Community Wheelchair Services


September 2009

Lead Contact Name: Ashley King

Type of Proposal: Quality Improvement

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Summary of Idea:

Purpose: To commission a Community Wheelchair Service that meets the health related mobility needs for all patients within the NHS South East Essex (NHSSEE) area. Background: The community wheelchair service is currently commissioned to · provide the framework to clinically assess clients of all ages with a permanent and regular mobility need. · provide Wheelchair equipment, postural support and seating to facilitate safe mobility. · support both client and equipment as long as necessary. · evaluate on an ongoing basis the service and equipment it provides. At present Community Wheelchair Services for adults and children are commissioned from the provider function of NHS South East Essex, Community Healthcare (CHC). The service is currently failing to meet the 18 week referral to treatment target for all patients, and at present stop the clock on initial assessment as opposed to provision of a wheelchair, or an alternative satisfactory provision. The service has received a number of complaints within the past 18 months and there is seemingly a general dissatisfaction of the service provided. It was agreed at JEG/MEX in September 2008 that a commissioner led service review would be undertaken. This report builds on the findings of the review, identifying an enhanced service the PCT should look to commission and makes a recommendation for future action. Aim: ·

to provide an enhanced service that builds on the existing foundations to a higher standard than the current provision.

Objectives: · Reduce waiting times for patients needing a wheelchair under the acceptance criteria within South East Essex · Improved access to obtaining wheelchairs following assessment · Maintain or improve current clinical quality for community wheelchair services · Improved patient experience with more personalised services for community wheelchair services · A service working in partnership with Southend University Hospital Foundation Trust to facilitate discharge Critical Success Factors of new service: · Quality of the future service is better than the current service, in particular in regards to the effectiveness of access and the experience for users · Waiting times for initial assessment is less than current waits, with a expectation of continuous improvement · Referral to receipt of functional wheelchair, or alternative satisfactory conclusion, within 18 weeks Congruence with PCT Priorities: The proposal is in line with the PCT's strategic direction and will contribute to the delivery of the following targets: · Improving referral to treatment times for community services · Ensuring no community service exceeds the 18 week target Governance (Conflicts of Interest): This commissioning case is led by the PCT Commissioning function and no members of the organisation involved directly in its preparation have any interest in companies that may wish to provide community wheelchair services.

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The spouse of the commissioner leading the review currently works voluntarily at one of the Special Needs Schools within the locality and has regular contact with some of the key stakeholders.

Current Service Provision & Performance

Understanding the nature of the service The existing community wheelchair service is provided by the PCT's Arms Length Trading Organisation, Community Healthcare. It operates within the boundaries as defined by the catchment of NHSSEE. The service currently has circa 3,000 wheelchair users on its books and receives approximately 120 referrals a month. These referrals are both adults and children, including new referrals and returning users. At present around 9% of service users are children, and statistically approximately 65% of all users require a standard chair. At present, and due to IT capabilities, the provider is reporting against 18 weeks based upon the time between initial referral and first appointment/assessment. At present there are 3 waiting lists · Occupational Therapy Technician (OTT) only, · Occupational Therapist (OT) only, or · OT & Rehabilitation Engineer (RE) joint assessment As of June 2009 no patient was waiting in excess of 18 weeks between referral to assessment, however the service provider is unable to report on the assessment to treatment phase and total length of time for the patient between referral and receipt of wheelchair. The current service pathway shown below identifies the internal processes of the service from referral to provision.

REFERRAL RECEIVED Date stamped Unknown client Entered on database & file created Known client Use existing client information

Inappropriate / incomplete referral

Re direct if Appropriate

Co-ordinator triage for direct Provision where able Return to referrer Screened daily by Occupational Therapist (OT) / Occupational Therapy Technician (OTT) / Office Manager

Needs immediate Intervention Direct Provision Telephone contact to seek/clarify position

Allocated to OT or OTT

Referrer informed Does not meet criteria Placed on Waiting list

Case opened

No further Wheelchair Service action

Waiting list letter sent Refusal letter sent to Client and GP Assessment in Clinic / At home Client exits process. File inactivated And archived Refer to Special Seating Services

Appointment made

Clinical reasoning to plan intervention

Equipment trialled with client Voucher Prescription Equipment handed over. Provision made. No further intervention required

The service has received a number of complaints over the past 18 months, with the main topic being the length of waits incurred by the user.

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Procurement/Provision At present the procurement routes taken by the service are complex with variation dependent upon the type of chair required. Clients can take the option to procure a wheelchair themselves with the use of a voucher which is equal to the value that the NHS would have incurred in providing the chair; although at present this is a complex process set by the Dh and only available if the client wants a chair that exceeds the specification available on the NHS. Handover & Aftercare The handover of the chair is normally done by the prescribing clinician. This is more evident in the prescription of non standard chairs whereby the clinician needs to ensure that it meets the needs of the client. Standard chairs can be delivered directly by the approved repairer who is skilled in the minor amendments required upon delivery. Once handover is complete the client has a two week window to raise queries with the service, following this the case is closed and any re-referral is treated as new. Assuming the client is not referred back to the service the only contact the patients have is through the approved repairer who is contracted to undertake annual Planned Preventative Maintenance on all stock. Sub-Contractors The service is currently reliant on a number of critical services being provided by external bodies, they are namely 1. Rehabilitation Engineers, 2. the Approved Repairer Service and 3. Special Seating Services. The service also runs clinics hosted by a company rep from GBL. The service does receive referrals from external Occupational and Physio Therapists who are able to prescribe for direct provision; this means that the Wheelchair Service does not have to undertake an assessment. These can be transit chairs, self propelling chairs, buggy and/or standard cushions. Hospital Engagement The current service is not commissioned to actively engage within the discharge, or rehabilitation, process at the local acute trust. Short-term Provision The service is not commissioned to provide short term loan stock, for those patients that require a chair for less than 6 months. This is quite normal for NHS wheelchair services, although it is known that NHS Plymouth have recently started a Short Term Wheelchair Loan Service to aid in hospital discharge and rehabilitation. Some local charities do have wheelchairs available for hire.

Service Review

Between March 2009 and May 2009 a commissioner led service review was undertaken as a result of the concern at the number of complaints received in regards to the service. The focus was to understand the current service as commissioned by NHS South East Essex which has been outlined above, and to identify the current concerns and gaps within the existing service. Stakeholder Engagement During this period the reviewer spent time with the current service provider. Time was spent alongside the administration function of the service as well as with most of the clinical staff who were met on a one to one basis. The reviewer also sat in on a couple of clinical sessions.

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The review also included user and carer perspectives by distributing questionnaires during two weeks of clinic appointments resulting in the receipt of 12 completed questionnaires ­ the responses to which varied depending mainly upon the wait which the client had incurred. A session was held at the Lighthouse Centre when the reviewer, along with the Assistant Director for Children, Young People & Maternity Commissioning, met with parents/carers of wheelchair users giving them the opportunity to raise their issues with the service as currently provided. The local acute trust was approached and asked to provide a summary of the current issues that they have observed with the service and this was submitted back to the PCT. In addition to this report the Head of Rehabilitation, and a Paediatric Occupational Therapist, from the trust were met with on an individual basis. Other engagement included · a brief questionnaire circulated to GP practices, · introductory discussions with a Strategic Services Advisor from Whizz-Kidz, · discussion with the chair of the local Disability Information and Advice Line (DIAL); and · comparative fact finding meeting with the Service Manager for South West Essex Community Wheelchair Services.

Information on other Wheelchair Services

Appendix 1 shows information identified through the recent NHS Benchmarking report into NHS Provider Services. In summary, using the information submitted, the average staff whole time equivalents per 100,000 of population is 1.94 compared to our provider employing 0.99, whilst average cost per 100,000 of population is higher than the average cost for wheelchair services. It must be noted that these numbers may not be directly comparable due to interpretations of the information requested, for example whether the staff included includes just clinical, or clinical and administration. These statistics also do not account for the differences in criteria, current service provision or quality of service. South West Essex, the nearest provider outside our boundary are currently undergoing a process of change themselves. The service has split itself into services for adults and children with different waiting lists for each stream. They also subcontract their Approved Repairer service, Rehab Engineer time and Special Seating services from the same contractors as used by the current provider. Waltham Forest NHS Trust is currently tendering their Wheelchair Service as a whole for a three year period; this has been listed on NHS Supply2Health and has been given estimated contract values of between £1,920k and £2,070k. Waltham Forest has a population of circa 257,000 and an anticipated wheelchair user base of 3,500. An advert has recently been published on Supply2Health for wheelchair services to be provided to seven London based Primary Care Trusts with the procurement being led by Westminster PCT.

Description of Service to be Commissioned

Following the work undertaken during the review it can be concluded that the service that is currently being commissioned does not meet all the health needs of the population of South East Essex, as such it is proposed that the PCT commission a Wheelchair Service that meets the health needs of the population that it serves. Service Outcomes A draft service specification has been developed for this service. In summary the enhanced service would include developments in the following areas:

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· · · · · ·

Provision of a service that works alongside the rehabilitation team at the local acute trust to provide wheelchairs on discharge as appropriate, for both long and short term use for patients with a health requirement An annual contact/review for those patients whose needs are likely to change over time The creation of an effective wheelchair user group enabling users the means to influence and feed into service provision Regular approved assessor training courses to be run to enable greater prescription through other professionals, and reducing the pressure on the Wheelchair Service Improved provision of information to users and carers on handover Enabling approved third sector organisations to refer directly into the Wheelchair Service

There would also be expectations that the service meets predefined wait times, and Key Performance Indicators. The proposed service would be expected to work within 18 week guidelines and in line with recommendations made within the document `Health Care Standards for Wheelchair Services Under the NHS' as detailed below. Response Times (to Client) (wds = working days) Referrals All referrals screened by approved personnel within the service Referrals acknowledged to referrer Incomplete referrals returned to referrer From receipt of referral to assessment From prescription to delivery Locally held stock Orders from manufacturers Made to measure For Made to measure the service to obtain an estimated delivery date from manufacturer and inform client within Non emergency repairs completed in Emergency repairs/responses within Deliveries completed within Collections completed within 2 wds 5 wds 2 wds 15 wds 15 wds 30 wds 30 to 65 wds 5 wds 3 wds 24 hours 5 wds 5 wds

For equipment required for discharge the expectation would be that equipment is available for discharge, if not before. Following approval to proceed a task and finish group will be developed to discuss and agree the final specification that the organisation should aspire to involving input from key stakeholders identified, including the local acute trust rehabilitation department and user/carer representation ­ they would also help define the KPI's to feed into the contract. What options were considered There are a number of possibilities in regards to structure for a wheelchair service, including the splitting of adult and children services and the separation of the procurement process from the assessment service. These options are assessed below. Service Structure Single Provider Strengths and Weaknesses Strengths ­ enables multiple areas for innovation, potential for economies of scale for larger provider, greater resource may allow for greater knowledge amongst staff, single contract for all aspects of provision to be monitored by commissioner

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Adult only service

Weaknesses ­ requires range of skills and knowledge, as opposed to specialism Strengths ­ smaller service may attract different providers to the market place, would enable specialists in terms of clinicians Weaknesses ­ smaller service is likely to require proportionately higher overheads to clinical input, requires transition of patients at a key stage of life, would inherit patients from childrens service who may have been managed with different expectations and with different service standards, additional contract to manage for commissioner Strengths ­ enables specialism amongst clinicians and service provider, could attract new providers to the market place Weaknesses ­ smaller service is likely to require proportionately higher overheads to clinical input, requires transition of patients at a key stage of life, additional contract to manage for commissioner Strengths ­ would allow for defined focus in the providers around targeted KPI's and service outcomes Weaknesses ­ the clinical judgment, and potential subjectivity, required on some cases may result in user needs not being met Strengths ­ allows potential for specialist service providers with dedicated KPI's to operate against Weaknesses ­ potential for conflict between providers reliable upon each other for achieving expected targets, and a potential to shift blame, additional contracts with complexity of relationships to manage for commissioner, adds additional accountable organisation into patient journey

Children only service

Separate providers for short term and long term users

Separation of Assessment and Procurement processes

Following this assessment and for the purpose of this paper the preferred service structure, in line with the organisations desire to manage pathways, and Integrated Organisations, is assumed to be as a single provider. This should enable them more opportunity to be innovative in provision, as opposed to stripping services back to the lowest denominator and the requirement then for the PCT to micromanage each step of the process for multiple user groups and contract holders. The decision to keep all elements of the pathway under a single service specification and contractual relationship should enable a more strategic view for the commissioners and give the provider operational responsibility for delivering, either directly or through sub-contractual mechanisms, each step of the process and sole accountability. Impact Assessment Patient Carers

Primary Care No perceived

The service will be more

No perceived

Community Health Services Potential significant

Hospital Services Expectation that a

Other agencies No perceived negative

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accountable to patients through the development of a user group, whilst providing a service that better meets their needs

negative impact on carers

negative impact

impact on community health services

reduction in workload through the efficient use of multidisciplinary clinics for discharge planning


Information Technology & Governance The PCT IM&T strategy for community service providers is for the use of TPP SystmOne as the standard clinical system and this would be fed into any contractual documents for the new wheelchair service. The system allows integration across service providers in relation to clinical information and will enable the development of more complete summary care records. The PCT would determine what information they would wish to be recorded through the system. It would be the providers' responsibility to identify and use an appropriate business management system for the organisation of service provision and the procurement of equipment. As the enhanced service is likely to be based at the existing site there are no expected issues with them accessing the existing N3 connection for this service. If a new site was required then this could have implications in terms of IT connections required and timelines for implementation. The provider would be required to meet all Information Governance standards in line with the IG Toolkit Annual Assessment. They would be expected to evidence that they have relevant structures and processes in place to be able to complete this assessment.

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Finance & Contractual Matters

Since the 1st April 2009 the Community Healthcare contract, who are the current provider, has been commissioned on both cost and volume, and a block basis for those services not part of the reference costs data collection exercise. As a result the Wheelchair Service is contracted on a block basis, which lacks a means of incentivising completion of cases or quality of service. The budget has been at a relatively consistent level for the past number of years, the only annual uplifts being standard generics. The service did receive a further £56,000 in 2008/9 to target the waiting list problems it was experiencing. The provider has indicated a notional contracted level of activity of 1269 face to face contacts for 2009/10; given that the service receives an average of 120 referrals a month, which equates to circa 1440 (120x12) per annum the current contracted activity volume is insufficient to provide each new referral with a single face to face contact, some require more than one. Either further investment is required or a change in service model, or provider innovation is required to manage the demand in a cost neutral way. The budget for the service for 2009/10 is summarised within the table below. Annual Budget 2009/10 (£000's) 159 41 292 36 291 9 828

Pay Non Pay Rehab Engineers Chairs & Accessories Specialist Seating Approved Repairer (inc spares) Miscellaneous Total

These costs do not include the administration team, estimated at circa £75k based on existing establishment, or estate. These are direct costs only and do not include any allowance for organisational overheads. The existing provider has recently entered into a new 5 year contract with DGT to operate as the approved repairer. The agreements for Rehabilitation Engineer time and Special Seating Assessments are signed up to on an annual basis and do not provide the existing community wheelchair provider with adequate leverage in ensuring outcomes are as desired. It would be proposed that a new service be contracted for on the basis of service outcomes, for example provision of chair, or patient pathway, as opposed to the existing block mechanism or face to face to contacts. Example currency options include `per year of care' for patients known to the service, and `pathway' for those referred into the service, or a hybrid mechanism. These examples are detailed within the Dh publication `Transforming Community Services: Currency and Pricing Options for Community Services'. Equality Impact Assessment Initial screening suggests there is medium relevance with regard to equality and as such a full EIA requires completion within 9 months.

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Human Rights

Community Wheelchair Service









Total Points



Service, Function, Policy, Procedure.

Impact High Medium Low Low

Proposal for Procurement Route

Principles It is important when identifying possible procurement routes that the following principles are adhered to. · · · Be deliverable in logistical terms and give NHS South East Essex sufficient assurance on matters such as service quality and sustainability Be affordable, and maximise the available resources, for both provider and commissioner from the available budget Complement the other services that provide care to Wheelchair users such that the whole system delivers high quality and accessible services to users

There are several procurement options open to the PCT for the development of new services, for example Any Willing Provider (AWP), Tender, Contract Variation and Pilot. It is felt that the specialist knowledge required to undertake this service excludes the AWP option, whilst a fixed term pilot is more suited when the design of a service, and expected outcomes are not fully known. As such the other two options are compared in the table below for their strengths, weaknesses and risks. The table below summarises key points behind these two procurement routes: Tender Contract Variation Strengths Evidences contestability and market Provider already in place and price allows timely resolution Opportunity to develop the market and encourage provider innovation Enables a clean start for new service under new service specification Needs to align with notification requirements within existing contract, or agreement of transitional dates and period Potential loss of existing staff during time of uncertainty Barriers to entry may deter new providers to bid, and set up costs required may make bids incomparable Contract price exceeds current costs and available funding No bids received New service start date fails to align with existing service end date


Does not evidence contestability Requires change on a service level during a time of change for the provider organisation as an entity May not encourage a cultural shift in attitudes Would require negotiation with existing provider around resource implication Public continue to perceive the service in the same negative light Provider continues to struggle to recruit Service change postponed during


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Destabilisation of existing provider and deterioration of current service.

time of organisational restructure and development

The PCT needs to consider the current economic climate within the UK and the current financial position of the PCT, as such there are limited funds available for simple service investment. However the PCT is required to evidence contestability for all community services over the coming years, and it is possible the new service models could provide efficiencies to the system. Following information obtained during the review it is considered that the potential to develop the market does exist through not only existing providers but also through attracting alternative providers to the market, for example local councils and/or the third sector. It is also possible that advertising within OJEU could attract providers from further afield, including within Europe and Globally. It is proposed at this stage that the recommendation to be made to the Procurement Committee is to go to the market and tender the service under a restricted process. The timetable below identifies a draft plan for the delivery of the project Date 20th August 24th September 5th October 7th October 20th November 8th January February 1st March 25th March 26th March 9th April 1st June Action Commissioning Group Board Approval Procurement Committee Advert PQQ and Shortlisting Circulation of bidder pack Bids received back Evaluation completed Procurement Committee ­ approval of process Board ­ approval of provider Contract Award Contract Signed Service start date

It is requested that the commissioning group approve this project to proceed, at which point a project team will be created, involving members of the PCT and key stakeholders, to formally oversee the delivery of this project.

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