Introduction

Wheelchairs provide a significant gateway to independence, wellbeing and quality of life for thousands of adults and children. They play a substantial role in facilitating social inclusion and improving life chances through work, education and activities that many people who do not need wheelchairs take for granted.

Variation in wheelchair service provision can affect the timely access to necessary equipment and services. This impacts clinical outcomes and the quality of life of people who rely on these services.

Addressing these inconsistencies is crucial to ensuring equitable access and improved outcomes for all wheelchair users. This framework aims to support integrated care boards and NHS wheelchair providers in achieving these goals.

Purpose of the wheelchair quality framework

This framework is designed to assist integrated care boards (ICBs) and NHS wheelchair service providers in delivering high-quality provision that offers improved access, outcomes and experience.

It outlines several core principles and enablers that provide a foundation for local systems to:

• develop specifications
• adhere to relevant policies and guidance
• self-assure quality, identify areas for improvement
• monitor progress
• improve the experience of wheelchair service users

Ultimately, it seeks to reduce unwarranted variation in outcomes and ensure equitable access to high-quality wheelchair services for all.

The framework aligns with the Care Quality Commission Assessment framework and supports the 4 aims of integrated care systems:

1. Improve outcomes in population health and health care.
2. Tackle inequalities in outcomes, experience and access.
3. Enhance productivity and value for money.
4. Help the NHS support broader social and economic development.

This framework has been co-produced with the NHS England National Wheelchair Advisory Group. The membership of the advisory group represents people with lived experience, clinicians, commissioners and key organisations including British Health Trade Association, Posture and Mobility Group, ResMag, National Wheelchair Managers Forum, Wheelchair Alliance, Whizz Kidz and New Life.

Principles and enablers

Several core principles and enablers should underpin all aspects of the wheelchair pathway.

This will ensure people have a good experience and are supported to achieve the outcomes that are important to them and agreed in their personalised care and support plan.

Principles

The principles from the National Quality Board Shared commitment to quality should underpin all aspects of the wheelchair pathway. Principles guide the approach and decision-making process to ensure the delivery of high-quality wheelchair services.

Enablers

Enablers support the delivery of high-quality wheelchair services and cut across all steps in the wheelchair pathway.

Data

• Relevant data is used to support resource allocation, drive improvement and understand demand.

Communication

• Effective communication with people throughout the entirety of pathway for people who access services and wider professionals involved in their care.

Workforce

• Wheelchair services are included in local workforce planning and a clear training and development strategy is in place.

Integration

• Wheelchair services are incorporated into wider multidisciplinary team assessments, ensuring a holistic approach to patient care.
• This integration aligns with the NHS’s broader strategy to enhance collaboration and streamline services across different healthcare providers.

Digital

• Digital technology is leveraged to enhance user experience and accessibility.

Co-production

• People with lived experience work alongside providers and commissioners to support self-assessment and quality improvement.

Wheelchair pathway and quality standards

Wheelchair services provide assessment and provision of wheelchairs, including seating and associated accessories to support people’s mobility and postural needs.

The wheelchair pathway has been broken down into 6 steps. Each step is explored in detail below, setting out:

• what good looks like for people who access wheelchair services, in the form of ‘I statements’
• Integrated care board (ICB) quality standards
• provider quality standards
• policy and guidance
• case studies

Quality standards

The principles of quality outlined in the National Quality Board (NQB) Shared commitment to quality underpin the Wheelchair quality framework.

We expand here on the NQB principles providing co-produced quality statements specific to the wheelchair pathway and standards for ICBs and providers.

The quality standards outlined in this framework should be used to develop local service specifications and to benchmark current commissioning and provision. The wheelchair pathway can vary and may not always be sequential, depending on level of need and ongoing care and support required. As a result, the statements may apply to more than 1 step, and ICB and provider expectations may overlap.

What this means for people

Developed by people with lived experience of wheelchair services, the ‘I statements’ outline what people should experience at each step of the wheelchair pathway.

They provide a framework for ICBs and providers to continually review and improve services, alongside the quality standards. l statements could be replicated through co-production at a local level.

The NHS Wheelchair Alliance has been instrumental in the development of the I statements, which includes experiences of people across the county who access wheelchair services.

Step 1: Referral and triage

This step in the pathway covers access into the NHS wheelchair service, prioritisation, assessment of level of need to assign appointment or direct issue of wheelchair.

Referral and triage I statements

1. I know where to go and who to contact for clear, accessible and timely information and advice about how to be referred to my wheelchair service.
2. I know my referral has been received and will be reviewed promptly and efficiently.
3. I am confident that the wheelchair service will request further information if it is missing.
4. I feel well informed throughout the processing of my referral.

Quality standards: what is expected from ICBs and providers

ICBs:

• Commissioned wheelchair service is based on local data and intelligence, including wheelchair activity data and joint strategic needs assessment, to effectively meet demand and needs of wheelchair users within their ICB population.
• Commissioned wheelchair services are outcome focused and eligibility is fair and equitable across ICB footprint.
• Commissioning is outcome focused and based on population need with an equality impact assessment in place. Commissioning responds to identified gaps in any eligibility criteria, such as end of life, rapidly deteriorating conditions.
• Referral pathways align with wider commissioned services where postural and mobility needs impact on outcomes, for example learning disability and autism services, education, housing and social care.
• Commissioned wheelchair service is set up to receive e-referrals and have access to relevant electronic patient records to ensure optimal multidisciplinary team decisions. Data sharing agreements are in place.
• Commissioned wheelchair service offers self-referral routes.
• A process is in place to ensure consideration is given to cases that fall outside of standard eligibility criteria.

Providers:

• Accessible and transparent information is available about referral routes, assessment process and eligibility criteria, so people know what to expect.
• Self-referral pathways are available for new referrals (where clinically appropriate) and re-referrals for those already registered with the wheelchair service.
• Triage process clinically prioritises referrals and optimises waiting lists effectively.
• Triage supports those not eligible for NHS wheelchair provision to be signposted to relevant information and services.
• Triage enables assessment and generation of a prescription to provide direct issue of wheelchair when clinically appropriate.
• Training and support is in place for professional referrers. (including trusted assessor models).
• Clear processes are in place to support those who lack capacity to ensure they can access wheelchair services, including wider multidisciplinary team input – for example, best interest decisions (Capacity Act).

Step 2: Assessment

This step in the pathway covers how people will have their individual needs considered in collaboration with appropriately trained personnel to define their physical, functional, environmental and lifestyle needs and preferences.

Assessment I statements

1. I have time and information to allow me to prepare for my assessment.
2. I feel listened to, understood and involved in an assessment that is personalised taking in to account my health and wider needs together with those of my carers.
3. I have an equal voice in the assessment process and my expertise about my own health and wellbeing needs is valued and respected.
4. I can involve others to support me if I want them to be included.

Quality standards: what is expected from ICBs and providers

ICBs:

• ICB personal health budget (PHB) strategy includes the provision of personal wheelchair budgets and all budget deployment options in line with the right to have guidance.
• Governance is in place to support personal wheelchair budgets processes and facilitate access to wider funding streams, supporting an integrated approach to care planning and assessment.
• Commissioned wheelchair service adheres to requirements in Children and Families Act and Special educational needs and disability (SEND) strategy includes wheelchair services.
• Carers’ needs are strategically considered as part of commissioning recognising assessment and provision of wheelchairs.
• Outcome-based commissioning and use of outcome measures is used to understand the impact and outcomes of the commissioned wheelchair service.
• Commissioned wheelchair service aligns with national Wheelchair Data Collection Counting guidance to ensure clock stopping standards are applied consistently. Where clock stopping is applied, cases are monitored through regular contract review meetings.
• Commissioned wheelchair service premises are accessible and meet disability access needs, including parking, and toileting facilities. Consideration should be given to where assessments could take place other than the clinic environment, such as school sites or homes.
• Level of need is considered in local commissioning models, for example low need (occasional use) compared to high need (complex).

Providers:

• Training and relevant competencies of staff are regularly reviewed and updated in line with National Wheelchair Managers Forum guidance.
• Personalised care and supporting planning (PSCP) is core to assessment, including wider care and support plans such as education, health and care plan.
• PCSP identifies the outcomes people and their carers wish to achieve and uses an appropriate outcome measure.
• Wheelchair clinicians form part of multidisciplinary teams, ensuring wheelchair assessments incorporate people’s wider health, social, educational, work and housing needs; and promote how wheelchair provision impacts on wider needs, such as reduction in package of care, housing adaptations.
• The wheelchair service has the appropriate skill mix to optimise the assessment process and does not rely on manufacturer’s representatives.
• Assessments take place in the most appropriate environment to best address the wheelchair user’s needs, and all appropriate equipment is available.
• Where possible, modification, adjustment, equipment or accessories are provided at assessment.

Step 3: Prescription

This step in the pathway informs the decision on what equipment meets the person’s assessed needs.

Prescription I statements

1. I am provided with and understand the options to meet my assessed needs and am supported to make an informed choice.
2. I feel well informed about personal wheelchair budgets and the budget options available, with details about when this can be reviewed.
3. I feel confident that the equipment prescribed will meet my assessed needs.
4. I have a timeframe for receiving my equipment and who to contact for queries and interim support.

Quality standards: what is expected from ICBs and providers

ICBs:

• Commissioned wheelchair services apply the principles of shared decision making and offer all options including personal wheelchair budgets to ensure prescriptions are based on the outcomes identified in personalised care and support plan.
• Strategy is in place to ensure an integrated funding approach that enables access to higher specification equipment.
• Supply contract promotes choice through use of Supply Chain Co-ordination Limited framework or other local framework, ensuring access to a wide range of products and manufacturers.
• Commissioning of wheelchair service considers value for money; that is, higher cost equipment with greater longevity and adaptability where clinically appropriate.

Providers:

• Prescription is decided through effective multidisciplinary team engagement, assessment, personalised care and support planning and shared decision making, ensuring any compromises on functionality are clearly articulated and captured in the personalised care and support plan.
• Staff training is kept up to date as and when new functions and models of equipment are available.
• Notional, notional with contribution, and third-party personal wheelchair budgets are available.
• Processes for notional contribution are enabled via multiple funding streams to include:
  • wider statutory services
  • access to work
  • voluntary, community and social enterprise
  • self-pay
• People are supported with third-party budget decisions including clinical sign off to ensure assessed clinical need is met.
• Third-party equipment is not provided via the provider commissioned to deliver NHS wheelchair service with whom the person is registered (including commercial business).
• Personalised care and support plans capture responsibilities for ongoing care and maintenance of prescribed equipment for all personal wheelchair budget deployment options.

Step 4: Handover

This step is when prescribed equipment is provided to the person and fitting takes place, to ensure the wheelchair fits as intended, and to assess the person’s ability to use the chair safely.

Handover I statements

1. I am confident that my wheelchair and necessary equipment will be handed over at a time and place appropriate to me and that any delays will be discussed and worked through with me.
2. I understand my responsibilities regarding how to use and maintain my wheelchair and how to access repairs when necessary.
3. I have adequate time and guidance to support me to use my wheelchair, including signposting to training skills if required.

Quality standards: what is expected from ICBs and providers

ICBs:

• Regular contract monitoring meetings are in place to support providers and identify any national and local issues impacting on 18-week performance, including any locally agreed timelines for priority pathways.
• Commissioning encompasses wheelchair skills training to optimise outcomes for all wheelchair users including power chair users and children and young people.

Providers:

• Issues impacting on 18-week referral to handover are identified at individual and systemic level and raised with ICB.
• Protocols are in place to ensure all equipment and parts are available at point of handover, including making adjustments to achieve optimal mobility and function.
• Handover processes consider the varying levels of need and complexity with appropriate skill mix to successfully fit and handover chair.
• Handover should be flexible ensuring people are given a choice of place and time. The wheelchair service should allow flexibility around the number of contacts required to ensure optimum mobility and function.
• Adjustment and adaptions must adhere to medical device regulations.
• Information packs are available giving wheelchair users key information relating to the model, including basic care, battery charging and how to access repair and maintenance services.
• Training is given to wheelchair users on the safe and effective use of their wheelchair.
• Staff can signpost to wider skills training.

Step 5: Follow-up

This step encompasses planned clinical review, patient-initiated follow-up (PIFU) and capture of outcome measure.

Follow-up I statements

1. I have accessible information on how to request a follow-up.
2. I have accessible information about any planned review and what is expected, including timescale.
3. I know who to contact if I have concerns throughout the process.
4. I am given the opportunity to feedback about my experience.

Quality Standards: what is expected from ICBs and providers

ICBs:

• Commissioned wheelchair services offer PIFU and planned follow-up where clinically appropriate.
• Commissioned wheelchair services capture and report outcome measures.

Providers:

• PIFU is available to all people known to the wheelchair service, for as long as they require a wheelchair.
• Clear accessible information about how to contact the wheelchair service for follow-up is available.
• Planned reviews should take place where clinically appropriate, based on individual needs, such as when there are significant postural needs or deteriorating conditions.
• Planned maintenance (see step 6) contact can result in a follow-up if a change in need is identified, or equipment is beyond economical repair.
• Outcome measures should be captured via service-initiated follow-up using a range of methods including digital tools.
• Accessible and specific feedback loop is in place to inform continuous quality improvement.
• Accessible and transparent complaints policy is in place.

Step 6: Repair and maintenance

This step includes regular maintenance of issued wheelchairs and repairs when wheelchairs and or associated parts are malfunctioning and or not working.

Repair and maintenance I statements

1. I have accessible information about any maintenance and repair of my wheelchair including when, who and where to contact if needed.
2. I am confident that repair and maintenance appointments will be at a time and place appropriate to me.
3. I am informed on the progress of the repair of my wheelchair.
4. I have appropriate interim support whilst my wheelchair is being repaired.
5. I know who to contact in an emergency.

Quality standards: what is expected from ICBs and providers

ICBs:

• Commissioned wheelchair service provides integrated technical, repair and maintenance service aligned with commissioned clinical wheelchair services that ensures equity of access for all users.
• Commissioned wheelchair services deliver sustainable, and responsive repair and maintenance activities, including planned preventative maintenance in line with manufactures guidance.
• Performance relating to repairs and maintenance are captured as part of wheelchair performance monitoring in regular contract meetings, including a target for first-time fix rates.

Providers:

• Ensure timely and equitable access to repair services, meeting targets for first-time fix rates, including access to virtual support if appropriate.
• Appropriately skilled technical capacity and expertise that supports service delivery and works collaboratively with clinical teams along the care pathway.
• Where a first-time fix cannot be achieved and users do not have access to alternative equipment, processes are in place to provide a same-day loan chair, ensuring no user is without provision.
• Processes are in place to refer into clinical services when re-assessment need is identified.
• Widely advertise and signpost access to repair services across areas served, offering multiple routes to communicate with the service.
• Planned preventative maintenance regime is in place that meets manufacture guidance.
• Implement systems and accessible and specific feedback loops to inform continuous quality improvement.
• Collection and refurbishment and reconditioning of equipment is prioritised, ensuring users can access equipment through safe re-use of equipment.
• Deliver social value strategies, including ‘green commitments’, minimising impacts of services on the environment.
• Deliver responsive ‘roadside’ assistance ensuring no user is left stranded when away from their place of residence. Work with community and patient transport providers to repatriate users back to their place of residence or safety.

Provision of a responsive repair service for all wheelchair users who may be temporarily residing or travelling within area in line with National Wheelchair Managers Forum ‘Right to Travel UK’.

Annex A: demonstrating evidence of assessment, provision and repair

Publication reference: PRN01643