Scottish Government

9 SERVICE DELIVERY MODELS

74. Previous guidance referred to lists of equipment and adaptations that health and local authorities were obliged to provide. The Audit Scotland report found that "national guidance about roles and responsibilities for equipment and adaptations is confusing for providers and is out of date. It can get in the way of joint working by reinforcing artificial distinctions between social care and nursing needs, and housing and social work provision". This message has been reinforced by stakeholders during the review of current guidance. It was agreed that specific roles and responsibilities for specific types of equipment and adaptations would not be helpful in reducing some of the current barriers to access. This guidance recommends that partnerships work closely together to agree jointly their models of provision for equipment and adaptations.

75. The Rehabilitation Framework identifies three main groups of people who access rehabilitation services. These include people requiring vocational rehabilitation, older people and people living with long term conditions. The new model of rehabilitation advocates a single point of entry to rehabilitation services that aims to ensure service co-ordination.

76. This future model identifies three distinct stages in the rehabilitation process as:

• Specialist rehabilitation teams utilising case management
• Locally based rehabilitation and maintenance teams
• Self management population

77. Equipment, adaptations, assistive or ' SMART' technology and tele-health will play a significant role in future rehabilitation services. Anyone requiring equipment and adaptations or other care services should experience a seamless journey through the pathway of care that ensures they receive the right intervention at the right time. To ensure that changing care needs are managed effectively it is essential that equipment and adaptations are seen as an integral part of the rehabilitation /enablement structure.

78. Some users have progressive conditions that change over time. Anticipatory approaches to provision are needed to ensure that services, including equipment and adaptations, are made available to accommodate these changes.

79. Some users of equipment and adaptations may also require the use of a wheelchair. This may involve adaptations to the home to enable wheelchair use and independent living. To help support case management, meaningful partnerships need to be established between wheelchair and seating centres and the NHS/local authority partners responsible for equipment provision and adaptations.

Partnership Model for Standard and Specialist equipment and adaptations

80. To help clarify local partners' roles and responsibilities and avoid disagreements, local authorities, health boards and any other agencies should work together to:

• agree the range of equipment and adaptations that will be provided by the partnership, and the funding streams for these.
• include equipment and adaptations within eligibility criteria for all community care services;
• ensure that, irrespective of the original provider, equipment is not withdrawn due to a change in circumstances or age until new arrangements are in place. (e.g. assistive communication equipment that may be provided by education should not be withdrawn when the child leaves school or further education).

81. For the purpose of the guidance standard and specialist equipment can be defined as:

82. The Audit Scotland Report 2004 defined minor and major adaptations as:

83. There is evidence that improved performance and satisfaction can be achieved for standard equipment and minor adaptations through an integrated model of provision. Standard items of equipment (e.g. standard wheelchairs, raised toilet seats, shower chairs etc.) and minor adaptations (e.g. grab rails or temporary ramps etc.) can be accessed without the need for a full community care assessment of need by any appropriately trained front-line member of staff or directly by the user themselves.

84. Where more specialist equipment or major adaptations are required, partnerships need to develop joint protocols for the assessment, referral and provision for this level of service. These protocols should be streamlined and detail who to contact for specific services, (e.g. wheelchair centres, RSLs, housing associations, etc.). Details of different funding options should also be provided. This type of approach has already been endorsed by professional bodies and guidance on providing minor adaptations can be found in Minor Adaptations Without Delay¹⁶ produced by the College of Occupational Therapists.

85. The provision of stair lifts challenged the definitions for equipment and adaptations. In principal models of stair lifts which require no structural alterations would be defined as equipment, with models requiring a structural alteration to the property by housing being defined as adaptations. It is recognised that in using these definitions of stair lifts the current range of funding options could be limited. These issues require to be addressed locally by recognising the range of funding available across local partners ensuring that the outcome for the individual is the joint priority for all partners.

86. To help develop these models the Scottish Government will produce a "good practice guide" for equipment provision that will allow partnerships to benchmark their current services.

• It is recommended that local areas adopt a standard (including minor adaptations) and a specialist/major, model to the provision of equipment and adaptations.
• Local Authorities should identify all of their spending on equipment and adaptations across its services including social work, education and housing services with the aim of integrating provision of 'standard' equipment (including minor adaptations) with their health colleagues. Health services should carry out a similar review. This could involve the use of pooled budgets and establishment of joint stores for the provision of 'standard' equipment and adaptations.
• Models of provision should cover: protocol for access, information for service users, review of equipment catalogues, training, and quality assurance as well as provision, including, maintenance, review and recycling. Models should also ensure there are robust performance management systems in place.

87. Local partners should review the benefits from their current models of delivery and consider the advantages from an integrated approach and pathway across services and agencies for both 'standard' and specialist /major provision.

Managing risk in equipment provision

88. Where the equipment prescribed by staff is standard ( non-complex) and the needs of the service user are straightforward and indicate no specific risks, then appropriately trained front-line staff should be able to assess for and provide this directly. For this level of need, in many cases it will also mean that service users themselves can directly access the equipment.

89. If it were evident that there may be more complex issues/risks (with needs being met by either 'standard' or 'specialist' equipment) then a referral would be required to be made to appropriate specialist practitioner.

Recycling, Infection Control and Decontamination

90. The Health and Safety at Work etc. Act (1974) ³⁵ places a number of duties on employers and employees concerning the requirements of safe working practices. Furthermore, The Management of Health and Safety at Work Regulations (1999) ³⁶ place a statutory duty of co-operation between employer and employee to provide each other with clear communication in health and safety matters, including any hazards associated with their activities, e.g. decontamination, transfer of material or equipment etc.

91. The Medicines and Healthcare Products Regulatory Agency ( MHRA) Community Equipment Loan Stores: Guidance on Decontamination provides detailed advice on the decontamination and infection control of community equipment in loan stores.

Using Occupational Therapy Services More Effectively

92. Existing examples of mainstreaming the assessment and provision of equipment and adaptation services have demonstrated an impact on the work of a range of staff, including occupational therapy staff. This opportunity needs to be captured to maximise the use of individual professional skills and expertise.

93. For occupational therapy staff existing organisational boundaries can result in inappropriate numbers of transitions of care for an individual between health occupational therapy staff in hospitals and community based services as well as to staff in the local authority. It has been long recognised by the occupational therapy profession and within Scotland that there is scope to maximise the use of occupational therapy skills within rehabilitation and enablement: by addressing these boundaries and reducing transitions: as well as enabling users and carers and other staff, to play their part in assessing and providing equipment and adaptation services.

94. Along with nurses, occupational therapy staff should no longer be perceived as the main route to equipment and adaptations. They should contribute to training and supporting others in managing "simple" solutions while becoming more widely involved with inreach and outreach models of rehabilitation and enablement as outlined in the rehabilitation framework. The rehabilitation co-ordinators appointed in each health board area will provide the strategic direction to enable this model.

95. Over the past eight years in Scotland a range of good practice approaches have been developed to provide simplified pathways for access and co-ordination of occupational therapy interventions. They have demonstrated a pivotal and equal role in joint, community-based rehabilitation/enablement services co-ordinated hospital discharge arrangements, and have become an integral part of intensive support services within multi-disciplinary/agency teams.

96. One of the challenges these changes have highlighted is a tension in the balance of reallocation of occupational therapy skills, expertise and capacity between rehabilitation and care management responsibilities. Good practice has demonstrated that this needs to be defined by the type of service, taking account of rural and care group resources. Wherever possible intensive care management responsibilities should only be allocated where the case also requires the skills and experience of that profession.

97. It is recommended that within the context of the wider agenda for joined up health, housing and social care services, community care partnerships can mainstream the assessment of equipment and adaptations and improve the utilisation of occupational therapy staff across hospital and community and between health and social services in parallel. In doing so they should have individual project plans for the two areas of work and project management capacity including training to implement the recommended changes.