5. Delivery
5.1 National Service Delivered LocallyRecommendations Covered
Recommendation 2 - reorganise into a national, integrated, assistive technology service (also applies to section 3.1 - Pilot National Service)
The provision of all assistive technology services (including wheelchairs, seating, prosthetics, orthotics, augmentative communication, environmental controls) will be integrated into a single national service, funded centrally but delivered locally. The NHS Wheelchair and Seating Service will be accountable for expenditure through a budgetary process. With guidance from an Advisory Group comprising representatives of users, carers, service professionals and appropriate government departments, the national service will establish minimum performance standards for the service.
Recommendation 17 - establish as a national service delivered locally
The national service (as proposed in Recommendation 2) will be operated by a Management Group comprising members of the user and carer working groups (Recommendation 18) and representatives of other relevant stakeholders.
Executive's response
As indicated in response to recommendation 2, the Executive supports the establishment of an Advisory Group, with representation from users and carers and the range of agencies involved in providing services to this client base, to focus on national standards and key performance indicators. Delivering for Health promotes local delivery through Community Health Partnerships and Local Improvement Targets are set by the partnerships themselves under the Joint Performance Information and Assessment Framework (JPIAF) . Work is currently being taken forward to develop a number of national outcome targets for community care, which will be published in 2007. The Executive, therefore, does not see the need to establish a separate management group. The national guidelines should be managed regionally, with compliance monitored nationally by the Advisory Group, which could then raise areas of concern with the Executive and advise on future policy direction.
In setting up the Advisory Group, it will be necessary to provide it with clarity of role and remit to ensure its effectiveness as a driver for improvement.
The Wheelchair and Seating Service providers should work towards achieving the national quality assurance system standard ISO 13485. Effective quality management systems are recognised as a key regulatory consideration for allowing, for example, medical device manufacturers to market their products around the world. ISO 13485 provides a focus and structure for improving systems involved in providing a service.
5.2 More Centres/Clinics etc.
Recommendations Covered
Recommendation 4 - increase number of centres, local facilities and clinics
The number of centres, local facilities and clinics will increase in a manner to be determined by further consultation. There will be a substantial increase in the number of local facilities and clinics that will be staffed by centre staff. Suitably trained community staff will also support local facilities as they become available.
Executive's response
Delivering for Health believes that locating health services close to communities will promote the provision of faster and more effective treatment nearer to people's homes. To achieve this, there is a need for services to join up, co-locate, share resources and to seek to achieve a seamless patient journey.
The delivery of the Wheelchair and Seating Service falls neatly into this model. The challenge is not to try to achieve a "one size fits all" model, but to allow local partnerships to identify local needs and to work up a delivery service that best meets the needs of the client in a way that is cost effective.
The main route for this is through the Community Health Partnerships, which involve community partners beyond health - most notably, local authorities.
A major barrier that has been encountered to date in increasing the number of satellite centres has been the cost and availability of adequate premises. Within partnerships, there should be scope for the sharing of premises, for example by co-locating social services, primary care and Wheelchair and Seating Services. The need for geographical spread may be addressed by using shared premises, part time in different locations within a wider area.
Joint Future - Joint Premises - The Executive established a Joint Premises Project Board to work towards delivery of the 22 recommendations from the Short Life Working Group in 2002. A toolkit to assist practitioners in the delivery of Joint Premises project was published in 2004. In December 2005 Ministers accepted the Joint Venture model for Scotland and the hub initiative was launched in February 2006.
The Executive feels that, while significant progress has been made on the Joint Future agenda to date, there is still room for improvement. The national partnership of COSLA, NHSScotland and the Executive has agreed to put new emphasis on the achievement of outcomes. A National Outcomes Project Board has been established and consultation on a number of themes is underway. Following this, it is hoped final plans for delivery will be agreed and implemented during 2007/08.
Consideration should also be given to the option of a mobile unit for remote areas.
The difficulties in travelling to centres was highlighted as a major issue for this client group. Discussions need to take place with the Scottish Ambulance Service and other providers of non-urgent patient transport facilities to establish how such an arrangement might be implemented. There may be a need to train community staff, and there might also be a requirement to increase staffing levels within the Wheelchair and Seating Service to accommodate this change.
5.3 Accessible Premises
Recommendations Covered
Recommendation 33 - ensure facilities are fully accessible to people with disabilities
All wheelchair service facilities must be fully accessible to people with disabilities and their carers.
Executive's response
NHS Boards have a statutory duty to ensure their services are accessible and appropriate for disabled users. The Review highlighted instances where this was not the case for the Wheelchair and Seating Service. The Executive considers it a priority for NHS Boards to address any inadequacies in access to the existing wheelchair and seating services, and to ensure such facilities as disabled toilets are available. These issues should also be addressed when establishing satellite centres where a storeroom and clinical facilities should be together.
5.4 Space for Assessment
Recommendations Covered
Recommendation 34 - ensure facilities have adequate space for clinical assessment
All facilities should be provided with appropriate space for clinical assessment, storage and the equipment needed to support effective assessment.
Executive's response
This recommendation links to the previous recommendation. Users should have fast access to properly equipped facilities at assessment without facing the difficulty of being sent somewhere else to receive this, unless clinically necessary. Consideration should be given to opportunities to link to the wider advice and demonstration agenda within local authority services.
5.5 Link to Community Service
Recommendations Covered
Recommendation 7 - improve co-ordination with community services
A review in the context of recommendations made in this report will be undertaken to improve co-ordination between wheelchair and seating provision and community services responsible for making home, school and workplace adaptations to ensure compatible solutions are developed in an efficient and timely manner.
Executive's response
The overarching equipment and adaptations agenda is already looking at arrangements and joint working, including those between wheelchair providers and those responsible for home modifications across Social Work Services.
The Single Shared Assessment (SSA) has the potential to address much of this together with some form of local partnership arrangement to meet local needs. The Executive encourages NHSScotland and social services staff to collaborate on finding local solutions. However, home, education and the workplace are distinct sectors and the types of stakeholders required to make progress in each of those areas should reflect this. The Project Board should consider how best to achieve local solutions across each sector.
The eligibility criteria should be seen as a barrier to progress and all services must decide how best to minimise the impact on users.
5.6 Delivery to User Within Known Times
Recommendations Covered
Recommendation 16 - equipment to be delivered within known timeframes
Systems will be established to ensure that equipment is available within a known timeframe following the assessment process. Agreed timescales and lead-times will be stated following the assessment, and a commitment will be made to communicate any unexpected delays.
Executive's response
The Executive acknowledges the need to establish national standards and appropriate performance indicators for the delivery of this element of the service. These should be carefully monitored and any national system should be able to identify problems and overdue orders to allow NHS Boards to measure performance against national criteria and address delays. The Executive would expect the service to address this through the ReTIS system and suggests that ReTSAG be asked to ensue a system is in place within 12 months and monitor effectiveness in improving delivery targets.
5.7 Punctual Repairs
Recommendations Covered
Recommendation 28 - agreed response times for repair and maintenance
The NHS, at all levels in the service, will provide repair and maintenance support. It should have response times that are determined through the national service consultation process involving users and carers.
Recommendation 29 - provision of out-of-hours support
Out-of-hours support, including weekends and holidays, will be provided. The feasibility of using NHS 24 as a means for users and carers to contact centres and obtain emergency response outside normal business hours will be considered.
Recommendation 30 - review of in-house refurbishment practices
A review of using in-house workshops to refurbish and customise chairs will be carried out.
Executive's response
The Executive supports recommendation 28 and that a nationally agreed response time should become a key performance indicator. It is acknowledged that there is currently no national definition of "emergency" for this service and that services vary according to local arrangements. NHS Boards are encouraged to consider this aspect of the service when looking to set up satellite centres. These should include sufficient space for storage and the carrying out of local repairs/minor adjustments.
The Executive supports recommendation 29. It would be helpful to users and carers if such a service fitted with social work services out of hours services so that enquiries could be passed on appropriately and speedily should they come through that route. NHS24 should be in possession of contact details to be able to direct users to the appropriate local out of hours arrangements.
The Executive agrees that an independent review of the efficiency of in house workshops and refurbishment practices should be carried out. This would highlight whether there is scope for efficiency savings and also consider the issue of equipment safety.
5.8 Mobile Service
Recommendations Covered
Recommendation 31 - provide mobile service
To provide dedicated area technician support for preventative maintenance and minor repairs, centres will consider provision of a suitably qualified mobile service.
Executive's response
The Executive is aware that a mobile service has been introduced by the Inverness Centre and recommends other NHS Boards consider adopting this. Early evidence indicates this resolves a number of issues raised by users and carers. For example, there is a reduction in equipment failure which, in turn, reduces the need for repairs and would relieve pressure on any out of hours service. It also removes, in most cases, the need for wheelchair users to visit centres. It is particularly helpful in rural areas where transport is difficult and would relieve pressures on the Ambulance Service. It is recognised that most Centres do try to undertake repairs in the home situation and minimise the need for travel.
5.9 Planned Maintenance
Recommendations Covered
Recommendation 32 - establish planned preventive maintenance programmes
Planned preventive maintenance (PPM) programmes should be established. Inventory management systems should include measures to remove obsolete equipment from use to ensure that stocks keep pace with currently available technology.
Executive's response
The Executive recommends NHS Boards consider introducing Planned Preventative Maintenance (PPM) across Scotland. The issues around repair time and out of hours funding would then diminish. Such a scheme would be in line with the Medicines and Healthcare products Regulatory Agency (MHRA) guidelines on medical devices.
5.10 Repairs in Any Area
Recommendations Covered
Recommendation 20 - services available to users and carers at any centre in Scotland
Users and carers will be able to obtain services from any centre in Scotland.
Executive's response
Currently, most users have the option to have an assessment, or get repairs, in their own home, or locally. They are only required to attend a clinic where a specialist service is required. If further satellite centres as part of CHPs' local delivery strategy are introduced, this will cut down on the amount of travel required to regional centres.
If a user is on holiday in another area, then appropriate arrangements exist to allow them to access the services in that area.
CHPs, generally follow Local Authority boundaries. However, regional planning groups, when considering locations of any satellite services for the future should take into account the location of users who might be affected by lengthy travel.
5.11 Extended Loans
Recommendations Covered
Recommendation 39 - extended equipment loan programmes
Extended equipment loan programmes will be introduced to provide longer periods of time for children to be trained so that they can learn to use equipment during the assessment process, prior to making a decision for its provision.
Executive's response
The Executive understands that all equipment currently supplied is on a loan basis. If the assessment is of sufficient quality, this should preclude problems arising in most cases. It is acknowledged, however, that there will be some occasions where re-assessment or review is required. We would look to the service to provide adequate support and expect services to hold more items in stock.
It is, however, recognised that clients are well informed of what equipment is available on the open market and that agreement should be reached at assessment on what is clinically appropriate and available within the NHS contract rather than on what may have merely a cosmetic value.