CSP Wales Office
1 Cathedral Road
Cardiff CF11 9SD
029 2038 24289
Health and Social Care Committee
Access to medical technologies in Wales
Evidence from Chartered Society of Physiotherapy– MT 10
16th of October 2013
Dear Chair and Committee Members
HEALTH AND SOCIAL CARE COMMITTEE INQUIRY INTO ACCESS TO MEDICAL TECHNOLOGIES
General introduction
The Chartered Society of Physiotherapy (CSP) in Wales is pleased to provide a written contribution to this review.
Physiotherapists use a range of technologies within the scope of treatment modalities and techniques that make up the practice of physiotherapy. For example:
· Respiratory technologies in relation to weaning patients from ventilators
· Electromechanical medical technology (for developing diagnostics) and electrotherapy treatment modalities such as transcutaneous electrical nerve stimulation (TENS)
· Hospital hardware in relation to treatment beds, plinths and walking/running equipment for gym based physiotherapy
· Non-invasive implantable technology in relation to advancing rehabilitation for joint replacement
· Single use technology in relation to syringes and needles for injection therapy
· Technical aids for those with disabilities such as in relation to advances in wheelchair development, advances in adjuncts to walking (frames, functional electrical stimulation (FES), prosthetics and orthotics)
· Digital telehealth/telecare technologies that facilitate therapists being able to remotely monitor patients with long term conditions
Physiotherapists, support workers and physiotherapy students will work with a range of technologies/equipment and will come into contact with companies promoting new and innovative technologies in their speciality field. Clinicians will attend conferences and training where they will learn about new developments. It continues to be an important aspect of maintaining professional registration with the Health and Care Professions Council (HCPC) for registrants to demonstrate they are undertaking regular continuous professional development and keeping up to date with best practice.
Key points from the Chartered Society of Physiotherapy
The Committee is looking at access to medical technologies in Wales and this response addresses the questions posed in the terms of reference, as far as possible in relation to physiotherapy service provision in NHS Wales.
1. Examine how the NHS assesses the potential benefits of new or alternative medical technologies
1.1 In the experience of physiotherapists working clinically potential benefits of new or alternative medical technologies will be assessed by scrutinising any evidence or research available. Invariably this will be provided by the company which has developed the technology but there may be other studies and trials that can be accessed.
1.2 Sometimes the clinicians may be able to access the equipment ‘on loan’ to trial the equipment themselves with patients in order to demonstrate benefits locally.
2. Examine the need for, and feasibility of, a more joined up approach to commissioning in this area
2.1 CSP members report lack of funding, time consuming procurement processes and no strategy for commissioning in this area that they are aware of, also no time for evaluation. Evaluation needs to take into account clinician and patient time and may require longer timescales to allow the equipment/technology to have time to work. The limiting factor for accessing new or alternative technologies is nearly always cost. Even if there may be potential savings to be made, the cost of equipment may prohibit any opportunities to use it.
2.2 The CSP considers there is a requirement for a more joined up approach to commissioning. It needs to be addressed at both an all-Wales level and a local level and would benefit from patient involvement.
2.3 There are examples of joined up working such as Community Equipment Services in Wales which pool budgets across several health boards and local authorities working together in partnership. These services provide community equipment such as that required for daily living (eg raised toilet seats, bath seats, shower chairs, trolleys etc.), nursing equipment such as commodes and pressure mattresses, communication equipment for those with speech, writing and reading difficulties, children’s equipment, environmental control systems and other types of equipment and technologies that might be needed in the home and community. By coming together and indeed by development of ‘Wales-wide’ Guidelines, commissioning is improved, stock management is improved and patient access is improved. There are lessons that can be learned from developments such as this.
2.4 Joined up approaches are needed, not only for commissioning but also for the maintenance, repair and reconditioning of new and innovative technology.
2.5 Members of the physiotherapy profession highlight that difficulties experienced by clinicians are not only restricted to the lack of a joined up approach. CSP members report a complicated and protracted process for trying to access new equipment/technology and that even making simple requisitions can be time consuming because of protocols and levels of management being required to sanction purchases. They report that generally equipment levels of even the basics are much lower in clinical environments now than they ever used to be. Staff, while appreciating the need for prioritisation in a time of austerity, are restricted to ordering from standard lists and have limited access to orthotics, for example, for their advice and expertise. Clinicians find it almost impossible to incorporate the new technologies that they may see at conferences and training into their every day service. The process for doing it is seen as arduous and complicated thus discouraging innovative activity.
3. Examine the ways in which NHS Wales engages with those involved in the development/manufacture of new medical technologies
3.1 The opportunity for physiotherapy clinicians to gain experience is currently limited. There may be opportunities for a few physiotherapists to be involved in research led by universities but there are frustrations expressed by members at the slowness of the NHS in giving the go-ahead for involvement in trials. Universities working with the NHS often need timely discussions when bidding for grants and deadlines are often short.
3.2 The CSP would like to see more opportunities for clinicians to be involved in the development and manufacture of new medical technologies. Often some of the best ideas and innovations come from the clinicians working closely with their patients and devising a solution with them.
For example, Paediatric Physiotherapists Elaine Owen from Betsi Cadwaladr University Health Board has gained an international reputation for her innovative work with children with disabilities. Her approach is based on using biomechanics to change the nervous system through motor learning, while also treating patient’s muscles and bones. Elaine was responsible for putting the transportable video vector generator gait laboratory into routine practice at the Bangor Centre.
4. Examine the financial barriers that may prevent the timely adoption of effective new medical technologies, and innovative mechanisms by which these might be overcome
4.1 Currently, in physiotherapy services it is often the case that new and innovative equipment is only available when ‘on-loan’ from companies. Members report there is no prospect of procuring funding unless capital bids or charitable funding becomes available. Otherwise, they are at the mercy of very generous companies that sometimes allow clinicians to keep machinery on extended loan.
4.2 Bids for equipment over £1,000 must go to a panel within the Health Board. The CSP is unclear about the process undertaken within the panel, who sits on the panel, what clinical expertise they have or what cost/benefit analysis is undertaken in relation to the piece of equipment/technology to be discussed by the panel. The CSP considers this whole area should be reviewed and made more transparent.
4.3 Cost is the biggest barrier. However, evidence to the Cross Party Group for Neurological Conditions ‘Inquiry into Physiotherapy Services for People Living with Neurological Conditions’ (February 2013) highlighted the problem of upfront costs for equipment being high but in comparison with the long term cost of medicines they can in fact be very good value for money.
4.4 In a case study, a piece of equipment to assist with standing was required for a service user but at £6,000 it was said to be too expensive when compared to medication. However, the equipment if used for 10-years would have cost £3.85 for each time the person stood (30 minutes x 3/week) or for 5-years £7.70 each time it was used. For health technologies a direct cost to cost comparison is not always appropriate as the potential additional health benefits need to be taken into consideration. The actual cost of the equipment should be compared against the cost of care delivered if the patient’s condition deteriorates or they needed staff to support them in access to physical activity.
4.5 Functional Electrical Stimulation (FES), a technique that uses low levels of electrical current to stimulate nerves was also highlighted to the Cross Party Group. This is another relatively new technology which is not being accessed due to cost. The technique is relatively cheap, costing £1,000/year to use, but as most service users may require FES for a number of years Health Boards have not currently allocated funding for the growth in patient demand. NICE published international guidance in 2009 confirming the safety and efficiency of the procedure but a postcode lottery has existed across Wales with some Health Boards funding the treatment routinely whilst others are restricting supply. The absence of Wales-wide guidance on cost effectiveness of equipment means that even when a treatment has NICE international procedure guidance, there is no guarantee it can be accessed.
4.6 The Cross Party Group recommended that the All Wales Medicines Strategy Group should appraise new equipment and technology and question whether it is cost effective. The CSP supports the development of an ‘all Wales’ approach to appraisal of equipment and technology that would provide guidance to NHS Wales on cost effectiveness and best use.
4.7 The CSP also suggests the need for more joined up thinking in relation to management of equipment and new technologies. The CSP would like to see the development of a ‘virtual all-Wales store’ for complex, expensive equipment linked to solutions for collection, maintenance and management so that these technologies will have maximum use and benefit for patients. Joined up solutions could include developments within contracts and purchasing agreements for maintenance, delivery and collection.
4.8 An example is provided of one service where an agreement was reached with a company to service all pieces of a certain type of equipment at the same time. Savings were made in not having several visits to locations in the health board to maintain the equipment but the service did have to bring the equipment to the one location. Whilst this might not work for large pieces of equipment the principle is possible for some types of technology.
Concluding comment
The CSP hopes the committee finds these points useful and looks forward to following the progress of the review. Please contact the CSP if you require further information.
In association with:
The Welsh Board of the Chartered Society of Physiotherapy
The Welsh Physiotherapy Leaders Advisory Group
The All Wales Children and Young People’s Physiotherapy Leaders Group
About the CSP and Physiotherapy
The Chartered Society of Physiotherapy is the professional, educational and trade union body for the UK’s 50,000 chartered physiotherapists, physiotherapy students and support workers. The CSP represents over 2,000 members in Wales.
Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity. Physiotherapists and their teams work with a wide range of population groups (including children, those of working age and older people); across sectors; and in hospital, community and workplace settings. Physiotherapists facilitate early intervention, support self management and promote independence, helping to prevent episodes of ill health and disability developing into chronic conditions.
Physiotherapy delivers high quality, innovative services in accessible, responsive and timely ways. It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person centred professionalism. As an adaptable, engaged workforce, physiotherapy teams have the skills to address healthcare priorities, meet individual needs and to develop and deliver services in clinically and cost-effective ways. With a focus on quality and productivity, physiotherapy puts meeting patient and population needs, optimising clinical outcomes and the patient experience at the centre of all it does.
Philippa Ford MCSP
CSP Policy Officer for Wales
07990 542436