Will Personal Health Budgets for wheelchairs fix the problems?

NHS England recently announced that to give people more choice and control about the care they receive, personal health budgets will be extended to cover wheelchairs from April 2017.

This move is intended to support the government’s target of enabling 100,000 people to benefit from greater control via personal health budgets by 2020/21.

It is proposed that Personal Health Budgets (PHBs) will replace the current wheelchair voucher scheme as part of efforts to improve services for over 1.2 million people that currently use wheelchairs.

NHS England claims the new personal health budget scheme will offer more choice over what wheelchair can be acquired, and will include a detailed care plan to help users make informed decisions about their wheelchair. They claim care plans will not only cover purchasing the chair, but will also include guidance on future maintenance, repair and replacement needs. Without a business case or impact assessment or relevant evidence, it is difficult to assess at this stage exactly how the model will work in practice.

NHS England has been reviewing wheelchair provision over the past 2.5 years, and introducing PHBs would appear to be in response to the findings of that review; however we sincerely hope that issuing PHBs for wheelchair users is not the only outcome of that review, as PHBs cannot possibly be a solution to the numerous problems associated with these services.

As the independent standards body in the UK for wheelchair services, CECOPS welcomes the move to extend personal health budgets to these services, and we have in fact already included the use of PHBs in our Code of Practice. The use of PHBs for wheelchairs will be an area which our assessment processes will cover, for organisations seeking accreditation with us.

Notwithstanding our support of measures to improve wheelchair services and user experience, we do have some concerns which we hope will be addressed before the introduction of PHBs for wheelchairs in April 2017.

We feel that if the areas of concern below are not sufficiently addressed, the roll-out of PHBs for wheelchairs will not achieve its well-intended aims. At this point it is unclear how PHBs will work better than the existing voucher scheme, and this is something we would like to hear more about from NHS England Personal Health Budget team.

Could PHBs exacerbate current difficulties associated with disjointed services?

Disabled people often require a range of assistive technology (AT) related services e.g. communication aids, posture equipment, adaptations. As the different AT services generally operate independently of each other, people usually undergo several different assessments to cover their various and holistic equipment needs.

The current model is costly and is far from being person-centred. Offering a PHB exclusively for one type of assistive technology (i.e. wheelchair) could potentially exacerbate the problem, and would appear to go against the direction of offering more holistic, personalised and person-centred care.

NHS England has indicated that it hopes to start off with PHBs for wheelchairs and then move on to other types of AT. However we feel it would be much better to offer PHBs for all AT needs at the commencement of the initiative; this would help stimulate the drive for more holistic and person-centred assessments, offering real benefits in terms of user experience, as well as improving clinical and financial outcomes.

The following quote from a service user clearly demonstrates current difficulties, and why offering PHBs exclusively for wheelchairs won’t help with wider issues:

“It was great that I eventually got an indoor/outdoor wheelchair, but I couldn’t get in or out of my home because the adaptation hadn’t been done. I was given a communication aid but no-one would agree to mount it to my wheelchair.”

Will PHBs address long waiting times?

One of the main problems associated with many wheelchair services is the waiting times. It is not uncommon for people to wait 18 months for a wheelchair.

PHBs won’t address waiting times, as they are not set up for that purpose. In fact, PHBs could even increase waiting times, for reasons explained below.

The main reason currently for long waiting times is lack of funds. PHBs won’t introduce any new money, and purchasing a wheelchair at retail price under a PHB rather than at bulk contract price will be more expensive. In addition, wheelchairs bought under a PHB belong to the user and will never come back into the wheelchair service to be reissued to another user. This could add significant pressure to current overstretched budgets and increase waiting times for all wheelchairs, whether under a PHB or not.

Will PHBs help people who need equipment urgently?

People with rapidly progressive conditions, such as motor neurone disease or some types of multiple sclerosis, require access to equipment urgently. Sadly, fast-tracking of services for these people is not generally in place.

Providing people with PHBs is not likely to address this serious problem. Presumably there will be a waiting list for accessing PHBs just as there is for loaned equipment, as without new money there will still be funding issues. We feel strongly that this area should be looked at as a priority; it is disgraceful that some people die whilst waiting to receive vital equipment.

One solution could be that the PHB scheme includes a fast-tracking arrangement so that eligible people have access to funds immediately to buy everything they need quickly. Obviously there would need to be clinical professionals involved to facilitate and advise.

Could PHBs for wheelchairs actually be more costly?

As previously mentioned most wheelchairs are purchased by the NHS or out-sourced provider under a bulk contract or framework, in some cases at significantly discounted prices. With PHBs, people will purchase equipment outside of these agreements from retailers at high street prices, which are very likely to be much higher than the prices currently paid by the NHS for wheelchairs. PHBs will have to be of sufficient value to cover the retail price of a wheelchair, otherwise people will not take them up! As this cost is likely to be higher than is currently paid by the wheelchair service, this could strain wheelchair budgets.

In addition, there are significant savings and cost avoidances under the current model where wheelchairs are reissued by wheelchair services. For example, a wheelchair costing £2000 issued 3 times over its life results in a cost avoidance of £4000; whereas 3 of the same wheelchairs purchased using PHBs will cost £6000. Equipment purchased using a PHB will not be recycled within the wheelchair service, and is in effect a sunk cost.

If PHBs for wheelchairs are widely taken up it could have a drastic effect on wheelchair service budgets.

Could wheelchair users be exploited?

There will need to be proper support and safeguards in place to ensure people using their PHBs to buy wheelchairs are not exploited by retailers i.e. being sold something they don’t actually need, or charged an excessive amount. It is recognised that people are consumers in other aspects of their lives, and should be able to make their own choices; however some buyers will be in a vulnerable position, making a large purchase in an unfamiliar market, which could leave them open to exploitation without appropriate guidance, safeguards or support.

When the Department of Health introduced the retail model several years ago for aids to daily living, there were cases reported of people being exploited by retailers, so this is a real concern. 

Could using a PHB compromise clinical needs being met?

A PHB for a wheelchair will only be for a limited amount, although it is currently unclear how this will be set. Wheelchair users will be able to top up from personal funds if they want a higher specification wheelchair. There is a risk that wheelchair users acquire an item which does not meet their clinically assessed needs.

This is a high risk area and it is vital that users get the right wheelchair to avoid problems associated with postural care and pressure, for example. It is difficult to see how it can be ensured that retailers are competent to advise on these matters, some of which require specialist clinical input.

Failure to address the above issue could mean people end up with equipment that doesn’t meet their clinical needs, resulting in further health problems such as a pressure ulcer.

PHBs and Training

As yet no guidance has been made available from NHS England Personal Health Budgets team on training for frontline staff with regards to PHBs for wheelchairs e.g. what training is needed, who needs to be trained, who would carry out the training and who pays for it. It could be a costly and timely exercise for local areas to formulate their own guidance on this, and deliver their own training, which could potentially be a barrier for wider adoption.

Conclusion

CECOPS hopes the above issues will be sufficiently addressed before commencement of this initiative in April 2017; we would be willing to work with the NHS Personal Health Budget team to work through possible solutions.

Many of the areas of concern can be addressed by following our Code of Practice and working with our accreditation framework, which is now formally approved by Care Quality Commission and being adopted by many wheelchair services across the country.

 

Brian Donnelly, CEO, CECOPS