NHS prosthetics review by Dr Andrew Murrison

24th October 2011

The report by Dr Andrew Murrison – A Better Deal for Military Amputees has been accepted by the Government. The report, which was submitted at the end of June 2011, makes 12 recommendations to honour the Armed Forces Covenant and to benefit the wider amputee community.

Dr Murrison said “I am delighted that my report has been accepted by the Government….. …The rapid roll out of the recommendations I made last year on veterans mental health has been impressive and I look forward to these latest proposals being progressed with the same enthusiasm. I hope the action points I have offered honour the military covenant and benefit military amputees but I have been clear that they should also help to improve the service available to all limb centre users”.

Recommendations

The key recommendations of the report are that:

  • there should be specialist commissioning of prosthetics and rehabilitation through five centres in England to cater for those veterans leaving the armed forces;
  • veterans should be able to access mainstream NHS provision through a Disablement Services Centre (DSC) of their choice;
  • The National Institute for Health and Clinical Excellence (NICE) should be tasked with the production of national guidelines for prosthetic prescription and rehabilitation for all amputees;
  • There should be a programme of military /civilian exchange for healthcare professionals to grow the specialist prosthetic and rehabilitation network rapidly.

The report notes that the care package currently available to the armed forces (the Defence Medical Rehabilitation Programme (DMRP) and its consultant based Complex Trauma Teams) has no equivalent in the NHS. It also notes that the DMRP is aimed at delivering optimal functional recovery, regardless of an amputee’s likely future role. This is an extension of the “no disadvantage” view expressed in the military covenant.

By way of example, the report states that 100 C-Legs were fitted in the UK during 2010; 62 of which went to Headley Court and 11 to the NHS. It also notes that service personnel can expect to receive 6-8 hours of physiotherapy a day for 5 days/week while the NHS can only provide 2 hours/week.

For these reasons, concerns have been voiced by both service personnel and staff at DSCs that the level of care and the provision of prosthetics would not be able to be met by the NHS. This led to the Murrison Review.

Other observations made in the report include the view that while military personnel are managed in accordance with “no disadvantage”, other users should not be disadvantaged as a result. This assumes that the DMRP would be more likely to be replicated at the specialist centres for the benefit of suitable NHS patients. It also recognises that the lack of national guidelines for prosthetic prescription leads to geographic variation in provision (i.e. the postcode lottery).

Our view

The report is to be welcomed in that it recognises the potential pressure that the NHS will face if the needs of those amputees leaving the armed services are not addressed; both in terms of the number of high end prosthetics being issued and the approaching expiration of existing high end prosthetic warranties; points clearly acknowledged by the Government in its acceptance of the report findings.

On the face of it, it is also heartening to read that the report recognises that the key to amputee satisfaction is not componentry but socket fit and the relationship between amputee and prosthetist. However, that recognition is made in the context of the number of ex-military amputees currently receiving NHS care and the proportion of those who might be expected to seek optimal treatment at one of the specialist centres.

The recommendation to establish 5 specialist centres in England to make the DMRP practices and measures more available across the NHS are broadly welcomed, but there is an inference in the report that these measures would be accessible by “suitable” NHS patients and that the specialist centres would be the best way to extend DMRP to “…..young, fit amputees….“.

In our view, this has the very real prospects of introducing a two tier system. Those amputees not “requiring” improved rehabilitation and prosthetics, i.e. potentially the majority of the civilian amputee population (depending on the criteria used to determine the need for improved services), will receive a potentially inferior treatment. This would be on top of the existing postcode lottery that serves to limit civilian patients choice due to the funding levels available to individual PCTs.

There are a number of other issues that will potentially arise from the report including

• the sustainable aspects of providing access/transport to the five specialist centres across England;

• The ability of amputees to be able to travel the likely distances involved to reach these centres;

• These five centres with their leading edge treatment and technologies will be very attractive to any prosthetists looking to further their experience and benefit their career. What measures will be put in place to prevent a skill drain away from the existing DSCs?

• Will there be a drive to train and recruit new prosthetists and fitters to supplement the dwindling numbers currently working across the country and to reinforce the skill base that has declined over recent years?  As noted by Dr Murrison, “…..the key to amputee satisfaction is not componentry but socket fit and the relationship between amputee and prosthetist”;

• Such measures do not appear to be being provided by the Governments £15M which, in its press release to support this report, states is being invested to support the recommendations of the Murrison report to improve services for military veterans;

• While the report notes that NICE should be tasked to develop national guidelines for prosthetics and rehabilitation, there is no timescale identified, and importantly, no budget to allow PCTS to meet such guidelines;

Summary

While there is a clear need to address the issues surrounding ex- military amputees and how their needs can be met by the NHS, the Limbless Association is concerned that the measures and recommendations outlined in the Murrison report, which are aimed at preventing increased pressure on services at the existing DSCs, will also serve to create a two tier system to the potential detriment of the majority of amputees in this country.

Press Release

We have issued a press release to put forward our views on the Murrison report and this can be found by clicking here.  The press release is also posted on the APLLG website.