Transcript Doctor, Engineer or Architect”

“Doctor, Engineer or
Architect”
The Aldersea Lecture
2009
The year is 1964…..
I
am 15 yrs old and I have just completed
my GCE’s
 I was sent to a Vocational Guidance
company on the Marylebone Road, and
spent a whole morning doing multiple
choice questionnaires
The answer came back…..
“Doctor, Engineer or Architect”
Becoming a doctor
A
few months later my father was playing
golf with Myles Formby, an ENT surgeon,
family friend and Dean of UCH.
 “What is Linda going to do when she
leaves school?”
 “ Not quite sure but she’s been to look at
becoming an O.T”
 “Why isn’t she doing medicine?”
Becoming a doctor
I
applied for 3 London Medical schools
and 3 provincial Medical schools.
 Amazingly,
I got into the Middlesex
Hospital (which was my first choice). I say
amazingly, as when asked why I had put
the Middlesex as my first choice, I replied;
“I’m female, I like shopping and
you are the nearest to Oxford
Street”
Medical student years
 Medical
school was great fun!
 Hard work but lots of other activities
including coxing the second eight, and
amateur dramatics…..
Xmas
Student
Concert
1968
1973
Dr Linda Marks MB,BS.
(University of London)
Rheumatology and Rehabilitation
 After
MRCP and various training posts I
got a Senior Registrar job in
Rheumatology and Rehabilitation at the
Middlesex Hospital.
 Towards the end of my 4 yr post, my
husband got his consultant post, and…
 There were too many Rheumatology
senior registrars for the available
posts……
? Another stroke of
fate
Medical officer at Stanmore LFC
heard I had got the job on July 29th
1983, about two hours after giving birth to
my son, James.
 I started the job in November 1983,
although at that stage it was just doing
prosthetics.
I
1986
The McColl report
was published.
Although its
recommendations
were not
implemented as
stated, it was to
have a profound
effect on
wheelchair
services.

The Disablement Services Authority (DSA), an
interim health authority, was set up in 1987 to
oversee the transfer of the ALAC services to the
NHS in 1991.
 In order to achieve this, ALAC boundaries were
re-drawn co-terminus with the NHS Regional
and District Health Authorities.
 Stanmore was to be the wheelchair centre for
North West Thames RHA
 …. and I became involved in wheelchairs.
1987-1990

I worked as a DHSS medical officer doing
wheelchair clinics twice a week at Ealing and
then at Acton.
 I screened all requests for ROHO and Jay
cushions, and answered numerous ‘file’ queries.
 I assessed people for manual wheelchairs (at
the discretion of the T.O),EPICs, 28B’s, the
occasional ’special’ buggy, a few Matrix, MSIs
and a Snug Seat.
 When one day I insisted on examining a patient,
the couch had to be brought in from another
room!
Stanmore wheelchair service

Opened officially in Jan 1990.
 Evolved from Ealing ALAC (which had been part
of Kingston) for London districts and Cambridge
ALAC for Hertfordshire and Bedfordshire to
cover the North West Thames region.
 Initially, the whole of the Regional service was
run from Stanmore (15 District services!)
 Between Jan 1990 and April 1991, the ‘District’
services became established, and much of the
work was devolved.
Stanmore Special seating - 1991
 From
1991, Stanmore and the local
District services worked as a continuum
with:


District services doing all the manual chairs,
all the EPIC’s and 28B’s.
Stanmore doing all the special seating and
the specialised buggies, and providing second
opinions for cases referred by the District
services.
 Roughly
400 cases. No waiting list!
The doctor’s role in the early days
at Stanmore special seating service







Assessing people referred for special seating
Assessing children for buggies.
Undertaking all post delivery checks of bespoke
contoured seats manufactured by subcontractors.
Reviews as required.
Still an element of budget keeping.
Moved from always working with the T.O’s to working
with reps and Seating companies.
Medical element ?? Yes. Virtually all the patients were
examined and postural abnormalities identified and
analysed.
Stanmore Special seating service,
1991-1997






Special seating systems proliferated, and so did the
Stanmore caseload.
We devolved buggies to Districts due to the pressures of
the increasing seating caseload.
We employed our first seating therapist 1991.
We employed our first dedicated special seating
engineer in1992.
The doctor continued to see all the new patients (as part
of an MDT) and the majority of informal reviews, but the
engineer and therapist did all the deliveries, post delivery
checks and screened the requests for advice.
69% of the caseload were under 18, and still under the
paediatric umbrella.
1997
EPIOC’s and vouchers arrived!
In NWT it was decided to site the EPIOC service
at Stanmore.
 More doctors, more engineers and more
therapists.
 First signs of funding (for seating) being
inadequate.
 Pressure on MDT appointments, so more formal
review mechanisms were put in place, with
regular visits to schools and Day Centres (done
by therapists and engineers)


In the new millennium….

From 2001, we had an increasing number of
people in EPIOCs with special seating, and they
were coming to separate clinics for their seat
and chassis.
 2002 we started ‘joint clinics’ (as well as
separate) to better meet client needs. At that
time 400 EPIOC’s on issue of whom approx 100
(25%) also using seating.
 2003 we rebranded from Stanmore Special
seating service to Stanmore Specialist
Wheelchair services.
Doctor’s role 2003-2009





Continuing to do MDT assessments, mainly at Stanmore
but also on a domiciliary basis as required.
Seeing people who required joint assessments for both
their EPIOC and their seating.
Complexity of assessments increasing due to people
needing ventilators, feeding pumps, and complex
switching to work powered chairs, EC’s and
communication aids.
Age group shift with 69% now between 18-60 and only
27% paediatric.
Total caseload now 1646 patients.
So, in 2009 is there a medical role
in posture and mobility services?
 YES!,
but primarily for those with complex
postural or changing needs
The doctors role in 2009 -1






To take a holistic overview of the management of the person needing
specialist seating to ensure that all needs (medical, engineering and lifestyle
factors) are considered and optimised as much as possible.
Advise team on medical aspects of care that may impact on the prescription
e.g. evaluation of joint ranges and tone, drug therapy, course of progressive
disease, verifying diagnosis.
Communicating/liasing with other colleagues (particularly medical) who are
involved in the person’s care, to obtain and or share information, and
optimise management e.g. timing of surgical interventions, proposed post
operative management.
Initiating new aspects of management e.g. referral for bracing, spasticity
management, insertion of PEG, orthopaedic interventions.
Introduction of new practices, sometimes from other aspects of healthcare
e.g. Botulinum toxin injections, setting up joint assessments with myopathy
services.
To ensure that posture and mobility equipment is fully integrated with all
other aspects of a person’s care and lifestyle.
The doctors role ….(?)





To arbitrate when differences of
opinion/perception, within or between team
members, threaten to interfere with delivery of
best care.
Provide leadership within the team
Educate medical and other colleagues, about
postural and seating issues.
To be the patient’s advocate for optimum care.
The lead for audit/clinical governance/ research.
The doctors role…..(?)
Management and strategic issues
 To work with local managers to optimise service
delivery.
 To ensure that commissioners and policy
makers are cognisant with factors relevant to
delivery of a quality service. Service champion.
 To promote the understanding that posture and
mobility equipment are integral aspects of
overall healthcare
 Advise on strategic planning of services in
relation to overall healthcare.
An Engineer ?
 No
I’ve not had any formal training, but..
 Just look at the services in which I work!
Prosthetics and wheelchairs
 As a result I’ve had a fair induction into
biomechanics, durability, stability,
standardisation of measurement, correct
nomenclature, risk management…..
Engineers
I
don’t think any would dispute the role of
Rehabilitation Engineers in wheelchair
services.
 The role of Clinical engineers seems less
defined. However in my view, they are
indispensable in complex seating and
postural areas.
An Architect ?

I wish to take a liberal interpretation of this word,
and use it in considering “developing services”.
 You have heard me allude to the setting up of
the seating service at Stanmore, the arrival of
the EPIOC service, and the evolution to
Stanmore Specialised Wheelchair services, as
well as some of the subtle changing roles within
those shifts.
 However financial issues began to arise as far
back as 1997, and this resulted in waiting lists
being created as PCT’s ran out of money within
each financial year.
£45,000
£40,000
£35,000
£30,000
£25,000
£20,000
£15,000
£10,000
£5,000
£0
New Provision
Repairs
Replacement
Total
Year
1
Year
3
Year
5
Specialised Commissioning

We have continued our dialogue with our
commissioners over the years, and during 2000
the scoping exercise for Specialised
Commissioning was taking place. I believe that
some of our discussions fed into the
incorporation of Special Seating in Definition
set 5.
 Specialised commissioning was set up to
provide alternative commissioning
arrangements for ‘Low volume, high cost
services’
Specialised Services National Definition
Set: 5 Assessment and provision of
equipment for people with complex
physical disabilities (all ages)
This definition has been subdivided into five main areas:
• Prosthetics and complex orthotics
• Specialised wheelchair provision including complex postural
seating/postural management systems and specialised powered
wheelchair controls
• Communication aids (excluding all forms of hearing aids and cochlear
implants)
• Environmental controls and other electronic assistive technology
• Specialised aspects of telecare
Specialised Services National Definition
Set: 5 Assessment and provision of
equipment for people with complex
physical disabilities (all ages)
“Whilst the services are based on the provision of equipment in
some form, the hardware does not comprise the totality of any of
these services. Specialist assessment, provision of equipment and
training should be delivered as part of a total package of care, to
ensure that service users are provided with the most appropriate
equipment and are enabled to use it to optimal advantage.
The other aspect common to many of these services is the longterm nature of the provision. Users will often need provision
throughout their lifetime. Commissioning arrangements should
therefore provide the resources to review and maintain equipment
in order to accommodate the changing needs of this client group.”
Specialised Healthcare Alliance
(SHCA)
 Are
an association of many of the
consumer groups that come under the
specialised commissioning definition set.
 Surveyed the Special Health Authorities
(SHA’s) last year asking for the named
lead commissioner for each definition set.
 Only 50% of SHA’s had a named
commissioner for definition set 5.
The Wheelchair
collaborative
2002-2004
Wheelchair collaborative

Set up because the second Audit Commission
Report (2002) demonstrated very few
improvements in wheelchair services.
 A partnership of the Dept of Health, the NHS
Modernisation Agency, the Audit Commission,
and about 1/3 of the wheelchair services in the
UK.
 The Collaborative showed that very significant
improvements can be achieved in areas such as
quality of information, reduction of waiting times,
better use of resources, and improved
outcomes.
After the Wheelchair Collaborative

There was much concern that the gains that had
been made during the collaborative should be
maintained and rolled out to the remaining 2/3 of
the services.
 Various National Service Frameworks (NSF’s)
had been published and recognised the
importance of wheelchairs to independence and
health
 As a result the Care Services Improvement
Partnership (CSIP) was tasked to review how
wheelchair services could be reformed.
 CSIP carried out its review 2005-6.
CSIP report 2006


Whole systems working
Joint commissioning
 Patient centred services
 Access to information
 Co-ordinated assessment
and provision
Transforming Community Equipment
and Wheelchair Services (TCEWS)
Care Services Efficiency Delivery
Programme (CSED)

Announced even before the CSIP report came
out.
 A chance to get some of the changes
implemented??
 Working party discharged early 2007 but the
report was imminent.
 A draft report went to ministers in February
2008……….
Stanmore SWS
2007 - 2 of our 11 PCT’s gave notice.
 Sept 2007 - 3 more PCT’s gave notice.
 Nov 2007 - The consortium announced a
competitive tendering exercise for the
service.
 July 2008 – no contract was awarded.
NWLHT contested the legality of the
tender exercise, and ‘won back’ the
opportunity to deliver the services.
 May
Stanmore SWS
August 2008 – awaiting information about the
Project Board that was to be set up to determine
the service specification for a 5yr contract
starting April 2009.
 Oct 2008 – the consortium decided that they
would devolve the EPIOC service by April 2009
and the Special Seating service by April 2010.
 March 2009 – the consortium decided to bring
forward the devolvement of the Special Seating
service to September 2009.

What could Stanmore have done
differently?
Run our service as a business ?



Ensured that we had an accurate and contemporary
specification of our service at all times.
Rigorously monitored our capacity to ensure we could
‘deliver’ the service/had the information to negotiate with
commissioners.
Set up formal contracts with our own sub-contractors
specifying time scales, and facilitating monitoring.
So what other messages are
there?

At PCT level there is so little importance placed
on these services, that there is often no
nominated lead/ they change frequently.
 Wheelchair and special seating services are
poorly understood by commissioners,
particularly the funding to provide a sustained
and continuous service.
 Despite the efforts of the Audit commission 2002
and the CSIP report, there are no agreed
commissioning guidelines in place.
Specialised commissioning
 Special
seating is rightly covered by this
arrangement.
 Only 50% of SHAs have nominated leads
for this area of specialised commissioning.
 PCT’s can apparently commission and
decommission Specialist Services without
reference to the SHA, providing they follow
general commissioning guidelines.
Dept of Health
 The
DH are aware that most wheelchair
services are cash strapped, and equally
acknowledge that population
demographics are making this worse year
by year.
 Despite many reports over the years, there
is still no definitive plan.
Recommendations
To individual services:
 Be clear about what you do and what you need to do it.
Review this annually and document it.
 Work at local level to get recognition for the value of
wheelchairs and seating as part of health and social
agendas and not stand alone pieces of equipment.
To PMG:
 Consider setting up a session at PMG NTE for sharing
service delivery achievements.
 Continue to lobby for recognition and proper
commissioning for wheelchair and seating services.
End of term report
Profession
Y/N
Comment
Doctor
Y
Has had a good career
Engineer
N
Has a reasonable grasp of
some of the principles
Architect
N
Unfortunately her ‘house’
fell down. She has passed
on some information learnt
from this experience.
And finally…..
 Thank
you to the many patients with whom
I have had the opportunity to work over the
years, and who have taught me so much.
 Thank you to my colleagues, who have put
up with me through the ups and downs,
and have given 100% to the services.
 Thank you to PMG for their excellent work,
and for the opportunity to give this lecture
today.