy. In part, the aim of this process was also to begin creating a cohort of service users and staff who will go on to co-design future services during the second year using an Experience Based Co-Design (EBCD) advocated by the Kings Fund. The findings will also inform a feedback system which will be an ongoing source of insight for ALAS. It is also anticipated that this comprehensive baseline work with ALAS service users will begin a dialogue whereby the service can better understand how users prefer to be informed of developments within the service.

 

As well as this we have information screens at the Cardiff Centre that are regularly updated with service user information, each clinic has user questionnaires available for feedback as well as the ALAS website.

 

Cardiff has also prepared an over view of the service we provide in layman’s terms which describes what a service user can expect from us when they are referred to the service. This is in final draft and will be put on the web site.

 

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.

          

Under the rules of RTT we are obliged to contact every service user to confirm they are happy to accept the appointment we offer them. Appointment times and venues are agreed by telephone unless we are unable to make contact at which point we would write to the client and or the referrer. To ensure we are compliant appointments are currently being made within 3 weeks of referral to ensure the appointment for assessment is within 6 weeks of referral.

Written information is currently being reviewed in readiness to translate into Welsh.

 

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.

 

The service has met with British Red Cross (BRC) to review closer working opportunities. We have provided wheelchair assessment training for their staff, and both agencies collect and return equipment for each other. Data protection issues prevent us from giving personal client information to BRC. It should be noted that for complex users an interim solution may not be suitable and if an inappropriate seating system is provided, long term harm could be caused.  

 

South Wales ALAS has developed drop-in clinics at the Cardiff depot to improve clients’ access to timely assessment and repairs. We have also appointed a delivery driver and a fitter in West Wales which both reduces travel time and costs for the service and also makes the service more available to the clients in that area. The service provides a 365 day emergency call out service and all urgent calls are visited within 24 hours. Where possible if a repair cannot be undertaken immediately every effort is made to provide a temporary solution for those service users who are dependent on their wheelchair.

Recommendation 11 

We recommend that the Welsh Government should conduct an assessment of the long-term 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.

 

NLIAH has supported the service in conducting a capacity and demand analysis which in South Wales has identified a number of service improvements. An additional 13% of clinical time has been released by the appointment of a band 2 administrator for both the clinical and technical teams. We have increased satellite clinics; introduced one-stop clinics and weekend clinics and as a result we have reduced waiting times for assessments for paediatrics to a maximum of 6 weeks (32 weeks at April 2011) and adult waiting times for assessments to a maximum of 16 weeks( 44 weeks in April 2011).  Work is being undertaken to introduce an off line working system which will enable staff to review and input data off site and release even 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.

 

Work is underway to strengthen relationships with children’s charity groups on joint training for children. BRS for collection of equipment and training of their staff, Joint clinics are held in conjunction with paediatric therapists, meeting all Wales professional groups like paediatric Occupational Therapy and Physiotherapy managers and District Nurses and Tissue Viability nurses.

 

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.

 

A great deal of preparatory work has been undertaken with regard to the referral form and joint meetings are being facilitated by NLIAH to complete this work. At present on line referrals are limited because health is able to only shared patient identifiable data between NHS establishments.

 

Within the NLIAH 60 day review process a Referrals work stream has been established to review the referral process with the aim of developing an improved referral form which is consistent across both the South and North Wales Services.

 Following an audit of referrals to South Wales reviewing 12 months of referral data, 5.6% of all referrals were returned to the referrer as incomplete, with a further 22% of these being returned a second time. The audit also identified the common reasons why referrals were returned, one of which being the quality of the clients measurements given. As a result, the redesigned form seeks to clarify the expected measurement standards and an explanatory DVD has been produced for referrers by the All Wales Trainer. The DVD is currently being trialled by clinicians in the community to ensure it is fit for it’s purpose.  

 

A final workshop to agree a revised referral form for piloting is currently being arranged and is anticipated to take place in March 2012. At this meeting, Soft Options, the BEST IT system developers, will be showcasing the latest developments in electronic referrals to discuss how this could be developed in future within ALAS.

 

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.

 

Since the Review, the South Wales ALAC has systematically reduced paediatric and adult waiting times for assessment. The current position is a 6 week wait for paediatrics (32 weeks in April 2011) and 16 weeks for adults (44 weeks in April 2011). This has been achieved because of a range of improvements which include:

·    Improvements in the links between the BEST IT system and the ORACLE procurement system has reduced duplication and enabled faster ordering.

·    Developments in the BEST IT system which facilitate a more efficient note keeping system.

·    Appointment of admin support staff for the clinical and technical teams which has freed them to under take more complex duties.

·    All referrals are triaged within 24 hours of receipt.

 

With this level of continuous improvement the need for training community therapists in South Wales to undertake Level 3 assessments is therefore no longer required.

The service would be unable to support the knowledge, skills and expertise of community staff based on other sites. There is a range of 160 seating solutions + accessories and referrers must maintain comprehensive product knowledge to be able to safely prescribe. As well as this the clinician must be able to retain contact with the client in case problems arise and have access to the BEST IT system which holds the patient record.

 

The service has year long rotational band 6 posts which enable occupational therapists from other services to gain a high level of expertise in assessment and fitting for postural and mobility issues. This skill is then taken back out to other areas and improves the quality of referrals and allows us to prescribe straight from the referral.

“Trusted assessors” work in conjunction with the service in settings where clients have a high level of postural problems. These clinicians have an adequate knowledge of a specific range of chairs to be able to make recommendations directly into the service.  

.

The all Wales training manager has trained over 1,000 nurses and therapists to level 1 standard over the past 2 years.

 

NLIAH has also supported the Cardiff based all Wales training manager in the development of a DVD. This DVD resource is intended to support the training of referrers by providing clear, explicit instructions on what measurements are required and how these should be undertaken. Inaccurate or incomplete measurements are the major reasons why referrals are delayed. It is anticipated that there will be a reduction in the number of incomplete or inaccurate measurements leading to a quicker dispatch of equipment. It is essential for client safety to have accurate measurements. For those service users who require further assessment the improvements in the accuracy of this initial information will reduce delays.

 

Recommendation 15

We recommend that, as a matter of urgency, the Welsh Assembly Government should clarify and make public the policies and arrangements for joint funding with organisations and individuals.

 

Local agreements are being developed, for example with children’s charities both to provide training for children and in joint funding for equipment.

Further work must be undertaken to ensure that where ALAS costs are increased due to the size of council accommodation joint funding should be arranged, also in the case of education where joint funding could reduce overall costs. This will be raised in relation to discussion in the Partnership Board

 

 

 

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 service offers a wide range of chairs and accessories. Our clinical and technical staff are all trained to ensure that they have a high level of knowledge to assess, fit, maintain and repair the equipment. There are currently 160 chairs in the range, we hold over 200 commonly used parts in stock and can access other parts in a timely fashion.

 We do not have the product knowledge and could not hold the parts for the full range of chairs available on the market. If we undertook this role we would not be able to guarantee the safety of the client or their equipment. We would not be able to purchase at the prices we have negotiated for the current range.

 

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.

 

The service is in agreement with this and will pursue the potential via the Partnership Board.

 

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.

 

This work has been led by North Wales but supplemented by meetings held locally. Assessment training has been provided for British Red Cross staff

 

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.

 

As well as the work undertaken at national level the service has met with British Red Cross (BRC) to review closer working opportunities. We have provided wheelchair assessment training for their staff, and both agencies collect and return equipment for each other. Data protection issues prevent us from giving personal client information to BRC

 

 

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 brought the approved repairer service in house in February 2010. Improvements in service have been implemented since then which include:

 

 

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.

 

Service user representatives were fully involved in the process to select the new range of wheelchairs in the contract that will commence on 1/4/2012 and will run for 3 years. The Cardiff Rehabilitation Engineering department has a user group chaired by one of their clients who is also a member of the Partnership Board.

The service user engagement work stream (see recommendation 8) consultation undertaken in partnership with the “Kafka Brigade” will also gather any service user experiences relevant to this recommendation.

 

 

Recommendation 22

We recommend the Welsh Government should ensure that regular reviews for users are delivered, particularly for children and other users with changing conditions.

 

Regular reviews are in place for Rehabilitation Engineering Unit service users, because of the complexity of their client’s conditions. Children are reviewed twice a year, adults once a year.

In South Wales ALAS is offering the parent /carer and the referring therapist the opportunity to bring children for review once a year. Feedback from paediatric therapists is very positive

 

Recommendation 23

We recommend that the Welsh Government should ensure that ALAS explores joint working opportunities with charities to provide training for users.

 

Funding has been allocated to support training of service users, in particular certain Paediatric clients.

A tender is being drafted in conjunction with NLIAH to provide this training across Wales.

Cardiff ALAS staff are being trained to provide weekend training for children at the wheelchair depot. This is on a voluntary basis.