"IF THE SHOE FITS"
REPORT BY
Philip J Taylor, Bespoke Shoemaker
THE ORIGINAL REPORT WAS SUPPORTED BY
The British Polio Fellowship and emPOWER.
Revised July 2008 Text version only
Click here to download the full version including photographs.
This report was compiled with the help of the following:
Fully qualified Orthotists. Recipients of NHS footwear. Members of the British Polio Fellowship, Orthotic Department Managers and Manufacturers of NHS supplied footwear.
This report was presented to:
Mr Andy Burnham MP, Minister of State for Health (Delivery and Quality).
Mrs Annie McGuire MP, Minister for the Disabled.
and
The NHS Purchasing and Supply Agency, Older People and Disability Division, The Department of Health. RADAR, The British Polio Fellowship, The Multiple Sclerosis Society. The British Council of Disabled People, The Limbless Association. Jim Dobbin MP. Jonathan Shaw MP. David Crausby. MP
Introduction.
Summary of previous reports.
Minutes of a meeting of the NHS PASA Orthotics External Reference Group (June 2005)
Summary of Investigation (items 1-9).
Recommendations.
Conclusion.
Investigation.
1. Impact of poor footwear and service on the disabled person.
2. Impact of the current system of contracts on manufacturing companies.
3. Impact of the current system of contracts for Orthotist services.
4. Skills within Manufacturers of Made-to-Measure Footwear
5. Training of Orthotists working within the N.H.S.
6. The role of Surgical Appliance Managers/Officers within NHS Trusts.
7. The effect of the different clinic systems on Patient Care and Choice.
8. Recommendations from the emPOWER report of February 2000.
9. Case Histories. Miss C. Merseyside. Mr H. Leigh. Mrs C. Lancashire. Mr F. Manchester. Mrs A. Kent. Mr C. Merseyside. Mrs B. West Yorkshire. Mr M. Manchester. Mr W. Bolton. Mr T, Bolton, Ms S, Lancashire
Summary of other contributors. Mr K. London. Mrs D. Hull. Mrs Gray. Mrs Graham. Mrs Williams.
Appendix
1. Contracting for orthotics services (NH Executive 1995)
2. Orthotics in the New NHS (emPOWER 2000)
3. Fully Equipped (Audit Commission 2002)
4. Orthotic Pathfinder (Business Solutions 2004)
5. Curriculum Vitae for Philip J. Taylor
6. Qualifications and Experience.
References.
Letters from individuals (upon request).
Introduction.
Since contracting polio at the age of two, I have had to wear orthopaedic or “surgical” footwear. The skills of the professionals within the NHS and footwear manufacturers during my childhood made it possible for me to lead a full and active life and it was during my years at the Lord Mayor Treloar College at Alton in Hampshire that I was given the opportunity to learn orthopaedic shoemaking.
I have been involved in the manufacture of made-to-measure orthopaedic footwear since passing my City & Guilds Exams at the college in 1971. Since then I have worked in some of the leading manufacturers of orthopaedic footwear up until I started my own business in 1996.
Since 1996 I have produced around two thousand pairs of shoes, most of which have been to people who would have been entitled to free footwear through the National Health Service but have opted to obtain privately for many of the reasons outlined in this report.
I now concentrate on making footwear for more severely disabled people but up till 2007 I was also involved with teaching footwear manufacture to under-graduate Orthotics students at Salford University and working with the Skills Council to identify skills training needs for the future.
I have become increasingly aware that changes to the way footwear is provided through the National Health Service, and the consequences of those changes on the manufacturing industry means that there will be an inevitable shortage of the critical skills needed to sustain production of made-to-measure footwear in the future.
Recently, the Skills Council through their Skillfast programme have recognised the need to preserve and develop the traditional skills which will become essential in the future of the provision of orthopaedic footwear but are without the resources to put together a solution to the problem. Developments in technology and increased mechanisation of footwear manufacture have also had little impact on the industry; it has instead led to complacency within the Council in their belief that this would solve the problem. Whilst every person is affected in a different way by their particular disability, so is the need to impart that individuality into the provision of the care and the skills required to make footwear for their individual needs.
I have written this report for one reason only, to help to promote changes in a failing service in order to guarantee that disabled people will have the service they need in the future. I believe I am able to contribute positively to an ongoing debate on this subject because of my experience as both user and supplier to the service. I am not in a position to take advantage of the possible improvements recommended in this report as I am unable to take on extra work, my current work commitments allows the flexibility I need to undertake my teaching and other related interests. My wish would be that the work that I do now should be paid for through the National Health Service rather than by the individuals who feel their only option is to pay for the footwear they require.
It is inevitable that this report might well fall by the wayside as those mentioned below. If this is the case, collective responsibility for the failure to supply correct and comfortable footwear to those most in need will remain seated firmly with the National Health Service and those charged with the responsibility to change a failing system. In this modern age of litigation and fault finding, I feel the consequences in terms of cost would far outweigh the cost of improvements to the system.
Summary of previous reports. (*see Appendix)
Contracting for orthotics services (NHS Executive 1995) HSG(95)47 *
This report appears to have had little publicity outside the chain of management within the NHS, but makes a series of valid comments on the supply of orthotics including footwear. In the section headed meeting patients needs it states “It is recognised that some patients are prescribed orthoses (particularly footwear) which they are reluctant to use, either because they are uncomfortable or or unacceptable aesthetically.
In the main, the report fails to recognise that there might be a lack of expertise within suppliers to the service, or that there are inconsistencies within suppliers that inevitably affect the level of service and quality available to purchasers.
Orthotics in the New NHS (emPOWER 2000) *
In February 2000, emPOWER, the Charities Consortium of Users of Prosthetics, Orthotics, Wheelchairs, Electronic Assistive Technology and Rehabilitation services and formed by the Limbless Association produced a report entitled “Orthotics in the New NHS”. That report called for the introduction of a National Service Framework for Disablement Services which would include the supply of Orthoses. Despite the support of then Health Secretary, John Hutton MP very little of that report has been acted upon. In the years since the report was issued, little has been done to highlight the situation which continues to let disabled people become further disadvantaged, it seems that because this minority remains relatively silent, the issues which they continue to raise can be ignored.
Delivering the NHS Plan (Secretary for State for Health 2002) Cm5503
The report is sub-headed “next steps on investment, next steps on reform” and is mainly concerned with the reorganisation of the NHS and its performance and accountability.
One of the main elements of the report is the accent on patient choice but as the report is concerned primarily with the structure of the service, it does not attempt to indicate how this would affect patient choice in the supply of orthotics.
Orthotic Pathfinder (Business Solutions 2004) *
This independent report was prompted by the NHS Purchasing and Supply Agency (PASA) who “suspected that the way in which the services were contracted from the commercial sector could be potentially damaging to healthcare delivery but, seemingly, nothing could be done to improve the situation unless the NHS gained a better understanding of demand to enable it to become a more intelligent customer”.
Six trusts took part in the pathfinder project which has made positive and important recommendations that would improve the service to disabled people. However this report failed to identify a lack of skills within the suppliers that would in turn lessen the effectiveness of the changes.
This report is easily the most thought provoking document on the supply of orthotics within the NHS but still fails to fully recognise that both the present system and the proposed changes are reliant on a willingness of the service to accept change and the need to promote skills training within their contracting arrangements in order to maintain quality of footwear and orthoses.
However the report does not look beyond the orthotist in terms of supply into the service, thereby making many of the comments irrelevant as problems with supply of products cannot be addressed within the improvements proposed in the report.
Minutes of a meeting of the NHS PASA Orthotics External Reference Group (June 2005)
Colin Peacock [BHTA] stated that he felt the Pathfinder Report was the best report on orthotics analysis and benefits. There was a general feeling that the Pathfinder Project had run out of steam. There had been no apparent follow up mechanism or changes in direction due to the research. The document seemed to have been dropped when it was published. Denise Thompson [NHS PASA] explained that the draft report put immense pressure on the Department of Health, which caused unease. In the end NHS PASA were unable to put their name to it, which is why it was published under the Business Solutions title.
Summary of investigations (sections 1-9).
As can be seen from the detail set out in the investigations below, the perception of the provision of footwear through the National Health Service is that the system is at best inconsistent but in a great number of cases can be wasteful and that footwear provided is often of poor quality. The cost to the NHS in terms of wasted time and products could easily be saved in the future through adequate training and good practice. Patients have little or no alternative but to accept an inconsistent service.
There has not been a major revision in the provision of footwear through the National Health Service for over twenty years; this is despite the continued acceptance that problems exist within the service.
There are some excellent models of care and supply within the service, but in the main it is accepted that the NHS does not offer an adequate service to people who require footwear. Disabled people may not receive the footwear they require in the future.
The majority of footwear is supplied by companies who have been accepted as an Approved Supplier and who have tendered for contracts with trusts. However there are very few highly skilled shoemakers still employed by the Approved Suppliers with most companies employing semi-skilled workers performing separate tasks.
The National Health Service regularly talks about “patient choice” when discussing services but in reality patients have little choice in the provision of footwear as they cannot choose a particular NHS supplier.
Without change to the existing service it is generally accepted that there will be a further deterioration in the quality of footwear under the National Health Service. The investigations show there is no training package for new shoemakers and inadequate practical training of orthotists in the provision of footwear.
Without change to the existing service it is generally accepted that people with disabilities will be further disadvantaged and disenchanted with the service. With change disabled people may then begin to be confident about themselves and their appearance.
Without change to the existing service there will be a continuing decline in the skills of people involved in the industry. With change, it would be possible to create a skilled workforce capable of guaranteeing the supply of good quality footwear in the future.
Recommendations.
Footwear Vouchers.
1. Patients should be issued with a voucher to the equivalent of an accepted NHS central contract code for the product.
2. Patients would be able to use that voucher using the issuing hospital’s contracted supplier with no surcharge over the value of the voucher.
3. Patients would be able to use that voucher to purchase footwear from an Approved Supplier not contracted to the hospital.
4. Patients will then be liable to pay any difference between the value of the voucher and that supplier’s charge for the product.
5. This would encourage the growth of smaller businesses with the specialised skills required whilst larger companies would be forced into improving their skill base or lose work to those with a higher skill base.
Charges for footwear.
6. Patients should be expected to pay a reasonable charge towards footwear provided under the scheme if:
7. Their income is sufficient to enable them to afford to pay.
8. If they are being paid for by a charity / other organisation.
9. If they wish to receive extra footwear for cosmetic reasons.
10. A “reasonable charge” should be based on:
11. An average cost of good quality ladies and men’s shop bought shoes, say ladies shoes £75.00 and gents shoes £100.00.
Approval of Suppliers.
12. There is little need to change the approval criteria for larger companies.
13. Smaller companies should have a simpler system of approval to enable them to comply for approval.
14. Approval ratings should be given for product range, skill base etc so prospective users can identify an appropriate supplier.
Patient choice.
15. Patients should be offered a Service Agreement in which it is stated the level of care they should receive.
16. Patients should have a choice of clinic and supplier where a suitable alternative exists.
Replacement of footwear.
17. Patients should be able to have worn out footwear replaced whenever required and not be limited to one or two pairs per year.
Footwear Clinics.
18. Trusts should consider centralised specialist clinics for the provision of complex footwear and orthotics where the various professions can be bought together to assess and offer resolutions to consistent problems. This might well fit into the NHS’s proposed Strategic Health Authorities programme with nine centres of excellence.
19. These could be modelled on existing services offered by the Sheffield Teaching Hospitals Trust and others.
20. These clinics would be attended by orthotists, physiotherapists and rehabilitation specialists, but with the addition of a skilled technician.
21. Modular footwear and simple orthotics might well continue to be supplied within existing clinics
22. Clinics should be encouraged to use local suppliers and services where available.
Skills Training.
23. The adoption of the NVQ programme for Footwear Manufacture will provide a valuable resource for existing shoemakers and new trainees alike.
24. The implementation of a series of Technical Courses in conjunction with Skillfast UK on a national scale.
25. The formation of a Skills Training Body to develop skills training.
26. The compilation of a Skills Register for the UK.
27. The recognition of skills of Experienced Shoemakers through an assessment and award package.
Orthotist Training.
28. An increase in resources allocated to the teaching of footwear modules within University prospectus.
29. The standardisation of the footwear module within the prospectus.
30. Training placements to include time spent with a manufacturer of footwear.
31. Periodical reviews of footwear manufacturing methods and materials.
32. An increased use of case studies within the prospectus.
Management of Contracts.
33. Contracts should not be extended past the three years without the opportunity for newly formed companies to tender.
34. Smaller specialist suppliers should be encouraged to tender for specialist service contracts.
35. Smaller specialist suppliers should be encouraged to link with larger contractors to co-operate in the supply of specialist or complex footwear.
36. Hospitals, Trusts or Authorities should offer Honorary contracts to suppliers when it is found that the specialist service is not available through their contracted supplier.
Conclusion.
The National Health Service is failing a significant minority of patients requiring surgical footwear. This is because the service itself is not always aware that a problem exists and does not have the system, capacity or skills available to bring about suitable resolutions to problems as and when they arise.
Adequate provision for this minority requires close collaboration between the boot/shoemaker and the patient through clinics which include all suitable professionals including the shoemaker. John Lobb (shoemaker to the Queen, Royal family etc) supports this report and writes “A successful fitting shoe requires a close relationship between the customer and the person assessing what is required”. There are few models of this relationship in the NHS.
Investigation.
1. The impact of poor footwear and service on the disabled person.
a. Personal mobility and independence are key factors in helping a disabled person gain self assurance and confidence to lead a normal life.
b. Older people with disabilities have become increasingly dissatisfied with the quality and fit of footwear as the skills shortage effects manufacturers.
c. Younger people with disabilities are often critical at the lack of choice and standard of footwear they receive and opt to wear inappropriate fashionable footwear instead. This impact on the rate of worsening of their disability in later years.
d. Badly fitted and designed footwear affects disabled people’s perception about themselves. Many disabled people hold down prestige and responsible jobs, yet they feel let down by the footwear they are supplied with through the NHS.
e. Disabled people who experience problems with their footwear place an increasing burden on the service through increased attendance of clinics and the numerous alterations to their footwear.
f. Each visit to a clinic costs the NHS many hundreds of pounds but also costs the User in time off work, travel costs and unnecessary travelling to and from hospital.
g. The option of paying for footwear privately is only available to a small proportion of disabled people who hold “commercially equal” jobs.
h. Given a choice, disabled people would wear prescribed footwear if it was of good quality, appearance and durability.
2. Impact of the current system of contracts on smaller manufacturing companies.
a. The current system of tendering for contracts is seen by most as not encouraging skilled shoemakers to tender for footwear contracts with the NHS.
b. The reasons for this could be:
1. The increasing proportion of modular footwear being ordered by the NHS in proportion to made-to-measure footwear.
2. The pressure on companies to tender unrealistic prices for due to competition.
3. The prohibitive conditions required for small companies to tender for contracts.
4. The lack of consistency and transparency in the award of contracts.
5. The reluctance to look outside the contracts for suitable suppliers.
6. The three year Central Contracts are often extended therefore not allowing new or additional companies to join the process.
3. Impact of the current system of contracts for Orthotist services.
a. The current system allows three methods for contracting of Orthotist Services.
b. Trusts can opt to employ their own Orthotists whilst contracting for products only.
1. This system seems to work best in respect of patient care in the opinion of most patients.
2. Orthotists are more likely to seek alternative suppliers for products outside the range of the contract.
c. Trusts can opt to use Orthotists supplied by the contracted supplier.
1. Orthotists may less likely to seek alternative suppliers for products as an alternative to the product range of their company.
2. It can appear to the User that Orthotists may be more likely to consider profit above care when making decisions on product suitability and cost.
d. Trusts can opt to use independent Orthotists.
1. It can appear to the User that Orthotists are more likely to seek alternative suppliers for products outside the range of the contract although they may favour one or more suppliers.
2. It can appear to the User that Orthotists are more likely to consider profit above care when making decisions on product suitability and cost.
4. Skills within Manufacturers of Made-to-Measure Footwear.
a. A more comprehensive report into the continuing skills shortage in the Made-to-Measure footwear industry is the subject of a separate report.
b. There are very few highly skilled shoemakers still employed by the Approved Suppliers with most companies employing semi-skilled workers performing separate tasks.
c. Among the reasons for this could be:
1. The lack of training opportunities/apprenticeships within the industry.
2. The lack of a suitable college/university based vocational course.
3. The loss and retirement of the majority of experienced shoemakers.
4. The closure and absorption of companies involved in made-to-measure footwear.
5. The skilled shoemakers within these companies have little direct contact with their patients.
6. Pressure of contract prices leaves little scope for investment in training.
5. Training of Orthotists working within the Service.
a. There are two Universities involved in the training of Orthotists in the UK.
b. They are the University of Salford, England and the University of Glasgow, Strathclyde Scotland.
c. Around 50-60 Prosthetics students qualify each year from the two Universities. Many of those student have received little practical experience in a clinic with good work practices.
d. Students will not receive sufficient training in footwear assessment and manufacture to enable them to satisfactorily assess and prescribe footwear.
e. There is no revision of skills once a student has qualified.
f. There is no programme available for students to upgrade their skills in design and manufacture of footwear.
g. Only a small proportion of students will find employment that will enhance their skills.
6. The role of Surgical Appliance Managers/Officers within NHS Trusts.
a. Surgical Appliance Managers within multi-disciplinary centres are best placed to assess both the specific needs of patients and issues relating to appropriate suppliers because of the variety of skilled practitioners they can call upon for products but the lack of training opportunities limits their effectiveness.
b. Managers of Departments have a major role to play in the success of the supply of a satisfactory service to patients.
c. Surgical Appliance Managers are given targets by trusts to meet which often limit their ability to deliver an acceptable service to patients.
d. Surgical Appliance Managers often have to decide not to offer a specific service or product to because of financial restraints.
e. Surgical Appliance Managers do not always refer problem cases to Patients Services Managers or Clinical Assessment Managers.
7. The effect of the different clinic systems on Patient Care and Choice.
a. Patients who attend a Multi-Disciplinary Centre (i.e. Specialised Mobility and Rehabilitation Centre or similar) are far more likely to receive a service or product that matches their needs because of the input to the care package from a variety of professionals including an Orthotist, a Physiotherapist, a Rehabilitation Consultant and sometimes a Technician.
b. Patients who attend a Multi-Disciplinary Centre (i.e. Specialised Mobility and Rehabilitation Centre or similar) are far more likely to receive improved after-care and regular follow-ups following their initial care package.
c. Patients who attend smaller clinics are less likely to see other health professionals who might improve the assessment of the patient and are less likely to receive a satisfactory level of after care and follow-up following their initial care package.
8. Recommendations from the emPOWER report of February 2000.
a. emPOWER believes that there is a need for additional resources for education and training, research and development and time spent with a patient, in order that Users of an orthotic device may have a guarantee of excellence.
b. emPOWER and its members hear many complaints from wearers of Orthoses about the discomfort they suffer on a daily basis.
c. From the case studies received from emPOWER members, there appears to be a high level of dissatisfaction and frustration with Orthotics services.
d. The problems of an inconsistent service provision, poor quality equipment and poorly trained professionals are problems Users face all of the time. The complaints of inconsistency which appear to recur include (where they relate to footwear):
1. Number of pairs of orthopaedic shoes provided.
2. Standard of comfort and care.
3. Willingness to refer to others if the problem cannot be solved.
4. Waiting times for repairs.
5. Poor quality repairs.
e. There are significant and expensive variations in practice with regard to the provision of disablement services.
f. There is a growing consensus that current arrangements for the provision of disablement services are inadequate. The specific concerns highlighted here on Orthotics need to be addressed.
g. The variations are affecting service provision quality, performance and cost effectiveness, and the independent mobility of users.
h. These failures are costing the user, the NHS and the Government money.
i. There is a need for a national focus on disablement services as a whole.
9. Case Histories.
The following summaries are accounts of my involvement with clients who have come to me as a result of experiencing problems with NHS supplied footwear.
Miss C. Merseyside. Miss C. suffers from the late effects of polio “LEP” and for the past ten years has had increasing difficulty with the management of her condition. After many years of wearing NHS prescribed footwear, she opted to have her boots made privately and this made a significant and positive impact on her mobility.
The progression of the LEP meant that recently Mrs. C. sought advice on her worsening knee and ankle problems and it was recommended by her local Trust that she reverts to wearing a full length leg calliper and that they make her new footwear. When I saw her it appeared clear to me that the calliper and footwear was so badly made that they were greatly exacerbating the problem.
The boots, which were measured and for which a plaster cast was taken bear no resemblance to the shape of her foot and ankle and therefore she is unable to wear them.
The calliper can only be worn with the boots I have previously made for her privately, but as the weight bearing aspect of the calliper has been misjudged, Mrs C. is hardly able to walk around the house in which she feels confined to. She is reluctant to complain to the Trust because she feels they are not listening to her concerns and do not have the skills and resources available to get things right. She is now looking to have a new calliper made privately too.
Mr H. Leigh. This gentleman has suffered from arthritis in both ankles for the past 20 years; he is now over 50 years old. He suffered further damage to the 5th metatarsal bone in the left foot in 2000 which never healed properly. In 2001 he suffered a further break, following an accident at work. This injury to his right ankle was originally diagnosed as a sprain but in 2005 was re-diagnosed as a fracture; in the mean time the collapse to the ankle had become more severe.
In September 2005 Mr. H attended his hospital to be measured for footwear. The boots were completed in April 2006. Since then he has attended the hospital approximately 8 times for alterations and repairs.
In August 2006 Mr. H was advised by his employer to seek my advice. It is my belief that the footwear provided was totally inappropriate for the nature of the disability and was indeed causing increased damaged to the right foot. Mr. H had in fact reverted to wearing his own boot on the left foot which he considered to be giving him more support than the NHS supplied boot. He has now received two pairs of boots made privately that have provided the support and comfort he needs but has been told he cannot have these boots paid for by the NHS.
Mrs C. Rochdale. This lady of 87 years of age was first prescribed shoes through her Trust before I saw her. However she found they were uncomfortable from the beginning. The Trust then authorised a second pair to try and solve the problems but still without success. She came to me for help and the trust agreed to order a pair for her. The Manager of the department informed me that this lady “was going to complain about anything and everything” when confirming the order but her new shoes were a big improvement on her previous NHS footwear, she felt that she had now got a pair of shoes that would be comfortable.
There were some teething troubles with the new shoes and insoles, made worse by the patient’s age and changes in her feet, but the trust ordered a second pair from me and she was told she should now discard the first pair.
When Mrs C. then asked for a further pair of serviceable shoes (to replace the original shoes), the manager of the Department said that she would have to go back to the original supplier for future pairs. A pair was then made for her by them but after nine months and many fittings and alterations the shoes were found to be totally unsuitable.
Despite letters of support from her local Member of Parliament, her GP and others who had concerns over her treatment, the hospital refused to sanction a further pair to be made by myself. Eventually her case was forwarded to the Treatment Advisory Group in her area who considered that Mrs C.’s treatment by the Trust had been correct and that she should continue to receive shoes made for her by the original contractor to the Trust despite the continuing problems making her comfortable shoes.
Mrs C. felt her only option was for me to make her another pair at her own expense. The new shoes were supplied by me within five weeks and instantly comfortable. Her GP is now actively assisting Mrs C. in appealing against the decision of the Treatment Advisory Group.
Mr F. Manchester. This gentleman suffers from Charcot Marie Tooth disease and diabetes as a result of which his feet are among the most deformed I have ever had to make footwear for.
When I first saw him he was wearing boots which he found comfortable but heavy and which occasionally caused ulceration of his feet. They were being made for him by a shoemaker who he had found but was not contracted to his trust. The shoemaker was however disinterested in making one off shoes and Mr F was faced with many journeys of 60 mile round trip to have alterations and repairs done.
He came to me around 10 years ago and we have maintained a good relationship. Mr F has confirmed that the shoes I have made have drastically improved his life. It was the first time that he had ever been able to walk without pain. Neither did he have the recurring ulcers that were so much of a problem. His comments as follows ‘I didn’t know that it was possible to have such comfort. It has changed my life completely’.
In January 2006 he approached the NHS hospital which had supplied my footwear for a new pair of boots, he had not had a pair on the NHS for three years. He asked for the order to be sent to me aware that I was already making footwear for other NHS hospitals. He was told that this could not be considered at the time because the hospital trust was negotiating a contract with a new supplier. Although the appliance clerk advised him he would be informed when the contract was concluded. Mr F was left with a feeling that he had been bullied and intimidated by the attitude of the hospital
Mr F eventually spoke to the Manager for Clinical Professions who arranged an appointment in May to attend a clinic to be examined by an Orthotist. This Orthotist was a Director of the company which was awarded the NHS contract to supply footwear, therefore hardly independent. However, he immediately agreed that he did not want to make my boots as this would be too difficult and time consuming and would agree for them to be made by the supplier who had made them privately.
To my mind this backs up the belief that the NHS contractors can “cherry pick” the easiest and most profitable work. The severely disabled have to find the best solution for themselves, usually to have the footwear made privately.
Mr F also wrote: ‘It is also my opinion through many years of experience (fifty years) with many companies which have supplied me with useless boots on the NHS that no Orthotist can communicate the instructions to make footwear for people with severe disabilities. This can only be done by the person experienced in making the footwear”.
Mr F. has now received 4-5 pairs of NHS boots over the past 10 years at a cost of around £3500.00 plus clinic time, footwear that he cannot wear.
Mrs A. Kent aged 59 writes “Having had Polio at the age of two months I have had to wear a calliper and surgical boots. The poor appearance of these boots had a significant impact not only on comfort in walking but the negative psychological impact on my self image.
From my mid twenties onwards I chose to but ready made boots but they had to be two sizes too big to accommodate my calliper. As they did not fit they caused problems and I had to buy new ones regularly as they quickly became distorted. When I joined the British Polio Fellowship and saw an advertisement for the Cordwainer I decided to buy some hand made boots. What was so refreshing was that there was someone who completely understood my predicament having had polio himself.
The boots he made for me were exceptionally comfortable, extremely well made and looked good and I bought several pairs. As I am in full time employment I had the opportunity to pay for these but high quality boots like this are not cheap and I chose to ask my local NHS hospital to make me a pair of boots hoping they would be of an equal standard. Unfortunately I was extremely disappointed. The boots did not fit despite several fittings and they were also very uncomfortable and caused pain when I walked. Inevitably they have stayed in the back of a cupboard.
I had heard that patient choice would be coming to the NHS and The Cordwainer provided me with a comprehensive leaflet to give to my local hospital. Despite my letter and phone call they informed me that I could not be provided with footwear other than through the company with whom the hospital had the contract. I contacted my local MP who has written to the head of the Primary care Trust to make enquiries on my behalf. He forwarded the response and I am in the process of responding to that letter.
I am due to retire soon. I do want to have footwear of a high standard, something that will clearly be even more important as I get older. I have paid taxes for almost forty years and I feel that in being disabled I am being financially penalised. No one I know has to pay £500 for footwear; if they do it is because they can have several pairs for my one. I do think that I am entitled to have footwear made by someone in whom I have confidence and who can provide the high standard I require”.
Mr C. Merseyside. Mr C. has had a number of pairs of shoes made privately by me after experiencing difficulty in convincing his hospital for the need for surgical footwear. His hospital were reluctant to use any footwear manufacturer who remained outside of the national Contract but eventually agreed to purchase shoes through me at of Mr C.’s request.
Mr C. is able to visit me personally to undertake fittings and repairs, thus guaranteeing a successful service to him. This is particularly important as it enables changes in the foot to be accommodated more quickly with Mr C. not having to manage without footwear for long periods.
Mrs B. West Yorkshire writes “I have been disabled since having a stroke at the age of 19. Up until about 8 years ago I have managed my walking without to much difficulty by purchasing very flat shoes. However, over the years because of the weakness in my left foot and leg some deformity has resulted making it impossible to wear ordinary footwear. This was brought to the attention of my consultant who referred me to the relevant department in my local hospital. After many months of persistence I finally managed to get an appointment. The result of the assessment was to shape a piece of rubber to fit inside an ordinary sole which I was told to stick with some elastoplasts. This ‘wedge’ caused more discomfort and pain that it was impossible to walk more than a few steps. The next thing was to build up a wedge on the outside of the sole and heel, once again not satisfactory, pain in my leg, foot and back caused mobility problems. Their answer to my problem as far as they were concerned was a leg brace. No mention was made about making me a pair of shoes.
I found myself a private supplier who recognised the problem straight away and made me a pair of shoes I could walk in. when I went back to the hospital I showed them the shoes and was told immediately that there supplier could not do anything like that. I then asked if it was possible for them to sanction my shoemaker (who does not work for the N.H.S) to make my shoes in future, the reply was no. The Trust has its own supplier and cannot sanction footwear from anyone else. This I do not understand, because if they cannot supply me with suitable footwear which allows me to walk, what are they doing.
I am now dependant on adapted footwear which the N.H.S are unwilling to supply, perhaps this means they lack the technical competence or is it simply down to money I’m not sure which but I find this attitude unhelpful, condescending and high handed. I am not asking for anything fancy, just to be able to walk. Is that to much to ask.
Mr M. Manchester. For around fifty years this gentleman has worn an O’Connor Extension to accommodate his leg length discrepancy. He recently asked his hospital for a replacement appliance and was told “their supplier did not have a person with the skills to make this appliance”.
Mr M. informed the hospital that he knew that I had the skills required to manufacture this appliance but was told he would have to revert to wearing a normal shoe with the addition of an outside cork raise, this he felt was totally inappropriate for his needs.
Mr M. approached me with the intention of purchasing the appliance privately and I wrote to the hospital outlining his wish to be able to make the appliance through the NHS. The hospital failed to contact me the appliance was made privately at a cost of around £500.00.
Mr W. of Bolton has had a number of pairs of surgical boots over the past 15 years through his local hospital. Now into his eighties he has decided he would have to have his footwear made privately if he was to be comfortable during his later years.
His most comfortable shoes were full of holes and extra padding whilst his latest pair were totally unsuitable. It was clear to see that there was no accommodation for his collapsed ankle within the boot. Another boot had to have the toe stiffener removed by a cobbler to make to make wearable.
Mr W. asked his hospital if they would consider asking his private shoemaker just 15 minutes away to make his footwear in future. They instead took the decision to have his footwear manufactured by another independent shoemaker 50 miles away, a decision which astounded Mr W. as the hospital had already used a number of NHS contracted manufacturers previously without success. Mr W. has decided to continue his arrangement with the shoemaker whom he can visit at will for fittings and alterations but has also agreed to let the hospital make a further pair through the NHS.
The boots made for him by the hospital were completed but were un-wearable as they provided no support and cause much pain. Mr W. asked why the boots could not be made the same way as the pair he had made privately and was told his NHS boots would be altered to match the sample pair. Instead the boots were altered without any reference to the successful boots and the boots remained un-wearable.
Mr W. has now received a further pair made privately and says there is little point in returning to wearing the footwear provided by the NHS in the future.
Mr T. Bolton. A shoemaker himself, he is also disabled and has to wear surgical footwear. For twenty five years he had been able to make his footwear himself as he worked for companies contracted to the NHS and various hospitals. For the past ten years he has ran his own business of which 10% of all it’s work is directly paid by the NHS. His local hospital have now told him that because he does not have a contract with them, he can no longer be paid by them for the footwear. In October 2006 they agreed to have a pair of boots made by their contractor but after eight fittings these boots were scrapped without being finished. To date no arrangements are in place to supply another pair.
Ms S, Lancashire. This lady suffers from Proteus Syndrome and is unique due to the size of her feet and the sheer weight and volume of the boots required to give her any mobility (her legs and feet weigh around 11st). Her last pair we completed in 2003 and a replacement pair was ordered in November 2005. This pair were scrapped and restated in 2006 after a number of fittings and alterations.
In October 2007 Ms. S ordered a pair to be made privately and these were completed in May 2008. During the period these were being made she had further fittings on her NHS boots which again were scrapped without being worn, telling her that the boots are to be remade again for a third time.
Ms S. asked the hospital to consider funding the boots she had made privately at a cost of £2000.00 but they refused stating the NHS were still making boots for her.
For the purposes of compiling this report I sought the experiences of other users through a letter to the magazine of the British Polio Fellowship. The following are a sample of the many letters received.
Mr K. London writes “in 2002, on holiday in Italy, I overstrained my last two wearable shoes and became virtually immobile. Around the same time I had yet another failure of shoes ordered privately. The shoemaker (also working for the N.H.S) confessed that he had never heard either of ‘clubfoot’ or of the cuboid – which may well have contributed to his failure.
More recently, an Orthotist persuaded a private shoemaker to make shoes for me irrespective of the number of fittings required. This he has done with infinite patience and two pairs are slowly emerging which have greatly restored my mobility and may eventually, become fully suitable. Once I get a satisfactory pair done, I am promised two more to be paid by the N.H.S”.
Mrs D. Hull writes “I have had problems with surgical footwear since I left my native city (Glasgow) in 1970 and moved to Hull.I am a polio victim since was 3 months old I was born in 1950. Both my legs were affected (waist to toe) I wear a below knee plastic splint on my left leg. The right shoe has an inch raise and a Thomas heel.
My shoes got really bad about 25 years ago. I used to get them made [name] but now they’re made at [name]I went to see them last year, I asked for some moccasin style shoes they looked like the shoes elf’s wear so I decided to pay the shoemaker a visit. It seams to have done the trick if I don’t like the shoes I get, I don’t sign anything then they don’t get paid until they’re sorted.
Mrs D. wrote the following to her supplier. “This is another complaint about my blue surgical shoes that you dyed and put new soles and heels on. When you stripped the other sole and heel unit to put the new ones on, it looks like you have not gathered enough leather underneath the sole part, because my shoes are now at least two sizes too big. All the blue dye comes off and spoils my tights; I have just got the shoes back after about six weeks in all. [Name] have fixed my wedges as it should be. How do you manage to do all silly things? I am not the only patient to complain; as I found out at the [name] everyone I spoke to had a complaint. How do you justify being called a surgical shoemaker”?
“I have kept all the shoes in the past three years that you have made me, every pair is a disgrace. Do you not care about the unfortunate people who have to wear these shoes. All your shoes have done for me is spoil my appearance and make me look more crippled than I really am. I have four pairs of you surgical shoes at home and every right shoe has a different version of my surgical wedge I was prescribed”.
Mrs Gray writes “I hold a full time job and have done so since leaving university. I am very independent and do not intend to go into a wheelchair until I am in my dotage. Therefore you can imagine that shoes that are comfortable are an extremely high priority”.
Mrs Graham writes “I find it degrading having to ask for new shoes and trying to make them last a year, then I get offered shoes out of the ark”
Mrs Williams writes “I have had problems with footwear for ten years now and now I have to buy ordinary shoes which are unsuitable but necessary”.
P. Marshall writes “In May 2005 I required a new pair of shoes as my existing shoes were no longer repairable. After waiting several months my so called “made to measure” shoes were ready for a fitting, only to find that my left shoe was two sizes too big. [name] said they must have used the wrong last and proceeded to make the shoe smaller. After several months of waiting the shoe was finally ready for another fitting. This time the shoe was too small. [name] then tried to put the blame on the hospital fitter and said that the hospital would have to pay for another shoe making”. “It is now fourteen months since the original shoes were ordered and they are still not wearable”.
Mrs Lumley writes “My first pair of footwear had to be sent back as being totally unacceptable, I had to be re-measured. The next time again the footwear was not quite correct. I even gave them a pair of my old footwear made by [name] to use as a template”.
Mrs Parry writes “Over the last 15 years I’ve been wearing Orthopaedic shoes made by the N.H.S. All has been going well until about 3 years ago when the N.H.S changed the people who made my shoes since then I have been totally disappointed. It does not matter how many times I go back to the hospital for them to try again they can not get my pair of shoes right. All they needed to do was copy the old pair as a pattern but no they keep saying they need to start fresh from my old company and cannot copy. What a waste of time. I am still wearing my old shoes from over three years ago which are falling apart. The new ones are too painful to wear”.
Mr Seaman wrote to the Parliamentary & Health Service Ombudsman following his complaint about the replacement of his worn out footwear. He wrote “When contacting the hospital I explained my shoes were now in a dangerous state and were putting my health at risk, not just that they were worn out”. Although his request for footwear was eventually granted, he felt he had no alternative but to seek to have footwear made privately and seek re-imbursement of the cost at a later date.
Unfortunately, Mr Seaman had not followed correct procedure and was refused a refund, but the ombudsman agreed in principal that his case was not managed entirely satisfactorily by the various bodies involved.
APPENDIX
1. Contracting for orthotics services (NHS Executive 1995)
The Audit Commission produced a report into the supply of services to disabled people in 2000, this was updated in 2002. The report only referred briefly to the provision of orthotics and footwear, relying on two instances of good practice and general comments on service provision.
The main points in the report were:
Good Practice.
Para 107. A project at the Royal national Orthopaedic Hospital is seeking to modernise orthotics service with the introduction of computer-aided design and manufacturing (CAD/CAM).
2. Orthotics in the New NHS (emPOWER 2000)
The Audit Commission produced a report into the supply of services to disabled people in 2000, this was updated in 2002. The report only referred briefly to the provision of orthotics and footwear, relying on two instances of good practice and general comments on service provision.
The main points in the report were:
Good Practice.
Para 107. A project at the Royal national Orthopaedic Hospital is seeking to modernise orthotics service with the introduction of computer-aided design and manufacturing (CAD/CAM).
3. “Fully Equipped”. Audit Commission; update 2002.
The Audit Commission produced a report into the supply of services to disabled people in 2000, this was updated in 2002. The report only referred briefly to the provision of orthotics and footwear, relying on two instances of good practice and general comments on service provision.
The main points in the report were:
Good Practice.
Para 107. A project at the Royal national Orthopaedic Hospital is seeking to modernise orthotics service with the introduction of computer-aided design and manufacturing (CAD/CAM).
The report proceeds to describe the benefits of CAD/CAM over traditional manufacturing methods; however the bias towards CAD/CAM is significantly overplayed. CAD/CAM can only replace more of the straight-forward work which could be directed towards modified stock footwear or simpler bespoke footwear. CAD/CAM could not replace the higher level of skills required to take on the more complicated work involved in cases where patients needs are not being met.
The cost of implementing a CAD/CAM system can only be justified by companies, who in effect are able to mass produce footwear, not by the smaller companies with highly skilled shoemakers producing the highly specialised footwear.
Para 108. A further example of innovative practice is found at East Lancashire NHS Trust, where the trust has included two users on the panel that is responsible for re-specifying and tendering orthotics service in Blackburn and Burnley. The procurement manager believes that they have brought a unique perspective to specifying the new service and the tendering process.
This is seen as an important step forward and I understand this is becoming policy in an increasing number of NHS trusts.
Additional recommendations of this report.
Exhibit 16.
Strategy. Integrate policy with other strategies, for example, home adaptations; disabled facilities grants; direct payments; voucher schemes.
Tactics. Ensure that additional funding for equipment is spent as intended. Establish a national centre or forum to deliver the strategy. Commission integrated services through hub-and-spoke models.
These points highlight the areas within the summary, investigations and recommendations of my report.
The implementation of Fully Equipped’s recommendations.
Recommendations.
Managers need to ensure that their trust chooses a model of orthotics services that is rationally based, and has sufficient throughput to ensure high quality service. Stand-alone orthotics services dealing with fewer than 150 patients a week are probably too small to be viable, both in terms of quality and cost.
It has been proven over the years that scale of service and economy are often the prime cause of poor quality in footwear manufacture through the NHS. The past twenty years has seen an 75% decrease in the number of companies supplying to the NHS as smaller companies are absorbed by larger companies. The high number of highly skilled shoemakers lost through retirement and closure lost in that time has resulted in companies employing only semi-skilled workers for much of the process.
Trusts should use NHS Supplies national framework agreements, unless they can clearly demonstrate that better value for money can be achieved by purchasing elsewhere.
It should be noted again that the most highly skilled shoemakers often work for companies who wish to remain outside the national framework agreement, instead opting to work with trusts who recognise their work as valuable. Those companies are not encouraged to participate in the national framework.
4. Orthotic Pathfinder (Business Solutions 2004)
“For many years NHS orthotic services have been a poor relation in healthcare delivery, hidden away in secondary healthcare system and behind the ‘commercial wall’ that results from being a largely outsourced clinical service. Patients have rarely complained and those most closely associated with delivering the service (orthotists) are unable to challenge the situation for fear of losing their commercial contracts. As a result the service has come under increasing pressure to both survive and deliver quality care to patients and is simply not acknowledged for what it can do for patients”. This introduction to what is a wide ranging and challenging report sets the scene for the need for change within the delivery of an orthotic service within the NHS.
The report acknowledges that part of the problem is “The Orthotic service has consequently suffered from being a low priority service deprived of resources and has struggled to deliver a clinically effective and high quality service in the face of growing demand”
The report constantly refers to the orthotist as being the provider of the service without reference to the commercial structure the orthotist relies upon to deliver the service. The report also seems to assume that all orthotists are trained to both an individual level and across the board to a high enough standard to deliver the required quality of service and product. This is clearly not the case in practice.
The report states that one of the benefits of resolving this problem is “For many patients, particularly the elderly, improved orthotic services will have a huge impact on quality of life by enabling them to maintain themselves as independently mobile citizens”. It adds “For the Government, with the proposed co-ordinated health and social care approach, the quality of delivered care will be improved and the ‘health of the nation’, particularly in the elderly, will benefit. In addition there will be a major net annual saving to the Exchequer of approximately £40 million after five years rising to £390 million in ten years”.
If only 1% the suggested savings were to be reinvested back into training of the skilled technicians and care professionals involved in the supply of orthotics, this would help to guarantee that future promises of quality and delivery within the service could be realised and that manufacturing and employment opportunities would be able to develop over a shorter time scale, leading to a reduction in the deterioration rate of the present.
At a meeting of the NHS PASA Orthotics External Reference Group June 2005, Colin Peacock of the British Health Trades Association stated that he felt the Pathfinder Report was the best report on orthotics analysis and benefits, but there was a general feeling that the Pathfinder Project had run out of steam. There had been no apparent follow up mechanism or changes in direction due to the research. The document seemed to have been dropped when it was published. Denise Thompson [NHS PASA] explained that the draft report put immense pressure on the Department of Health, which caused unease. In the end NHS PASA were unable to put their name to it, which is why it was published under the Business Solutions title.