Health and Social Care Committee
HSC(4)-16-12 paper 1
One-day inquiry on wheelchair services in Wales – Update from the Welsh Government
Welsh Government Update for the Health and Social Care Committee on implementation of recommendations of the Health, Wellbeing and Local Government Committee’s report on Wheelchair Services.
Introduction
The National Assembly for Wales Health and Wellbeing Committee undertook an inquiry into Wheelchair Services in Wales and reported in May 2010 with 23 recommendations. The Minister for Health and Social Services subsequently sent a written update to the Chair of the committee in November 2010 following the release of the All Wales Posture and Mobility Review Phase 2 report. This paper updates the Health and Social Care Committee on progress against each of their recommendations up to November 2011 when the All Wales Posture and Mobility Partnership Board last met.
Background
In May 2008 the Minister for Health and Social Services announced a review of wheelchair provision in Wales. The review would encompass long and short-term loans, adult and paediatric wheelchair services. The review was undertaken in two phases. Phase 1 reported to the Minister in October 2009 and described service provision across Wales including how current services were managed. The review recommended changes to improve the experience of service users.
In May 2010 the National Assembly Health, Wellbeing and Local Government Committee published its report on the ‘Inquiry into Wheelchair Services in Wales’. The Committee made twenty three recommendations.
The Minister responded to the Committee’s report in June 2010 accepting all of the recommendations. A project board for a Phase 2 review of Posture and Mobility services was initiated and the Minister for Health and Social Services appointed Ms Sue Kent, Vice Chair of Aneurin Bevan Local Health Board, as Chair. The Project Board met for the first time in May 2010. A Wider Reference Group was also established to support the Project Board. The Project Board took the main themes of the Phase 1 work and further developed the recommendations to ensure service improvement proposals addressed the main issues identified. Workstreams were set up to consider the key issues and develop recommendations for action. The work of individual workstreams looked, in closer detail, at the eligibility criteria, quality indicators and key performance indicators together with a range of actions to ensure provision of an efficient and effective service to both established and new users.
The project board reported in October 2010, a copy of which was sent to Darren Millar AM the then Chair of the Health, Wellbeing and Local Government Committee with details of the improvements which needed to be made.
One of the recommendations from the report was the proposed All-Wales wheelchair specifications be implemented and performance managed through a Partnership Board would replace the previous Posture and Mobility Steering Group.
An All Wales Posture and Mobility Partnership Board chaired and led by WHSSC (Welsh Health Specialised Services Committee) as the commissioners of wheelchair services was set up to oversee all work programmes. The Partnership Board includes service user and service provider representatives and reviews performance against agreed quality and performance indicators. The Board meets quarterly and is due to meet next on 1st March 2012.
The Artificial Limb and Appliance Service (ALAS) is provided by a collaboration between three Local Health Boards (LHBs): Cardiff and Vale, Abertawe Bro Morgannwg and Betsi Cadwaladr. The ALAS centres are situated in Cardiff, Swansea and Wrexham and work together to provide an All Wales service. These are supported by Rehabilitation Engineering Units (REU) based in Cardiff, Swansea and Bryn y Neuadd Hospital in North Wales. The REUs provide bespoke solutions for the most complex patient requirements.
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.
Update
Work is nearing completion on a summary specification which will form the basis for the All Wales Posture and Mobility service design and development of a full specification. Also being considered is a framework for decision making based on various criteria and levels of decision which will serve as an annex to the above. This will provide clarity for service users and clinicians regarding provision of equipment. This work is due to be signed off by the Partnership Board at the next meeting on 1st March. This work complements the eligibility criteria already produced in an earlier phase.
WHSSC, as the commissioning organisation, requires the service to work towards compliance with the Welsh Government Referral To Treatment criteria for acute services, and the National Service Framework for Children.
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.
Update
A Partnership Board with membership including service users and providers has been established and is providing strategic direction to the service over the coming years. This includes the development of a service specification and of quality indicators.
A service user engagement workstream has been established to ensure staff, service user views and stakeholders inform ongoing and future development of the wheelchair service The approach is led by a service user and supported by National Leadership and Innovation in Healthcare Agency (NLIAH) and will consult with service users, in particular to;
It is planned, as part of this workstream, to produce an electronic model for regularly capturing service users’ views to provide a feedback loop for informing service delivery and service developments.
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.
Update
The ALAS services are working closely with community staff on an individual basis and also, for example, through providing training for professional groups such as tissue viability nurses across Wales. A training video has also been developed for this purpose which Therapists, social care and Third Sector organisations are able to use.
A system has been established to rotate therapy staff into ALAS.
In South Wales, 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 and shared with colleagues leading to improvements in the quality of referrals which enables ALAS services to prescribe an appropriate wheelchair from the referral.
In North Wales, a rotational 12 month therapist post has been established with LHB Community Therapies Services to work in ALAS. This will improve the knowledge base in community therapy services and promote working together.
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.
Update
This is being addressed by the LHBs and the ALAS services who are working closely to agree joint specifications for the services in conjunction with NLIAH. Restructuring has commenced by bringing the previous ALAS and REU into one ALAS service from August 2011. In North Wales, a new post of Clinical Director has been put in place and new staffing structures are under review.
Recommendation 5
We recommend that new performance measures should focus on outcomes for users, taking account of their wider needs.
Update
To date, work on performance indicators has focussed on provision of a responsive service which has been identified as a key user need. Key performance indicators have been developed which include:
Referral To Treatment (RTT). This sets out a framework of rules for clock starts and clock stops to measure waiting times for patients when accessing NHS. The clock starts at receipt of completed referral. For the Wheelchair Service the clock stops at delivery of wheelchair equipment to the client.
Acknowledgement of referrals. This measures the time between receipt of referral and the issue of an acknowledgement to the referrer and service user.
Standard wheelchair referral to delivery time. This measures the time between point of referral and the point of delivery of a standard wheelchair.
Complex wheelchair and/or posture management system ordered from manufacturer referral to delivery time. This measures the time between point of referral and the point of delivery to the client of a complex wheelchair.
Repaired on time (Emergency repairs). This measures the performance of the Wheelchair Service against emergency repairs.
Repaired on time (Non emergency repairs). This measures the performance of the Wheelchair Service against non emergency repairs.
Collected on time (Non emergency repairs).This measures the performance of the Wheelchair Service and approved repairer against collection.
See also information at Recommendation 2 which will also inform any further indicators that may need to be collected.
Recommendation 6
We recommend that the Minister should keep under review the planned performance measures and targets and should introduce sanctions for non-compliance.
Update
NLIAH and the Delivery Service Unit (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.
Performance data will be collected by WHSSC from April 2012 onwards. The Welsh Government will receive reports of these and will hold LHBs to account for delivery of the required performance standards.
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.
Update
This work is included in the Referral To Treatment information.
In South Wales, the NSF standards have been met and also annual reviews have been implemented for children in the wheelchair service and six monthly reviews in Cardiff REU.
In North Wales the ALAS service will be providing assessments for all children within 6 weeks of referral by end of March 2012. The service intends to be fully compliant with the NSF by end of March, including 8 weeks from delivery to fitting of equipment.
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.
Update
A Wales-wide Service User Engagement Workstream, with a working group consisting of ALAS and service user members, has been funded for a three year period by the Welsh Government to:
The work commenced in 2011 following a competitive tendering process where 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 inform a feedback system which will be an ongoing source of insight for ALAS. It is also anticipated this comprehensive baseline work with ALAS service users will begin a dialogue whereby the service can better understand how service users prefer to be informed of developments within the service.
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.
Update
See response to Recommendation 8 regarding the Service User Engagement Work stream.
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.
Update
Each ALAS service has developed practical solutions to this issue:
In South Wales, NLIAH has supported South Wales ALAS in the development of a drop-in repairs clinic in Cardiff to enable client’s equipment to be assessed and repaired at their convenience. Also a delivery driver and a fitter has been allocated for West Wales which both reduces travel time and costs and also makes the service more accessible to the clients in that area.
In North Wales, the ALAS service identifies an appropriate temporary loan chair (as close as possible to the original specification) and authorises the approved repairer to deliver whilst modifications or repairs are being carried out. ALAS are working with their approved repairers to ensure delays are avoided when possible e.g. by keeping higher stock levels of spares.
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.
Update
NLIAH has supported the service in conducting a capacity and demand analysis which in South Wales has identified a number of service improvements to release 13% of clinical time; increase satellite clinics; introduce one-stop clinics and weekend clinics and, therefore, reduced waiting times for assessments for paediatrics to a maximum of 5 weeks and adult waiting times for assessments to a maximum of 16 weeks.
A similar capacity and demand analysis for North Wales will be undertaken in April and similar benefits and improvements are expected. The delay relative to South Wales is due to local staffing issues
There has been central investment of £2.2m to increase capacity specifically targeted to improve the quality of children’s services. Improvements in children’s service has involved modernisation and service redesign and this is anticipated to have a positive effect on adult waiting times as well.
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.
Update
NLIAH has supported ALAS in the development of joint clinics, which ensures the referrer and Wheelchair Technician or Wheelchair Occupational Therapist assess together to develop a definitive prescription solution therefore reducing the length of the pathway for the service user.
Also see update for Recommendation 17
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.
Update
The development of referral arrangements, including protocols and processes, has been a key part of the work undertaken as indicated by the following examples:
The ALAS services are making the transition to the national rules for Referral To Treatment (RTT) and an online resource has been developed. All referrals are triaged within 24 hours of receipt and the BEST (Better Equipment Services Together) bespoke IT system allows for patients to be entered onto the system at the point of referral, collect the RTT information and provides a robust reporting system for reporting or triggering any who might breach the RTT.
A Referrals Workstream has been established by NLIAH 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, for example, inadequate measurement of clients. As a result, the redesigned form seeks to clarify the expected measurement standards and an explanatory video has been produced for referrers by the All Wales Trainer.
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.
The NLIAH workstream will produce a new referral form that will streamline the referral process and ultimately provide an electronic referral facility that can be used with the current patient management system (BEST).
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.
Update
The intention of this recommendation was to assist with the sustainable reduction in waiting times for assessments. However, since the Review, with the level of continuous improvement, the need for training community therapists to undertake Level 3 assessments is no longer felt to be urgent.
Across Wales over a 1000 community staff and referrers have been trained to level 1 as have staff within the British Red Cross. Some community therapists have been trained to Level 3, however, in order to make full use of their assessment abilities, they would need to be continually updated on over 160 pieces of equipment. Therefore, the ALAS services feel training community therapists to this level is not the best way of achieving this objective and other plans will be put in place to train community clinicians to make good referrals into the service.
An example from the North Wales region, is that there are currently seven Trusted Assessors in place who have received advanced training. The Trusted Assessors working in the community are staff that are competent in performing to an agreed set of nationally recognised competencies and have the requisite skills, knowledge and understanding for an effective ‘service-user’ approach to equipment provision, whatever role or level they are working in. Within the context of this training, they are able to assess and prescribe equipment thereby reducing the workload for the North Wales ALAS therapists and technical officers.
In South Wales, the ALAS has systematically reduced paediatric and adult waiting times for assessment. This has been achieved because of a range of improvements which include:
a. Improvements in the links between the BEST IT system and the ORACLE procurement system has reduced duplication and enabled faster ordering.
b. Developments in the BEST IT system which facilitate a more efficient note keeping system.
c. Appointment of administrative support staff for the clinical and technical teams which has freed them to undertake more complex duties.
d. 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.
NLIAH has also supported the Wales-wide training post 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 as more information is sought by ALAS. It is anticipated there will be a reduction in the number of incomplete or inaccurate measurements leading to a quicker dispatch of equipment. 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.
Update
The Welsh Government provides guidance on how to set up and deliver partnerships and pooled budgets through the SSIA hosted website at http://www.ssiacymru.org.uk/partnerships
LHBs are already undertaking some joint funding with the charity Whizz Kids for seat risers. Self funded wheelchair modifications (not required for health purposes) can also be carried out providing these do not compromise safety or the functionality of the wheelchair.
Also see response to Recommendation 17
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.
Update
The accepted policy has been the responsibility for maintenance and repair for equipment bought by individuals remains with that individual and this policy is being maintained
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.
Update
LHBs already have powers to establish pooled budgets and joint working arrangements with Local Government. The Welsh Government will very shortly launch a consultation on the forthcoming Social Services Bill which will set out further powers in relation to partnership working. As previously stated under Recommendation 15 the Welsh Government provides guidance on how to set up and deliver partnerships and pooled budgets through the SSIA hosted website at http://www.ssiacymru.org.uk/partnerships
The prime focus of the Partnership Board to date has been on delivering improved waiting times and increasing capacity. Local Government is represented on the Partnership Board and there is now an opportunity to look at ways in which service delivery could be improved through further collaborative working (including pooled budgets) and this will be included in the work programme for 2012.
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.
Update
The first step in achieving this is through a number of pilots which will be delivered by the British Red Cross (Wales) in conjunction with the NHS (Wales). These will initially be funded by the Society and the Welsh Government which has made available the sum of £100K pa for the years 2011/12, 2012/13 and 2013/14.
The pilots will be delivered with Aneurin Bevan Health Board, Betsi Cadwaladr University Health Board and Hywel Dda Health Board.
Expected outcomes of the project include:
· Production of a Model Service Specification for the short term wheelchair service including eligibility criteria.
· A service with standard access criteria, equipment and availability
· More integrated working within the Health Board, Local Authority and BRC ambit.
· Clearer signposting to improve the speed of access to those with a short term wheelchair need.
· Development of an appropriate BRC IT data management system to monitor the use and outcomes for the short term wheelchair service.
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.
Update
A Short Term Wheelchair Loan group lead by Betsi Cadwaladr University Health Board was established with representatives invited from the ALAS, BRC (Wales), NLIAH, with representatives from other NHS bodies and WG.
The key areas the group decided to initially concentrate on were:
These areas have been progressed as follows:
Equipment Pick up
There are good examples of equipment being picked up by both services and returned to each other across Wales thereby saving time and other resources.
Training
The ALAS trainer met with the BRC (Wales) teams and reviewed their training documentation. The initial training with 5 members of the Red Cross took place at the Cardiff ALAS on the 4th February 2011 with further sessions scheduled in April and May for BRC staff and volunteers.
Procurement
The Group has since been advised that it is not possible for the wheelchair procurement contract the NHS had to be extended to include BRC(Wales).
Information Sharing
The Welsh Accord on Sharing Personal Information (WASPI) provides a framework for service providing organisations and other organisations directly concerned with the well being of an individual to share information between them in a lawful and intelligent way. Richard Howells, a member of the national team developing WASPI, attended the meeting on the 5th January 2011 to present WASPI and discuss how it might be used to establish an Information Sharing Protocol between the organisations if needed.
This work is now being taken forward as a project with the BRC(Wales) as described in Recommendation 18 above and is reported to the Posture and Mobility Partnership Board.
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.
Update
Standards have been developed and are being used by the LHBs to monitor their own performance.
The South Wales service has gained flexibility in service delivery since maintenance and repair was brought in-house and a break-down service is available 24/7 7am to 9 pm.
In North Wales quarterly review meetings are held with the Approved Repairer where performance statistics are monitored as well as receiving monthly reports.
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.
Update
Service users and representatives have been involved in the wheelchair contracting process and attended product selection and presentations sessions in the ALAS services. 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 Service User Engagement Workstream (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.
Update
Standards have been defined and are being considered as part of the quality indicators workstream. It is acknowledged that the frequency of review will vary between users and further work is scheduled for March 2012.
Recommendation 23
We recommend that the Welsh Government should ensure that ALAS explores joint working opportunities with charities to provide training for users.
Update
The Welsh Government has allocated funding for the next 2 years to set up the wheelchair training courses to support training of service users, in particular certain Paediatric clients. A tender is being drafted by NLIAH to provide this training across Wales.