Wheels in Motion July 2015

Putting the wheels in motion: Assessing the value of British Red Cross short-term wheelchair loan Refusing to ignore people in crisis

Putting the wheels in motion: Assessing the value of British Red Cross short-term wheelchair loan Alison McNulty, Chloë Carter and Jacob Beswick

© British Red Cross 2015 Any part of this publication may be cited, translated into other languages or adapted to meet local needs without prior permission of the British Red Cross, provided that the source is clearly stated. ISBN 978-0-900228-21-6 The photographs used for some of the case studies in this publication (Janis, Laura, Margaret and Sameena) are of models and there is no intention to associate any of them with any of the conditions or circumstances referred to in this publication. Some names have been changed to protect anonymity. Photographs: Sameena © iStock Laura © iStock Margaret © iStock Janis and her husband © iStock Ron – provided by kind permission of his family Joanna – provided by kind permission of her family For all others; © Matthew Percival/British Red Cross ii

1 Introduction 1 What is short-term wheelchair loan and why is it important? 3 Policy context 4 Opportunities for change 7 2 Methods 9 Research aims and methods 9 Identification and selection of case study participants 9 Case studies 10 Health care professional interviews 10 contents Analysis 10 3 Case studies 11 Ronald, South Yorkshire 12 Sameena, Nottinghamshire 14 Ashleigh, Cornwall 16 Melvyn, Dorset 18 Laura, Nottinghamshire 20 Holly, Yorkshire 22 Janis, Cumbria 24 Joanne, Kent 26 Margaret, South Yorkshire 28 Key themes 30 4 Recommendations 32 References 34 Appendices 36 Appendix A: Numbers of selected participants 36 Appendix B: Screening interview schedule 37 Appendix C: Wheelchair user interview (case studies) 38 Appendix D: Health care professional interview 40 Appendix E: Note on definitions and calculations 42 iii

There is no clearly defined duty for statutory provision of wheelchair loans in England. The British Red Cross is the largest national provider, but we know there remains unmet humanitarian need. “Not having the wheelchair would have been the straw that broke the camel’s back…it would have been unbearable” (Laura’s mother, p.21) This research report shares the experiences of nine people who have recently borrowed a wheelchair from the Red Cross mobility aids service. The stories illustrate various reasons for needing a short- term wheelchair loan and show the positive impact that they have on people’s lives. Short-term wheelchair loans are an enabler of recovery, choice, control, independence and wellbeing. This report demonstrates that short-term wheelchair loans can prevent and delay people’s needs for health care, social care and support. They can also reduce the level of need that already exists. There are cost savings associated with this prevention; each story is accompanied by an economic evaluation that documents the savings across health and social care, as well as to personal income. We believe that everyone who needs a wheelchair should be entitled to quickly and easily get one that is right for them, for as long as they need it. iv

Acknowledgements The British Red Cross is hugely grateful to Andy Garwin Warby and Emma Rattenbury from Envoy Partnership, who advised us on the methodology for this research and were commissioned to complete the case studies, including the analysis. Their dedication, insight and passion were tremendous. We also thank Mike O’Driscoll for his help in overseeing the commissioning and recruitment to this project. A big thank you also goes to those who helped us secure respondents for the interviews and, most of all, we are grateful to those who gave up their time to share their stories and experiences. v

1 Introduction The British Red Cross helps millions Working with politicians, policymakers of people in the UK and around the and the public, we can improve the world to prepare for, respond to and humanitarian situation of people, recover from emergencies, disasters families and communities in the UK and conflicts. Our volunteers and and around the world. staff help people to live independently by providing support at home, transport, and mobility aids that The Red Cross has a include short-term wheelchair loans. We also teach first aid skills humanitarian vision: and support asylum seekers and “Everyone who needs refugees in the UK. a wheelchair should be We are committed to speaking up entitled to quickly and for and improving the lives of people easily get one that is right in crisis and we have provided health for them, for as long as and social care services for more than a century. Our operational they need it. Everyone experience enables us to pursue who uses or handles a focused advocacy that is backed wheelchair should know by evidence, in order to bring about how to do so safely and changes in policy and practice at comfortably.” the national, local and international levels. 1

During and immediately after World War One, the Red Cross provided short-term wheelchair loans for both injured servicemen and the general population. The service proved to be very popular. By the time the NHS was established in 1948, we were the go-to organisation for short-term wheelchair loans. Today we are the largest national provider of short-term wheelchair 1 loans, operating from around 250 sites across the UK. We loan wheelchairs as part of our mobility aids service, which loaned 111,000 items of equipment in the UK in 2014. The majority of those items – 83,000 – were wheelchairs.2 We loan wheelchairs to both children and adults, although the majority of people who borrow our wheelchairs 3 are aged 65 years and older. People can access the service in a number of ways, including via an online portal, by telephoning our Area Offices and by visiting local Red Cross loan sites. Red Cross staff and volunteers are often based directly in hospitals and medical centres, working with medical staff to respond to humanitarian need. Our wheelchairs are loaned free of charge. We are grateful to receive donations from 80 per cent of those who use the service (MacLeod, 2015), but we nonetheless spent over £1 million on our mobility aids 4 service in 2014; a service that is dedicated primarily to short-term wheelchair provision. These costs are primarily property costs. We own some of the sites from which we provide the service, but in many sites we pay rental costs for space from which to loan out wheelchairs, including some hospitals and general practices where we work collaboratively with health care professionals. These rental costs can amount to tens of thousands of Private Wells at Normanhurst using a Red Cross short-term wheelchair loan pounds per year. during WWI © British Red Cross 1 Other charities also provide short-term wheelchair loans. These include Age UK, Shopmobility, St John Ambulance and Disability Action. 2 The other items were predominantly commodes, but also included rollators, walking sticks and other mobility aids. 3 Internal data capture and reporting. 4 Including the rental costs of space from which we loan out wheelchairs. 2

What is short-term will be able to provide equipment to receive longer-term provision wheelchair loan and on a temporary loan” (National from the NHS. While some people why is it important? Wheelchair Managers Forum, borrow a wheelchair to facilitate 2013a). The guide advises people to their participation in social activities, contact their local NHS wheelchair such as attending events, groups service to be signposted to other and classes, the negative impact of “Not simply a piece of organisations that might be able to social isolation on physical health is 6 medical equipment, but provide short-term loans, citing the well proven and worth preventing. often essential to all Red Cross and St. John’s Ambulance By meeting the need for short-term aspects of a person’s life” as examples. The corresponding wheelchair loans, the Red Cross online version of Frequently Asked enables people with mobility issues to (NHSIQ, 2014: 37). Questions reiterates this advice, with be discharged from hospital; maintain the additional suggestion to “try these their independence at home; attend links”, beneath which is a single link hospital appointments, school or According to NHS best estimates, to the Red Cross independent living work; maintain their dignity at the there are 1.2 million wheelchair users page (National Wheelchair Managers end of life; and participate in family in the UK, two-thirds of whom use Forum, 2013b). and social activities from which their wheelchairs regularly (NHSIQ, While ‘short-term’ is generally used they would otherwise be excluded 5 2014). Wheelchairs are recognised to refer to a period of six months or (Gardiner and Kutchinsky, 2013). by the NHS to be “not simply a piece less, the distinction between short- of medical equipment, but often term and long-term provision is In addition to the challenge of essential to all aspects of a person’s blurred and contentious, providing accessing short-term wheelchair life” (NHSIQ, 2014: 37). The NHS another barrier to provision. As provision highlighted above, the makes a distinction between short- identified in the Red Cross report NHS E-digest further identifies eight term and longer-term provision of by Gardner and Kutchinsky (2013), issues around the acquisition of wheelchairs. ‘Short-term’ is generally A Prisoner at Home, and despite wheelchairs for longer-term use. Two used to refer to a period of six months recognition by the NHS that a of these are especially relevant to or less. NHS wheelchair services wheelchair is “not simply a piece considerations around short-term are focused primarily on longer-term of medical equipment, but is often wheelchair provision: “unacceptable provision: “wheelchair services are essential to all aspects of a person’s waiting times for assessment and available to people of all ages who life” (NHSIQ, 2014: 37), short-term repairs” and “need for consistently have a long-term need for mobility wheelchair use is associated with applied eligibility criteria” (NHSIQ, help” (NHS, 2015). Local eligibility meeting social needs. The report 2014). The former is relevant criteria and thresholds for longer-term includes findings from a Red because unacceptable waiting provision can “vary depending on Cross survey of NHS wheelchair times for long-term wheelchair where [one lives]” (NHS, 2015). service managers. The majority of loans create demand for short- managers reported the main reason term loans. The latter is important Individuals can apply to the NHS because, in most areas, eligibility for short-term wheelchair loans for short-term wheelchair loans not criteria do not incorporate short-term after being discharged from being provided by the NHS is that needs, resulting in patchy provision hospital following, for example, an short-term need is a social need, and variation in the corresponding accident or injury. However, a study rather than a clinical one (Gardiner entitlements of individuals. conducted by the Red Cross found and Kutchinsky, 2013). The NHS is that 127 out of 151 NHS wheelchair unambiguous that the “wheelchair Although the Red Cross loaned services would not provide a service will not provide a wheelchair 83,000 wheelchairs last year, we wheelchair for short-term use. if it is only required for day trips or know that there remains unmet need Those that did provide short-term outings” (NHS, 2015). for short-term wheelchair loans, wheelchair loans almost always did Yet the majority of people who particularly in London, where there so in instances of terminal illness use the Red Cross wheelchair is currently no Red Cross wheelchair 7 (Gardiner and Kutchinsky, 2013). loan service are referred by health service provision. In A Guide to NHS Wheelchair professionals (hospital staff, 6 A Brigham Young University study found “that Services, the NHS recognises that “it therapists and GPs) for reasons such individuals who were socially isolated, lonely or as recovering from fractured limbs, living alone at study initiation were more likely is unlikely an NHS Wheelchair Service to be deceased at the follow-up, regardless the fluctuation or deterioration of of participants’ age or socioeconomic status, long-term conditions, and end-of- length of the follow-up, and type of covariates 5 The British Red Cross has previously identified accounted for in the adjusted models” (Holt- that this figure was a result of 91 completed life needs (Gardiner and Kutchinsky, Lunstad, et al., 2015: 233). The same authors questionnaires conducted by the NHS 2013), as well as associated reasons identify that substantial research “has also Purchasing and Supplies Agency 14 years ago. elucidated the psychological, behavioural and Consequently, the data is insufficiently robust such as attending appointments biological pathways by which social isolation to provide an accurate estimate and the actual for those with limited mobility. and loneliness lead to poorer health and figure is likely to have changed with an annual decreased longevity” (ibid: 235). population growth of 0.8%, improved neonatal Some of the people who use our 7 We plan to reintroduce a mobility aids service care and increased life expectancy (Gardiner wheelchair loan service are waiting in London in 2016, or – if funds permit – late in and Kutchinsky, 2013: 6). 2015. 3

Policy context Section 3 of the same Act provides (f) such other services or In England, there is no clearly more ambiguous language within facilities as are required for defined duty for statutory provision which short-term wheelchair the diagnosis and treatment of short-term wheelchair loans. Yet provision may fit. The Section of illness.” the policy and legislative framework holds that the Secretary of State “Illness” is understood as: “includes is focused strongly on promoting the “must provide…to such extent as mental disorder within the meaning wellbeing of individuals, achieved he considers necessary to meet of the Mental Health Act 1983 through integration of services all reasonable requirements… (c. 20) and any injury or disability and prioritisation of preventing such other services or facilities for requiring medical or dental treatment and reducing need in order to the prevention of illness, the care or nursing” (NHS Act, 2006: 275). prevent, reduce and delay any loss of persons suffering from illness A “disabled person” refers to “a of independence. This resonates and the after-care of persons person who has a physical or mental with recognition by the NHS that who have suffered from illness impairment which has a substantial wheelchairs aren’t just a piece of as he considers are appropriate and long-term adverse effect on his equipment (NHSIQ, 2014: 37). as part of the health service” ability to carry out normal day-to- (NHS Act, 2006: 2). This language day activities or who has such other In this section of the report we lends itself to the experiences of disability as may be prescribed” discuss policy considerations individuals who require short-term (NHS Act, 2006: 256). This definition relating to wheelchair provision wheelchairs, but does not explicitly seems to incorporate a person with 8 within England. We examine include them. In particular, they a long-term condition – such as the provision of short-term may be recovering from an illness Parkinson’s, asthma, diabetes or wheelchair loans within relevant or ailment for which short-term multiple sclerosis – but, elsewhere policy and legislation, focusing use of a wheelchair is an essential within NHS literature, having a long- on the ambiguity of statutory part of their after-care, as well term condition is considered to be responsibilities to provide short- as preventing further injury or quite distinct from being a disabled term wheelchair loans. And we deterioration of health. person. Indeed, having a long-term consider key policy drivers within While Section 3 of the NHS Act condition is identified as being a the health and social care systems, 2006 empowered the Secretary of potential cause of disability, rather exploring the opportunities these State to act through the NHS, the than the two being synonymous or present for change. Health and Social Care Act 2012 the former incorporated within the Policy landscape amended this, placing the duty to latter (NHS, undated). The National Health Service Act meet all reasonable requirements The NHS’s lack of clarity as to the 2006 refers to wheelchairs in upon clinical commissioning interpretation of “frailty” poses further Section 5 (schedule 1), stipulating groups (CCGs). CCGs, while ambiguity with regard to whom the that the Secretary of State overseen by NHS England (“the CCGs’ duties extend. Professor John “may provide vehicles (including NHS Commissioning Board” Young, NHS England’s Director for wheelchairs) for persons appearing within legislation), have significant Integration and Frail Elderly Care, to him to be persons who have a devolved powers. In particular, the argues: “we must recognise frailty physical impairment which has a amendments made by Section 13 as a long-term condition”, reasoning substantial and long-term adverse of the 2012 Act to Section 3 of the that: “frailty behaves just like a long- effect on their ability to carry 2006 Act provide that: term condition. It is progressive, it out normal day-to-day activities” 1. “A clinical commissioning group impacts adversely on life experience (179; italics added). This explicitly must arrange for the provision of and – if unmanaged – it can cause excludes short-term wheelchair the following to such extent as the sufferer to become very sick, very provision. it considers necessary to meet quickly” (Young, 2014). However, this the reasonable requirements interpretation does not seem to have 8 Information about the policy context within of the persons for whom it has been adopted formally within the Scotland is available within the British Red responsibility: NHS. Cross report Making a move: increasing choice and independence for people with short-term mobility needs, which is available … As in the 2006 Act, the duty to online: http://www.redcross.org.uk/~/media/ provide a wheelchair for short-term BritishRedCross/Documents/About%20us/ (e) such other services or Scotland%20mobility%20aids%20report.pdf facilities for the prevention of use is ambiguous in the 2012 Act. Information about the policy context within CCGs need only meet “reasonable Wales is available within the National Assembly illness, the care of persons requirements” in providing services; for Wales Health and Social Care Committee suffering from illness and the report Wheelchair services in Wales: follow-up the terms of which are not defined inquiry, which is available online: http://www. after-care of persons who and are therefore susceptible to assembly.wales/Laid%20Documents/CR- have suffered from illness LD9028%20-%20Health%20and%20Social%20 inconsistent interpretation, or, as is Care%20Committee%20Report%20on%20 as the group considers are presently the case, are interpreted Wheelchair%20Services%20in%20Wales%20 appropriate as part of the Follow-up%20Inquiry%20-13082012-237712/ by the NHS to preclude short-term cr-ld9028-English.pdf health service, wheelchair provision. 4

Most recently, throughout the Care that is written into primary legislation “the Act…signifies a shift Bill debate in 2013, wheelchairs were – resonates with the NHS’s from existing duties on discussed on only four occasions, recognition that a wheelchair is “not local authorities to provide each time within the House of simply a piece of medical equipment, particular services, to the Lords, and on only one of these four but often essential to all aspects of a occasions were wheelchair services person’s life” (NHSIQ, 2014: 37): concept of ‘meeting needs’ referenced and identified as requiring 2. “Wellbeing [refers to:] (set out in sections 8 and improvement (HL Deb, 2013-14: 745 18–20 of the Act). This is col. 818). The Care Act 2014 itself does (a) personal dignity (including the core legal entitlement not discuss wheelchairs; however the treatment of the individual for adults to care and statutory guidance recognises the with respect); support, establishing one provision of short-term wheelchair (b) physical and mental health loans as an example of a secondary and emotional wellbeing; clear and consistent set preventative service (Department of duties and power for all of Health, DH, 2014a: 9). This (c) protection from abuse and people who need care and acknowledges the preventative value neglect; support.” of short-term wheelchair loans, but (d) control by the individual over does not create a duty to provide them day-to-day life (including or an entitlement to receive them. over care and support, or According to a legal analysis Currently, the two most significant support, provided to the commissioned by the Red Cross sources of health and social care individual and the way in 9 policy are the Care Act 2014 and its which it is provided); (Knight, 2014), the responsibility of local authorities to provide supporting guidance, and the NHS (e) participation in work, wheelchairs also lacks clarity. Where Five Year Forward View (5YFV; NHS, education, training or an individual is “substantially and 2014). The former represents the recreation; permanently disabled”, under the largest and most comprehensive National Assistance Act 1948 (section transformation of adult social care (f) social and economic 29(1)), a local authority is obliged since 1948; the latter presents a wellbeing; to provide welfare services in order compelling vision of NHS reform. (g) domestic, family and to meet the individual’s needs, The Care Act and the 5YFV share a personal relationships; including through the provision of number of priorities that make this an “practical assistance for that person opportune time for local authorities, (h) the individual’s contribution to in his home” or “the provision of the NHS and the voluntary sector society” (Care Act, 2014: 1). any additional facilities designed to to work together to ‘put the wheels The 5YFV identifies promoting secure his greater safety, comfort or in motion’ and deliver this report’s wellbeing and preventing ill health convenience”, as found in sections recommendations (see Section 4). as the main goals of the NHS 2(1)(a) and (e) of the Chronically Sick These shared priorities of wellbeing, and Disabled Persons Act 1970. integration and prevention are However, because most people who explored below. need short-term wheelchair loan Wellbeing “The concept of ‘meeting will not conform to these stringent The Care Act 2014 reframes the social needs’ recognises that criteria, local authorities, according care responsibilities and activities of everyone’s needs are to the 1970 Act, will not be obliged to local authorities within the concept of different and personal to provide one. promoting individual wellbeing (Care them. Local authorities While there are many powers Act, 2014: 1). The statutory guidance must consider how to that might be said to enable a is clear that “the core purpose of meet each person’s local authority to make short-term adult care and support is to help specific needs rather wheelchair loan available (Section 29 people to achieve the outcomes that than simply considering of the 1948 Act and Section 45 of matter to them in their life…local what service they will fit the Health Service and Public Health authorities must promote wellbeing Act, 1968, in relation to older people; when carrying out any of their care into. The concept…also and Section 3 of the Carers (Equal and support functions in respect of recognises that modern 10 Opportunities) Act 2004 ) there is no a person (DH, 2014a: 1; bold and care and support can be statutory duty requiring them to do so underline in the original). provided in any number (Knight, 2014). Despite short-term wheelchair loans of ways, with new models 9 Prior to the Care Act coming into force on 1st being omitted from the legislation, emerging all the time….” April 2015. the Care Act’s new framework of (DH 2014a: 2). 10 This duty might require a local authority to promoting individual wellbeing – request a wheelchair is provided to a disabled including the definition of ‘wellbeing’ person to ease the burden on a carer. 5

(NHS, 2014: 2). It recognises that The 5YFV proposes a set of The intention to integrate services local authorities are increasingly priorities to enhance prevention. is not just a policy objective shared working together to drive health and One such priority focuses on by the Care Act and 5YFV; it is wellbeing, and that the NHS can play “local democratic leadership on being put into practice around the its part in this through local Health public health” (NHS, 2014: 10). country. Greater Manchester is one 11 and Wellbeing Boards (HWBs). Specifically, by participating in local such example (or ‘vanguard site’ to HWBs, the NHS will play a part in use the NHS term) where the triple initiatives contingent on integrated integration ambition could become “as we think about the services and the realisation of a reality through a radical new changing needs and local-level priorities that necessarily model of a single integrated health preferences of the people incorporate considerations around and social care budget. Ten local we are here to serve, we wellbeing. This integrative approach authorities, the 12 CCGs for Greater is reflected in the Care Act 2014, Manchester and NHS England need to have integration which states that a local authority are working together to “devolve between primary and “must co-operate with each of its responsibility for the health and specialist services, we need relevant partners, and each relevant social care budget to a new Greater to have integration between partner must co-operate with the Manchester partnership” (LGA, physical and mental health authority, in exercise of…their 2015). This partnership will oversee services, and we need respective function relating to adults a £6 million budget from April 2016, with needs for care and support” which will be used to improve to have more integration (Care Act, 2014: 6). services, and health and wellbeing between health and social Integration outcomes. care services; that is the The Care Act’s ‘new models’ Prevention triple integration agenda include approaches towards The Care Act 2014 places a new that we are pursuing” (The greater integration of services. As duty of prevention onto local King’s Fund, 2015). the guidance explains, “the vision authorities: is for integrated care and support 1. “A local authority must provide [to be] person-centred, tailored to or arrange for the provision of HWBs were established through the needs and preferences of those services, facilities or resources, the Health and Social Care Act, needing care and support, carers or take steps, which it considers 2012. They are intended to act as a and families” (DH, 2014a: 281). will – forum where leaders from the health Integration encompasses health and care sector work together to and health-related services, as (a) contribute towards improve the health and wellbeing of well as achieving parity of esteem preventing or delaying the their local population and to reduce for mental and physical health, development by adults in its health inequalities. and integrating the corresponding area of needs for care and services in order to treat, care support; According to the 2012 Act, a HWB for and support the ‘whole (b) contribute towards must “for the purpose of advancing person’. Integration is recognised preventing or delaying the the health and wellbeing of the within the statutory guidance to development by carers in its people in its area, encourage… be dependent upon enhanced area of needs for support; the provision of any health or social cooperation between local care services…in an integrated authorities and partners, including (c) reduce the needs for care manner” (201). Through HWBs, local the NHS and CCGs. and support of adults in its authorities and CCGs undertake area; Joint Strategic Needs Assessments Simon Stevens, Chief Executive (d) reduce the needs for support 12 (JSNAs) and develop a Joint of NHS England, has extolled of carers in its area.” Health and Wellbeing Strategy to the “triple integration agenda” of best address these needs. This the 5YFV: “as we think about the The Red Cross advocated strongly includes making recommendations changing needs and preferences of for prevention to be not only included for joint commissioning and the people we are here to serve, we in the Care Act, but also defined. We integration of services across health need to have integration between were successful, with three equally and care. primary and specialist services, important forms of prevention being we need to have integration written into the statutory guidance. between physical and mental health The 5YFV does not share the Care 11 Providing a framework for reciprocity, Sections services, and we need to have 14Z11 and 14Z13 of the Health and Social Care Act’s recognition that prevention is Act 2012 indicate how HWBs participate in the more integration between health a continuum: across the life course; development of CCGs’ annual plans. and social care services; that is the 12 JSNA is a process that assesses and maps across the pathology of a long- the needs and demand for health and care triple integration agenda that we are term condition; and across physical and support. This information should feed into pursuing” (The King’s Fund, 2015). the board’s development of joint Health and health, mental health and emotional Wellbeing Strategies. 6

The Care Act definition of ‘triple wellbeing. The 5YFV makes little, if incorporated the continuum of prevention’: any, reference to tertiary prevention primary, secondary and tertiary PREVENT: primary and only limited reference to prevention, but all bar one of the prevention/promoting secondary; much of its emphasis is studied Strategies mentioned wellbeing on primary prevention with the initial prevention (Field, 2014). focus of delivered action being the Opportunities for Primary prevention is aimed at introduction of a nationwide diabetes people who have no particular prevention programme. It does, change health or care and support however, state the commitment that Local authorities and the NHS share needs. The intention is to help a the NHS is “getting serious about the priorities of meeting needs person avoid developing needs prevention” (NHS, 2014: 9). within the context of promoting for care and support, or help a individual wellbeing, integrating carer avoid developing support Despite little, if any, incorporation of services, and preventing, reducing needs. It includes universal tertiary prevention within the 5YFV, and delaying need in order to policies like health promotion, according to its Mandate, one of minimise the loss of independence. first aid learning and universal the responsibilities of the NHS is to The case studies in the next section services like community activities help people recover from episodes of this report demonstrate that that prevent social isolation. of ill-health. The Mandate goes on short-term wheelchair loans can REDUCE: secondary to explain that recovery is achieved promote individual wellbeing, with prevention/early intervention “through effective treatment but also some of those interviewed stating through on-going help in recovering that the loan was essential to their Secondary prevention is more quickly and regaining independence” wellbeing. The preventative value targeted. Interventions are aimed (DH, 2014b: 15). The combination of short-term wheelchair loans is at people who have an increased of the 5YFV’s recognition of primary also demonstrated within the report risk of developing health or and secondary preventative findings; not only with regard to care and support needs, or at approaches, plus the Mandate’s individuals and their families, but carers with an increased risk of recognition of tertiary preventative also with regard to associated cost developing support needs. The approaches, demonstrates that the savings. goal is to help slow down or NHS commitment to “get serious reduce any further deterioration, on prevention” is in parallel with the The current landscape is one of to prevent further needs from 2014 Care Act’s new duty on local health and social care planning, as developing, and to prevent a authorities to do the same. well as commissioning intentions crisis occurring. Secondary HWBs – in which local authorities being integrated through HWBs. prevention includes short-term and the NHS come together locally New integrated models of care, provision of wheelchairs, – recognise prevention as a key underpinned by single, integrated handyman services, “social driver for planning, commissioning budgets, are emerging through prescribing” services and and provision of services. Research initiatives such as the Greater telecare. conducted by the Red Cross in Manchester devolution. The DELAY: tertiary prevention 2014 showed that, among 138 integration ambition is increasingly HWBs studied, the majority of being realised, and this landscape Tertiary prevention is aimed at their Joint Health and Wellbeing affords us a new opportunity to minimising the effect of disability Strategies put an emphasis on ensure that everyone who needs or deterioration for people with prevention. There was variation as short-term use of a wheelchair can established or complex health to the extent to which the Strategies get one. conditions. The goal is to support people to regain confidence and skills, and to manage or reduce need, where possible. For people who have already reached the point of crisis, the goal is also to prevent this recurring. Tertiary prevention includes reablement, rehabilitation and bed-based intermediate care. (DH, 2014a: 7–12, bold added) 7

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2 Methods Research aims and Identification and methods selection of case study The aims of the research were participants to gain insight into how service Potential case study participants users perceive the impact of their were recruited via a two-stage short-term wheelchair loan on process: a) identification of themselves, their families, friends geographic area (study site), and b) or carers and, based on this data, selection of potential participants to calculate the economic impact within that area. of the Red Cross short-term wheelchair loan service in terms of Five areas across England were the logical cost savings to health selected as case study sites. or social care services in those This fulfilled the need to have cases. representation from rural and urban The research aims were areas. These areas had higher levels achieved through a mixed of wheelchair loan to provide a wide method design, which used case sample base. studies to provide information Key staff at the selected sites were for the economic evaluation, contacted and worked with to help and interviews with health care identify potential participants who professionals to validate the had some key characteristics: assumptions made during the > they had loaned a wheelchair economic evaluation. within the last 12 months and for less than six months in total (short-term) 9

> they represented a range of of existing services (e.g. visits > reduced or prevented the need needs, including medical, social to hospital), the impact of these for residential care. and those not easily fitting a changes (e.g. not needing a taxi) and clearly distinct medical or social any changes in non-service-specific The economic evaluation did not need activities (e.g. reduced isolation). use a societal perspective – not all savings to service users and their > some were waiting for long-term Health care families are included (such as taxis) provision professional interviews – however, where consequences on > they comprised a range of ages income were present, these were and ethnicities. Interviews with a number of health noted and presented distinctly. care professionals (HCPs) validated Once a long list was identified, the assumptions underlying the The identified outcomes were costed screening interviews were conducted economic evaluation. Since the using the standard tariffs devised with the potential participants to primary aim was to avoid asking by the Personal Social Services discuss their situation further, verify the HCP to comment directly on a Research Unit (PSSRU, 2014) the fulfilment of criteria and ascertain patient known to them, vignettes and NHS National Tariff prices for whether they would consent to were created based on anonymous 2014/15 (Monitor and NHS England, the research. (See Appendix A for situations, as identified in the case 2013), which are accepted widely details on the numbers selected studies. These were presented to across the health care professions. and Appendix B for the screening the HCPs and they were asked to Further definitions for the analysis interview schedule). comment on the relative impact of can be found in Appendix E. Health care professional interviewees the wheelchair in those scenarios. Following identification of the were sought from a range of (See Appendix D for the interview outcomes, we adopted a simple professions (including medical, schedule). decision analytic model, using the nursing, occupational therapy Of the six HCPs identified across service user’s own perspective to and social work). This range was key regions where the service user examine the alternative journey of the mapped against the outcomes of the case studies were based, three service user if the wheelchair had service user interviews. were interviewed (two occupational not been available and the reported therapists and one nurse). outcomes had not been achieved. Case studies Costs were modelled for the 13 Analysis timescale of the wheelchair loan and Nine case studies were conducted, which comprised semi-structured The economic evaluation focused projected only when the service user interviews with individuals who on self-reported outcomes from the indicated a consequence due to not had loaned a wheelchair from the service user and/or their carer/family having a wheelchair (e.g. needing Red Cross on a short-term basis. member. In addition to the case longer to recover). (See Appendix C for the interview studies, interviews with health care schedule). providers validated the logic of the Four of the interviews included calculations and assumptions made questioning an accompanying family in the analysis. member alongside the wheelchair Analysis was based primarily on the user, three interviews involved only identification of outcomes specific the user, and for one interview only to health and social care savings. 14 the carer was present. These specific outcomes were: The interviews sought to understand > reduced or prevented the perspectives of the wheelchair unnecessary GP attendance users, family members and carers regarding the short-term wheelchair > reduced or prevented attendance loan service, including the effect at A&E of the service on the users’ health, > reduced or prevented admission lifestyle and the type of care they from A&E needed; and what they think would have happened if the service had not > reduced or prevented ambulance been available. use The participants’ responses were > reduced or prevented hospital then analysed to identify reported attendance, admission or outcomes, such as changes (or re-admission projected changes) in the use > reduced or prevented the need 13 Eight face-to-face and one via telephone. for on-going care and support 14 In one case the user had recently died. 10

3 Case studies This section presents the case study Although one case study was data. It illustrates various reasons for conducted without the wheelchair needing short-term wheelchair loan user, demographic data was and the impact of this service on both collected for all wheelchair users. the wheelchair user and their family They comprised seven females and carers. and two males. The age range of The case studies are presented participants was six to 93 years individually and include statements old, with an even distribution of age 15 from HCPs, where relevant, to groups. support the position and perception Seven of the nine wheelchair of the wheelchair user. They also users reported themselves as include an economic evaluation White British; one as White or for each case study, documenting Black Caribbean; and one as savings across health and social care, Pakistani ethnicity. Three of the nine and personal savings, where relevant. service users in the case studies The section concludes with a were registered disabled. Their summary of key findings, which occupational status also varied highlights common themes across and included retired, in education, the case studies and HCP interviews. employed and unemployed. Nine case studies and three HCP interviews were conducted for this 15 16–24 n=2; 25–34 n=1; 35–44 n=1; 45–54 n=2; research. 65–70 n=1; the oldest two respondents were aged 89 and 93. 11

If Ron and his family had not been able to Ronald, use the Red Cross wheelchair, he would have missed out on the final South Yorkshire NVA 70th Anniversary commemorations in France and Armistice commemorations in London. Being able to participate boosted Ron’s emotional state th Ronald (Ron) is a 93-year-old of walking involved in the 70 and reduced his level of World War Two veteran. He lives in Anniversary Normandy celebrations, isolation during recovery. sheltered housing and receives daily but it was unthinkable that he would When he was hospitalised support visits from his daughter, not attend as the NVA was being before the November Pam, and son, David, as he is very disbanded at the end of 2014. This frail. In the early 1980s he became was the last opportunity for Ron to commemorations in active in the Normandy Veterans visit the beaches and cemeteries London, knowing that Association (NVA), organising and of Normandy and to remember his he might be able to attending several trips to Normandy, fallen comrades. After the summer attend with the aid of the th th th including the 40 , 50 and 60 events, Ron became ill and had wheelchair motivated his commemorations of the Normandy to stay in hospital for two weeks. improved rate of recovery Landings. He rallied with the thought that he In 2014, the family realised that Ron could use a wheelchair to attend the during and after hospital would need a wheelchair since he November remembrance events in rehabilitation. would struggle with the amount London. 12

Impact of our wheelchair loan Economic resource savings Pam found out about the Red Cross condition would have relapsed or £1,404 short-term wheelchair loan service worsened, requiring re-admittance through internet research, which to hospital. The wheelchair also gave Reduced rehabilitation time in was a great relief to her. Having the them peace of mind in case of such hospital by half a week through chair meant the family could take an emergency. boosting Ron’s recovery = Ron to Normandy in June 2014. Pam felt that the trip to London They borrowed the wheelchair for in November played an important £486 resource savings a week, during which he attended part in her father’s recovery after a for NHS hospital-based the main remembrance ceremony period of being really low. She felt rehabilitation care service and visited several cemeteries and strongly that he would have needed (based on £973 average weekly cost of beaches to pay his respects to those a longer stay in rehabilitation without bed in hospital-based rehabilitation care; who had sacrificed their lives. Ron PSSRU, 2014) said: “It was the answer, because it. “It made a massive amount it was heavyweight and it could go of difference to his recovery – it anywhere, we weren’t restricted...I boosted him up and meant so much Improved recovery helped to couldn’t have done it without the to him to be there, especially when avoid likely early relapse and chair – it was an opportunity not to the Normandy Veterans were asked re-admission to hospital for be missed.” that Sunday morning to lead off the further tests and observations 16 parade. It was quite an emotional for a minimum five days = The family asked to borrow a Red time for them all, but uplifting as £685 resource savings for Cross wheelchair again in November well. …It made a real difference to 2014, so Ron could attend the his recovery, considering how poorly NHS hospital day care/palliative Festival of Remembrance at the he had been; he was in his element service Albert Hall and the remembrance – waving to the crowds as they (based on £137 cost per bed day, which is ceremony and parade to mark 70 were clapping and cheering for the a combined national average of inpatient hospital specialist palliative care for adults years since the Armistice. Just veterans.” £117 and inpatient day care for elderly before this, Ron was hospitalised for patients £157; PSSRU, 2014) two weeks as he had become very As a veteran of those historic run down and he was unable to eat wartime events, it has been properly. A big motivating factor that important for Ron to remember £233 resource savings for helped him to rally and recover was his comrades and to promote the NHS ambulance service the plan to attend the November significance of these events to future (ambulance service: see, treat and convey, Festival of Remembrance, if he could generations. Ron and his family cost per incident; PSSRU, 2014) be sufficiently mobile and the family found the Red Cross wheelchair could help him get around. service to be “an invaluable service… In terms of our experience Without the chair, Ron and his it would have been impossible to do family would not have been able to those once-in-a-lifetime things… I attend these events. Pam said that don’t think people realise how much if they had been unable to go, her it means.” dad “would have been extremely disappointed to say the least … For us it would have been heart-breaking not to have been able to take him… we couldn’t have considered it without the wheelchair and it would have been very upsetting and distressing knowing that.” When Ron returned from the Armistice weekend, he went into 16 Based on Ron’s recent four-week admission, this is felt to be a reasonable rehabilitation for four weeks before attributable minimum number of days, being discharged home. The family when in reality the period as inpatient is likely to be much longer (other factors will kept the wheelchair so Ron could have contributed). Note this value aims attend family outings. They feared to reflect the avoided costs falling within a quarter of a year – i.e. no re-admission that, without the wheelchair, Ron’s within the period to March 2015, to better align with the service user’s condition. 13

Sameena is a mother and home- maker. She has three children, including a baby girl who she is still nursing. She is registered disabled due to muscular dystrophy, a progressive condition that gradually Sameena, causes the muscles to weaken. In January 2015, Sameena fell at * home and broke her ankle. She was Nottinghamshire in a plaster cast for five weeks and unable to bear weight on her ankle for several more weeks after the cast was removed. The hospital only allowed Sameena home because her mother was able to look after her and the baby for two weeks after discharge, and because she has her own transit wheelchair. This type of wheelchair requires someone to push the occupant, as it is not self-propelling. Social care was provided, with two short visits a day from carers to help with personal care and meals. After two weeks, however, Sameena’s mother had to return home to care for her frail and ill father; they live over 100 miles away. This meant Sameena’s husband had to go to half-time working for a week, and Sameena and her husband feel this did not go down well with his employer. Sameena’s mother was able to help out for only the first two weeks of Sameena’s recovery. After this, Sameena’s husband worked half-time for one week. Sameena had carers during this time and also for the following three weeks. During the latter three weeks she had to be on her own at home more with her baby, and she would have required a much higher level of support from her carers had she not been able to borrow the Red Cross wheelchair. * Not her real name. 14

Impact of our wheelchair loan Economic resource savings When her mother left and her As one occupational therapist notes: £963 husband returned to full-time work, “it’s essential for day-to-day life Additional personal finance Sameena borrowed a self-propelled (during rehabilitation), getting out of savings wheelchair from the Red Cross. This the house, even just getting to the enabled her to move around her bathroom…potentially the wheelchair home and to look after her daughter is the key part of your rehabilitation £341 with the continued support of two process and it’s crucial that you need short visits a day from her carers. She that equipment.” would otherwise have needed a more Sameena and her whole family have Avoiding at least one ambulance substantial level of support. benefitted from a very real sense of call out for a scheduled hospital “At least I can move from one side of being able to maintain mobility and appointment = the room to the other and if she [baby] quality of life through the Red Cross £233 resource savings for has dropped a toy I can pick it up…. It short-term wheelchair loan. She NHS ambulance service per has given me more independence in would have missed out on some incidence the house,” she said. key parts of her children’s lives, had (based on £233 per incidence of ambulance she not been able to go and show call out: see, treat and convey cost per Without the Red Cross wheelchair, incident; PSSRU, 2014) Sameena and her daughter would her support at her 11-year old son’s have needed almost constant school ‘graduation’ ceremony. This, support from care services, as there in her words, “would have been Avoiding 2 x home calls from would have been concerns for her very devastating. It was a very nice the GP for her sick daughter = and her baby’s wellbeing in this moment and it would have been quite Approximately £110 situation. Sameena could not have upsetting if I hadn’t been there.” got herself off her bed, fully attended Sameena summed up the difference resource savings for local GP or to her baby daughter, moved to the that the chair has made for her as clinic (based on GP cost per hour = £146, and bathroom or helped with meals. follows: “It has made a big difference assuming 11.4 minute average visit time plus She would have required a further to my overall view of that period (her 12 minute average travel time = GP cost £55 increase in her care package and/or recovery) and the emotional feelings. per visit or a health visitor = £51 per visit; PSSRU, 2014) her husband would have had to take I knew that once I had it, if I had to go even more time off work, which would somewhere, I wouldn’t have to rely Faster recovery by one week, have put his employment at risk. on others all the time…I had some plus avoiding three weeks of Because Sameena was able to push independence back. I do try and get home care at a “substantial” herself short distances with the Red out regularly even if I am not feeling level of support = Cross wheelchair, her husband was 100 per cent – for me to not get out able to accompany her to follow-up for weeks would be quite dreadful Total £620 resource hospital appointments and doctors’ really.” savings for social care services appointments for the children, while (based on the difference between £280 per pushing the baby in her buggy. week home care cost “substantial” level, and Sameena feels that the chair helped £125 per week “moderate” level; PSSRU, 2014) her to recover more quickly than she would have done otherwise. Six Additional three weeks half- weeks after the accident, she no time off work for her husband = longer needed the carers, but she thinks she would have needed their £341 immediate loss of support for at least an additional family income week if she had to manage without (at minimum wage £6.50 per hour and the Red Cross chair. assuming 35-hour week. However the real cost could have been higher if Sameena’s husband had lost his job, which was a likely outcome) 15

Ashleigh is 27 years old and in her third year of nursing training, which involves working at her local hospital. It is a highly demanding and intensive course. Ashleigh had an accident in January 2015 while walking her dog, when she broke her ankle badly. After a week in a cast, Ashleigh’s ankle was operated on. She was then unable to bear weight for two weeks, and had a total of six weeks in plaster. The hospital provided crutches but nobody mentioned a wheelchair loan to support her mobility during recovery. So it was unclear how Ashleigh and her partner were going to cope in terms of keeping her mobile and attending her studies, especially in a rural area where there are long distances to travel. Fortunately, around the time of her operation, Ashleigh found out from a neighbour about the Red Cross wheelchair loan and her partner visited the local Red Cross distribution centre to obtain one. Without the wheelchair, it is clear that there would have been higher economic costs to hospital services as a result of Ashleigh having to stay a night and day longer in hospital before discharge (after her operation), the likelihood of another fall and subsequent micro- fractures to her ankle, and associated ambulance call out. However, in addition to the positive social impact on her emotional and mental wellbeing that the wheelchair supported, Ashleigh, Ashleigh has been able to avoid significant personal financial costs to her and Cornwall her partner. Not having a wheelchair would have meant having to postpone and re-sit her final year of nursing qualifications. 16

Impact of our wheelchair loan Economic resource savings The wheelchair helped Ashleigh As a student nurse, Ashleigh was £831 return to university quicker. As a also aware of the consequences for Additional personal finance result of the accident, she missed her health and wellbeing if she lost savings four weeks at the start of the her independence. She feels strongly year and three weeks of practice. that the wheelchair was essential to Ashleigh was desperate to not miss help her get out of the house and £21,750 any more time because teaching feel less isolated. “If I didn’t have my regulations and accreditation wheelchair and just had crutches, requirements would force her to quit I would have done myself serious Avoided an extra night and day the third year and start again, re- damage [due to weight-bearing] in hospital = sitting exams the following academic and ended back in A&E and caused £469 resource savings to year. This would have cost her and sustained damage to my ankle. her partner a great deal, financially Also, if I didn’t have the wheelchair I NHS hospital services and emotionally. would have been admitted into the (based on £3,283 average cost of elective inpatient episode, divided by 7 days, She said: “I would have been orthopaedic ward at least for one assuming one week long episode before extra day rather than get discharged discharge; PSSRU, 2014) devastated…I’m three weeks behind to go home.” all my other classmates, but any longer than that and I wouldn’t have Ashleigh says she would not have Avoiding ambulance call out been able to qualify in September… been able to buy her own wheelchair following a fall = Without the wheelchair, I wouldn’t if there was no loan service, but even £233 resource savings for have gone back to university until if the recovery time with crutches I was fully weight-bearing. I would was about the same, having the NHS ambulance service have been confined to my house wheelchair improved [her] quality (based on £233 per incidence of ambulance for seven weeks if not longer and of life tenfold and helped to avoid call out, see, treat and convey; PSSRU, 2014) would have had to defer my course complications. [This service] is for a year – it would have cost me an invaluable part of recovery. Avoiding attending A&E as an financially to re-sit some of the Without that added support, my outpatient following a fall = modules, about £1000–£2,000. We recovery wouldn’t have been as have to maintain 45 weeks on the straightforward. It’s quite easy to slip £129 resource savings course... Without the wheelchair I back into that negative state of mind for Accident and Emergency would have set myself back a year.” when even going to the toilet is a department In addition, without the wheelchair, struggle. [Having the wheelchair] has (based on NHS National Tariff of £129 per definitely benefitted my mental health A&E incidence with category 2 investigation Ashleigh’s partner would have which is very much understated in and category 3 treatment, i.e. plaster had to take more time off work to removal or application, bone fracture, etc.) care for her during recovery. Not physical recovery.” being able to go out to work for Finally, Ashleigh commented 17 six weeks meant they “would have that patients of her colleagues, Personal cost = been crippled financially and with especially occupational therapists £19,500 loss of one year just crutches I would have become and physiotherapists, would benefit of income really depressed… personally, I greatly from this service, especially (income net of tax and national insurance, as didn’t realise how much I liked my if the wheelchair loan could be a qualified hospital nurse, based on £25,744 independence until it [the accident] involved earlier in patient recovery average wage for hospital-based nursing staff, day ward or 24-hour; PSSRU, 2014) happened.” options. 18 Personal cost = £1,500 exam fee 19 Partner personal cost = 17 Cost of missing one year’s salary, having to unclear if learning support allowance would postpone third year of course and thereby be available in all such cases, as the learning £750 net salary delaying graduation and employment as a institution’s policy is that this would only relate to approximately nurse. a student’s accident/injury if it coincided with an (based on £17,344 average annual salary in 18 Cost of nursing exams re-sit, if she had been assessment deadline or an examination/test). forced to defer and re-sit the whole year (unless 19 Avoided loss of income (or paid holidays) net Cornwall divided by 52 weeks and pro-rated; learning support allowance is available for this of tax and national insurance, if partner had Office for National Statistics, Annual Survey circumstance, however this is at the discretion to spend half of the working week caring for of Hours and Earnings, 2014) of the learning institution. In addition, it is Ashleigh for the six-week period. 17

Melvyn is a single father in his mid- 50s. He has sole custody of his nine-year-old daughter. Melvyn had Melvyn, an accident, which left him with a broken bone in his right lower leg. He made a choice to forego emergency surgery to insert pins as he could not Dorset afford the time to stay in hospital for the extended recovery period, due to the vulnerability of his daughter. Melvyn and his daughter have no other relatives or family in their part of the country, and although he has acquaintances, these are not friends to whom he can trust his daughter’s welfare for extended periods. Melvyn felt compelled to avoid going into hospital for a long period, as this meant his daughter would have had to go into the care of social services temporarily. The wheelchair loan from the Red Cross meant that Melvyn could at least recover at home while retaining sufficient mobility to avoid his daughter going into temporary care and without being confined to the house. Without the option to use a Red Cross short-term wheelchair loan, Melvyn could not have decided to forego surgery to be able to stay at home, with a chance of his leg healing temporarily. He would not have been able to leave the house for at least six weeks and probably longer, and he would not have been in a fit state to ensure his daughter would not be socially isolated during a key part of her development, recovery and social re-integration. There is a risk that going into the care of social services would have had a very negative effect on his daughter’s wellbeing. 18

Impact of our wheelchair loan Economic resource savings Melvyn’s leg had to be in plaster If the operation to insert pins had £3,088 for at least six weeks. The hospital proceeded, Melvyn would have provided a special bed, chair and been in hospital for several days, Melvyn’s daughter avoided crutches so he could navigate his possibly spending over a week having to enter the temporary home, which has two flights of stairs. there, including the immediate care of children’s social Yet they did not provide a self- recovery period and time to prepare services for up to two weeks = propelled wheelchair. He was not for going home. According to a allowed to put any weight on the leg chart he viewed in the hospital, £1,400 resource savings and had to ensure the bone did not the recovery process following the for social services move, since this would cause a need operation would have taken a year (£700 per week unit cost of local authority for immediate surgery. – and without a wheelchair loan, his foster care and social service support for daughter would be housebound with children with emotional needs; PSSRU, At the time of the accident, Melvyn him when not at school. 2014) asked the hospital for a wheelchair, “so my daughter is not stuck at In an interview, an occupational Being able to avoid five days in home – if I’m stuck here, then she’s therapist agreed that, in a similar hospital for a surgical operation stuck here. But the hospital said scenario, the medical, social and (non-elective, without critical they don’t do wheelchairs. I was personal impacts could have been care) = surprised, I don’t quite understand very negative. “In the case where a why they can do all of the rest single parent suffers a bone fracture £1,688 resource savings but not the wheelchair...it’s half- but has a vulnerable dependent at for NHS term coming up, so without the home, not having a wheelchair loan NHS National Tariff prices for wheelchair, she would’ve had to stay could result in a rapid downward “Intermediate” foot procedure and five indoors, and cooped up for 10 days, spiral for both of them, and they (the days trim point, thereafter £235 per missing out on her tenpin bowling. parent) wouldn’t be able to have bed day) The NHS are great, but why aren’t gone home sooner – that means short-term wheelchairs part of it?” potentially longer stays in hospital It is assumed that Melvyn Melvyn greatly appreciates having or else other types of care, greater would still have required the the wheelchair, to get out and about. care package needed at home, in community bed, crutches and He feels he is more independent addition to the frustration of being similar equipment from the and that it has made a big difference stuck indoors, or stuck in a cycle of hospital even if he had had the to his capability and wellbeing. going from sofa to commode and if operation. “We’re much less isolated, and people are attempting manoeuvres, there’s less emotional strain on especially if they’re not supposed both of us... biggest impact would to be bearing weight, there is some be on my daughter, she now has risk of falls, and a knock-on effect on some freedom, time interacting with their rehabilitation.” friends, and learning to be around people. She doesn’t have to suffer when it’s not her fault.” Melvyn’s daughter has a very close relationship with her father, to the extent that she becomes very upset if Melvyn has to leave her (other than at school). It is likely that if Melvyn had to stay in hospital, she would have gone into temporary social services care, which would have been traumatising for her. Melvyn asked: “why isn’t the wheelchair included in the local authority’s support package if they don’t want to commit themselves to the cost of my daughter having to go to social services?” 19

Laura would not have been able to use her crutches safely in snowy and icy weather, risking a fall and further damage to her Laura, knee after her complex operation. She would not have been able to get to Nottinghamshire her hospital appointments in many cases and, without being able to access the right medical and physiotherapy support, her recovery would have taken longer and she would Laura is 20 years old and for the a scan, which revealed that her have had to arrange for last five years has struggled with cruciate ligaments were missing medical home visits when repeated dislocations of her knee, and other ligaments in her knee the bad weather stopped forcing her to manage with crutches were severely damaged. At the her getting to the local GP for six months at a time on two beginning of December 2014 she separate occasions. Laura feels had a long and complex operation clinic safely. In addition, it that if she had known about the to reconstruct her knee ligaments. is highly likely that if she Red Cross short-term wheelchair Laura is now taking a ‘recovery did not have a wheelchair loan service on those occasions, it gap year’ before taking up her to help her get around would have made a big difference place at Liverpool University. The and out of the house, she to her life, as she was completely occupational therapist at the hospital would have needed further dependent on relatives and friends told Laura about the Red Cross to get her out and around the house. short-term wheelchair loan service, support during the week When intensive physiotherapy failed and she has used it since her from a care worker. to solve the problem, Laura had discharge. 20

Impact of our wheelchair loan Economic resource savings Laura’s mother is a single parent and difference to her wellbeing, especially £1,586 has to work full-time to provide for the during Christmas and generally being household, which includes Laura’s able to see her family. Additional economic resource younger brother and baby sister. “For some service users, it’s savings = She is therefore seldom available to important for them to feel they can help Laura get out of the house or be mobile to get out and engage Approximately £165 to take her to her weekly hospital with the local community, do basic resource savings for local GP appointments. Their house is in things like do some shopping, and or clinic a cul-de-sac, 300 yards from the reduce their isolation, otherwise this (based on GP cost per hour = £146, and nearest road, and vehicle access is assuming 11.4 minute average visit time plus not as convenient as it could be. The has a knock on effect on their mental 12 minute average travel time = GP cost health and whole wellbeing,” said the £55 per visit. Or health visitor = £51 per visit; hospital provided Laura with crutches occupational therapist. PSSRU, 2014). but not a wheelchair. During the winter ice and snow, it was not safe to Laura says that without the Avoiding 2 x follow-up visits to use crutches and Laura and her mum wheelchair, life would have been: fracture clinic/physiotherapy = worried that she could fall and do “horrible…My mum would have had to further damage to her knee, requiring see me suffer even more...especially £870 resource savings for additional time in hospital. emotionally and socially.” Laura hospital service avoiding further The Red Cross wheelchair has been believes that without her wheelchair knee damage procedure critical to Laura’s recovery. It enables she would have made far less (NHS National Tariff prices for “minor” knee her to wheel herself to the kerb where progress in her recovery and would procedure and five days trim point) the local non-emergency transport have needed support during the week service provider picks her up for from a care worker. her appointments. Laura has had to Laura’s mother agrees it would have + £233 resource savings attend weekly follow-up appointments been hard for her personally to cope, for NHS ambulance service per at the fracture clinic and additional saying that: “not having the wheelchair incidence sessions for splint removals and would have been the straw that broke (based on £233 per incidence of ambulance MRI scans. From the second month the camel’s back. It would have tipped call out: see, treat and convey; PSSRU, of her recovery she has attended me, Laura or both of us over the edge 2014) appointments three times a week with – stress levels have been so high a physiotherapist at the hospital. She already that I have broken down at Avoiding 2 x follow-up visits to would not have been able to get to work a couple of times, so if I had had fracture clinic/physiotherapy = many of these appointments without to try and physically support Laura to the wheelchair. the car whenever we went out or she £218 resource savings for Laura also needed the wheelchair to couldn’t have gone out at all, it would NHS travel to her GP, as she is prescribed have been unbearable.” (based on £109 cost per outpatient incidence, weighted average of all patients; morphine for severe pain relief, which Laura posed an important final PSSRU, 2014) has to be monitored carefully. When question: “How does it make sense – she was first discharged, she also the NHS says you can’t bear weight Avoiding three weeks of home suffered digestive problems due to for three months, but we are going care worker = the morphine, resulting in acute pain to discharge you with crutches and and a visit to the out-of-hours service. not going to give you a wheelchair?… Approximately £100 Without the wheelchair she would and if you need a wheelchair you’ll resource savings to local have had to call for home visits. have to pay for it or hope you can authority The wheelchair has also been find a charity who will donate one to (Three weeks at 1.5 hours per week = £24 you? The Red Cross was the only per hour home care worker charged to important in reducing Laura’s social one where there wasn’t something social services; PSSRU, 2014) isolation. She has been able to go ridiculous you had to pay to hire – it shopping with her mum at weekends, was just a donation, what you could to the cinema and for a meal in town. afford – and being a student and out She has started to go to Bingo with of work, and my mum being a single a friend as: “it’s something that you parent, we couldn’t have afforded can do sitting down.” Although she anything else.” still feels quite isolated and frustrated that she cannot get out more, these expeditions have made a big 21

Impact of our wheelchair loan 20 It is early days in Holly’s recovery, but the family has already used the chair on several occasions: > to visit the local park and small animal centre > to visit a street food and music festival in the city centre > to return to the hospital for X-rays when Holly’s leg was hurting during the night > to visit her grandmother > to attend school two afternoons a week for the last two weeks of the Spring term. Amy explained: “this meant Holly Holly, got fresh air and that can help with sleeping. There was another little girl at the park who asked her mum why Holly was in a wheelchair, so Yorkshire Holly told her and it became this whole teaching session...it was good for Holly, because she was a bit up and down at the time, for her Holly is six years old and confidence.” was diagnosed in 2014 with Amy intends to use the chair to developmental dysplasia of both get Holly (and herself) out of the hips. This condition causes general house most days, as they feel looseness and instability in the Holly needs to have her it is important for them to avoid hip joints. It is more commonly becoming housebound and diagnosed in younger infants, when legs elevated and splayed isolated. She feels it makes this it can be corrected fairly easily with following her operations, kind of experience more visible surgery. Due to the relatively late and a wheelchair is an in the local community and thus diagnosis, Holly had to undergo essential part of her encourages a sense of community an urgent double hip operation physical and emotional support and acceptance, rather to stabilise both hips. This meant recovery. It prevents her than feelings of being stigmatised, Holly had to be in a cast with her which could have a detrimental legs splayed and supported for two family being housebound effect on Holly’s sense of wellbeing. months following each hip operation and transports her to the Amy feels having the wheelchair is – a total of nearly four months GP and hospital for follow- also benefitting her own wellbeing: altogether. up. Being housebound for “not being cooped up, and not Holly’s mum (Amy) has taken time off four months would have a being so isolated. It would be very from her part-time job as a midwife. serious effect on Holly’s easy to become quite lonely and, With the support of her partner social skills, confidence as a parent, it would be really and extended family, she is looking with other children and hard to watch Holly’s distress after Holly at home. Holly also has and frustration when she can’t Vitamin D deficiency, so needs to education. The wheelchair get out.” Without the wheelchair have access to sunlight on a regular helps her parents to cope loan, the family would likely have basis. The family found out about and avoids the distress needed extra emotional support the Red Cross short-term wheelchair and pain of an isolating to cope with four months of being loan service from the occupational and frustrating long housebound. therapist and physiotherapist during recovery period. Holly’s pre-operation appointment at Sheffield Children’s Hospital. 20 The interview took place after Holly’s first operation and before the second one. 22

Impact of our wheelchair loan Economic resource savings Amy feels that without the Holly agreed that using the £1,434 wheelchair, the family would have wheelchair to keep mobile was needed an ambulance service for essential: “it’s good so I can get out Avoiding call out of registered their return visit to the hospital and of the house. I’ve been to a kind ambulance with medically for the trips to and from the hospital of festival place with lots of music trained ambulance staff for for Holly’s second hip operation. In and to my granny’s, and to the park one return trip to hospital for addition, they would not be able to and the deers were getting really X-ray and one return trip for the get Holly to hospital in an emergency interested in my chair and they really second hip operation = or if a complication arose during liked me.” her recovery, e.g. infection. She is Amy says it is hard to imagine how £932 resource savings for also likely to need to see a doctor or the family would have coped without NHS ambulance service visit a local clinic if she is in pain or the Red Cross wheelchair: “It would (based on £233 per incidence of ambulance becomes ill. Without a wheelchair, have been really, really limiting… call out, see, treat and convey; PSSRU, this would require a home call by 2014) medical staff. it would have had big implications for Holly in terms of keeping up Avoiding home call by local The family feel strongly that the friendships. Recovery and health is a nurse or health visitor per hip wheelchair is assisting Holly’s holistic thing – it’s not just a physical operation, as a result of not recovery greatly, as it gets her out recovery.” being able to get Holly to local of the house, provides her with At one point, the family was told that clinic = opportunities to interact with other there was a waiting list for paediatric children and adults, and reduces her wheelchairs with 11 names on it. £102 resource savings for isolation from the normal activities This sent them into despair so Amy NHS/local clinic and experiences of a six-year-old. did some research on the internet. (based on 2 x home visits by health visitor = The chair has already enabled Holly Without the Red Cross loan, they £51 per visit; PSSRU, 2014) to attend school two afternoons say they would have had to buy a a week for two weeks, and will be chair themselves, at a cost of at least Avoiding cost of family support used again for this after her second £500 and then adapt it to Holly’s worker one hour a week after operation. needs. This would not have been two months of recovery and, According to Holly’s teacher, this has easily affordable for them as they while second recovery phase had several benefits for Holly and her both work part-time. for second hip operation classmates: It helps her academically Amy felt the Red Cross short- commences, building emotional to not get behind with her work, term wheelchair loan is absolutely recovery and coping support = and reduces her isolation as she essential and was surprised to hear can be with her friends at school. the NHS do not provide wheelchairs £400 resource savings for It is also beneficial for the other for this type of case. Without this, on local authority services children. Holly’s mum came in with a recent trip back to hospital for an (based on one hour per week for eight her the first time and explained to weeks, at unit cost of £50 per hour for family the class about her operation... they X-ray appointment, they would have support worker; PSSRU, 2014) were fascinated and very caring and had to use the hospital’s ambulance careful of Holly and it makes her a bit service. of a ‘star’ in class, which is good for “It’s almost like doing a half service - her confidence. None of this could if the Red Cross weren’t doing it, it’s happen without the wheelchair.” like expecting you to lie on a hospital In an interview, a nurse on the floor after you’ve had surgery and surgery ward added that the then like saying ‘oh sorry, this other wheelchair “will likely have a major service provides the beds’.” impact on school attendance and education; it avoids what can be a very isolating experience for some kids at an important time in their development, so there’s better mental rehabilitation through being able to socialise when otherwise they can’t physically get up and get about.” 23

Janis, * Cumbria Janis is 65 years old and is retired. At the hospital, Janis and her She enjoys going shopping, looking husband picked up a leaflet about Without the wheelchair, it after the grandchildren and getting wheelchair services, but none were is clear that Janis would out and about to see friends and close enough to their home in the have had to stay in hospital family. She broke her ankle falling countryside. However, one of the for longer, and there would down steps after attending a health hospital staff mentioned that the Red have been higher economic class. It was not immediately evident Cross might provide a wheelchair costs to hospital services that she had actually suffered a loan, and so her husband looked up mild break. That evening, the pain their nearest distribution centre in as a result. Apart from the had become much worse, so she order to obtain a wheelchair to get impact on hospital services, and her husband decided to go to Janis home. the short-term wheelchar A&E. After diagnosis, Janis had to loan helped Janis to move undergo minor surgery, and was in around at home more easily, plaster for six weeks. and she could get out of the house. Her husband felt that having the wheelchair reduced the likelihood of her falling and improved her quality of life overall. * Not her real name; telephone interview 24

Impact of our wheelchair loan Economic resource savings Janis was discharged with a walking Her husband thinks that, without £469 frame and crutches. Her husband the wheelchair, they may well have felt that the wheelchair allowed his needed to attend A&E, as Janis Avoided cost of staying in wife to return home earlier, avoiding had stumbled a couple of times on hospital orthopaedic ward one an extra day or two in hospital. the crutches. He feels strongly that extra night and day = The occupational therapist said: the wheelchair had a significant “It’s also important because it gets and positive impact on maintaining £469 resource savings to service users fit to get home and his wife’s emotional wellbeing and NHS hospital services not stay in hospital, it helps them quality of life, and possibly led to a (based on £3,283 average cost of elective speedier recovery as a result of the inpatient episode, divided by seven days, recover more comfortably in their mobility it enabled over many weeks. assuming one week-long episode before own environment, and helps them discharge; PSSRU, 2014) participate with other people. I’ve He stated: “She would definitely have known families where a child’s been got down and depressed over time, stuck downstairs for months on end so having the wheelchair meant we without a wheelchair available, and didn’t need any further help to deal not been able to just get out and with that emotional stress. I’d score get fresh air… This can create even it 11 out of 10 for the impact it’s had more stress and it can be an awful on maintaining her quality of life. And strain on emotions.” mine!” The wheelchair helped Janis get Janis’ husband wants to encourage around the house much more easily others in a similar situation: “Don’t than relying on crutches, which hurt hesitate to contact the Red Cross her knee and ankle. As it was a and ask, it can make a world of self-propelled wheelchair, she could difference. Especially if it’s not a wheel herself to the kitchen, garden terribly wealthy area, so in deprived and toilet, and do day-to-day tasks areas [it’s] even more essential to by herself. She and her husband have one to save more suffering… said, “It enabled having a bit more especially if you need it for longer capability and independence… it’s than you first think.” reduced feelings of isolation for both of us for over four weeks and even longer, so there’s more freedom for both of us. Without it we would have been really stuck.” After ten days, she was able to use the walking frame to get to the car, but still appreciated having the wheelchair. Even after eight weeks it was of great value to the both Janis and her husband since it gave them more scope for mobility than the crutches or walking frame. Janis’ husband said, “It’s fantastic that the wheelchair is also foldable – because then we could fit it into the car and go out of the house to visit friends, and daughters, and go shopping, and generally go for longer distances. Our granddaughter rode along on her knee which she loved. We didn’t have to leave her stuck at home.” 25

a Red Cross wheelchair for three weeks in January/February, when she had the support of carers three times a day. Once she came home from hospital, someone had to be with Joanne most of the time. Julia explained: “We stayed nights as well. Family and really close friends, we did a rota so that someone could be with her during the day and night.” After just three weeks, Joanne’s leg broke due to the cancer eroding the bone. In her final week, Joanne’s parents could no longer get her into the wheelchair. Joanne died in th February 2015, just after her 48 birthday. The social value and emotional significance of the wheelchair loan, for Joanne, her family, and friends, far outweigh the significance of the economic resource savings in this case. Joanne, Kent* Joanne worked as a care and she deteriorated quickly. By professional, managing a house at a Christmas 2014, Joanne could only care facility. In June 2013, she was walk with the aid of a stick, and soon diagnosed with breast cancer. She after that, she had to use crutches. underwent intensive chemotherapy Going into the new year, she could and radiotherapy, which was a long no longer manage to walk. Julia says and draining ordeal. In October it had got to the stage where Joanne 2014, Joanne was given the all clear. had trouble with her mobility and Joanne’s parents, Julia and John, could not go out and do the things explained that “you don’t realise how she wanted to do. horrible these tests and treatments The local hospital did not provide are, until it happens to you.” short-term wheelchairs for this type Sadly, two weeks after the all clear, a of end-of-life situation, but told lump was detected in Joanne’s neck. Joanne and her parents about the Further tests revealed the presence Red Cross short-term wheelchair of an aggressive bone cancer, loan service. Joanne was able to use * Interview conducted with her parents, John and Julia 26

Impact of our wheelchair loan Economic resource savings The Red Cross wheelchair was hospital without causing further £699 of great value to Joanne and her discomfort or damage. In their family, despite the short time she words: “It made everything so much Avoiding weekly call out of had it before her death. Her parents easier… the wheelchair was the registered ambulance with explained: “We realised we wouldn’t central thing to have. We wondered medically trained ambulance be able to get Joanne out, even how we’d have managed without it, staff for hospital appointments from the house to the car… it took there’s nothing worse than trying to during three weeks of a lot of concerns about her lack of bundle someone into the car when wheelchair usage = mobility away. She would have got they can’t physically walk. This made depressed being stuck indoors, she the whole thing far less stressful, and £699 resource savings for would have really hated it. She would we felt better that we could at least NHS ambulance service have deteriorated even faster.” be doing something to help.” (based on £233 per incidence of ambulance The wheelchair allowed Joanne to The wheelchair helped Joanne to go call out: see, treat and convey; PSSRU, 2014) th access a local hospice, where she out with friends for her 48 birthday enjoyed embroidery and other hobby meal, on what turned out to be crafts. It also enabled her to enjoy her final weekend. Her parents feel moving around when she visited, strongly that she “would not have rather than being stuck in one place. been with us for as long. It opened Joanne was also able to go on a up her life again for a short while. final holiday weekend in Dorset with Without it she wouldn’t have survived her closest friends. She had been as long. More people should know looking forward to this for a long about this service and what the Red time and without the wheelchair she Cross does…anybody who needs would have been unable to go. anything like it, it will be an absolute Joanne’s parents were able to get godsend.” her into the car and take her to 27

Impact of our wheelchair loan Peggy’s good friend found out about the Red Cross service and arranged to loan a wheelchair for Peggy’s final few weeks of recovery, when her leg was still in plaster. Her friend then returned the wheelchair once she could manage with a walking frame and a stick. Throughout her recovery she had carers coming in twice a day, but that was phased out once she could manage to get about in the bungalow independently. She and her carers used the chair mainly to get her to the bathroom for her morning and evening washes. She had to have her ankle reset twice when it moved out of position. Her friend drove her to hospital and the chair was essential to get her from the house to his car and from his car to the relevant department in the hospital. Peggy says that having the chair has made her feel less helpless and dependent on others: “It has given Margaret, me peace of mind – helped me psychologically and given me more confidence.” South Yorkshire She thinks that having the chair has hastened her recovery by at least a week. Without it, she says she would have needed double the amount of time from carers, since she would have needed support to get to and from the bathroom. She would also have needed an ambulance, a Margaret (Peggy) is 89 and lives Having a short-term wheelchair and a porter to get her to independently in a bungalow. At the wheelchair meant that and from the hospital for her follow- end of 2014, she broke her ankle. Peggy was able to move up appointments. She commented Social services recommended around her home, making that, without the chair, there was a initially that she should go into a risk that she would have fallen and care home to recover following her her less dependent on had an accident while trying to get discharge from hospital, with her others and giving her more about at home. ankle in a cast. She did not want to confidence. Without the Peggy is part of a supportive do this and the local authority found short-term wheelchair community of older friends and her a wheelchair. With this and the she feels she would have neighbours. They have valued support of friends, she was able to required a much higher helping with her recovery and they return home. However, the chair was level of support from her too would have been disempowered recalled for another service user carers and would not have if she had not had the wheelchair. after less than two months. been able to engage with her community of friends as much as she wanted. 28

Impact of our wheelchair loan Economic resource savings Avoiding call out of registered ambulance with medically trained ambulance staff Speaking about the positive impact £4,607 for admittance for 2 x A&E of the wheelchair on reducing social incidences for resetting her isolation, an occupational therapist ankle, and return trip home noted: “I think if service users – Avoided community in plaster plus 2 x additional especially older people – don’t have rehabilitation unit care home follow-up hospital appointments the opportunity to get out and be costs, as per recommendations and return trip home = mobile, they can become insular and from social care services = £1,864 resource savings further isolated, feel like their physical £1,913 cost savings to for NHS ambulance service abilities have been limited and so Community Rehabilitation Unit (based on £233 per incidence of ambulance they make less effort to go out, may (combination of health trust and call out: see, treat and convey; PSSRU, 2014) even be tempted not to bother – this local authority care) can get them in a rut, and then they (based on £1,913 per typical low-cost Avoiding A&E attendance as stop looking after their hygiene, stop episode, in purpose-built units for older cooking and eating properly – it’s people requiring recuperation after an an outpatient, from likely fall at basically going through levels of illness, fall or temporary difficulty managing home if she had been without a daily living; PSSRU, 2014. Note this is equal wheelchair during recovery = depression. There may even be a to approximately three weeks’ recovery need for additional care as this can period with the Red Cross wheelchair, create a much bigger problem at that therefore consistent with timeframes of this £129 resource savings case, as the weekly cost is estimated at for Accident and Emergency point [for care services].” approximately £637; PSSRU, 2014) department Peggy’s personal message to others (based on NHS National Tariff of £129 per about the Red Cross short-term Improving her ability to recover A&E incidence with category 2 investigation wheelchair loan service is: “It’s there faster by one week, plus and category 3 treatment, i.e. plaster removal or application, bone fracture) when all else fails’.” avoiding three weeks of needing home carers at an increased “critical” level of support = £233 resource savings £468 resource savings for for NHS ambulance service to social care services transport to A&E (based on £117 difference between £397 per (based on £233 per incidence of ambulance week Home Care cost “Critical” level, and call out, see, treat and convey; PSSRU, 2014) £280 per week “Substantial” level; PSSRU, 2014) British Red Cross mobility aids service, South Yorkshire © Matthew Percival/ British Red Cross. 29

Key themes illustrating the wider impacts of Awareness levels The wheelchair allowed short-term wheelchair loan. These The case studies showed that, individuals to retain a include special occasions and although all the participants in our sense of independence activities that bear no relation to research were eventually able to and reduced social economic impact: attendance at access a wheelchair, routes to doing isolation by retaining social school graduation, telling childhood so – and awareness of the service – peers about a wheelchair and being varied. connectedness. These a part of the community. benefits had a positive While awareness of the short-term Knowledge of the availability of impact on health through wheelchair loan service has been the short-term wheelchair loan an increased sense of shown to be low (based on referral service was prompted primarily by wellbeing and a renewed or word of mouth), the case studies hospital staff (including occupational positivity – ensuring and HCP interviews raised other therapists and physiotherapist) in concerns. around half the case studies, leaving a mutually dependent the remainder to find out about the relationship between the Some wheelchair users in this study service through a friend, neighbour health and social impact. reported surprise and disappointment or their own research. However, that the service was not provided as there is broad recognition from the standard by the NHS, with a number health care professionals interviewed reporting that they had explored the of the value associated with the reduced social isolation by retaining private purchase of a wheelchair but service. It would seem therefore social connectedness. These had found the cost to be prohibitive. that raising awareness among other benefits had a positive impact on “…we have to review the situation HCPs is an area for development. health through an increased sense to make sure the service user is The users who were not immediately of wellbeing and a renewed positivity not becoming dependent on the aware, or made aware, of the – ensuring a mutually dependent wheelchair and we don’t have to service reported the potential or relationship between the health and delay hospital discharge as long as perceived consequences of this lack social impact. Indeed, our interviews they have a bed, a toilet, crutches of knowledge. At its most extreme, with HCPs supported the interplay and a chair, then a wheelchair can one service user who had been between the health and social be sorted out after.” (occupational dependent on crutches on two benefits associated with short-term therapist). occasions in the last five years said wheelchair loan. that the service (had she known The benefits of short-term wheelchair The resulting picture is one in which about it) would have made a big loan were felt, not only by the both wheelchair users and HCPs difference to her life, making her wheelchair user but also by the wider agree to the value of short-term much less dependent on family and family unit, especially when the user wheelchair loans and the impact friends for her mobility. had a family member dependent upon they can have on recovery and/or them, or the wheelchair meant the wellbeing. However, where those Drivers of need and wider user had less need for care from family who have made use of a short-term consequences members. HCPs also recognised wheelchair loan err towards this While the case studies revealed these wider benefits. The different provision being ubiquitous, at least different reasons for needing a ages represented in the case studies some HCPs warn of dependency and short-term wheelchair loan, the illustrate these wider impacts on the need to exert control over access majority were medical-related and family. For younger users and those in order to avoid their overuse. followed a broken bone (related to an with younger dependents, the issue Previous Red Cross research underlying health condition including of reducing their own social isolation found that NHS wheelchair service at the end of life, or following an and therefore the social isolation of the managers equated short-term accident). However, within the case child came out strongly, whereas adult wheelchair provision with social studies, where the need fell outside members of the family were affected needs (Gardiner and Kutchinsky, of a broken bone, it was related to in other ways – particularly when the 2013), which they reported to a health condition requiring surgery, carer needed to take time off work. be the main reason why their a dislocation, or inability to walk So, while the wheelchair may not service did not provide short-term any distance. Interviews with HCPs eliminate the need for support from wheelchair loans. By contrast, the supported the need for short-term others, it can make things easier. HCPs interviewed for this current loan as being primarily for health- What should not be underestimated research identified the importance related reasons. beyond the satisfaction of health of orientating short-term wheelchair Although the preceding need was and social need is that wheelchairs provision within a longer-term primarily health-related, this affected were found to add value to users outcome. The value of on-going and was related to social need. The by enabling them to continue their monitoring and review – especially wheelchair allowed individuals to normal lives. The case studies by allied health professionals – was retain a sense of independence and revealed a number of examples also emphasised: 30

“So it’s important we are focused on saving related to transport, whereby HCPs identified benefits beyond the longer-term outcome, because transport (such as an ambulance) savings to health and social care while wheelchairs are essential for would have been required to attend services. They spoke of the return to anything that is injury-based and has a heath care facility or home visits ‘normality’ in a faster return to work potential for rehabilitation, especially would have been required. or education, which is associated if people are non-weight bearing or The HCP interviews also strongly with positive mental and social partial weight bearing – and this advice supported the preventative value benefits. Although this economic has to come from the occupational of short-term wheelchair loans evaluation did not intend to examine therapist or physiotherapist – we and their centrality to the process personal income or savings in have to review the situation to make of rehabilitation. In regards to their any depth, benefits to these were sure the service user is not becoming preventative role, one HCP noted that identified. dependent on the wheelchair.” having a wheelchair reduced the risks In all, the interrelationship of health (occupational therapist). associated with getting about without and social care benefits observed Economic impact and one, and many of the case studies in the case studies married with the preventative value noted the risk associated with trying economic evaluation; both together The economic evaluation revealed to get around on crutches. aid recovery. HCPs associated such overall health and social care savings As highlighted in the case studies, the benefits with enhanced rehabilitation. ranging from £469 to £4,607 across loan of a wheelchair was felt to affect They noted that wheelchair loan the nine case studies, with an the wider family unit, and it is related could enable shorter hospital stays, average saving of £1,676 (see Figure to this wider unit where social care with patients returning home sooner 1). As such, the findings clearly savings were largely identified. These where they can recover faster and quantify the preventative value of savings played out in the prevention in more comfort. They also noted short-term wheelchair loans with of either an increase to an existing that the wheelchair could aid cost savings evidenced across both care package, the introduction of a rehabilitation inside and outside the health and social care. care package, or the need to support home, allowing the user to get about dependents of the wheelchair user. more easily. These findings indicate Health savings were particularly high Social care savings ranged from £100 both the benefits associated with and ranged from £343 to £4,139 (the to £1,400, with an average saving of wheelchair loans from the user and average saving per case study was £332. wider family perspective, and the £1,344). The most frequently reported cost savings generated. £ 0 1500 3000 4500 6000 7500 9000 10500 12000 13500 1500 16500 Sameena Laura Melvyn Holly Ronald Ashleigh Joanne Margaret Janis Heath sector savings Social care sector savings Total Average heath sector savings Average care sector savings Average total savings FIGURE 1 SAVINGS PER SERVICE USER RESULTING FROM WHEELCHAIR LOANS 31

4 Recommendations The emphasis of politicians and Recognition: policymakers in England is on > Of the positive impact that short- an integrated and preventative term wheelchair loans have on approach to health and social care people’s lives; they are an enabler that promotes individual wellbeing. of recovery, choice, control, It is in this context that we are calling independence and wellbeing. for recognition and action. We want > That short-term wheelchair loans to see politicians, policymakers and can prevent and delay people’s practice leaders working together needs for health care, social – supported by the Red Cross – to care and support. They can also improve the humanitarian situation reduce the level of need that of people who need short-term already exists. wheelchair loans. > That people’s needs and life Ultimately, we want to see the situations do not fit neatly into realisation of our humanitarian vision: ‘clinical’ and ‘social’ distinctions. “Everyone who needs a wheelchair > That there are associated cost should be entitled to quickly and savings to the public purse – easily get one that is right for them, especially to health and social for as long as they need it. Everyone care services – as well as to who uses or handles a wheelchair individuals and their families. should know how to do so safely > That there is no clearly defined and comfortably.” duty for statutory provision of short-term wheelchair loans in England. 32

> That there are people who need > We call on NHS England, NHS and Wellbeing Strategies. short-term use of a wheelchair, Improving Quality and the > We call on decision-makers but whose needs are not being National Wheelchair Leadership in areas where budgets are met. Alliance to incorporate short-term being truly integrated – such > That the British Red Cross is wheelchair provision into the as the Greater Manchester meeting more humanitarian ‘My Voice, My Wheelchair, My Strategic Health and Social Care needs through provision of short- Life’ programme of work and the Partnership Board – to seize this term wheelchair loans than any ‘Right Chair, Right Time, Right opportunity to eradicate the false other organisation in England, at Now’ campaign to transform distinction between people’s significant cost to our charitable wheelchair services in England. clinical and social needs for funds. > There is no estimate of the need short-term wheelchair loans, and Action: for short-term wheelchair loans to incorporate their provision into at any one time. We urge the integrated models of health and > The British Red Cross will act government – working with NHS social care. to raise awareness among England and NHS Improving health care professionals of Quality – to investigate this. > We call on the Government the preventative value of short- and NHS England to enable term wheelchair loans and of > We call on the government, an environment whereby local our short-term wheelchair loans NHS England, NHS Improving initiatives to integrate health and service. Quality, local authorities, HWBs, social care services (such as CCGs and NHS wheelchair better care fund plans, integration > We call on the government, NHS services to work together to meet pioneers and new models of care England and NHS Improving humanitarian needs within the vanguard sites) can incorporate Quality to recognise the established policy framework of the provision of short-term preventative value of short-term promoting individual wellbeing wheelchair loans into their wheelchair loans, both in terms and enabling people to live the planning and practice. of the positive outcomes they lives they choose and value. achieve for people and their families, and the associated cost > We call on members of savings to the public purse. parliament and chairs of HWBs to take a local lead on ensuring > We call on the Government that the preventative value of to incorporate the meeting of short-term wheelchair loans is short-term mobility needs into the recognised at the beginning of NHS Mandate to NHS England, the local commissioning cycle, within theme 3) Helping people to by ensuring that provision of recover from episodes of ill health wheelchairs for short-term use or following injury. is incorporated into Joint Health 33

References Care Act (2014) [Online] Available from: http:// HL Deb (2013–14) House of Lords Debate 2013–14: 745 www.legislation.gov.uk/ukpga/2014/23/pdfs/ col. 818 [Online] Available from: http://www.publications. ukpga_20140023_en.pdf [Accessed 13/05/15] London: parliament.uk/pa/ld201314/ldhansrd/text/130521-0001. TSO htm [Accessed 13/05/15] Carers (Equal Opportunities) Act (2004) [Online] Available Holt-Lunstad J., Smith T., Baker M., Harris T. and from: http://www.legislation.gov.uk/ukpga/2004/15/pdfs/ Stephenson D. (2015) Loneliness and Social Isolation ukpga_20040015_en.pdf [Accessed 13/05/15 London: TSO as Risk Factors for Mortality: a Meta-Analytic Review, Perspectives on Psychological Science, 10(2): 227–237. Chronically Sick and Disabled Persons Act (1970) [Online] Available from: http://www.legislation.gov.uk/ Knight, C. (2014) OPINION: In the Matter of British Red ukpga/1970/44/pdfs/ukpga_19700044_en.pdf [Accessed Cross and the Short-Term Provision of Wheelchairs. 11 13/05/13] London: HMSO King’s Bench Walk (11KBW): London Department of Health (2014a) Care and Support Local Government Association (2015) LGA briefing – Statutory Guidance Issued under the Care Act 2014 Greater Manchester Health and Social Care Partnership October [Online] Available from: https://www.gov.uk/ [Online] Available from: http://www.local.gov.uk/adult- government/uploads/system/uploads/attachment_data/ social-care/-/journal_content/56/10180/7060676/ file/366104/43380_23902777_Care_Act_Book.pdf ARTICLE [Accessed 13/05/15] Great Britain [Accessed 13/05/15] England MacLeod F. (2015) Making a Move: Increasing Choice Department of Health (2014b) The Mandate: A mandate and Independence for People with Short-term Mobility from the Government to NHS England: April 2015 to Needs [Online] Available from: http://www.redcross.org. March 2016 [Online] Available from: https://www.gov.uk/ uk/~/media/BritishRedCross/Documents/About%20us/ government/uploads/system/uploads/attachment_data/ Scotland%20mobility%20aids%20report.pdf [Accessed file/386221/NHS_England_Mandate.pdf [Accessed 13/05/2015] Scotland 13/05/15] England Monitor and NHS England (2013) National Tariff Payment Field, O. (2014) Researching Health and Wellbeing System 2014/15: Annex 5A-National Prices [Online] Strategies. Unpublished internal briefing. London: British Available from: https://www.gov.uk/government/ Red Cross publications/national-tariff-payment-system-2014-to-2015 [Accessed 13/05//15] England Gardiner F. and Kutchinsky N. (2013) A Prisoner at Home: Wheelchair Loan Provision and Need in the UK. London: National Assembly for Wales Health and Social Care British Red Cross Committee (2012) Wheelchair Services in Wales: Follow- up Inquiry [Online] Available from: http://www.assembly. wales/Laid%20Documents/CR-LD9028%20-%20 Health and Social Care Act (2012) [Online] Available Health%20and%20Social%20Care%20Committee%20 from: http://www.legislation.gov.uk/ukpga/2012/7/pdfs/ Report%20on%20Wheelchair%20Services%20in%20 ukpga_20120007_en.pdf [Accessed 13/05/15] London: Wales%20Follow-up%20Inquiry%20-13082012-237712/ TSO cr-ld9028-English.pdf [Accessed 13/05/2015] Wales Health Service and Public Health Act (1968) National Assistance Act (1948) [Online] Available from: [Online] Available from: http://www.legislation.gov. http://www.legislation.gov.uk/ukpga/Geo6/11-12/29 uk/ukpga/1968/46/pdfs/ukpga_19680046_en.pdf [Accessed 13/05/2015] London: HMSO [Accessed 13/05/15] London: HMSO 34

NHS (undated) Advice for Line Managers on Supporting National Wheelchair Managers Forum (2013b) Frequently Employees with Long-term Medical Conditions Asked Questions [Online] Available from: http://www. [Online] Available from: http://www.nhs.uk/Livewell/ wheelchairmanagers.nhs.uk/faq.html#temporary_ workplacehealth/Documents/ChronicConds_ wheelchair [Accessed 13/05/2015] England LineManagers_Factsheet_A4.pdf [Accessed 15/05/2015] Great Britain Office for National Statistics Annual Survey of Hours and Earnings (2014) [Online] Available from: http://www. NHS (2014) Five Year Forward View [Online] Available ons.gov.uk/ons/rel/ashe/annual-survey-of-hours-and- from: http://www.england.nhs.uk/wp-content/ earnings/2014-provisional-results/stb-ashe-statistical- uploads/2014/10/5yfv-web.pdf [Accessed 13/05/15] bulletin-2014.html [Accessed 13/05/2015] England England PSSRU (2014) Unit Costs of Health & Social Care Kent, NHS (2015) Choosing Mobility Equipment, Wheelchairs England: Personal Social Services Research Unit and Scooters [Online] Available from: http://www. nhs.uk/Conditions/social-care-and-support-guide/ Pages/mobility-equipment-wheelchairs-scooters.aspx The King’s Fund (2015) Simon Stevens on the NHS Five [Accessed 13/05/15] England Year Forward View [Online] Available from: https://vimeo. com/117918689 [Accessed 13/05/2015]. NHS Improving Quality (NHSIQ) (2014) Right Chair, Right Time, Right Now [Online] Available from: http://www. Young, J. (2014). We Must Recognise Frailty as a Long- nhsiq.nhs.uk/media/2574411/edigest.pdf [Accessed term Condition [Online] Available from: https://www. 13/05/15] England england.nhs.uk/2014/05/07/john-young/ [Accessed 13/05/2015] NHS England: England National Health Service Act (2006) [Online] Available from: http://www.legislation.gov.uk/ukpga/2006/41/pdfs/ ukpga_20060041_en.pdf [Accessed 13/05/15] England National Wheelchair Managers Forum (2013a) A Guide to NHS Wheelchair Services: Frequently Asked Questions – Version 1.1 [Online] Available from: http:// www.wheelchairmanagers.nhs.uk/A%20guide%20to%20 NHS%20Wheelchair%20Services%20v1-1.pdf [Accessed 13/05/15] England 35

Appendix A Numbers of selected participants Category Number Total number of service user contact details supplied by service managers 80 Total numbers called including no answer, no response or incorrect number 40 Total where screening call was carried out 25 Total agreeing to be interviewed 11* Total dropping out after initially agreeing 2 Total interviewed 9 *Four participants were not followed up due to being screened out by selection criteria (n=1) or numbers for study/site already achieved (n=3). 36

Appendix B Screening interview schedule Identify: > Self > Reason for contact/research study > What participation in screening would involve. If happy to continue: 1. Confirm identity to our records and check whether they loaned the wheelchair (if not – are they main carer, family, friend, etc). 2. Reason for the loan. Prompt for: > Medical need (e.g. returned from hospital after an operation and needed short-term loan or chronic/ longer-term condition where they may have applied for long-term loan from NHS but waiting for it come through) > Wanted to take part in particular social event (holiday, party, wedding). 3. Length of use/loan. 4. What benefit/s (if any) did the loan give to them and/or carer/family? Prompt for: > Able to get to medical appointments > Able to do own shopping > Able to take part in social events > Reduced dependence on family/carer/friends. 5. What would have happened if they had not been able to get a short-term wheelchair loan from the Red Cross? Prompt for: > Any other services that would have been needed (GP, A&E, home help, longer stay in hospital, etc.) > Increased dependence on carer/family/friends > Not able to do own shopping > Not able to take part in social events. 6. Anything else they would like to say in relation to the short-term wheelchair loan. 7. Anything they want to ask about the interview/research. 37

Appendix C Wheelchair user interview (case studies) Explain purpose of conversation to the participant and that they will have a chance to look at a write-up of their case and comment on it/correct any inaccuracies. 1. Please tell us how you found out about the British Red Cross short-term wheelchair loan service? Especially seek to understand their health/care pathway or main entity involved in referral, e.g. hospital, community nurse, OT, physio, GP, professional carer, etc. 2. What were the main reasons why you needed the short-term wheelchair loan? Prompts if needed > Medical need (e.g. returned from hospital after an operation and needed short-term loan – or chronic/ longer-term condition where they may have applied for long-term loan) > Expecting long-term loan from NHS but waiting for it come through > Wanted to take part in particular social event (holiday, party, wedding). Explore: > A bit of background about their physical health and wellbeing. 3. How long did/do you need the wheelchair loan for? 4. What benefits have you or your family experienced from taking up a British Red Cross short-term wheelchair loan? Explore: > Impact on health and wellbeing > Mobility, access, isolation issues > If there is any reduced need for health or social care services involvement > Impact on family/social relationships (including allowing carer to return to work or increase working hours). 5. What did it mean for you and your family to be able to get this wheelchair loan? NB If they have a carer or care package, has there been an impact on care delivery, relationship with carer, or their tasks? Explore: > Personal circumstances – what support they have at home and from family/friends/carer > If they have dependents who may be affected by their mobility > How they are managing with mobility now, if appropriate > If they might have had to pay for extra care or child care support. 38

6. What do you think would have happened if you had not had a Red Cross wheelchair? Include the following as prompts depending on circumstances: > Would it have delayed your hospital discharge? If so, how much longer might that have taken? > Without the wheelchair loan, what type of restrictions might have occurred if you needed to attend any follow-up appointments at hospital/with GP, or other care services? > Without the wheelchair, would you have had to call GP/A&E out to your home and how often do you think you might have had to do this? > Would you have required further support from social or long-term care services, or occupational therapy visits? > Would you have had to pay for a wheelchair (explore how realistic this is and if advice was received about where to get one) > What has the impact been on you getting around the home/garden? > Without the wheelchair, what kind of restrictions might there have been on your contact with the outside world, including social life, isolation, access to other services? > Without the wheelchair, might there have been more pressure placed on relatives, e.g. to carry you to and from the car or in/out of the house? > Would there have been an impact on your mental and emotional wellbeing? 7. What effect do you think having the wheelchair has had on your progress/recovery? Explore: > how it may have helped their mobility, but also socially and in wellbeing terms, e.g. confidence, sense of control, autonomy, dignity, etc. > And conversely, how do they think not having it might have affected their progress/recovery. Explore whether they think they would have needed more or less support from health or other care services with/ without the wheelchair and unpick this in some detail (if not already covered). 8. Are you able to say roughly how many weeks longer might your recovery have been without the wheelchair loan? 9. How would you sum up the difference that the British Red Cross short-term wheelchair loan has made for you? On a scale of 0–10, how would you rate the impact of the wheelchair loan on your quality of life while you were using it? 0 being no improvement to your quality of life; 10 being a very significant improvement to your sense of wellbeing/quality of life. 10. What messages would you like to send to potential funders or users about why this is an important service? 11. Are there any health or other care professionals, who you have had regular support from, who might be willing to talk to us on the phone about their general views on the value of this type of wheelchair loan service? (e.g. Community Nurse, OT, physio, hospital staff). We would not discuss any details of your case with them. 12. Is there anything else you would like to say regarding the short-term wheelchair loan from British Red Cross? 39

Appendix D Health care professional interview Explain the purpose of the conversation is to understand the impacts of the Red Cross wheelchair loan service, and the background to the service (if required), plus discuss hypothetical examples of when a service user might need the wheelchair loan service, e.g. following an accident, to help recovery, to aid mobility, etc. and how long the service is generally used (they should already be fairly familiar). Explain interviews are anonymous, their personal details will not be shared and comments are non-attributed, and no personal details of any service users will be shared with them or discussed. The interview will be formed around example scenarios and their opinions on likely outcomes. 1. Please can you tell us briefly about your role in the care services? 2. In your experience, what are the most common or typical circumstances for needing a wheelchair loan? How do they find out about this? Especially seek to understand the types of health/care pathway or main entity involved, e.g. hospital, community nurse, GP, professional carer, etc. 3. What main benefits come about for service users from taking up a British Red Cross short-term wheelchair loan? Prompts if needed: > Medical need (e.g. returned from hospital after an operation and needed short-term loan – or chronic/ longer-term condition where they may have applied for long-term loan) > Expecting long-term loan from NHS but waiting for it come through > Wanting to take part in particular social events. Explore: > Impact on health and wellbeing > Mobility, access, isolation issues > If there is any reduced need for health or social care services involvement > Impact on family/social relationships. 4. Please could you comment about the impact of the wheelchair loan in the following example scenarios, as we appreciate every case is specific and individual: (Interviewee to select one or two of the following scenarios for general discussion) i. A child between the ages of 6 and 11 years needing a wheelchair to recover from a knee operation ii. A single father who has suffered a broken ankle but has sole responsibility for a vulnerable child with emotional and mental health issues iii. An elderly couple where either the husband or wife has had a hip operation, but live far from town or are rurally based. 40

5. What do you think would potentially happen in these scenarios to service users or their family if they are not able to access a short-term wheelchair loan? Include the following as prompts depending on circumstances: > Would it have delayed their hospital discharge? If so, how much longer might that have taken? > Without the wheelchair loan what type of restrictions might have occurred if they needed to attend any follow-up appointments at hospital/with GP, or other care services? > Without the wheelchair, would they have had to call GP/A&E to their home? > Would they have required further support from social or long-term care services, or occupational therapy visits? > Would they have had to pay for a wheelchair? > Without the wheelchair, what kind of restrictions might there have been on their contact with the outside world, including social life, isolation, access to other services? > Without the wheelchair, might there have been more pressure placed on relatives, e.g. to carry them to and from the car or in/out of the house? > Would there have been an impact on their mental and emotional wellbeing? 6. What effect do you think having the wheelchair has on service users’ progress/recovery? What rough (percentage) proportion of time longer might their recovery be without the wheelchair loan? 7. Do you have any other comments or issues we might have missed? 41

Appendix E Note on definitions and calculations Regarding cost calculation workings, ‘Inpatients’ refers to people who are admitted to an available staffed bed in a hospital (either electively or as an emergency) and who either remain overnight (whatever the original intention) or who are expected to remain overnight but are discharged earlier. ‘Elective’ relates to treatment or care that is planned for by the hospital, rather than emergencies or outpatients (i.e. non-elective). ‘Day cases’ refer to episodes where a person makes a planned admission to an available staffed bed in a hospital for clinical care, and requires the use of a bed (or trolley in lieu of a bed) and is discharged on the same day as planned. We have omitted the unit cost per incident of needing to use a hospital wheelchair for follow-ups or re-admissions because PSSRU (2014) estimates (ranging from £91 to £183 unit cost per year, calculating 15–20 minutes of usage including a porter) would equate to comparatively small amounts that are less material to the analysis. 42

Editing and layout: Green Ink (www.greenink.co.uk)

British Red Cross 44 Moorfields London EC2Y 9AL Tel: 020 7877 7284 Fax: 020 7562 2000 wwww.redcross.org.uk [email protected] The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949) and Scotland (SC037738).