Scottish Government

This document is also available in pdf format (236k)

EFFICIENT GOVERNMENT FUND

Stage 1 application - expression of interest

Part 1: Summary Table

The figures quoted in the costs and benefits contained in this bid are an estimate only and will need to be further investigated and developed should a Phase 2 bid be required. A full business case is required to identify the full impact of the new service and the potential cost benefits etc.

Please note that there is the potential to make savings on the procurement side of equipment by better bulk purchasing, sharing purchase contracts, reducing stock levels and different types of equipment by standardizing equipment across Grampian. This bid supports the e.procurement initiative and has not included these savings due to the e.procurement initiative being looked at Nationally. If we included these costs it would result in double counting and not be applicable. However, if the e.procurement initiative is not successful or has not taken into account this project in its bid then the Grampian Equipment and Adaptations bid would like to be considered for these savings at a later date.

Part 2: Narrative bid - Grampian Equipment & Adaptation Service

BACKGROUND

Two reports "Equipped for inclusion" the report of the Strategy Forum: equipment and adaptations, supported by the Minister Rhona Brankin, and an Audit Scotland study of the management of community equipment and adaptations "Adapting to the future" make a number of recommendations in relation to equipment in Scotland. These include:

• Actively exploring the most suitable means to provide a unified approach to the processing of requests for equipment and subsequent purchase of equipment
• Work towards joint information systems that provide good management information on the community equipment and adaptation services within partnership areas
• Clarify partnership arrangements for the assessment and provision of community equipment and adaptations
• ensuring that all relevant partners are involved
• Ensure that community equipment and adaptation services are developed as part of an overall community care strategy
• Develop protocols which maximise the ability of staff from different partnership organisations to access equipment and adaptations and reduce the waiting time for users.
• Jointly publish comprehensive information on community equipment and adaptations
• Develop joint training plans for all staff involved in assessing the need for, and demonstrating, equipment and adaptations.

Funding has been provided until March 2006 for a Project Manager to lead this project and groups meet in Aberdeen, Aberdeenshire, Moray, the children's service and acute health services. A Grampian Steering Group has been formed and this reports into a Grampian Project Board. The Groups have representation from all organisations and a service user representative. Carer and User forums are involved to ascertain feedback on present services and assist in the planning of future services. A Grampian Equipment Event was held in December 2004, which was very successful, and it was apparent that service users, carers and staff working in the field of equipment are keen to see an integrated Grampian service.

All partners currently maintain independent systems and separate budgets relating to equipment. Record keeping is ad hoc with the majority of partners maintaining some form of record with varying degrees of accuracy, in some cases dependant on equipment value. Some equipment tracking or maintenance/servicing records are kept but this is not consistent across Grampian and this raises a number of health and safety issues. A lot of staff are trying to undertake work in the field of equipment on top of their existing roles. They attend meetings and produce reports, draft policies/protocols etc and have an interest in equipment that should be harnessed and supported.

A bid was made to the Grampian Integrated Care Group for bridging funding for a project team to assist with the implementation of a Grampian Equipment and Adaptation Service but no funding is available.

Therefore, Grampian wish to submit a proposal under the Efficient Government fund initiative to implement these recommendations and form an integrated Grampian Equipment and Adaptation Service.

AIMS OF THE PROJECT

The aims of the project are to achieve:

• A strategic approach to integrated, planned services involving all stakeholders
• Many access points leading to one-stop provision of information on equipment and services and appropriate assessments
• A state -of-the-art demonstration facility ( DLC)
• Identifiable outcomes for user from every contact
• The involvement of service users in monitoring and review of services
• A quality-management system for continuous service improvement with Grampian wide policies and procedures, management and performance information to support the service
• Improvements in efficiency and effectiveness of information, assessment and supply of both equipment and adaptations
• A purchasing regime that makes full use of technology and which aggregates purchasing power and efficiencies by linking into regional and/or national purchasing consortia where they exist without compromising personal choice
• A panel of professionals and users to resolve difficult product purchasing decisions should they arise
• A unified, person-based IT system capable of linking assessment, stock tracking, purchasing, equipment re-use and management information, that is in line with national and local policy initiatives. Such a system will have safeguards to uphold users' confidentiality.
• A robust industry-standard system to enable the quantity and location of stock to be identified, and its recall in case of the issue of safety or hazard notices by the Medical Devices Agency ( MDA)
• Equipment adverse incidents reported to MDA
• Better co-ordination, integration and joint working between organisations building on existing collaboration and joint working demonstrated under Joint Future
• Protocols in place for working relationships with services run by other agencies

All Community and Acute multidisciplinary teams are to be included in this project including Nursing, Occupational Therapy, Physiotherapy, Dietetics, and Care Management. Links with other services and partnership working is envisaged with GDocs, NHS 24, ambulance service, education, housing, employment services and voluntary organisations such as the Red Cross, ANEDS (Aberdeen & NE Deaf Society), Deaf Blind Scotland, GSB (Grampian Society for the Blind) some of whom hold local contracts with all the local authorities and NHS Grampian and are often relied upon for advice and provision of equipment.

PROJECTED COSTS/BENEFITS

Projected Costs

* It should be noted that at the end of the implementation period staffing costs will no longer be required. However, at the end of the funded period every effort will be made to absorb the costs of a Grampian Equipment and Adaptations Manager through a process of natural turnover and efficiencies to enable the effective management of any future service.

Projected benefits and potential savings

* The amount of time saved on clinical budgets has been based on the entire budgets and not just the proportion of time that would be spent dealing with equipment issues. Early work anticipates that on average approximately 10% of clinical staff time is spent on equipment but work is ongoing to collate this information and will be used to inform a Stage 2 bid if successful. Clinical time would not be released in the form of reduced budgets but would be used to allow practitioners more time to deal with specialist matters and reduce waiting times for assessment and equipment. (Breakdown attached)

1. Better use of existing equipment and re-cycling of equipment

The MSoft Equipment IT system has been purchased for Grampian with funding from the Grampian Integrated Care Group but no funding has been given to implement this system. The MSoft IT system is available via the internet and does not rely on any one organisation's IT network. It can be linked to other web sites and will be fully accessible to staff and the general public. Hand held units can be used for stores/delivery staff and tablets are available for practitioners to use when undertaking assessments/home visits. Equipment can be tracked and traced at all times and practitioners can ascertain availability of equipment instantaneously.

There are potential savings across all organisations if equipment is purchased, managed and maintained in a more cohesive and effective way. Monies can be saved on equipment budgets due to better re-cycling and sharing of equipment. Clinical staff will no longer be handling equipment and delivering it in their cars and this should reduce waiting lists and allow practitioners more time to deal with professional issues. Small ad hoc stores have been set up in areas across Grampian and this accommodation could be freed up and better used once a central store with satellite stores is created. Some stores are leased and these costs will be saved if existing health or local authority accommodation is adapted and used.

In England, Integrated Community Equipment Services, with pooled budgets, have been operational since April 2004. One of the first jointly commissioned services was the London Borough of Hillingdon Social Services and Hillingdon Health Authority who "contracted out" its store service in 1993/94 to be managed by the private sector. Central management accounting arrangements, complemented by line linked and interfaced computer systems, can effectively demonstrate performance and cost of service gains - as shown in the 1996/97 figures within "Community equipment services - why should we Care?" (Maggie Winchcombe).

• £557k equipment issues cost £295k, through credited equipment recovery of £282k
• service has doubled with a similar level of prescribers and operational costs
• 90% of its deliveries, collections and technical services are being completed within 48 hours
• although working to a higher service specification, every £1 of equipment issues cost £1.48 with overheads, compared to £1.57 in 1992/93

A small pilot has been initiated within Aberdeen City to form a joint store for hoists only. The budgets are being pooled and all hoists identified and stored within a central area of Aberdeen with health and local authority staff having joint access to the store. During the initial period of the pilot 34 hoists, not already on any organisation's stock lists, have been "discovered", had a maintenance check and repairs undertaken and been added to the stock of hoists to be utilised in Aberdeen by all organisations..

The value of a new hoist is approximately £600 so 34 new hoists would cost £20,400. Although this is not their stock value it allows these hoists to be used before purchasing any new ones and has a potential saving of approximately £20,000. The pilot is only for one type of equipment and in one area of Grampian. When rolled out to all equipment there will certainly be other equipment that will be "discovered" not only within Aberdeen City but also in Aberdeenshire and Moray. Equipment will gradually be identified over the next few years as items are returned and added to the equipment database on MSoft and this will ultimately release monies presently being used to purchase new equipment. The majority of these hoists belong to NHS Grampian and it has been identified that NHS Grampian has the poorest records held for equipment stock hence it is envisaged that the majority of the savings on equipment being used better and re-cycled is within NHS Grampian as highlighted in the benefits table.

2. Better use of Practitioner time and reduction in waiting times for users

The skill mix of staff across the various organizations is diverse and will be better utilised if an integrated service were implemented. For example, the local authorities have good stores staff whilst NHS Grampian has staff skilled in maintenance/repair. By creating a central store this expertise can be shared and the service can be more flexible creating less duplication or outsourcing of work and creating potential savings. The "Back to Work" scheme would also be utilised within the stores workplace as it lends itself to supporting disabled or long time unemployed people and posts would be funded via the European Social fund. A career structure would be put in place so that staff could progress on to other employment within health or the local authorities and assist with long term recruitment issues.

Self assessment and the "Trusted Assessor" scheme will be implemented with planned training for all personnel and carers working with assistive technology. An NVQ has been developed in England and the Scottish Qualification Board is being approached with a view to implementing this new training initiative in Scotland. If alternative methods of assessing equipment needs is adopted it will release practitioner's for specialist work and reduce waiting times.

An Occupational Therapy Equipment/Time Audit was undertaken in one area of Aberdeenshire in July 2004. Although this was undertaken within a limited period and with limited personnel the findings can be used to estimate what the impact would be across Grampian.

Health and Local Authority Occupational Therapists were asked to record the amount of incidents that occurred with equipment and the amount of time it took them to deal with them on top of their existing workload. As this was the holiday period and a very quiet time of the year any data collated is presumed to be on the low side. This did not include the time spent on relevant equipment issues dealt with by Occupational Therapists. The Audit quoted:

"The total time spent on inappropriate activity was 10 hours and 38 minutes in one month in Central Aberdeenshire alone, mostly by senior professionals. This does not include two incidents that were mis-recorded, involving delivery of equipment. All agreed June had been a fairly quiet month! Over a year this would amount to 127.5 hours in Central. Projecting to include North and South Aberdeenshire, we might assume the time would be triple to 383 hours. If we were then to include nursing and physiotherapy staff, whom I understand have similar problems, we would assume a total of 1149 hours. Therefore, it might be reasonable to assume we could be saving the cost of approximately 0.61wte staff (£16,000 approx.) by taking action on these issues".

As this projected saving is for Aberdeenshire only and it was agreed that the data collected was on the low side it is assumed that approximately 6 wte staffing costs (£155,000) would be saved across Grampian if all aspects of the Equipment and Adaptation project were implemented. The savings have been phased in and a percentage of the staffing budgets identified for each area in line with the following criteria:

• Population - Moray 85,000, Aberdeen 236,000 and Aberdeenshire 223,000
• Staffing establishments - Moray Local Authority 11wte, Aberdeen 31wte, Aberdeenshire 35wte and NHS Grampian 70wte
• Geography - Aberdeenshire is split into three areas due to its size and is less condensed than Aberdeen
• Existing equipment service - Moray already has a joint occupational therapy store and has made some initial savings in relation to occupational therapy time.
• Staffing duties - NHS Grampian has a large number of nursing staff who provide a different service to occupational therapists, physiotherapists and therapy assistants.

An Audit of Shared Equipment for children with Special Needs in Aberdeen City was undertaken in September 2004. Forty nine staff who deal with equipment responded to the audit (21 Occupational Therapists, 2 Teachers and 7 Physiotherapists). Some of the results were:

• 30 staff were not aware of what information was held on equipment
• 13 staff were still cleaning equipment themselves
• 31 staff and 9 parents were delivering equipment in their own cars
• 21 staff and 8 parents were collecting equipment in their own cars

By incorporating the children's services into a Grampian Equipment and Adaptation Service practitioners will be aware of all information on equipment held in Grampian and avoid purchasing new equipment unnecessarily. They will no longer need to clean equipment themselves or deliver/collect equipment in their own cars. The time taken to undertake these tasks was not recorded but it would equate to a gradual projected benefit in clinical time over the next few years as estimated in the projected benefits table.

3. Reduction in paid/unpaid carers time

One of the strongest and most significant pieces of research has examined how the use of equipment and personal assistance compares and the efficacy of such assistance. The conclusion reached was that both personal assistance and equipment work, relieving dysfunctions for most people and eliminating them for many. However, equipment by itself is more efficacious than personal assistance. Achieving compliance with the European Working Time Directive will also place a premium on scarce staff resources. Equipment can release the time of both informal and formal carers and equipment and adaptations are inexpensive relative to the equivalent cost of care staff. For example the median cost of installing a special bath is £10,470. The annual discounted cost over the 10 year life of the bath (at 4%) is £1291 which would buy just over 50 hours of staff time. It therefore makes clear economic sense wherever possible to substitute kit for carers. (Audit Commission analysis of data provided in Ernst and Young (1994) Benchmark study of the costs of aids and adaptations)

Equipment enables children and adults who require assistance to perform essential activities of daily living to maintain their health and autonomy and to live as full a life as possible. This equipment includes, but is not limited to:

• Home nursing equipment, such as pressure relief mattresses and commodes
• Equipment for daily living such as children's special seating, shower chairs, raised toilet seats teapot tippers and liquid level indicators
• Minor adaptations, such as grab rails, lever taps, improved domestic lighting and improving the use of contrasting colours
• Ancillary equipment for people with sensory impairments, such as flashing doorbells, low vision optical aids, text phones and assistive listening devices
• Equipment for short term loan, including wheelchairs
• Communication aids for people who are speech-impaired
• Telecare equipment such as fall alarms, gas escape alarms, health state monitoring and "wandering detectors" for people who are vulnerable.

A survey was undertaken in 2001 entitled "Equipment and Adaptation Services in Scotland: A survey of waiting times for Social Work provision by Dr Edward Hall with Social Work Services Inspectorate - Scottish Executive Central Research Unit 2001." Results highlighted the high number of people waiting for assessments and this is still the case despite efforts to reduce them mainly due to the increase in demand on the service over the past five years.

"Snap shots" of caseload waiting times were conducted by Aberdeenshire Local Authority. The figures from 2003 and 2005 can be compared as follows:

The longest waiting times compare as follows:

Overall there has been a slight reduction in the numbers of service users waiting for assessment but an increase in the time some have had to wait for assessment. There has been a 15% increase in staffing levels over the last five years but there has been a 36% increase in referrals to occupational therapy over the same five year period.

Very often carers are employed to support people in their homes until an assessment is carried out and often equipment is provided that results in the individual being able to support themselves independently thus reducing the care costs. The information provided by Aberdeenshire can be replicated across Grampian and would result in a reduction in care costs as highlighted in the benefits table.

CONCLUSION

The Kerr Report - National Framework for Service Change in the NHS in Scotland - Care in Local Settings: recommends that "Community equipment services should be integrated across health, social services and education with the multi-agency protocols that set benchmarks for the assessment and provision of equipment including wheelchairs. Pooled budgets are an option which should be considered"

Equipment and Adaptation services will require to be implemented across Scotland and work is ongoing in various areas to look at creating integrated services. A National Steering Group is being set up to look at equipment and adaptation issues led by Rhona Brankin, MSP. Clear guidance on the way Equipment and Adaptation Services are provided across Scotland is required and it is hoped that participants will be able to influence the final outcomes.

A number of NHS and Local Authority organisations across Scotland have been contacted to make them aware of this bid and the National Steering Group. Some areas have used Modernising Government Funds to create joint stores. It is apparent that all areas are at different stages in their implementation process and many are not ready to make a bid for Efficient Government Funds.

Far more than joint storage and/or co-location is required and Grampian wish to undertake this project in a strategic manner incorporating all aspects of an equipment and adaptation service including assessment and provision. Senior Management from all organisations support this project in line with the Joint Futures initiative "Community Care: A Joint Future - the report of the Joint Future Group, Scottish Executive November 2000".

A Scottish branch of the National Association of Equipment Providers ( NAEP) has been established and regular meetings will be held in Scotland to improve networking and share good practice. If this bid is successful and a high quality Equipment and Adaptation Service can be established in Grampian there is no reason why other areas in Scotland cannot replicate this and make better use of Scotland's resources.