Putting the wheels in motion: Assessing the value of British Red Cross short-term wheelchair loan - Refusing to ignore people in crisis
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Putting the wheels in motion:
Assessing the value of
British Red Cross
short-term wheelchair loan
Refusing to ignore people in crisis
Putting the wheels in motion: Assessing the value of British Red Cross short-term wheelchair loan Alison McNulty, Chloë Carter and Jacob Beswick
© British Red Cross 2015
Any part of this publication may be cited, translated into
other languages or adapted to meet local needs without
prior permission of the British Red Cross, provided that
the source is clearly stated.
ISBN 978-0-900228-21-6
The photographs used for some of the case studies in
this publication (Janis, Laura, Margaret and Sameena)
are of models and there is no intention to associate any
of them with any of the conditions or circumstances
referred to in this publication. Some names have been
changed to protect anonymity.
Photographs:
Sameena © iStock
Laura © iStock
Margaret © iStock
Janis and her husband © iStock
Ron – provided by kind permission of his family
Joanna – provided by kind permission of her family
For all others; © Matthew Percival/British Red Cross
ii
contents
1 Introduction 1
What is short-term wheelchair loan and why is it important? 3
Policy context 4
Opportunities for change 7
2 Methods 9
Research aims and methods 9
Identification and selection of case study participants 9
Case studies 10
Health care professional interviews 10
Analysis 10
3 Case studies 11
Ronald, South Yorkshire 12
Sameena, Nottinghamshire 14
Ashleigh, Cornwall 16
Melvyn, Dorset 18
Laura, Nottinghamshire 20
Holly, Yorkshire 22
Janis, Cumbria 24
Joanne, Kent 26
Margaret, South Yorkshire 28
Key themes 30
4 Recommendations 32
References 34
Appendices 36
Appendix A: Numbers of selected participants 36
Appendix B: Screening interview schedule 37
Appendix C: Wheelchair user interview (case studies) 38
Appendix D: Health care professional interview 40
Appendix E: Note on definitions and calculations 42
iii
There is no clearly defined duty for statutory provision of wheelchair
loans in England. The British Red Cross is the largest national
provider, but we know there remains unmet humanitarian need.
“Not having the wheelchair would have been the straw that
broke the camel’s back…it would have been unbearable”
(Laura’s mother, p.21)
This research report shares the experiences of nine people who have
recently borrowed a wheelchair from the Red Cross mobility aids
service. The stories illustrate various reasons for needing a short-
term wheelchair loan and show the positive impact that they have
on people’s lives. Short-term wheelchair loans are an enabler of
recovery, choice, control, independence and wellbeing.
This report demonstrates that short-term wheelchair loans can
prevent and delay people’s needs for health care, social care and
support. They can also reduce the level of need that already exists.
There are cost savings associated with this prevention; each story is
accompanied by an economic evaluation that documents the savings
across health and social care, as well as to personal income.
We believe that everyone who needs a wheelchair should be entitled
to quickly and easily get one that is right for them, for as long as they
need it.
iv
Acknowledgements
The British Red Cross is hugely grateful to Andy Garwin Warby and Emma Rattenbury
from Envoy Partnership, who advised us on the methodology for this research and were
commissioned to complete the case studies, including the analysis. Their dedication,
insight and passion were tremendous. We also thank Mike O’Driscoll for his help in
overseeing the commissioning and recruitment to this project. A big thank you also goes
to those who helped us secure respondents for the interviews and, most of all, we are
grateful to those who gave up their time to share their stories and experiences.
v
1 Introduction
The British Red Cross helps millions Working with politicians, policymakers
of people in the UK and around the and the public, we can improve the
world to prepare for, respond to and humanitarian situation of people,
recover from emergencies, disasters families and communities in the UK
and conflicts. Our volunteers and and around the world.
staff help people to live independently
by providing support at home,
transport, and mobility aids that
include short-term wheelchair The Red Cross has a
loans. We also teach first aid skills humanitarian vision:
and support asylum seekers and
refugees in the UK. “Everyone who needs
a wheelchair should be
We are committed to speaking up
entitled to quickly and
for and improving the lives of people
in crisis and we have provided health easily get one that is right
and social care services for more for them, for as long as
than a century. Our operational they need it. Everyone
experience enables us to pursue who uses or handles a
focused advocacy that is backed wheelchair should know
by evidence, in order to bring about
how to do so safely and
changes in policy and practice at
the national, local and international comfortably.”
levels.
1
During and immediately after
World War One, the Red Cross
provided short-term wheelchair
loans for both injured servicemen
and the general population.
The service proved to be very
popular. By the time the NHS was
established in 1948, we were the
go-to organisation for short-term
wheelchair loans.
Today we are the largest national
provider of short-term wheelchair
loans,1 operating from around
250 sites across the UK. We loan
wheelchairs as part of our mobility
aids service, which loaned 111,000
items of equipment in the UK in
2014. The majority of those items
– 83,000 – were wheelchairs.2 We
loan wheelchairs to both children
and adults, although the majority of
people who borrow our wheelchairs
are aged 65 years and older.3
People can access the service in
a number of ways, including via an
online portal, by telephoning our
Area Offices and by visiting local
Red Cross loan sites. Red Cross
staff and volunteers are often based
directly in hospitals and medical
centres, working with medical staff
to respond to humanitarian need.
Our wheelchairs are loaned free of
charge. We are grateful to receive
donations from 80 per cent of those
who use the service (MacLeod,
2015), but we nonetheless spent
over £1 million on our mobility aids
service in 2014;4 a service that is
dedicated primarily to short-term
wheelchair provision. These costs
are primarily property costs. We
own some of the sites from which
we provide the service, but in many
sites we pay rental costs for space
from which to loan out wheelchairs,
including some hospitals and
general practices where we work
collaboratively with health care
professionals. These rental costs
can amount to tens of thousands of
pounds per year.
Private Wells at Normanhurst using a Red Cross short-term wheelchair loan
during WWI © British Red Cross
1 Other charities also provide short-term
wheelchair loans. These include Age UK,
Shopmobility, St John Ambulance and
Disability Action.
2 The other items were predominantly
commodes, but also included rollators, walking
sticks and other mobility aids.
3 Internal data capture and reporting.
4 Including the rental costs of space from which
we loan out wheelchairs.
2What is short-term will be able to provide equipment to receive longer-term provision
on a temporary loan” (National from the NHS. While some people
wheelchair loan and Wheelchair Managers Forum, borrow a wheelchair to facilitate
why is it important? 2013a). The guide advises people to their participation in social activities,
contact their local NHS wheelchair such as attending events, groups
service to be signposted to other and classes, the negative impact of
“Not simply a piece of organisations that might be able to social isolation on physical health is
provide short-term loans, citing the well proven and worth preventing.6
medical equipment, but Red Cross and St. John’s Ambulance
often essential to all By meeting the need for short-term
as examples. The corresponding
aspects of a person’s life” wheelchair loans, the Red Cross
online version of Frequently Asked
enables people with mobility issues to
(NHSIQ, 2014: 37). Questions reiterates this advice, with
be discharged from hospital; maintain
the additional suggestion to “try these
their independence at home; attend
links”, beneath which is a single link
hospital appointments, school or
According to NHS best estimates, to the Red Cross independent living
work; maintain their dignity at the
there are 1.2 million wheelchair users page (National Wheelchair Managers
end of life; and participate in family
in the UK, two-thirds of whom use Forum, 2013b).
and social activities from which
their wheelchairs regularly (NHSIQ, While ‘short-term’ is generally used they would otherwise be excluded
2014).5 Wheelchairs are recognised to refer to a period of six months or (Gardiner and Kutchinsky, 2013).
by the NHS to be “not simply a piece less, the distinction between short-
of medical equipment, but often In addition to the challenge of
term and long-term provision is
essential to all aspects of a person’s accessing short-term wheelchair
blurred and contentious, providing
life” (NHSIQ, 2014: 37). The NHS provision highlighted above, the
another barrier to provision. As
makes a distinction between short- NHS E-digest further identifies eight
identified in the Red Cross report
term and longer-term provision of issues around the acquisition of
by Gardner and Kutchinsky (2013),
wheelchairs. ‘Short-term’ is generally wheelchairs for longer-term use. Two
A Prisoner at Home, and despite
used to refer to a period of six months of these are especially relevant to
recognition by the NHS that a
or less. NHS wheelchair services considerations around short-term
wheelchair is “not simply a piece
are focused primarily on longer-term wheelchair provision: “unacceptable
of medical equipment, but is often
provision: “wheelchair services are waiting times for assessment and
essential to all aspects of a person’s
available to people of all ages who repairs” and “need for consistently
life” (NHSIQ, 2014: 37), short-term
have a long-term need for mobility applied eligibility criteria” (NHSIQ,
wheelchair use is associated with
help” (NHS, 2015). Local eligibility 2014). The former is relevant
meeting social needs. The report
criteria and thresholds for longer-term because unacceptable waiting
includes findings from a Red
provision can “vary depending on times for long-term wheelchair
Cross survey of NHS wheelchair
where [one lives]” (NHS, 2015). loans create demand for short-
service managers. The majority of
term loans. The latter is important
Individuals can apply to the NHS managers reported the main reason
because, in most areas, eligibility
for short-term wheelchair loans for short-term wheelchair loans not
criteria do not incorporate short-term
after being discharged from being provided by the NHS is that
needs, resulting in patchy provision
hospital following, for example, an short-term need is a social need,
and variation in the corresponding
accident or injury. However, a study rather than a clinical one (Gardiner
entitlements of individuals.
conducted by the Red Cross found and Kutchinsky, 2013). The NHS is
that 127 out of 151 NHS wheelchair unambiguous that the “wheelchair Although the Red Cross loaned
services would not provide a service will not provide a wheelchair 83,000 wheelchairs last year, we
wheelchair for short-term use. if it is only required for day trips or know that there remains unmet need
Those that did provide short-term outings” (NHS, 2015). for short-term wheelchair loans,
wheelchair loans almost always did particularly in London, where there
Yet the majority of people who
so in instances of terminal illness is currently no Red Cross wheelchair
use the Red Cross wheelchair
(Gardiner and Kutchinsky, 2013). service provision. 7
loan service are referred by health
In A Guide to NHS Wheelchair professionals (hospital staff, 6 A Brigham Young University study found “that
Services, the NHS recognises that “it therapists and GPs) for reasons such individuals who were socially isolated, lonely or
living alone at study initiation were more likely
is unlikely an NHS Wheelchair Service as recovering from fractured limbs, to be deceased at the follow-up, regardless
the fluctuation or deterioration of of participants’ age or socioeconomic status,
length of the follow-up, and type of covariates
5 The British Red Cross has previously identified long-term conditions, and end-of- accounted for in the adjusted models” (Holt-
that this figure was a result of 91 completed life needs (Gardiner and Kutchinsky, Lunstad, et al., 2015: 233). The same authors
questionnaires conducted by the NHS identify that substantial research “has also
Purchasing and Supplies Agency 14 years ago. 2013), as well as associated reasons elucidated the psychological, behavioural and
Consequently, the data is insufficiently robust such as attending appointments biological pathways by which social isolation
to provide an accurate estimate and the actual and loneliness lead to poorer health and
figure is likely to have changed with an annual for those with limited mobility. decreased longevity” (ibid: 235).
population growth of 0.8%, improved neonatal Some of the people who use our 7 We plan to reintroduce a mobility aids service
care and increased life expectancy (Gardiner in London in 2016, or – if funds permit – late in
and Kutchinsky, 2013: 6). wheelchair loan service are waiting 2015.
3Policy context Section 3 of the same Act provides (f) such other services or
more ambiguous language within facilities as are required for
In England, there is no clearly
which short-term wheelchair the diagnosis and treatment
defined duty for statutory provision
provision may fit. The Section of illness.”
of short-term wheelchair loans. Yet
holds that the Secretary of State
the policy and legislative framework “Illness” is understood as: “includes
“must provide…to such extent as
is focused strongly on promoting the mental disorder within the meaning
he considers necessary to meet
wellbeing of individuals, achieved of the Mental Health Act 1983
all reasonable requirements…
through integration of services (c. 20) and any injury or disability
such other services or facilities for
and prioritisation of preventing requiring medical or dental treatment
the prevention of illness, the care
and reducing need in order to or nursing” (NHS Act, 2006: 275).
of persons suffering from illness
prevent, reduce and delay any loss A “disabled person” refers to “a
and the after-care of persons
of independence. This resonates person who has a physical or mental
who have suffered from illness
with recognition by the NHS that impairment which has a substantial
as he considers are appropriate
wheelchairs aren’t just a piece of and long-term adverse effect on his
as part of the health service”
equipment (NHSIQ, 2014: 37). ability to carry out normal day-to-
(NHS Act, 2006: 2). This language
day activities or who has such other
In this section of the report we lends itself to the experiences of
disability as may be prescribed”
discuss policy considerations individuals who require short-term
(NHS Act, 2006: 256). This definition
relating to wheelchair provision wheelchairs, but does not explicitly
seems to incorporate a person with
within England.8 We examine include them. In particular, they
a long-term condition – such as
the provision of short-term may be recovering from an illness
Parkinson’s, asthma, diabetes or
wheelchair loans within relevant or ailment for which short-term
multiple sclerosis – but, elsewhere
policy and legislation, focusing use of a wheelchair is an essential
within NHS literature, having a long-
on the ambiguity of statutory part of their after-care, as well
term condition is considered to be
responsibilities to provide short- as preventing further injury or
quite distinct from being a disabled
term wheelchair loans. And we deterioration of health.
person. Indeed, having a long-term
consider key policy drivers within
While Section 3 of the NHS Act condition is identified as being a
the health and social care systems,
2006 empowered the Secretary of potential cause of disability, rather
exploring the opportunities these
State to act through the NHS, the than the two being synonymous or
present for change.
Health and Social Care Act 2012 the former incorporated within the
Policy landscape amended this, placing the duty to latter (NHS, undated).
The National Health Service Act meet all reasonable requirements
The NHS’s lack of clarity as to the
2006 refers to wheelchairs in upon clinical commissioning
interpretation of “frailty” poses further
Section 5 (schedule 1), stipulating groups (CCGs). CCGs, while
ambiguity with regard to whom the
that the Secretary of State overseen by NHS England (“the
CCGs’ duties extend. Professor John
“may provide vehicles (including NHS Commissioning Board”
Young, NHS England’s Director for
wheelchairs) for persons appearing within legislation), have significant
Integration and Frail Elderly Care,
to him to be persons who have a devolved powers. In particular, the
argues: “we must recognise frailty
physical impairment which has a amendments made by Section 13
as a long-term condition”, reasoning
substantial and long-term adverse of the 2012 Act to Section 3 of the
that: “frailty behaves just like a long-
effect on their ability to carry 2006 Act provide that:
term condition. It is progressive, it
out normal day-to-day activities” 1. “A clinical commissioning group impacts adversely on life experience
(179; italics added). This explicitly must arrange for the provision of and – if unmanaged – it can cause
excludes short-term wheelchair the following to such extent as the sufferer to become very sick, very
provision. it considers necessary to meet quickly” (Young, 2014). However, this
the reasonable requirements interpretation does not seem to have
8 Information about the policy context within of the persons for whom it has been adopted formally within the
Scotland is available within the British Red
Cross report Making a move: increasing responsibility: NHS.
choice and independence for people with
short-term mobility needs, which is available … As in the 2006 Act, the duty to
online: http://www.redcross.org.uk/~/media/
BritishRedCross/Documents/About%20us/ provide a wheelchair for short-term
(e) such other services or
Scotland%20mobility%20aids%20report.pdf use is ambiguous in the 2012 Act.
Information about the policy context within facilities for the prevention of
CCGs need only meet “reasonable
Wales is available within the National Assembly illness, the care of persons
for Wales Health and Social Care Committee requirements” in providing services;
report Wheelchair services in Wales: follow-up suffering from illness and the
the terms of which are not defined
inquiry, which is available online: http://www. after-care of persons who
assembly.wales/Laid%20Documents/CR- and are therefore susceptible to
LD9028%20-%20Health%20and%20Social%20 have suffered from illness
inconsistent interpretation, or, as is
Care%20Committee%20Report%20on%20 as the group considers are
Wheelchair%20Services%20in%20Wales%20 presently the case, are interpreted
Follow-up%20Inquiry%20-13082012-237712/ appropriate as part of the
by the NHS to preclude short-term
cr-ld9028-English.pdf health service,
wheelchair provision.
4Most recently, throughout the Care that is written into primary legislation
“the Act…signifies a shift Bill debate in 2013, wheelchairs were – resonates with the NHS’s
from existing duties on discussed on only four occasions, recognition that a wheelchair is “not
each time within the House of simply a piece of medical equipment,
local authorities to provide Lords, and on only one of these four but often essential to all aspects of a
particular services, to the occasions were wheelchair services person’s life” (NHSIQ, 2014: 37):
concept of ‘meeting needs’ referenced and identified as requiring
2. “Wellbeing [refers to:]
(set out in sections 8 and improvement (HL Deb, 2013-14: 745
18–20 of the Act). This is col. 818). The Care Act 2014 itself does (a) personal dignity (including
the core legal entitlement not discuss wheelchairs; however the treatment of the individual
statutory guidance recognises the with respect);
for adults to care and provision of short-term wheelchair
support, establishing one (b) physical and mental health
loans as an example of a secondary
clear and consistent set and emotional wellbeing;
preventative service (Department
of duties and power for all of Health, DH, 2014a: 9). This (c) protection from abuse and
people who need care and acknowledges the preventative value neglect;
support.” of short-term wheelchair loans, but
(d) control by the individual over
does not create a duty to provide them
day-to-day life (including
or an entitlement to receive them.
over care and support, or
According to a legal analysis Currently, the two most significant support, provided to the
commissioned by the Red Cross sources of health and social care individual and the way in
(Knight, 2014),9 the responsibility policy are the Care Act 2014 and its which it is provided);
of local authorities to provide supporting guidance, and the NHS
(e) participation in work,
wheelchairs also lacks clarity. Where Five Year Forward View (5YFV; NHS,
education, training or
an individual is “substantially and 2014). The former represents the
recreation;
permanently disabled”, under the largest and most comprehensive
National Assistance Act 1948 (section transformation of adult social care (f) social and economic
29(1)), a local authority is obliged since 1948; the latter presents a wellbeing;
to provide welfare services in order compelling vision of NHS reform.
(g) domestic, family and
to meet the individual’s needs, The Care Act and the 5YFV share a
personal relationships;
including through the provision of number of priorities that make this an
“practical assistance for that person opportune time for local authorities, (h) the individual’s contribution to
in his home” or “the provision of the NHS and the voluntary sector society” (Care Act, 2014: 1).
any additional facilities designed to to work together to ‘put the wheels
The 5YFV identifies promoting
secure his greater safety, comfort or in motion’ and deliver this report’s
wellbeing and preventing ill health
convenience”, as found in sections recommendations (see Section 4).
as the main goals of the NHS
2(1)(a) and (e) of the Chronically Sick These shared priorities of wellbeing,
and Disabled Persons Act 1970. integration and prevention are
However, because most people who explored below.
need short-term wheelchair loan “The concept of ‘meeting
Wellbeing
will not conform to these stringent
The Care Act 2014 reframes the social
needs’ recognises that
criteria, local authorities, according everyone’s needs are
care responsibilities and activities of
to the 1970 Act, will not be obliged to different and personal to
local authorities within the concept of
provide one.
promoting individual wellbeing (Care them. Local authorities
While there are many powers Act, 2014: 1). The statutory guidance must consider how to
that might be said to enable a is clear that “the core purpose of meet each person’s
local authority to make short-term adult care and support is to help
wheelchair loan available (Section 29 people to achieve the outcomes that
specific needs rather
of the 1948 Act and Section 45 of matter to them in their life…local than simply considering
the Health Service and Public Health authorities must promote wellbeing what service they will fit
Act, 1968, in relation to older people; when carrying out any of their care into. The concept…also
and Section 3 of the Carers (Equal and support functions in respect of recognises that modern
Opportunities) Act 200410) there is no a person (DH, 2014a: 1; bold and care and support can be
statutory duty requiring them to do so underline in the original).
(Knight, 2014).
provided in any number
Despite short-term wheelchair loans of ways, with new models
9 Prior to the Care Act coming into force on 1st
being omitted from the legislation, emerging all the time….”
April 2015. the Care Act’s new framework of
10 This duty might require a local authority to promoting individual wellbeing –
(DH 2014a: 2).
request a wheelchair is provided to a disabled
person to ease the burden on a carer. including the definition of ‘wellbeing’
5(NHS, 2014: 2). It recognises that The 5YFV proposes a set of The intention to integrate services
local authorities are increasingly priorities to enhance prevention. is not just a policy objective shared
working together to drive health and One such priority focuses on by the Care Act and 5YFV; it is
wellbeing, and that the NHS can play “local democratic leadership on being put into practice around the
its part in this through local Health public health” (NHS, 2014: 10). country. Greater Manchester is one
and Wellbeing Boards (HWBs).11 Specifically, by participating in local such example (or ‘vanguard site’ to
HWBs, the NHS will play a part in use the NHS term) where the triple
initiatives contingent on integrated integration ambition could become
“as we think about the services and the realisation of a reality through a radical new
local-level priorities that necessarily model of a single integrated health
changing needs and incorporate considerations around and social care budget. Ten local
preferences of the people wellbeing. This integrative approach authorities, the 12 CCGs for Greater
we are here to serve, we is reflected in the Care Act 2014, Manchester and NHS England
need to have integration which states that a local authority are working together to “devolve
between primary and “must co-operate with each of its responsibility for the health and
specialist services, we need relevant partners, and each relevant social care budget to a new Greater
partner must co-operate with the Manchester partnership” (LGA,
to have integration between authority, in exercise of…their 2015). This partnership will oversee
physical and mental health respective function relating to adults a £6 million budget from April 2016,
services, and we need with needs for care and support” which will be used to improve
to have more integration (Care Act, 2014: 6). services, and health and wellbeing
between health and social outcomes.
Integration
care services; that is the The Care Act’s ‘new models’ Prevention
triple integration agenda include approaches towards The Care Act 2014 places a new
that we are pursuing” (The greater integration of services. As duty of prevention onto local
King’s Fund, 2015). the guidance explains, “the vision authorities:
is for integrated care and support
1. “A local authority must provide
[to be] person-centred, tailored to
or arrange for the provision of
the needs and preferences of those
HWBs were established through services, facilities or resources,
needing care and support, carers
the Health and Social Care Act, or take steps, which it considers
and families” (DH, 2014a: 281).
2012. They are intended to act as a will –
Integration encompasses health
forum where leaders from the health
and health-related services, as (a) contribute towards
and care sector work together to
well as achieving parity of esteem preventing or delaying the
improve the health and wellbeing of
for mental and physical health, development by adults in its
their local population and to reduce
and integrating the corresponding area of needs for care and
health inequalities.
services in order to treat, care support;
According to the 2012 Act, a HWB for and support the ‘whole
(b) contribute towards
must “for the purpose of advancing person’. Integration is recognised
preventing or delaying the
the health and wellbeing of the within the statutory guidance to
development by carers in its
people in its area, encourage… be dependent upon enhanced
area of needs for support;
the provision of any health or social cooperation between local
care services…in an integrated authorities and partners, including (c) reduce the needs for care
manner” (201). Through HWBs, local the NHS and CCGs. and support of adults in its
authorities and CCGs undertake area;
Joint Strategic Needs Assessments Simon Stevens, Chief Executive
(d) reduce the needs for support
(JSNAs)12 and develop a Joint of NHS England, has extolled
of carers in its area.”
Health and Wellbeing Strategy to the “triple integration agenda” of
best address these needs. This the 5YFV: “as we think about the The Red Cross advocated strongly
includes making recommendations changing needs and preferences of for prevention to be not only included
for joint commissioning and the people we are here to serve, we in the Care Act, but also defined. We
integration of services across health need to have integration between were successful, with three equally
and care. primary and specialist services, important forms of prevention being
we need to have integration written into the statutory guidance.
between physical and mental health
11 Providing a framework for reciprocity, Sections The 5YFV does not share the Care
services, and we need to have
14Z11 and 14Z13 of the Health and Social Care Act’s recognition that prevention is
Act 2012 indicate how HWBs participate in the more integration between health
development of CCGs’ annual plans. a continuum: across the life course;
and social care services; that is the
12 JSNA is a process that assesses and maps across the pathology of a long-
the needs and demand for health and care triple integration agenda that we are
and support. This information should feed into term condition; and across physical
pursuing” (The King’s Fund, 2015).
the board’s development of joint Health and health, mental health and emotional
Wellbeing Strategies.
6The Care Act definition of ‘triple wellbeing. The 5YFV makes little, if incorporated the continuum of
prevention’: any, reference to tertiary prevention primary, secondary and tertiary
and only limited reference to prevention, but all bar one of the
PREVENT: primary
secondary; much of its emphasis is studied Strategies mentioned
prevention/promoting
on primary prevention with the initial prevention (Field, 2014).
wellbeing
focus of delivered action being the
Primary prevention is aimed at introduction of a nationwide diabetes Opportunities for
people who have no particular prevention programme. It does, change
health or care and support however, state the commitment that
Local authorities and the NHS share
needs. The intention is to help a the NHS is “getting serious about
the priorities of meeting needs
person avoid developing needs prevention” (NHS, 2014: 9).
within the context of promoting
for care and support, or help a
individual wellbeing, integrating
carer avoid developing support Despite little, if any, incorporation of
services, and preventing, reducing
needs. It includes universal tertiary prevention within the 5YFV,
and delaying need in order to
policies like health promotion, according to its Mandate, one of
minimise the loss of independence.
first aid learning and universal the responsibilities of the NHS is to
The case studies in the next section
services like community activities help people recover from episodes
of this report demonstrate that
that prevent social isolation. of ill-health. The Mandate goes on
short-term wheelchair loans can
to explain that recovery is achieved
REDUCE: secondary promote individual wellbeing, with
“through effective treatment but also
prevention/early intervention some of those interviewed stating
through on-going help in recovering
that the loan was essential to their
Secondary prevention is more quickly and regaining independence”
wellbeing. The preventative value
targeted. Interventions are aimed (DH, 2014b: 15). The combination
of short-term wheelchair loans is
at people who have an increased of the 5YFV’s recognition of primary
also demonstrated within the report
risk of developing health or and secondary preventative
findings; not only with regard to
care and support needs, or at approaches, plus the Mandate’s
individuals and their families, but
carers with an increased risk of recognition of tertiary preventative
also with regard to associated cost
developing support needs. The approaches, demonstrates that the
savings.
goal is to help slow down or NHS commitment to “get serious
reduce any further deterioration, on prevention” is in parallel with the The current landscape is one of
to prevent further needs from 2014 Care Act’s new duty on local health and social care planning, as
developing, and to prevent a authorities to do the same. well as commissioning intentions
crisis occurring. Secondary being integrated through HWBs.
HWBs – in which local authorities
prevention includes short-term New integrated models of care,
and the NHS come together locally
provision of wheelchairs, underpinned by single, integrated
– recognise prevention as a key
handyman services, “social budgets, are emerging through
driver for planning, commissioning
prescribing” services and initiatives such as the Greater
and provision of services. Research
telecare. Manchester devolution. The
conducted by the Red Cross in
integration ambition is increasingly
DELAY: tertiary prevention 2014 showed that, among 138
being realised, and this landscape
HWBs studied, the majority of
Tertiary prevention is aimed at affords us a new opportunity to
their Joint Health and Wellbeing
minimising the effect of disability ensure that everyone who needs
Strategies put an emphasis on
or deterioration for people with short-term use of a wheelchair can
prevention. There was variation as
established or complex health get one.
to the extent to which the Strategies
conditions. The goal is to support
people to regain confidence and
skills, and to manage or reduce
need, where possible. For people
who have already reached the
point of crisis, the goal is also to
prevent this recurring. Tertiary
prevention includes reablement,
rehabilitation and bed-based
intermediate care.
(DH, 2014a: 7–12, bold added)
78
2 Methods
Research aims and Identification and
methods selection of case study
The aims of the research were participants
to gain insight into how service
Potential case study participants
users perceive the impact of their
were recruited via a two-stage
short-term wheelchair loan on
process: a) identification of
themselves, their families, friends
geographic area (study site), and b)
or carers and, based on this data,
selection of potential participants
to calculate the economic impact
within that area.
of the Red Cross short-term
wheelchair loan service in terms of Five areas across England were
the logical cost savings to health selected as case study sites.
or social care services in those This fulfilled the need to have
cases. representation from rural and urban
areas. These areas had higher levels
The research aims were
of wheelchair loan to provide a wide
achieved through a mixed
sample base.
method design, which used case
studies to provide information Key staff at the selected sites were
for the economic evaluation, contacted and worked with to help
and interviews with health care identify potential participants who
professionals to validate the had some key characteristics:
assumptions made during the
>> they had loaned a wheelchair
economic evaluation.
within the last 12 months and
for less than six months in total
(short-term)
9>> they represented a range of of existing services (e.g. visits >> reduced or prevented the need
needs, including medical, social to hospital), the impact of these for residential care.
and those not easily fitting a changes (e.g. not needing a taxi) and
clearly distinct medical or social any changes in non-service-specific The economic evaluation did not
need activities (e.g. reduced isolation). use a societal perspective – not all
savings to service users and their
>> some were waiting for long-term Health care families are included (such as taxis)
provision – however, where consequences on
professional interviews income were present, these were
>> they comprised a range of ages
Interviews with a number of health noted and presented distinctly.
and ethnicities.
care professionals (HCPs) validated
Once a long list was identified, the assumptions underlying the The identified outcomes were costed
screening interviews were conducted economic evaluation. Since the using the standard tariffs devised
with the potential participants to primary aim was to avoid asking by the Personal Social Services
discuss their situation further, verify the HCP to comment directly on a Research Unit (PSSRU, 2014)
the fulfilment of criteria and ascertain patient known to them, vignettes and NHS National Tariff prices for
whether they would consent to were created based on anonymous 2014/15 (Monitor and NHS England,
the research. (See Appendix A for situations, as identified in the case 2013), which are accepted widely
details on the numbers selected studies. These were presented to across the health care professions.
and Appendix B for the screening the HCPs and they were asked to Further definitions for the analysis
interview schedule). comment on the relative impact of can be found in Appendix E.
the wheelchair in those scenarios. Following identification of the
Health care professional interviewees
(See Appendix D for the interview outcomes, we adopted a simple
were sought from a range of
schedule). decision analytic model, using the
professions (including medical,
nursing, occupational therapy Of the six HCPs identified across service user’s own perspective to
and social work). This range was key regions where the service user examine the alternative journey of the
mapped against the outcomes of the case studies were based, three service user if the wheelchair had
service user interviews. were interviewed (two occupational not been available and the reported
therapists and one nurse). outcomes had not been achieved.
Case studies Costs were modelled for the
Nine case studies were conducted,13 Analysis timescale of the wheelchair loan and
which comprised semi-structured The economic evaluation focused projected only when the service user
interviews with individuals who on self-reported outcomes from the indicated a consequence due to not
had loaned a wheelchair from the service user and/or their carer/family having a wheelchair (e.g. needing
Red Cross on a short-term basis. member. In addition to the case longer to recover).
(See Appendix C for the interview studies, interviews with health care
schedule). providers validated the logic of the
calculations and assumptions made
Four of the interviews included
in the analysis.
questioning an accompanying family
member alongside the wheelchair Analysis was based primarily on the
user, three interviews involved only identification of outcomes specific
the user, and for one interview only to health and social care savings.
the carer was present.14 These specific outcomes were:
The interviews sought to understand >> reduced or prevented
the perspectives of the wheelchair unnecessary GP attendance
users, family members and carers
regarding the short-term wheelchair >> reduced or prevented attendance
loan service, including the effect at A&E
of the service on the users’ health, >> reduced or prevented admission
lifestyle and the type of care they from A&E
needed; and what they think would
have happened if the service had not >> reduced or prevented ambulance
been available. use
The participants’ responses were >> reduced or prevented hospital
then analysed to identify reported attendance, admission or
outcomes, such as changes (or re-admission
projected changes) in the use >> reduced or prevented the need
13 Eight face-to-face and one via telephone.
for on-going care and support
14 In one case the user had recently died.
103 Case studies
This section presents the case study Although one case study was
data. It illustrates various reasons for conducted without the wheelchair
needing short-term wheelchair loan user, demographic data was
and the impact of this service on both collected for all wheelchair users.
the wheelchair user and their family They comprised seven females
and carers. and two males. The age range of
participants was six to 93 years
The case studies are presented
old, with an even distribution of age
individually and include statements
groups.15
from HCPs, where relevant, to
support the position and perception Seven of the nine wheelchair
of the wheelchair user. They also users reported themselves as
include an economic evaluation White British; one as White or
for each case study, documenting Black Caribbean; and one as
savings across health and social care, Pakistani ethnicity. Three of the nine
and personal savings, where relevant. service users in the case studies
were registered disabled. Their
The section concludes with a
occupational status also varied
summary of key findings, which
and included retired, in education,
highlights common themes across
employed and unemployed.
the case studies and HCP interviews.
Nine case studies and three HCP
interviews were conducted for this 15 16–24 n=2; 25–34 n=1; 35–44 n=1; 45–54 n=2;
research. 65–70 n=1; the oldest two respondents were
aged 89 and 93.
11If Ron and his family
Ronald, had not been able to
use the Red Cross
wheelchair, he would have
South Yorkshire missed out on the final
NVA 70th Anniversary
commemorations in
France and Armistice
commemorations in
London. Being able to
participate boosted
Ron’s emotional state
Ronald (Ron) is a 93-year-old of walking involved in the 70th and reduced his level of
World War Two veteran. He lives in Anniversary Normandy celebrations, isolation during recovery.
sheltered housing and receives daily but it was unthinkable that he would
support visits from his daughter, not attend as the NVA was being
When he was hospitalised
Pam, and son, David, as he is very disbanded at the end of 2014. This before the November
frail. In the early 1980s he became was the last opportunity for Ron to commemorations in
active in the Normandy Veterans visit the beaches and cemeteries London, knowing that
Association (NVA), organising and of Normandy and to remember his he might be able to
attending several trips to Normandy, fallen comrades. After the summer attend with the aid of the
including the 40th, 50th and 60th events, Ron became ill and had
commemorations of the Normandy to stay in hospital for two weeks.
wheelchair motivated his
Landings. He rallied with the thought that he improved rate of recovery
could use a wheelchair to attend the during and after hospital
In 2014, the family realised that Ron
would need a wheelchair since he
November remembrance events in rehabilitation.
London.
would struggle with the amount
12Impact of our wheelchair loan Economic resource savings
Pam found out about the Red Cross condition would have relapsed or £1,404
short-term wheelchair loan service worsened, requiring re-admittance
through internet research, which to hospital. The wheelchair also gave Reduced rehabilitation time in
was a great relief to her. Having the them peace of mind in case of such hospital by half a week through
chair meant the family could take an emergency. boosting Ron’s recovery =
Ron to Normandy in June 2014.
Pam felt that the trip to London
They borrowed the wheelchair for
a week, during which he attended
in November played an important £486 resource savings
part in her father’s recovery after a for NHS hospital-based
the main remembrance ceremony rehabilitation care service
period of being really low. She felt
and visited several cemeteries and (based on £973 average weekly cost of
strongly that he would have needed
beaches to pay his respects to those bed in hospital-based rehabilitation care;
a longer stay in rehabilitation without PSSRU, 2014)
who had sacrificed their lives. Ron
it. “It made a massive amount
said: “It was the answer, because
of difference to his recovery – it
it was heavyweight and it could go
boosted him up and meant so much Improved recovery helped to
anywhere, we weren’t restricted...I
to him to be there, especially when avoid likely early relapse and
couldn’t have done it without the
the Normandy Veterans were asked re-admission to hospital for
chair – it was an opportunity not to
that Sunday morning to lead off the further tests and observations
be missed.”
parade. It was quite an emotional for a minimum five days16 =
The family asked to borrow a Red time for them all, but uplifting as
Cross wheelchair again in November well. …It made a real difference to £685 resource savings for
2014, so Ron could attend the his recovery, considering how poorly NHS hospital day care/palliative
Festival of Remembrance at the he had been; he was in his element service
Albert Hall and the remembrance – waving to the crowds as they (based on £137 cost per bed day, which is
a combined national average of inpatient
ceremony and parade to mark 70 were clapping and cheering for the hospital specialist palliative care for adults
years since the Armistice. Just veterans.” £117 and inpatient day care for elderly
before this, Ron was hospitalised for patients £157; PSSRU, 2014)
As a veteran of those historic
two weeks as he had become very
wartime events, it has been
run down and he was unable to eat
properly. A big motivating factor that
important for Ron to remember
his comrades and to promote the
£233 resource savings for
helped him to rally and recover was NHS ambulance service
significance of these events to future (ambulance service: see, treat and convey,
the plan to attend the November
generations. Ron and his family cost per incident; PSSRU, 2014)
Festival of Remembrance, if he could
found the Red Cross wheelchair
be sufficiently mobile and the family
service to be “an invaluable
could help him get around.
service… In terms of our experience
Without the chair, Ron and his it would have been impossible to do
family would not have been able to those once-in-a-lifetime things… I
attend these events. Pam said that don’t think people realise how much
if they had been unable to go, her it means.”
dad “would have been extremely
disappointed to say the least … For
us it would have been heart-breaking
not to have been able to take him…
we couldn’t have considered it
without the wheelchair and it would
have been very upsetting and
distressing knowing that.”
When Ron returned from the
16 Based on Ron’s recent four-week
Armistice weekend, he went into admission, this is felt to be a reasonable
rehabilitation for four weeks before attributable minimum number of days,
when in reality the period as inpatient is
being discharged home. The family likely to be much longer (other factors will
kept the wheelchair so Ron could have contributed). Note this value aims
to reflect the avoided costs falling within
attend family outings. They feared a quarter of a year – i.e. no re-admission
that, without the wheelchair, Ron’s within the period to March 2015, to better
align with the service user’s condition.
13Sameena is a mother and home-
maker. She has three children,
including a baby girl who she is still
nursing. She is registered disabled
due to muscular dystrophy, a
Sameena, progressive condition that gradually
causes the muscles to weaken.
In January 2015, Sameena fell at
Nottinghamshire* home and broke her ankle. She was
in a plaster cast for five weeks and
unable to bear weight on her ankle
for several more weeks after the cast
was removed.
The hospital only allowed Sameena
home because her mother was able
to look after her and the baby for two
weeks after discharge, and because
she has her own transit wheelchair.
This type of wheelchair requires
someone to push the occupant, as
it is not self-propelling. Social care
was provided, with two short visits a
day from carers to help with personal
care and meals. After two weeks,
however, Sameena’s mother had to
return home to care for her frail and ill
father; they live over 100 miles away.
This meant Sameena’s husband had
to go to half-time working for a week,
and Sameena and her husband feel
this did not go down well with his
employer.
Sameena’s mother was
able to help out for only
the first two weeks of
Sameena’s recovery. After
this, Sameena’s husband
worked half-time for one
week. Sameena had carers
during this time and also
for the following three
weeks. During the latter
three weeks she had to
be on her own at home
more with her baby, and
she would have required
a much higher level of
support from her carers
had she not been able
to borrow the Red Cross
wheelchair.
* Not her real name.
14Impact of our wheelchair loan Economic resource savings
When her mother left and her As one occupational therapist notes: £963
husband returned to full-time work, “it’s essential for day-to-day life
Additional personal finance
Sameena borrowed a self-propelled (during rehabilitation), getting out of
savings
wheelchair from the Red Cross. This the house, even just getting to the
£341
enabled her to move around her bathroom…potentially the wheelchair
home and to look after her daughter is the key part of your rehabilitation
with the continued support of two process and it’s crucial that you need
short visits a day from her carers. She that equipment.”
would otherwise have needed a more Avoiding at least one ambulance
Sameena and her whole family have call out for a scheduled hospital
substantial level of support.
benefitted from a very real sense of appointment =
“At least I can move from one side of being able to maintain mobility and
the room to the other and if she [baby] quality of life through the Red Cross £233 resource savings for
has dropped a toy I can pick it up…. It short-term wheelchair loan. She NHS ambulance service per
has given me more independence in would have missed out on some incidence
(based on £233 per incidence of ambulance
the house,” she said. key parts of her children’s lives, had call out: see, treat and convey cost per
she not been able to go and show incident; PSSRU, 2014)
Without the Red Cross wheelchair,
her support at her 11-year old son’s
Sameena and her daughter would
school ‘graduation’ ceremony. This,
have needed almost constant
in her words, “would have been Avoiding 2 x home calls from
support from care services, as there
very devastating. It was a very nice the GP for her sick daughter =
would have been concerns for her
moment and it would have been quite
and her baby’s wellbeing in this
situation. Sameena could not have
upsetting if I hadn’t been there.” Approximately £110
resource savings for local GP or
got herself off her bed, fully attended Sameena summed up the difference
clinic
to her baby daughter, moved to the that the chair has made for her as (based on GP cost per hour = £146, and
bathroom or helped with meals. follows: “It has made a big difference assuming 11.4 minute average visit time plus
She would have required a further to my overall view of that period (her 12 minute average travel time = GP cost £55
per visit or a health visitor = £51 per visit;
increase in her care package and/or recovery) and the emotional feelings. PSSRU, 2014)
her husband would have had to take I knew that once I had it, if I had to go
even more time off work, which would somewhere, I wouldn’t have to rely
have put his employment at risk. on others all the time…I had some Faster recovery by one week,
independence back. I do try and get plus avoiding three weeks of
Because Sameena was able to push home care at a “substantial”
out regularly even if I am not feeling
herself short distances with the Red level of support =
100 per cent – for me to not get out
Cross wheelchair, her husband was
able to accompany her to follow-up
hospital appointments and doctors’
for weeks would be quite dreadful
really.” Total £620 resource
savings for social care services
appointments for the children, while (based on the difference between £280 per
pushing the baby in her buggy. week home care cost “substantial” level, and
£125 per week “moderate” level; PSSRU,
Sameena feels that the chair helped 2014)
her to recover more quickly than
she would have done otherwise. Six
weeks after the accident, she no Additional three weeks half-
longer needed the carers, but she time off work for her husband =
thinks she would have needed their
support for at least an additional £341 immediate loss of
week if she had to manage without family income
(at minimum wage £6.50 per hour and
the Red Cross chair. assuming 35-hour week. However the real
cost could have been higher if Sameena’s
husband had lost his job, which was a likely
outcome)
15Ashleigh is 27 years old and in
her third year of nursing training,
which involves working at her local
hospital. It is a highly demanding
and intensive course. Ashleigh had
an accident in January 2015 while
walking her dog, when she broke her
ankle badly. After a week in a cast,
Ashleigh’s ankle was operated on.
She was then unable to bear weight
for two weeks, and had a total of six
weeks in plaster.
The hospital provided crutches but
nobody mentioned a wheelchair
loan to support her mobility during
recovery. So it was unclear how
Ashleigh and her partner were going
to cope in terms of keeping her
mobile and attending her studies,
especially in a rural area where
there are long distances to travel.
Fortunately, around the time of
her operation, Ashleigh found out
from a neighbour about the Red
Cross wheelchair loan and her
partner visited the local Red Cross
distribution centre to obtain one.
Without the wheelchair,
it is clear that there
would have been higher
economic costs to hospital
services as a result of
Ashleigh having to stay
a night and day longer in
hospital before discharge
(after her operation), the
likelihood of another fall
and subsequent micro-
fractures to her ankle, and
associated ambulance call
out. However, in addition
to the positive social
impact on her emotional
and mental wellbeing that
Ashleigh, the wheelchair supported,
Ashleigh has been able to
avoid significant personal
Cornwall
financial costs to her and
her partner. Not having
a wheelchair would have
meant having to postpone
and re-sit her final year of
nursing qualifications.
16Impact of our wheelchair loan Economic resource savings
The wheelchair helped Ashleigh As a student nurse, Ashleigh was £831
return to university quicker. As a also aware of the consequences for
Additional personal finance
result of the accident, she missed her health and wellbeing if she lost
savings
four weeks at the start of the her independence. She feels strongly
£21,750
year and three weeks of practice. that the wheelchair was essential to
Ashleigh was desperate to not miss help her get out of the house and
any more time because teaching feel less isolated. “If I didn’t have my
regulations and accreditation wheelchair and just had crutches,
requirements would force her to quit I would have done myself serious Avoided an extra night and day
the third year and start again, re- damage [due to weight-bearing] in hospital =
sitting exams the following academic
year. This would have cost her and
and ended back in A&E and caused
sustained damage to my ankle. £469 resource savings to
her partner a great deal, financially Also, if I didn’t have the wheelchair I NHS hospital services
(based on £3,283 average cost of elective
and emotionally. would have been admitted into the inpatient episode, divided by 7 days,
orthopaedic ward at least for one assuming one week long episode before
She said: “I would have been discharge; PSSRU, 2014)
extra day rather than get discharged
devastated…I’m three weeks behind
to go home.”
all my other classmates, but any
longer than that and I wouldn’t have Ashleigh says she would not have Avoiding ambulance call out
been able to qualify in September… been able to buy her own wheelchair following a fall =
Without the wheelchair, I wouldn’t if there was no loan service, but even
have gone back to university until if the recovery time with crutches £233 resource savings for
I was fully weight-bearing. I would was about the same, having the NHS ambulance service
(based on £233 per incidence of ambulance
have been confined to my house wheelchair improved [her] quality call out, see, treat and convey; PSSRU, 2014)
for seven weeks if not longer and of life tenfold and helped to avoid
would have had to defer my course complications. [This service] is
for a year – it would have cost me an invaluable part of recovery. Avoiding attending A&E as an
financially to re-sit some of the Without that added support, my outpatient following a fall =
modules, about £1000–£2,000. We recovery wouldn’t have been as
have to maintain 45 weeks on the straightforward. It’s quite easy to slip £129 resource savings
course... Without the wheelchair I back into that negative state of mind for Accident and Emergency
would have set myself back a year.” when even going to the toilet is a department
struggle. [Having the wheelchair] has (based on NHS National Tariff of £129 per
In addition, without the wheelchair, A&E incidence with category 2 investigation
definitely benefitted my mental health and category 3 treatment, i.e. plaster
Ashleigh’s partner would have
which is very much understated in removal or application, bone fracture, etc.)
had to take more time off work to
physical recovery.”
care for her during recovery. Not
being able to go out to work for Finally, Ashleigh commented Personal cost17 =
six weeks meant they “would have that patients of her colleagues,
been crippled financially and with
just crutches I would have become
especially occupational therapists
and physiotherapists, would benefit
£19,500 loss of one year
of income
really depressed… personally, I greatly from this service, especially (income net of tax and national insurance, as
didn’t realise how much I liked my if the wheelchair loan could be a qualified hospital nurse, based on £25,744
average wage for hospital-based nursing
independence until it [the accident] involved earlier in patient recovery staff, day ward or 24-hour; PSSRU, 2014)
happened.” options.
Personal cost18 =
£1,500 exam fee
Partner personal cost19 =
17 Cost of missing one year’s salary, having to
postpone third year of course and thereby
delaying graduation and employment as a
unclear if learning support allowance would
be available in all such cases, as the learning
institution’s policy is that this would only relate to
£750 net salary
nurse. a student’s accident/injury if it coincided with an approximately
18 Cost of nursing exams re-sit, if she had been assessment deadline or an examination/test). (based on £17,344 average annual salary in
forced to defer and re-sit the whole year (unless 19 Avoided loss of income (or paid holidays) net Cornwall divided by 52 weeks and pro-rated;
learning support allowance is available for this of tax and national insurance, if partner had Office for National Statistics, Annual Survey
circumstance, however this is at the discretion to spend half of the working week caring for of Hours and Earnings, 2014)
of the learning institution. In addition, it is Ashleigh for the six-week period.
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