Modernisation
of the
Wheelchair & Seating
Service provided by
NHS Highland
Lead Officers:-
Fraser Brunton, Director of Medical Physics, NHS Highland,
Raigmore Hospital, Inverness
Dr Lorna Fisher, Consultant in Rehabilitation Medicine, Raigmore
Hospital, Inverness
1
Outline Business Case Submission to Wheelchair and Seating Services
Project Board
Modernisation of the Wheelchair and Seating Service
provided by NHS Highland
Specialist Centre: Inverness, NHS Highland
Lead Officers:
Dr Andy Menzies, Head of Rehabilitation Engineering Section and Wheelchair Services
Manager, Dept. of Medical Physics, Raigmore Hospital, Inverness
Employer: NHS Highland
Dr Lorna Fisher, Consultant in Rehabilitation Medicine, Raigmore Hospital, Inverness
Employer: NHS Highland
1. Introduction and Background
The proposals presented in this paper indicate the plans that have being developed in
conjunction with our Community Health Partnerships (CHPs) to modernise the wheelchair
and seating service provided by NHS Highland and to address the recommendations made in
the Moving Forward report1 and the Draft Action Plan3.
The Initial Agreement Submission to the SGHD Wheelchair Project Board in May 2008
requested funding to address the Moving Forward Report’s criticism of NHS Highland’s poor
existing infrastructure for disabled patients in the north of Scotland. NHS Highland’s Initial
Submission included a request for purpose built accommodation which would, for the first
time, have enabled all elements of the Service to be co-located and which would have
provided a suitable location for wheelchair patients to be seen at clinics. The building would
have addressed the specific criticisms in Section 2.2.19 in the Moving Forward report on the
poor infrastructure for patients in NHS Highland. The proposal would have enabled the
various parts of its Wheelchair Service to be modernised and co-located, as they are in the
other Scottish Centres.
Since the Initial Submission was made, it has become clear that the £16M allocation for the
Moving Forward Report may not be used to support capital bids. Although the NHS Highland
Board could be asked to provide capital to modernise Wheelchair Service accommodation,
this is unlikely to be successful given the current financial position and uncertainty about
continued central recurring revenue funding after the current spending revenue period.
Although unprecedented central funding has been made available over three years to
modernise Wheelchair Services in Scotland, it is regretted that none of it is appears
accessible to enable NHS Highland to provide co-located Wheelchair Service facilities for
disabled patients in the north of Scotland at a level comparable with that in the rest of
Scotland.
Whilst the Initial Submission contained proposals for providing purpose-built, centrallylocated accommodation, more recent work, driven by the Board’s need to shift the balance of
care from the centre to the Community Health Partnerships (CHPs), is also evaluating the
feasibility of increasing Wheelchair Service facilities, clinics and accommodation in the NHS
2
Highland CHPs. Significant capital and revenue funding will be required to implement either
of the two options being considered.
The Wheelchair Project Board is requested to reconsider the terms and timing of its £16M
allocation so that NHS Highland may benefit more appropriately from the significant funding
available to modernise Wheelchair Services in Scotland.
It is also requested that the Wheelchair Project Board works directly with NHS Highland
officers to develop and achieve this objective. If this request is deemed inappropriate, NHS
Highland would wish to proceed with the other bids described in the following amended
Business Case. These proposals are believed to be viable without the building but it remains
our belief that the overall effectiveness of the Service will continue to be hampered by
reliance on our current facilities.
The proposals presented here are intended to develop the Service so as to provide more
efficient and effective local delivery to patients throughout the large area covered by our
Centre. We will do this by increasing the involvement of local healthcare and community staff
in patient assessment and by increasing the delivery of local wheelchair servicing and repair
services.
3
2. Strategic Objectives:
2.1 Local Health Plans are driven by the “Better Health, Better Care: Action Plan” 2 and there
are a range of corporate objectives in relation to the 2008/2009 HEAT targets. The strategic
direction of the NHS Highland Wheelchair and Seating Service reflects these objectives.
These proposals, therefore, will enable NHS Highland to ensure better, more local and faster
access to wheelchair services by improving the efficiency and governance of access to
services and treatment. A key factor in this will be an improvement in the communication and
joint-working arrangements with locally based health care staff in the Community Health
Partnerships and in the Western Isles and west Grampian Health Board area.
2.2 Fit of Proposals with Moving Forward Report’s objectives.
The table below indicates which of the recommendations in the Moving Forward report the
proposals presented in sections 6.2 and 7 of this paper will address.
Proposal
Employ Redesign Lead to help modernise Service
Planned clinical reviews for more complex patients
Train community-based staff as Approved and Preferred
Prescribers
Extend PPM scheme to cover all our patients and
develop capability to repair wheelchairs at patients’
homes
Staff training/Career path development
Database development
Video conferencing equipment and remote access to
database to support staff away from the Centre
Wheelchair repairs local to patients
Wheelchair depot temporary upgrading
Modernise range of wheelchairs available
Produce a DVD for purposes of training patients, carers,
referrers to service, and colleagues in education and
community settings
Additional Special Seating clinics
Recommendations Met
16
8
4, 6, 7, 10, 14, 21, 23, 27, 39, 40
15, 32, 26, 28, 29, 31,32
7, 21, 24, 26
22,23,
4, 6, 14, 23, 27
28, 29
33,
12
13
10,11,14,16
3. Clinical needs addressed and proposed outcomes/benefits
The proposals detailed in this document will result in a more effective and efficient service for
patients of the NHS Highland Wheelchair Service. Patients will receive an initial assessment
of their clinical needs from a health-care professional with the right level of expertise needed
for the complexity of their mobility and seating needs. This will occur within the patients’ own
locality, which will ensure that they receive the right equipment more quickly, with an
improved service for set up and instruction in its use.
In addition, there will be an improved range of chairs available, which, in conjunction with a
more holistic assessment of need, will result in improved opportunity for social inclusion for
many patients. Regular, planned, reviews of more complex situations, regular servicing and
an increase in repairs in patients’ homes will all contribute to ensuring that patients’ needs
are monitored and addressed on an ongoing basis.
4
4. Method of Evaluation
A mixture of objective measurements and feedback from patients, users, and staff will assess
the effectiveness of the changes to service proposed here. The objective measures will be
made using our own Oracle database to compare performance pre and post the changes.
For example, the time taken from patient referral to the service until delivery of a wheelchair
can be, and already is, used as a KPI to measure a parameter that is known to be of
significance to patients. Our proposals include some additional IT support for the duration of
the project to enable suitable database queries to be developed to provide the desired
outcome measures. The feedback from patients and carers on the changes will come from
our existing Wheelchair User Groups and through our Patient Focus Public Involvement
networks. The feedback from staff will be in the form of informal contacts between
Wheelchair Service staff and Community-based clinical staff and Education staff. We will also
consider seeking this feedback by way of questionnaires sent to a sample of our wheelchair
users and to other staff with whom the Service has contact.
5. Local Action Plan
We have set up a local Wheelchair Services Modernisation Project Board that has developed
the proposals detailed in this business case as well as developing a business case for
suitable accommodation for the Wheelchair Service in Inverness. The proposals have been
discussed with management from all four CHPs in NHS Highland, with NHS Western Isles,
and are also being passed to User Focus Groups for consultation. There has also been an
opportunity for staff-side involvement in the development of the plans through the partnership
forum. It is anticipated that we will shortly appoint a Project Manager to coordinate the
implementation of the proposals presented here as well as expanding the Lean management
techniques, which our Service explored over a six week period earlier this year, throughout
the Service.
In developing these proposals we are trying to use the available funding in a way that will
both have an immediately beneficial effect on the quality of service and equipment received
by existing and new patients and also allow us to develop staff within the Wheelchair Service
so as to embed improvements beyond the three-year lifespan of the project. As detailed
above, it is intended to monitor the results of all of the proposed changes over the three
years of the project. It is anticipated that they will all demonstrate improvements in the
Service delivered to wheelchair patients and it is of course hoped that funding will be
available either from central funds or from Health Boards after the end of the current project
to enable the improvements and initiatives to be maintained. However details of the possible
“exit strategy” from each of the proposals are detailed below in case the additional funding
ceases to be available beyond 2011.
6. Description of Service Concerned
6.1 Current service:
NHS Highland has hosted one of the five Scottish Wheelchair Services since 1988. The
Service provides a postural support and mobility service to NHS Highland, NHS Western
Isles, and the west part of NHS Grampian patients, and is part of the Rehabilitation
Engineering Section of the Medical Physics Department at Raigmore Hospital.
In the twenty years that the Service has been based in Inverness the number of patients has
more than tripled to 3,285 so that now roughly one in every seventy five members of the
public has a wheelchair. In addition, there is a fast turnover of wheelchair patients each year;
5
about 25% of our patients are new to the service each year. This, combined with the
changing requirements of existing patients, means that about 33% of our wheelchairs are
issued afresh each year. For economic reasons, the returned wheelchairs are usually
refurbished which currently results in about 63% of the wheelchairs that we issue to patients
being refurbished chairs.
The Service has no dedicated building of its own. The clerical and office space is based
within the Medical Physics building at Raigmore Hospital and the Repair and Refurbishment
Workshops are at an industrial estate two miles away. This Workshop has no facilities to
accommodate patients and so no drop-in repairs are possible. Clinic space is only available
to the Service on one afternoon per week within the Outpatient Department at Raigmore and
we have no space available to store wheelchairs for assessment purposes at these clinics.
We have no indoor or outdoor area to train patients in the use of their wheelchairs. Our
upholsterer is based in a hospital building that is about four miles away from Raigmore and
from the Workshops.
Due to the deficiencies in available facilities referred to above, very few patients who are
referred to us for a wheelchair are seen at a clinic at Raigmore. Currently 92.5% of the
referrals are dealt with “blind” i.e. based solely on the information provided on the referral
form. While this is appropriate in some cases, it does mean that in about 8.5% of cases the
initial prescription has to be reviewed when the wheelchair proves to be unsuitable within
three months of issue. It also means that most patients have their wheelchairs, especially
manual wheelchairs, delivered by a carrier with no instruction or setting up of the wheelchair
provided. This unsatisfactory and frustrating situation provides cause for concern both for
patients and those managing resources.
The Service also undertakes clinics at Golspie, Wick, Fort William, Portree, Stornoway and
the Uists throughout the year. Most of these clinics are held every three months and are
attended by senior technical and therapy staff as well as by the Consultant in Rehabilitation
Medicine.
We currently provide a Planned Preventative Maintenance Service (ppm) from two mobile
workshops, staffed by wheelchair technicians, to all patients living more than ten miles away
from Inverness. The frequency of service visits to individual patients is based on a number of
factors such as wheelchair type, frequency of use and the patient’s reliance on the
wheelchair. This scheme has proved to be highly effective at improving the condition of
wheelchairs on issue and also as a means of providing feedback to therapy staff where a
chair appears to no longer suit a patient or where postural or pressure problems are
developing.
When a wheelchair needs repaired we usually require to bring it back to the Inverness
Wheelchair depot by carrier, repair it, then return it to the patient, again by a carrier. This is
expensive, slow and often unsatisfactory.
6.2 Proposed service:
We plan to deliver most aspects of the Wheelchair Service closer to the patient than is the
case at present. Assessment for, and prescription of, a wheelchair will be undertaken by
community-based staff where appropriate. Additionally, the speed of access to the
Wheelchair and Seating Services will be improved by increasing our frontline staff and the
range of equipment available will be modernised. We will extend our existing servicing
6
scheme to cover all patients and will undertake repairs to wheelchairs in patients’ homes as
far as possible. We will also introduce planned clinical reviews of our more complex patients.
These changes to the Service will be effected by the following proposals:
6.2.1 Service Delivery within Inverness Area.
We intend to house the wheelchair service in a purpose built facility which will, for the first
time, enable all parts of the service to be located under the one roof. It is believed that this
will greatly improve the efficiency of the service and will allow many more patients to attend a
clinic, be assessed, try a variety of wheelchairs, be involved in the choice of chair which is
prescribed, have it adjusted to suit their needs and leave the clinic appointment with their
new wheelchair after receiving instruction in its use. It will also be possible for the first time
for patients to have appointments for repairs undertaken on their wheelchairs at the Centre.
The Centre will become the hub in a hub and spoke model of service delivery throughout our
area.
The most suitable location for a new Wheelchair Centre to be sited has been explored by
means of calculating the average return journey distance and time for all our patients from
their homes to any of twelve possible sites around NHS Highland. This clearly showed that
the most convenient location for most patients was Inverness. This is perhaps not surprising
given that a third of all our patients live within ten miles of Inverness.
Since the WSS Project Board are unable to fund the capital and long-term revenue costs of
this proposal we intend to seek the funding from NHS Highland and this will be the subject of
a separate business case.
We intend to expand our PPM scheme to cover those patients who live within ten miles of
Inverness. We also intend to undertake a pilot study in which wheelchair repairs will be
undertaken at patient’s homes as far as possible where the address is accessible within one
hour from Inverness. These repairs will be undertaken by technical staff, currently employed
at the Wheelchair Depot, using an existing leased vehicle.
We propose to extend our PPM Wheelchair Servicing Scheme to cover all wheelchairs
belonging to our patients. At present the scheme only covers the 65% of patients who live
more than ten miles away from Inverness.
We also intend to trial extending the home-based repair service currently undertaken by our
own staff from our repair and refurbishment depot to cover all patients within ten miles of
Inverness. More complex repairs will continue to be undertaken at the Repair Depot.
6.2.2 Service Delivery outwith Inverness Area.
The frequency and location of clinics outwith Inverness will be at least the same as at
present. We are proposing that patients will be grouped into three categories in line with
recent discussions on the three-tier model of Service Delivery proposed by the WSS Project
Manager. We will use our Wheelchair Service staff to train and provide on-going support to
locality-based staff to prescribe wheelchairs at locations throughout our area for the least
complex, but most numerous, patients. By upskilling these staff to be Approved Prescribers
we expect that the service will be delivered more locally, personally, and more quickly to
patients. Details of patients assessed and equipment issued by community based staff will
be entered onto the Service’s existing database by the admin team at Raigmore. To aid in
7
the quick local prescription and issue of wheelchairs we will extend our range of
assessment/available-for-issue wheelchairs stored at the locations where the peripheral
clinics are held. This will enable local staff to assess patients with a variety of wheelchairs. If
the correct size is not available then this can be quickly supplied from the main wheelchair
store. These caches of wheelchairs will also be available for short-term use if a patient’s
wheelchair is awaiting repair.
Patients who are in the middle tier between routine and the most complex cases will normally
be assessed locally by specially trained local therapists, acting as Preferred Prescribers. It is
envisaged that support for these local clinics for the middle tier of patients will be available
from specialist staff based in Inverness by telephone or video conferencing links. Local
assessment stock can be used at these clinics with the patient’s definitive wheelchair usually
being supplied from stock held at the Centre or ordered by our admin team as a bespoke
wheelchair from the manufacturer.
We will continue to undertake clinics throughout NHS Highland and NHS Western Isles with
specialised technical and therapy staff travelling from the Centre to see the most complex
patients at these locations. We propose to increase from the current two technician/therapist
teams to three and to split our geographical area between these three teams. In addition to
undertaking clinics assessing and reviewing the most complex patients, these teams will also
have a role in the training of community-based staff as Approved and Advanced Prescribers
and in running training sessions for wheelchair users and their carers.
We intend to enter into partnership with a not-for-profit organisation that currently installs
equipment in the homes of the elderly and disabled whereby they will be contracted to
undertake simple repairs to patients’ wheelchairs at their homes.
7. Details of Proposals to Modernise Service
7.1 Project Manager and PA support for Wheelchair Services Manager
In order to assist with and monitor the implementation of the proposed changes and also to
extend the implementation of Lean management techniques which we started in the summer,
we will require to recruit a project manager for the remainder of the project. The funding for
this post was agreed following our Initial Agreement submission. We also require PA support
for the Wheelchair Service manager throughout the project in order to free up management
time and thus increase effectiveness during this period of rapid change.
7.2 Training for Locality-Based Prescribers
We plan that each of our three technician/therapist teams will provide training to communitybased staff to enable them to deliver the service closer to the patients. This will cover both
Approved Prescribers and Preferred Prescribers as described earlier in this paper. This will
significantly alter the way in which we deal with patients in the lower and middle tiers of the
three-tier model. The community-based prescribers will also be able to escalate any
concerns they have with wheelchair patients to the technician/therapist teams.
We want to continue collecting data on the effectiveness of using an OT Assistant to
undertake some of the simpler work previously done by our Senior OTs in order to quantify
the effectiveness of this skill-mix in reducing waiting times for the delivery of wheelchairs and
the associated training for patients and carers. The absence of one of our two OTs on sick
leave over much of the last year compromised the data collection undertaken so far. We
8
would like to maintain this post for the next two years to bolster the effectiveness of the
additional senior therapist post requested for the third team. Funding to enable us to retain
the existing, trained, post-holder until 2011 was agreed following our Initial Agreement
submission.
7.3 Planned Clinical Reviews for more complex Patients
We plan to introduce proactive clinical reviews of complex patients, the upper tier in the
model, by therapy staff in the service. This will improve the clinical service for complex or
deteriorating patients by allowing us to anticipate their seating and mobility needs rather than
reacting to problems as tends to be the case at present. The increase in wheelchair
therapists requested in this business case will provide us with the capacity to introduce this
proposal.
7.4 Extension of PPM Scheme and Home-Based Repairs
To implement the changes referred to earlier in the way repairs are undertaken, and to
extend the PPM scheme to cover all of our patients, will require extra wheelchair technician
input. We envisage that some technician time will be released by the reduction in
refurbishment rates during the project and believe therefore that we can implement both
aspects of this proposal with one additional wheelchair technician and some re-deployment
of existing technical staff. Funding for this additional post until 2011 has already been agreed
following our Initial Agreement submission.
7.5 Staff Training
One of our existing Wheelchair Therapists has already undertaken postural management
training in Oxford and we intend that the other two would also undertake this course. This
would then mean that each of the technician/therapist teams has the same level of
competence to deal with our most complex patients and it would also provide improved
continuity during periods of staff leave or sickness.
We would also like to introduce a Basic grade OT rotational post within our Wheelchair
Service. This would help to build up the level of competence in wheelchair prescription
amongst OTs working within NHS Highland meaning that we likely to have more candidates
with previous wheelchair experience when therapy vacancies arise in the Service in the
future. It also helps to bolster the backfill needed to enable the trained therapists to undertake
the training of locality-based staff throughout the project.
In order to create a higher level of theoretical knowledge in addition to pre-existing light
engineering experience, and also to help create a career path for technical staff, we would
like to develop SVQ level training for wheelchair technicians in conjunction with our local
further education college. We have had some favourable experience of this approach to
certifying training appropriate to the demands of technical posts in the past. We are also
keen to explore using any distance learning training packages that may be available
elsewhere. We propose to train our depot and PPM technicians over two years, possible in
two groups. Two of our five depot technicians will be of retirement age within the next two
years so the extra technician we are requesting funding for would be expected to be well
placed as a candidate for either of these posts at the end of their two year fixed-term
contract. The additional funding requested would therefore help with workforce planning fro
the Service as well as enabling much needed certification of training of technical staff. To
create the backfill necessary to allow staff to undertake this training we are requesting an
additional technician post for 2009-2011.
9
We would also like to use the additional resources over the duration of the project to develop
protocols and procedures throughout the Service. Pressure of work has prevented us from
doing this as comprehensively as we would have liked to in the past. The development of
these documents would involve all staff and will leave a beneficial legacy for both existing
and new staff beyond the life of the project. The capacity to undertake this work will be
generated by the additional staffing requested in our proposals.
7.6 Home-based Wheelchair Repairs away from Inverness.
We intend to enter into partnership with a not-for-profit organisation that currently installs
equipment in the homes of the elderly and disabled whereby they will be contracted to
undertake simple repairs to patients’ wheelchairs at their homes. This will be undertaken as a
pilot study over the next two years in the North Highland CHP area, plus some other adjacent
postcode areas, to assess its effectiveness. We currently have 880 patients who live in this
area which represents 27% of our wheelchair patients. We will initially provide 2 days training
to their staff in wheelchair repairs at our depot and will provide a stock of spare parts for them
to carry in their vans. We anticipate that this will allow many more repairs to be done quickly
at the patient’s home rather than the wheelchair being brought by carrier to Inverness for
repair. We will monitor repair times and costs throughout the pilot scheme for comparison
with those outwith the pilot area. If successful, we would plan to extend the scheme by
partnerships with similar “third sector” networks to cover the remaining areas which are more
than ten miles or so from Inverness.
7.7 Database Developments
We wish to develop the capability to access the wheelchair database remotely. This is
already possible from any NHS Highland facility and is also be possible from any internet
connection as the database is web-based. We have already started to explore accessing the
database from patients’ homes and from our mobile PPM workshops using mobile phone
cards and laptops but the project needs some additional IT expertise to reach fruition quickly.
In addition we will need to extend the access to our database to the locality-based staff
referred to above as Approved and Preferred prescribers. It is clear that there will be
additional IT work throughout the project in capturing the data needed to assess the
effectiveness of the proposed changes to our Service. We would also like to develop the
capacity to receive on-line patient referrals from clinical colleagues and also to pilot setting up
on-line patient forums as an adjunct to existing Wheelchair User Groups.
To undertake this additional IT work we would require a band 6 post from 2009-2011.
7.8 Modernisation of Wheelchairs on-issue to Patients
We want reduce the proportion of wheelchairs that are refurbished so as to enable the
modernisation of the range of wheelchairs. The refurbishment rate may increase again
following the fleet modernisation phase, although it is unlikely to return to the current level of
about 63%. The proposed KPI for this is a maximum of 25%. The reduction in refurbishment
rates of wheelchairs will require additional capital to purchase replacement chairs. The
technician capacity freed up by the reduction in refurbishment will be used to undertake some
of the additional PPM activity and home-based repairs referred to above.
We would like to start to modernise the range of wheelchairs on issue to patients. The single
most common complaint received about our current range of basic modular wheelchairs
(Unis) is that patients and carers find them heavy to manoeuvre and to take in and out of
10
cars. We propose to introduce this improvement by changing the basic manual wheelchair
that we issue from steel framed to aluminium framed. This will cost somewhere in the region
of £100 extra per issue although the lifetime costs are not yet known.
We also intend to improve the quality of powered wheelchairs which we have on issue by a
programme of gradual replacement of older powered wheelchairs with new wheelchairs. The
new chairs offer many advantages over the older models in terms of greater postural
adjustment in addition to the greater reliability to be expected from a newer chair.
7.9 Training DVD
We would like to produce a DVD for the purpose of training users and carers, community
staff, and staff working with wheelchair users in the education sector. We have already
discussed this in some detail with the Community Care Forum. They have the capability and
experience to produce such a DVD and we have an estimate from them of £10,000 for the
production costs. It will require an input of time from wheelchair service staff but this should
be possible using the addition staffing referred to above. We know from feedback we have
received from our Wheelchair Users Groups that the printed information which we issue to
patients with their wheelchair is often not effective as a means of providing training. In
addition to our plans described above to deliver more individual training to patients and to
provide regular training sessions to groups of patients and carers we think that the use of a
DVD or video would be an effective way to provide information and training.
7.10 Temporary Upgrading of Wheelchair Depot
We intend to seek capital and revenue funding for an integrated Wheelchair Centre building
from NHS Highland in order to provide a suitable facility at which to see the 30% of patients
who live within 10 miles of Inverness and to house the administrative, repair and
refurbishment activities of the Service. Although this facility will replace the repair and
refurbishment depot which we currently lease there are a number of pressing improvements
which need to made to the current building in order for it to be able to support the other
proposals detailed here while we await its replacement. The first of these is that we need to
improve the way in which we clean returned equipment both in order to ensure its proper
decontamination and to protect staff from the potentially harmful aerosol produced by
cleaning chairs using a high-pressure hot water cleaner. We propose to purchase a
wheelchair cleaner and to house it within the depot. The equipment can easily be moved
when the new facility is built.
The other improvements relate to heating the current building and to painting its bare
concrete block walls. The current building has a very high roof and is poorly insulated. This
means that the storage area gets extremely cold in the winter months which makes it a most
unpleasant place to work and also leads to damp and mould formation on the fabric of
wheelchairs. We have used a propane fuelled space heater in the past to try to heat the
facility but this does not distribute the heat effectively and adds to the damp problem. Our
Estates department have recommended the installation of nine wall-mounted electric fan
heaters (54kW in total) within the building.
11
7.11 Review of the Special Seating Service
We want to review the way in which we provide a special seating service to patients. At
present we employ a specialist contractor (Otto-Bock) to see patients at a Special Seating
clinic twice per year and while this does produce a high quality, expert, service it is expensive
and can produce long waits for patients which can be detrimental clinically. In the first
instance we would like to increase the frequency of these clinics from twice per year to three
times per year in order to reduce the waiting times. In the course of the next two years we
would like to undertake an option appraisal on alternative ways of providing this service. As
mentioned earlier, we also intend to train two of our Wheelchair Therapists in postural
management (one has already attended the course in Oxford).
We envisage that this option appraisal will be undertaken jointly by the project manager and
the Senior OT who has already received training in postural management.
8. Health Benefits of Proposals
By engaging with locality based staff to increase the local delivery of services to our
wheelchair patients we believe that assessment for and delivery of wheelchairs will happen
quicker, the chairs will be set-up to suit patients better, and patients and carers will receive
better instruction in the use of their wheelchairs. Quicker supply and better instruction should
increase the benefits to health and social inclusion of patients.
For patients with more complex needs we believe that the introduction of planned clinical
reviews will have significant health benefits in terms of allowing us to deal with changes in
prescribed equipment before a patient’s changing size, postural requirement, pressure
management, or social circumstances create a crisis to be dealt with.
9. Value for money
The proposals detailed below are believed to represent a cost –effective way to modernise
the Wheelchair and Seating Service provided by NHS Highland in line with the WSS Project
Board’s draft Action Plan and also with the Scottish Government’s “Shifting the Balance of
Care” proposals. They will increase our emphasis on anticipatory care and will provide more
continuous care and support closer to patients’ homes. This will be achieved by a partnership
approach between the NHS, Local Authorities, and the third sector.
10. Effect on Equity of Proposals
By creating closer links with locality-based staff and enabling them to prescribe wheelchairs
where appropriate, we intend to reduce the impact of location on the standard of service that
we are able to provide to patients throughout our area. Similarly, our plans to use a not-forprofit organisation’s network of repair vans to undertake home-based wheelchair repairs
should make the service more equitable for patients.
11. Exit Strategies for Proposals
In developing these proposals we are trying to use the available funding in a way that will
both have an immediately beneficial effect on the quality of service and equipment received
by existing and new patients and also allow us to develop staff within the Wheelchair Service
so as to embed improvements beyond the three-year lifespan of the project. It is intended to
monitor the results of all of the proposed changes over the three years of the project. It is
expected that they will all demonstrate improvements in the Service delivered to wheelchair
patients and it is of course hoped that funding will be available either from central funds or
from Health Boards after the end of the current project to enable the improvements to be
12
maintained. However details of the possible “exit strategy” from each of the proposals are
detailed below in case the additional funding ceases to be available beyond 2011. 26% of the
proposed expenditure is for “one-off” pump-priming purposes and the remaining 74% is for
staff costs. Essentially the exit strategies are that additional staff employed during the project
would be on fixed-term contracts, changes to the way in which services are provided will be
undertaken as pilot projects and may prove to be cost neutral in any case, or the funding will
be used as pump-priming to implement new ways of working which should be sustainable
after the end of the project.
12. Fit of Proposals with Draft Action Plan
Proposal
New Wheelchair Centre
Recommendations Being Addressed
Collaborations and Partnerships
 WSS centres will develop referral pathways and
protocols in partnership with other rehabilitation
service providers to enhance MDT working
Service Redesign  A part of the patient journey, WSS centres will work
towards meeting the overall RTT of 18 weeks
Building Capacity
 Each NHS Board will put in place separate local
wheelchair and seating clinics for children and for
adults. Local clinics will be supported by WSS
Centres
Equipment, Repairs and Maintenance
 WSS Centres will modernise equipment and renew
the wheelchair fleet in relation to current demand
and technological advances
2. Train community-based staff as
Approved and Preferred Prescribers –
adopting 3 tier system
Collaborations and Partnerships
 WSS centres will develop referral pathways and
protocols in partnership with other rehabilitation
service providers to enhance MDT working

WSS centres will form partnerships with local
health, education and social care services with a
view to establishing case management approaches

Opportunities for joint working between health and
social care equipment services to develop capacity
locally for managing wheelchair storage,
decontamination and uplift of equipment should be
explored
Service Redesign
 A skill mix review to be carried out in each WSS
13
centre to include medical, technical, therapy,
administrative and scientific staff

As part of the patient journey, WSS centres will
work towards meeting the overall RTT of 18 weeks
Building Capacity
 Each NHS Board will put in place separate local
wheelchair and seating clinics for children and for
adults. Local clinics will be supported by WSS
Centres


Protocols for assessment and issue of wheelchairs
will be NHS Boards
developed to support the delivery of local
wheelchair and seating clinics

Protocols for assessment and issue of wheelchairs
will be developed with a specific view to reduce
waiting times for users with progressive conditions

Practitioners with a special interest will be trained
and developed to provide clinical expertise locally

The education and training needs of technical and
scientific support staff in wheelchair services will be
identified and developments linked to support
worker and assistant practitioners in health care
science

Training needs for registered clinical and scientific
staff will be identified and education and training
programmes developed in line with the national
agenda for developing Healthcare Scientist
education and training
Referrals
 WSS centres will develop training for referrers to
the service in partnership with them
Assessment
 MDT approaches to assessment and care planning
should be introduced in partnership with health and
social care teams

Alternative pathways for provision of standard issue
equipment should be explored with other health
and social care equipment providers
Delivery
 Information and demonstration of equipment use
must be provided on delivery
14
2. Video conferencing equipment and
remote access to database to support
staff away from the Centre
Collaborations and Partnerships
 WSS centres will develop referral pathways and
protocols in partnership with other rehabilitation
service providers to enhance MDT working

WSS centres will form partnerships with local
health, education and social care services with a
view to establishing case management approaches
Service Redesign
 A part of the patient journey, WSS centres will work
towards meeting the overall RTT of 18 weeks
Building Capacity
 Each NHS Board will put in place separate local
wheelchair and seating clinics for children and for
adults. Local clinics will be supported by WSS
Centres

Practitioners with a special interest will be trained
and developed to provide clinical expertise locally
Referrals
 WSS centres will develop training for referrers to
the service in partnership with them
Assessment
 MDT approaches to assessment and care planning
should be introduced in partnership with health and
social care teams

2. Fund workplace assessment training
for specialist OTs in service
Alternative pathways for provision of standard issue
equipment should be explored with other health
and social care equipment providers
Collaborations and Partnerships
 WSS centres will be part of the rehabilitation
structure.

3. Investigate role of Occupational
Therapy Assistant in training patients
WSS centres will form partnerships with local
health, education and social care services with a
view to establishing case management approaches
Service Redesign
 A skill mix review to be carried out in each WSS
centre to include medical, technical, therapy,
administrative and scientific staff
Service Redesign
 A skill mix review to be carried out in each WSS
centre to include medical, technical, therapy,
administrative and scientific staff.
15

4 & 6. Extend PPM scheme to cover all
our patients and develop capability to
repair wheelchairs at patients’ homes
Outcomes will be measured using improvement
measuring tools
Building Capacity
 The education and training needs of technical and
scientific support staff in wheelchair services will be
identified and developments linked to support
worker and assistant practitioners in health care
science.
Service Redesign
 A skill mix review to be carried out in each WSS
centre to include medical, technical, therapy,
administrative and scientific staff.
Building Capacity
 The education and training needs of technical and
scientific support staff in wheelchair services will be
identified and developments linked to support
worker and assistant practitioners in health care
science
Equipment, Repairs and Maintenance
 Planned Preventative Maintenance programmes
will be introduced to all centres for power chairs,
heavy users and active users in the first instance

5. Staff Training
NHS wheelchair repair and maintenance services
should explore mechanisms to provide an extended
hours service in response to local need
Building Capacity
 Practitioners with a special
interest will be trained and
developed to provide clinical
expertise locally.
 The education and training
needs of technical and
scientific support staff in
wheelchair services will be
identified and developments
linked to support worker and
assistant practitioners in
health care science.
 Training needs for registered
clinical and scientific staff will
be identified and education
and training programmes
developed in line with the
national agenda for
developing Healthcare
Scientist education and
16
training.
 Training and education will
support the development of
career paths for wheelchair
and seating service and
related staff within the NHS
Scotland Career Framework.
Service Redesign
 A skill mix review to be carried
out in each WSS centre to
include medical, technical,
therapy, administrative and
scientific staff.
7. Database development
IM&T
 An options appraisal of IT
support needs will be carried
out.
 Clinical data standards and
data definitions will be
developed for wheelchair and
seating services
8. Modernise range of available
wheelchairs.
Provision
 Decision making for the
provision and supply of
wheelchairs will be supported
by evidence of the non
financial aspects of
equipment provision.
Equipment, Repairs and Maintenance
 WSS Centres will
modernise equipment
and renew the wheelchair
fleet in relation to current
demand and
technological advances
 A model of fleet renewal
will be developed that is
responsive to new
technology and changes
in demand
9. Produce a DVD for purposes of
training patients, carers, referrers to
service, and colleagues in education
and community settings
Collaborations and Partnerships
 Patient information will be developed in partnership
with service users and other providers.
Building Capacity
17

10. Wheelchair depot temporary
upgrading.
11. Additional Seating Clinics
Protocols for assessment and issue of wheelchairs
will be developed to support the delivery of local
wheelchair and seating clinics
Delivery
 Information and demonstration of equipment use
must be provided on delivery
Equipment, Repairs and Maintenance
 NHS wheelchair repair
and maintenance
services should explore
mechanisms to provide
an extended hours
service in response to
local need
Building Capacity
 Each NHS Board will put in
place separate local
wheelchair and seating clinics
for children and for adults.
Local clinics will be supported
by WSS Centres.
 Practitioners with a special
interest will be trained and
developed to provide clinical
expertise locally
Protocols for assessment and
issue of wheelchairs will be
developed to support the
delivery of local wheelchair
and seating clinics.
14. Fit of Proposals with local delivery plans
The proposals are in keeping with NHS Highland’s strategy for meeting 2008/2009
HEAT targets as follows:
14.1 Efficiency and Governance
The development of a proposal for a new Wheelchair Centre is included in NHS
Highland’s 2007/8 Property Strategy. Proposals around redesign of services will
increase staff efficiency and productivity.
14.2 Access
Proposals around redesign of services involve the training of staff in Community
Health Partnerships to enable more patients’ needs to be addressed closer to home.
This, combined with a purpose built Wheelchair Centre, will improve access to the
service and will, therefore, also improve waiting times for patients. Equally, the plans
to pilot undertaking wheelchair repairs at patient’s homes will minimise the effects of
18
home location from a patient’s point of view.
14.3 Treatment
Proposals for redesign to provide a more comprehensive and locally based service will
impact on the level of patients with complex care needs receiving care at home, assist
in the management of long term conditions and improve the quality of the health care
experience for service users.
15. Fit of Proposals with Property Strategy
The development of a proposal for a new Wheelchair Centre is included in NHS
Highland’s 2007/8 Property Strategy.
19
References
1. Moving Forward. Review of NHS Wheelchair and Seating Services in Scotland. March
2006.
2. Better Health, Better Care: Action Plan. Scottish Government, December 2007.
3. Scottish Government’s Wheelchair and Seating Service Modernisation Draft Action
Plan, August 2008.
20