Despite agreement on the benefits of improving orthotic services, most agree it is still a “Cinderella service”. Often a paediatric community orthotic service is an adjunct to the already established paediatric physiotherapy service, with the orthotist visiting and working from within the physio department or specialist schools.
The services however are still a post code lottery; with access, quality and variation in entitlement. The reasons for this are too multi-facetted to dissect in this article, but managers and commissioners still have no consensus on the best economic model, with services still commissioned using a “commodity product” approach with price and volume taking precedence over quality, outcomes and timeliness. The below is not all encompassing, but hopefully outlines what certainly has helped service delivery at some clinics.
Ease of access, not just from a location aspect, but from a referral standpoint. Most services thankfully have moved away from the consultant led pathway where often little clinical value was added, ensuring clients are not delayed in seeing AHP’s in a timely fashion. Easy access to refer and self-referral for follow up episodes once under care helps the clients experience, reduces formal reviews for the sake of it and hugely reduces waiting lists
Paediatric clients have changing needs and require responsive and dynamic orthotics service provision. Defined priority criteria with maximum wait times to meet the needs of patients requiring urgent treatment, alongside correct appointment time allocation for complexity and first assessments are a must at triage. All paediatric clients deserve faster turnaround times due to growth and a common time line across services is a 2 week delivery from assessment. The most surprising disparity is initial wait list time, with some services covered offering an appointment within a week and another 4 months. This is simply not good enough for a growing child.
Again to compare two clinics, one has a very effective comprehensive pathway with pre orthotics encompassing a physio only led assessment, + / – simple 2D gait analysis, lower limb measures. A gait report is then shown to orthotist for opinion; joint summarised for probable treatment plan before any orthotic appointment is given. The joint appointment then with physio has clear goals with no uncertainty of treatment direction due to the earlier work, followed by post orthotics encompassing tuning, further gait analysis with outcome measures, repeated as necessary. It has taken children out of orthoses that demonstrate little clinical and functional benefit and screened those who will progress no further on pathway if deemed unsuitable for orthotics. This efficiency has led to a one week wait time. We must be certain what we have prescribed is efficient, tolerated and working optimally, then to share this information with the client and parents to help them understand how conclusions for treatment are reached.
What the above illustrates however is data capture by various means and outcomes. Why not help managers and commissioners by demonstrating evidence and value in order to shape your services. Examples are one clinic preventing decommissioning of lycra by demonstrating efficiency in its selection criteria. Again a similar clinic using gait demonstrated for a select presentation and GMF that for best outcomes the properties of carbon fibre could not be replicated by thermoplastic; this group of clients now benefit from access to custom carbon fibre without financial funding barriers. Audit alongside evidence at another reshaped ASD Toe walking orthotic provision, which resulted in a pathway that bypasses orthotics completely now, resulting in savings that can be reallocated.
One, if not the most important is permanent experienced staff, established working relationships, familiarity to clients and parents, including dedicated admin and physio assistants. The ideal scenario is to work in a MDT setting with the same AHP’s, where a workflow rhythm is established, adding value for the client and aiding accuracy and repeatability of assessment measures. Clinics which rotate attending physio every clinic never flow well and working relationships are hindered. Where possible utilising appropriately trained physio assistants, there supportive role for physio and orthotist make the most efficient use of clinical time and supply slots.
And you? What are your experiences of community paediatric orthotic services? Do you work at a centre of excellence? What are your KPI’s? We’d really like to hear from you…..