Equipment failure

Last week health minister Alan Milburn announced plans to inject
£1bn per year into older people’s services to improve choice,
increase independence, and tackle bed-blocking. One of the key
targets will ensure that by 2004 all assessments of older people
start within 48 hours of first contact and are completed within a
month. And anyone assessed as needing equipment should have it
within a week.

This is pertinent in the light of a newly published Audit
Commission report which found service users are facing long delays
for equipment of dubious quality, while many who could benefit from
equipment services are excluded by stringent eligibility
criteria¹. The waiting time for some equipment is up to
six years – a period of time that would be unacceptable for other
NHS services, says the report. Equipment includes pressure-relief
mattresses, commodes, adapted baths, shower chairs, raised toilet
seats, grab rails, lever taps, flashing doorbells, assistive
listening devices, textphones, wheelchairs for short-term loan,
communication aids for people with speech impairments, fall alarms
and wandering detectors.

The report follows a similar study two years ago that found that
organisation of equipment services was a recipe for confusion,
inequality and inefficiency.² At the time of this first
report’s launch, health secretary Alan Milburn said: “It paints a
very stark picture of frankly a second-rate service in some parts
of the country. What we have to do now is ensure that the Audit
Commission’s recommendations are actioned in every part of the
health service.”

To achieve this, objectives in the NHS plan included the
government’s intention for health and social care provision to be
combined into a single, integrated community equipment service by
2004. Specific guidance for this was issued to the NHS and local
councils in March 2001.³ Providers are expected to
increase the number of individuals benefiting from the equipment
services by 50 per cent and to improve the quality and range of
equipment on offer. They should do this by pooling budgets and
integrating services through the Health Act 1999.

Running alongside this, the Department of Health set up a
three-year implementation programme, incorporating a team to help
trusts and social services implement the guidance by the target
date of April 2004. Additional funding for community equipment
services was pumped in: £12m for 2001-2, £28m for 2002-3,
and £65m for 2003-4.

An extra government grant was also promised to councils in the
personal social services settlement for 2001-2 to 2003-4. But,
according to the Audit Commission, little of the year-one money
appears to have reached its intended destination of front-line
services, with only 13 per cent of equipment services saying they
saw it.

How is it, then, that with extra money, guidance and an
implementation team, equipment services have made such limited
improvements over the past two years? There are several reasons.
First is the lack of awareness from services and users that any
money is available. Second, much of the thinking behind improving
equipment services involves establishing a single, integrated
service, but achieving such a cultural shift takes time. Finally,
and perhaps most significantly, the additional money was not
ring-fenced, so councils and NHS trusts were not sure how much
money was specifically for community equipment.

So where has the money gone? In all likelihood it has either
been ploughed into meeting other government priorities that are
seen to take a higher priority, or it hasn’t been spent at all,
says Gary Birkenhead, policy and research officer at cerebral palsy
charity Scope.

“The worry is that they are not spending the money when there is
a big need for it,” he says. And second-year funding will make
little difference unless it is ring-fenced, he says, arguing that
the cash is almost useless until there is appropriate
infrastructure in place to make use of it.

An additional problem is that it is central money being used
locally, he says. So, although the government can claim it has
given a lot of money, it might not feed through to the people who
need it, because the way it is spent depends on local
decision-making. This might be fine in an area that places a high
priority on equipment. But equipment is, on the whole, a low
priority. “It’s not a sexy subject and it’s not seen as the cutting
edge of medicine,” says Birkenhead.

A side issue is that the money does not address the shortage of
staff. So equipment services might have the money to provide the
equipment, but they do not have the staff, such as occupational
therapists, to carry out the assessment.

And while disabled and older people are forced to wait, the
impact on their lives is enormous. “It’s about the impact on
dignity, independence and basic access to things that others take
for granted,” says Liz Silver, housing and independent living
officer for disability charity Radar.

The Audit Commission found that many users, particularly older
people, had low expectations and were happier with the quality of
service than health care professionals. This comes as no surprise
to Silver, who says that users put up with more hassle and
inconvenience than you would expect. “They are terrified that if
they complain it could jeopardise future services.”

Meanwhile, those services that are spending the money on
government targets or not spending it all should heed the words
from the first Audit Commission report: “Equipment for older or
disabled people provides the gateway to their independence, dignity
and self-esteem…these services have the potential to make or
break quality of life.”

¹ Audit Commission, Fully Equipped 2002:
Assisting Independence, Audit Commission, 2002

² Audit Commission, Fully Equipped 2000:
The Provision of Equipment to Older or Disabled People by NHS and
Social Services in England and Wales, Audit Commission,
2000

³ Department of Health, Guide to
Integrating Community Equipment Services, DoH,
2001

A success story

The Audit Commission highlights the Safe at Home project in
Northamptonshire as an example of good practice in community
equipment services. Set up by Northamptonshire social services
department, the NHS and voluntary sector, the project enables older
people with dementia to live independently in their own homes for
longer.

A gas detector, for example, may be installed to switch off the
supply if someone turns on the gas when the oven is off. It will
also trigger a community alarm phone that is connected to a call
care centre. Help for older people with dementia comes from a
calendar clock that tells the time, day, date, month and whether it
is morning or afternoon.

An evaluation of the project shows that technological devices
such as these reduced both the risks for the older person and
carers’ anxiety¹. On average, the cost of installation
is £242 per person.

“We are turning the traditional response on its head, which is
to turn off the cooker or give them meals on wheels. It enables
them to carry on living in a familiar environment,” says project
manager Brian Frisby.

Analysis with a comparable group found that, although the
initial care package costs were slightly higher for the project
group, there were savings during 12 months of £68,000 based on
the 18 people in the scheme through a reduction in the demand for
residential care, nursing or hospital care.

“We are demonstrating how telecare services can be used in ways
that they are not at the moment to support people in their own
homes,” says Frisby.

¹ J Woolham et al, The Safe at Home
Project, Hawker, 2002