A Peer Review of Provision of Powered Mobility Within the West Midlands. Dr B Panagamuwa On behalf of Ms Rachel King West Midlands Rehabilitation Centre Birmingham 17 April 2009 PMG NTE 2009 Posture and Mobility Services

This presentation is about the observed outcomes of a study day arranged by the West Midlands Regional Posture and Mobility Services (P&M) for the West Midlands Wheelchair Services engineers and therapists. Theme was, Effective Mobility – Who needs a Powered Wheelchair?

Aim and Objectives Appraise and debate the current practices regarding provision of powered mobility throughout the West Midlands. Formulate a common strategy that would improve the provision of powered mobility in the region Presented here to ignite a wider discussion and debate

Format of the study day Listen to user views Expert MDT presentation of three representative case studies Group work on four real clinical situations to decide what the delegates would prescribe In current practice with local guidelines In an ideal practice without guidelines Listen to a DWS Manager’s view

User Views Two severely physically disabled but cognitively high functioning users Outdoor mobility essential Provision satisfactory for mobility NHS chair and a hired one Complaint - Many aspects crucial to users were not taken into consideration by DWS

MDT presentations A series of 3 case studies was presented Illustrated how and when powered mobility should be provided Highlighted multi-disciplinary approach as the best way to assess for provision of powered mobility. Case studies facilitated discussion of the assessment process based on clinical reasoning for example when supplying to children.

Group work Four groups of 6-7 clinicians spent an hour analysing 4 different scenarios trying to answer these questions; Would you provide Powered mobility in this situation If so what would you provide using your current criteria? What would you provide if not restricted by criteria?

Scenario 1 A young boy with CP who is able to walk short distances at home but required a powered chair for school. Some wheelchair services would not provide but expect education services to supply, some would joint fund with education and others would be happy to supply themselves. In the unrestricted mode, all wanted to provide powered mobility for home and school

Scenario 2 A gentleman with MND living with his wife in an-adapted property. All wheelchair services agreed that they would provide a TIS Comfort EPIOC, Fast track the client Make sure the EPIOC had a control system that can be specialised in the future. Also contact social services to check that access/ramps etc were being looked into. Consider a referral to ACT

Scenario 3 A lady with MS with slight visual impairment. All decided to supply Powered TIS, Attendant control (when required by the user) Seating and controls that could be adapted in the future. Again criteria did not seem to change what people felt they should do.

Scenario 4 A young man with Arthrogryposis who needed a powered chair and wished to use it for playing hockey. All agreed that they would supply an EPIOC with special seating and controls for day to day use but would not provide a chair from which sport could be played.

Scenario 4 Some suggested they may fund a voucher for a chair that could be used for both. Most suggested that a separate sports chair be funded separately. If they were not constrained, most said they would like to provide either a chair suitable for sport or 2 separate chairs.

Manager’s view Agreed with clinical reasoning based provision Requested help to convince Commissioners

Summary Recommendations from the group work varied widely for the more basic situations when using existing criteria. There was uniformity when criteria were disregarded for these scenarios. For complex conditions, recommendations were more uniform between the groups irrespective of current criteria.

Clinical reasoning Mobility is necessary for access Mobility facilitates participation and social inclusion Mobility improves independence These improve QoL and well being They also may help people to make better choices for themselves These are all aspects of rehabilitation

Prescription criteria Who decided on these and when? Often at cross purposes with clinical reasoning? Ageist, discriminatory and deprive some of the most needy eg children and elder physically disabled? Vociferous get what they want anyhow? Not applied uniformly? Demoralising for a caring profession?

Outcome of the day Frank and detailed discussion We did not have sufficient time to discuss and agree on a regional policy Fear that a change would open a flood gate, especially by creating a demand from elderly

What is the solution? Consider what has in happened in the DWS in the last 10 years Consider what is happening in other services and wider NHS Consider future population dynamics Consider progress and be innovative

Thank you very much