Following a private equity takeover last year, Millbrook has set its sights on not only maintaining the important work it does, but evolving that work and broadening what it can offer as a company.
In conversation with AMP, Annette Cairns, clinical and quality director, and Lauren Osborne, senior wheelchair therapist, explain how the investment has helped the company evolve its expertise to benefit the wider community.
So tell me more about the postural work?
LO: I’ve been working in Wheelchair Services now for almost 7 years and while I was doing my MSc in Rehabilitation and Posture Management and seeing different people in my work, it occurred to me that there are so many people out there that require a lot more postural support than what a wheelchair can offer. There are also times that they are not sitting in a wheelchair when they require alternative postural seating or supports in bed, particularly people in care homes.
Unfortunately, we do actually have to reject some referrals for wheelchairs because somebody has been in bed for so long, that they don’t actually have enough bend at the hip anymore so they can’t actually sit up, or they need postural seating without mobility and that is not something we are currently able to provide. I sometimes see people who have been in bed unsupported for so long that they have developed and can no longer be seated safely. I just felt heartbroken by this and that something needs to be done, it isn’t fair and it isn’t right that these people can’t do things because they’ve been cared for in bed rather than having postural seating that they need.
So, I decided to concentrate my dissertation on this area of unmet need. It’s a scoping review looking at the evidence for 24 hour posture management. We’re talking about people who can’t change their position independently, therefore all of their care is reliant on other people doing everything for them.
When you’re in one position all of the time and you can’t roll over in bed for example, gravity pushes you down and the supporting surface pushes you up and you get what’s called the human sandwich, where the person is stuck in the middle and muscles can shorten and lengthen over time, causing contractures and compression of the body structures. This has a knock on effect to bodily functions and it is a massive quality of life issue.
Would you say this can be prevented?
LO: I wouldn’t say it is an easy fix but it is definitely preventable. From the literature that I’ve read, there are pockets of postural care going on around the country and there are a few different services emerging. One other wheelchair service has started to provide night time positioning supports. We need to look at someone over a 24 hour period, because they’re only in their wheelchair for about 4-8 hours, so then you’ve got the rest of that period lying in bed or sitting in an armchair, potentially without any support and it can change their body shape. For example, if you’re spending thousands on providing custom moulded seating for their wheelchair, but the person is lying unsupported in bed, they’re posture can change whilst they’re lying so that the moulded seat no longer fits properly.
What I think should happen is that wheelchair services should expand to become a posture management service and provide not only static postural seating but also night time positioning equipment because if you’ve got one team assessing and supporting the person’s posture for the whole 24-hour period, they can prescribe the different equipment that works in harmony with each other so that you’re looking at that person’s posture throughout.
This is opposed to what we see now where services are really disjointed and you have wheelchair services which provides a wheelchair, you might get a static seat from social services or a neurological therapy team and you might get a sleep system from another community therapy team and they’re all looking at them separately and they should be looked at as a whole thing.
For Occupational Therapy, that is at the heart of the profession. We are all about holistic assessment and making sure the person can be involved and participating in life as much as possible but how can they do that if they can’t actually hold their head up or because their arms are supporting their trunk to remain stable. I think postural care is actually a prerequisite to occupational performance.
AC: We’ve just successfully tendered and retained the Eastbourne Wheelchair Service and that has static seating as part of a provision which means from Millbrook’s perspective, we’ll not only be assessing for the wheelchair, there will also be an element of prescribing and providing static seating. There are very few services which are currently commissioned to provide the static seating element.
The commissioners in East Sussex have obviously got a forward looking and forward thinking perspective and see that the assessments that Lauren and other wheelchair experienced OTs do, can be used for static seating so it is a real good use of a resource and a very highly skilled resource at that.
That’s one service and that’s really good but it still isn’t covering the full 24-hour postural support but at least it is a step in the right direction.
What needs to change to get this kind of attitude implemented nationwide?
LO: I think there are a few things which need to change. I think we need some national guidance and a postural care pathway. There has been some work by the charity Newlife on why people approach them for funding disability equipment and their campaign report “It’s not too much to ask” has all of the costings on how much each local authority spends on disability equipment. They found that, particularly for night time equipment, there was actually no budget set and no funds available.
Unfortunately, there’s a lack of research in the area and because it is a very complex topic, you can’t do the gold standard of testing and run a randomised controlled trial because it would be unethical to withhold treatment to a control group and the researchers can’t be blinded during the study. There have been a few case study research projects though, which have had interesting results.
One in particular was by Simple Stuff Works and Salford University; they introduced night-time positioning equipment to 12 residents in a care home over a three month period.
By the end of their study, they had one person who had been nursed in bed and tube fed at the beginning who could tolerate sitting out in a wheelchair and eat orally at the end, 60% of participants reported a reduction in pain, 40% reduction in pain medications, a 50% reduction in choke risk to name a few of the results. Although it was only a small study, when you look at what they achieved in three months with 12 people, what can you do for a bigger population?
AC: This type of project is vital for children as well because interaction at a young age is vital for how the brain develops. Being able to be mobile and being able to engage with people and function in a room is how we all develop. Not having that is detrimental to children and young people.
LO: Exactly, and that is similar for people living in care homes with advanced dementia. People need stimulation and to be sat in a basic wheelchair, parked in the corner of a lounge and not really interacted with, eventually so many people end up sitting with their head down and with a rounded spine which makes them look more disabled than they are but if they were sat better supported, they would be able to engage more and their cognitive behaviour would improve.
There’s some studies out there that show that people over 75 sit for an average of 11-13 hours per day and there’s no guidance on pressure care for sitting. For example, if someone has a pressure ulcer from lying in bed, immediately nurses come in with a turning regime to deal with their pressure needs but actually, if you’re sat for 11-13 hours a day, you’ve got higher pressure needs because more of the body’s weight is distributed over a smaller surface area.
Something needs to change with this because we do get a lot of referrals asking for help with the wheelchair, to add more supports or make it more comfortable so the person can sit in it for longer. We provide advice on repositioning and in some cases say no because ultimately, it is a mobility aid, it isn’t a replacement for an armchair, so we really need to look at how an individual’s posture is managed over the 24-hour period.
There’s a big black hole in the UK for postural static seating. There’s massive under-funding for it and it leads to people sitting longer in basic wheelchairs that are designed for transit purposes only. On the flip side to that, there are some families who do have a bit of money that want to do right by their relative that will go out and buy something, but with no therapy involvement in the assessment, they can end up with the wrong thing and thousands of pounds down just because of the lack of support.
So, you’d say getting the assessment and that considered planning is one of the most important things?
AC: Yes, of course, but it is also about the cost that seeps into other areas as well. I used to be a nurse, and what I used to see is that someone, for example in a care home again, who had only ever been moved from bed to chair, you’re going in to try and nurse them, and you can’t move them due to contractures, so if you tried to lift the bottom of their foot, their entire body moved. This meant it became a double up visit where two people were needed to attend to hold the leg, whilst the other person tried to change the dressing etc.
But then there’s the pain and other medical conditions that arise because of this, so by getting the mobility and seating wrong, it can all snowball. As well as that having a massive effect on a person’s quality of life, there is also a huge cost on the system, which could have been avoided.
Would you say getting the full 24-hour support right would save cost on the system in the long term?
AC: Absolutely. It would not only help with quality of life and sleep patterns, which goes hand in hand, it would also reduce the cost to the health and social care system because there would be less medical issues caused which then in turn lead to other areas of cost and ultimately discomfort and pain for the individuals and their families.
How do you come in to help with that?
LO: Well, as wheelchair therapists, we are perfectly placed to do those kinds of assessments but our hands are tied because we are only commissioned to provide wheelchairs, we’re not currently commissioned to provide sleep systems or static seating.
We have some people come to us, wanting advice. We’ve had some people say we’ve got this rep coming, can you provide this help? And to that, we have to say no because we cannot complete an assessment for equipment that we are not providing. Our time is tied to just providing wheelchair services and we’ve got skills and we’ve got expertise that can help with those assessments but we can’t give it and that is frustrating.
Is your hope that others around the country take Eastbourne’s lead?
LO: I hope so.
AC: This is why the work Lauren is doing is so important. I think the more exposure this issue gets, the more chance it has of improving. There are a pocket of wheelchair services which are doing little bits of it, and there’s some research by field experts on it, but it just needs to be higher up in the overall agenda.
This is even truer when looking at the long-term plan for the NHS and showing how this is about a collaboration between all providers and show how we can make an impact by all working together.
Tell me how PHBs and PWBs fit in with this?
AC: I know when Lauren was doing her dissertation, there was a number of people who contacted the service here at Welwyn Garden City to say that they had got the budget for static seating but couldn’t find anywhere to get the assessment for it. They wanted our therapists to go and complete the assessments with that.
The whole PHB project is a real positive, but we need to ensure we are exploring all ways that they can be really effectively and efficiently used and put into place around the country.
LO: The introduction of PWBs is very centred around a holistic assessment and has highlighted how important it is to consider a person’s posture over a 24 hour period as a result. It is designed to offer more choice and control to the individual and therefore is an ideal opportunity to pool budgets and use resources more efficiently to really deliver the equipment that is right for the person and their needs.
How do you see yourselves and others in the industry evolving around this?
AC: As the tenders come out, providers are asked to be innovative and demonstrate how we can drive improvements and that isn’t just in wheelchair services but it is also outside of that. We have to align ourselves to the commissioner’s goals and the NHS long term plan.
24 posture management made complete sense to me, when Lauren initiated this project, we both reacted with the feeling of ‹absolutely.’ This is a gap and this is perfect, we need to explore this further and the reason for that is as a provider it is the right thing to do. Sometimes it is difficult to know what the priority is when it comes to innovation, but we think this will help our service users as well as the wider needs of people and our health and social care system.
LO: I’ve spoken to a lot of people as part from this and they find it really difficult to know where to get a postural armchair from after recognising they need one. It is social services, is it the neuro team, is it a community OT service? Even for us, sometimes we think a person needs this piece of equipment, but we’re not sure who to refer them to.
Has technology began to play more of a role within Millbrook’s work?
AC: We have the view that technology can support people to stay independent for as long as possible, whether that’s on our wheelchairs or in people’s houses. We look at how things like Alexa can be used to keep someone at home for longer and enable them to interact and engage and how we can then further support people.
Wheelchair services or any other healthcare service can’t work in isolation, that approach is outdated. So using technology, Millbrook Healthcare as part of a larger group, that have contracts providing services to a variety of service users and their various needs, we are looking to place ourselves to be part of the offering for the whole care continuum.
Additionally, again using technology we’ve worked in partnership with commissioners on projects where we can use technology to reduce double handed care visits and how that can be beneficial to all. That’s been really successfully. Technology is definitely a key component to the way healthcare is going to be delivered going forwards, we’ve got to use it to keep people as independent and as mobile as possible.
As far as wheelchair services are concerned, we’ve got to focus on technology to keep up with user’s needs, whilst also remembering there is a cohort of people who actually aren’t comfortable with technology so we need to still offer more traditional methods for our service users as well.
From a business point of view, following the takeover last year, has that investment helped with helping you concentrate on wider issues like this?
AC: We have been looking at the wider issues for a number of years and it was already part of our strategy, but the move with co-ownership is actually helping because there is investment into the company with a view to looking at that being progressive and part of the whole care continuum.
It has enabled Millbrook Healthcare to consider what healthcare over the next five to ten years may look like and how we can actually prepare ourselves to offer that or those types of services to the commissioners and to the end service user.
From a clinical and quality perspective, it has been a real positive move, there is a real understanding that quality drives our business as is appropriate for a clinically led company. Quality is something that we work hard on and we understand that quality is about concentrating on both service delivery and our investment in our staff and sponsoring Lauren to complete her Master’s degree is a great example of that.
From my perspective there has been no negatives associated with our partnership with Cairngorms, apart from missing Colin who was a great character to have around.