October - November 2015
Consultation response form
Setting the mandate to NHS England for 2016 to 2017
Consultation Questions
1) Do you agree with our aims for the mandate to NHS England?
The Orthotics Campaign believes that the overall aims of the mandate to NHS England are
appropriate. However we also believe that it is also crucial to identify specific services that
are known to be falling short and to identify and target these for improvement.
It is widely recognised that NHS Orthotic services are failing to provide consistently good
and equitable standards of care. The recent NHS England report entitled "Improving the
quality of NHS Orthotic Care in England" illustrated this clearly: "Orthotics services play an
essential role in enabling quality of life for people with long term conditions, disabilities and
limb loss. Being able to access the right orthotics equipment, quickly, and with appropriate
support, is of paramount importance. Unfortunately, this doesn't always happen. People
can find themselves waiting a long time for equipment and develop secondary health
complications. Long waiting times mean that children in particular may have grown before
their orthotics equipment finally arrives. These are avoidable and unfair inequalities".
Widespread failings in Orthotic care result in worse outcomes, poor patient experience
poor value for public money and unnecessary costs to the NHS. In quantitative terms, the
“Orthotic Pathfinder” report estimated that the economic and social consequences of
denying patients orthotic care are significant, costing an estimated £390 million per annum
based on 2004 data. It suggested that for every £1 spent on improving orthotics service
provision, the NHS could save £4.
It is therefore imperative that Orthotic care is specifically prioritised in the NHS Mandate.
Failing to do so will hinder the improvement that is so desperately needed. In so doing it
will prolong a situation where the NHS is failing to benefit from the savings that could be
made in the health economy, if quality Orthotic care was provided to all patients in a timely
fashion.
If the NHS is to meet the needs of disabled people and reduce the health inequalities,
Orthotic services must be clearly targeted in the mandate.
The Orthotics Campaign is a group of service users and professionals who believe that
NHS Orthotic care needs radical reform. Our members know all too well the impact of the
lack of quality and consistency in NHS Orthotic services. We have heard terrible stories
from patients: the story of a young boy, who due to a lack of timely and quality Orthotic
care lost his mobility and had to rely unnecessarily on a wheelchair. Others who have had
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to undergo what should have been avoidable surgery. Parents up and down the country
are having to decide whether to force their child to wear an ill-fitting orthosis that causes
their child pain and blisters or to have them go without it and increase the chance of their
child becoming deformed.
I support the work of the Orthotics Campaign in asking for Orthotic services to be
specifically mentioned within the mandate.
With the evidence that the Orthotics Campaign has been able to collate from the following
sources, it is clear that positive change in Orthotic Care is essential if the aims of the
mandate are to be achieved:
• Events held by NHS England: Salford, March 2015 and London, November 2015
• Improving the Quality of NHS Orthotic Care in England
https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/11/orthcsfinal-rep.pdf
• Orthotic Service in the NHS: Improving Service Provision
http://www.nsoc.org.uk/evidence/york-report.pdf
• The economic impact of improved orthotic services provision
http://www.bhta.net/sites/default/files/documentupload/2012/Orthotics_review_Cebr_report_04_07_2011.pdf
• The Audit Commission report and update:
http://www.communityequipment.org.uk/wp-content/uploads/Fully-equipped-2000.pdf
http://www.communityequipment.org.uk/wp-content/uploads/Fully-Equipped-2002.pdf
• Arthritis Research UK: A call to action: Providing better footwear and Orthoses
http://www.arthritisresearchuk.org/~/media/Files/Policy%20files/Policy%20pages%20files/
Footwear_Report_ARUK%20(1).ashx
• Other evidence can be found at: http://www.orthoticscampaign.org.uk/evidence.html
2) Is there anything else we should be considering in producing the mandate to NHS
England?
There needs to be more specific service improvement targets for NHS England within the
mandate. This should state and prioritise a need for urgent improvement in orthotic
services. NHS England has stated why and how Orthotic care needs to improve. There
now needs to be a clear mandate to facilitate these urgent improvements. In this way the
NHS could simultaneously improve quality of care and reduce costs. In so doing the lives
of huge numbers of disabled people across England could be significantly improved and
the effectiveness of other rehab services like physiotherapy can be enhanced.
3) What views do you have on our overarching objective of improving outcomes and
reducing health inequalities, including by using new measures of comparative
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quality for local CCG populations to complement the national outcomes measures
in the NHS Outcomes Framework?
We support this proposal. However it is important that smaller services such as Orthotics
are specifically included in such measures. All too often Orthotics care is overlooked as
insignificant, low priority, or too difficult to tackle. Often CCGs do not understand the
complexities of commissioning a quality orthotic service. This type of service
commissioning is extremely complex. However there are significant gains to be made if
Orthotics commissioning is done properly: benefits to patients, enhancements in the
effectiveness of other services and a cost saving to the wider health and social-care
economies.
If the NHS aims to reduce variation and poor quality, then it needs to target areas where
there is greatest variation and where patient experience is known to be poor. Clearly
Orthotic care is one of these areas and this should be identified and given priority in the
mandate.
4) What views do you have on our priorities for the health and care system?
The Orthotics campaign generally supports the priorities. However in order to achieve
these priorities it will be necessary for Orthotic services to be specifically addressed.
Without Orthotic care being named in the mandate it is likely that orthotic services will
remain in the state they are now. This is how mandating Orthotic care improvements could
directly contribute to the priorities set:
 Preventing ill health and supporting people to live healthier lives.
Orthotic care does both of these things. By enabling people to maintain mobility and
function, Orthotic care allows people to stay fit and active and avoid the secondary
complications of immobility. For example, someone who has a progressive neuromuscular condition can be supported using Orthotic devices so they can mobilise or stand.
This means they can maintain bowel, cardiac and respiratory functioning. Orthotic care
contributes to falls prevention and can help people with diabetes avoid amputations. Many
disabled people rely on their Orthotic devices and Orthotic footwear to allow them to work,
access school, look after themselves and participate in social and leisure opportunities.
Lack of timely and quality orthotic care can undermine all of these things.
 Creating the safest, highest quality health and care service.
At present safety within orthotic care is of concern. Poorly commissioned services can
often not find the time to explain to patients how to use and care for their devices. When
devices begin to rub and blister patient’s bodies, they often have to wait for excessive
periods before they can access the help they need to rectify their devices. This leaves
patients at risk in the meantime. The risks are associated with damage to skin (which for
diabetics could be catastrophic) and with the patient being unable to wear the device that
they have an assessed clinical need for.
Furthermore many services suffer from an imbalance in demand and capacity, meaning
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appointment slots are reduced to potentially unsafe lengths. The national shortage of
trained Orthotists is also of concern for patient safety, with some services unable to recruit
the staff they need to fill vacancies. For more details about why the patient experience of
orthotic care can be poor, please see this document:
https://www.england.nhs.uk/wp-content/uploads/2015/11/orthcs-rep-attach-1.pdf
 Maintaining and improving performance against core standards while achieving financial
balance, by ensuring the NHS meets the needs of patients and operates within its budget.
There is clear evidence that the NHS is failing to fully benefit from the cost savings that
Orthotic care provides. By making Orthotics a priority within the mandate we could
increase the likelihood of being able to fully realise this cost saving. See report:
http://www.bhta.net/sites/default/files/documentupload/2012/Orthotics_review_Cebr_report_04_07_2011.pdf
 Transforming out-of-hospital care, ensuring services outside hospital settings are more
integrated and accessible.
Orthotic users are generally people living with long term disabilities who would not
consider themselves to be ‘sick’. However, they are usually provided with their Orthotic
care in busy acute hospitals rather than in community-based settings. By recommissioning
care into more appropriate and community environments, CCGs can give Orthotic users a
much more accessible and positive experience of their care whilst releasing space
pressure on acute hospitals.
 Driving improvements in efficiency and productivity by reducing waste and inefficiency to
ensure every penny delivers the maximum possible benefit to patient care.
Sadly at present there can be a lot of wastage in Orthotic services. This comes from
devices taking so long to get to the patient that they are outgrown or unsuitable when they
are fitted. As Orthotics products are often bespoke to the patient and are for single patient
use, devices are then wasted. Furthermore Orthotists are having to see patients in clinical
slots that are too short. This means higher chances of measuring errors, or crucial details
being omitted from orders. These are symptoms of poor commissioning that are impacting
patients across England.
 Supporting research, innovation and growth, and influencing global health priorities.
There are many technologies that could enhance orthotic care and improve outcomes (eg
3D printing technology, 3D scanning). However due to the lack of investment in NHS
Orthotic services over a long period of time, orthotists are generally still relying on
outdated traditional measuring methods. Better commissioning of Orthotic services, that
supports the use of innovation, is needed if patients are to benefit from these technologies
and the NHS is to benefit from the reduction in waste. Ultimately technology can reduce
error and waste, but unless Orthotic care is specifically mandated then this issue is
unlikely to resolve.
Making orthotic services a priority improvement area in the mandate would bring about
huge benefits to patient and carer experience to what is currently an overlooked and
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vulnerable, yet important, group of people.
5) What views do you have on how we set objectives for NHS England to reflect
their contribution to achieving our priorities?
Whilst it is necessary to have general objectives for NHS England, it must also be
recognised that there are services which do not fit well into these generalised principles.
Orthotics is a clear example of this and the quality of this service has suffered from being
treated under a generalised approach. For too long services that focus on the needs of
disabled people are seen as less important. For too long Orthotic care has been regarded
as a commodity-based service that simply dishes out equipment; and not the highly
specialist clinical service that it is. It is this kind of thinking that has led us to the poor state
that services are now in. We believe that decisive action and prioritisation of Orthotic
services is required now, if society is to benefit from the huge benefits that this service can
provide. Unfortunately the budget holder for orthotics is not the one who benefits from the
savings that Orthotics makes in the local health economy. As long as this is the case, it is
critical that Orthotic care improvements are clearly stated and prioritised in the mandate. It
is also important to see the needs of people with long-term conditions and disabilities
being given as much priority as those with acute needs. The NHS needs to hear the voices
of this group of patients and strongly reflect their needs when setting priorities.
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