HL Deb 14 January 1991 vol 524 cc1057-79

8.10 p.m.

Lord Allen of Abbeydale asked Her Majesty's Government:

Whether they will provide an indoor/outdoor wheelchair for the most severely disabled in the light of the findings of the Disablement Services Authority.

The noble Lord said: My Lords, it is some relief that on this third attempt we are at last able to debate an issue which is so important to some of the less fortunate members of the community. I have to confess that since the last attempt to ask this Unstarred Question I have succeeded in completely mislaying my notes and now have some slight understanding of how Carlyle must have felt. I should like to thank those noble Lords who have put down their names to speak. Perhaps I may be forgiven for expressing my particular pleasure that the list includes the name of the noble Lord, Lord Banks.

The Disablement Services Authority—the DSA—was set up in July 1987 to take over the artificial limb and appliances service run by the DHSS and to integrate the service into the NHS this year. A major responsibility of the DSA is to meet, in the jargon, the short-range mobility needs of people of all ages who have serious and permanent difficulties in walking. In that role it provides a wide variety of wheelchair. The great majority are non-powered, but last year there were nearly 8,500 powered chairs in issue, most for use indoors but some for use outdoors, alas of a rather clumsy and unattractive construction and capable of being used only by an attendant. It is not always the case that a suitable attendant is available. It was the committee chaired by the noble Lord, Lord McColl, which highlighted the fact that there was a serious gap in the provision of wheelchairs by the DSA in that there was no powered wheelchair usable both indoors and outdoors, and that as a result a number of people were s suffering an avoidable lack of mobility or were having to resort to the private sector to buy a chair which they could ill afford.

By some juggling of finances, the DSA succeeded in mounting a pilot scheme in 1989, based on Newcastle and Manchester, involving the issue of some 400 chairs, made by three manufacturers, to people who met certain fairly strict requirements. For example, the individuals had to satisfy the conditions for mobility allowance; they had to be under 65; they had to be unable to walk or self-propel effectively within their home; and they had to meet the eyesight standard required for a car driving licence. I have before me a careful study of the outcome of that pilot scheme, including the answers to a questionnaire sent in by most of those who took part. It is not surprising that the results fully confirmed that the independence allowed by the use of these chairs, the ability to go to the shops or the cinema or to visit friends, made a very great difference to the quality of life. Indeed, it does not require much imagination to see what a difference to one's existence is made by an ability to get around by one's own independent efforts.

Some questions arose which called for further thought. Is it right, for example, to have an age limit of 65? Is it really essential to retain the sight test required of car drivers? There is also the point that if it were possible to adapt chairs to meet individual needs, even greater benefits would flow. In the longer term, there could be problems of repairs and maintenance. There is also the practical question of producing a chair which is small enough to be usable inside the rather modest dwellings of some of those concerned but which at the same time is strong enough to mount the kerbs which are met with outside, perhaps when a carelessly parked car prevents the use of a graded entry to a pavement. But obviously the overriding problem is that of cost. A basic non-powered chair costs about £130. A new electric indoor chair costs about £750. But the cost of the chairs used in the pilot scheme came out at £1,500 to £2,000.

The DSA put in an interim bid for £10 million, for the present financial year, for an expansion of the scheme. That bid was not successful. But Mr. Kenneth Clarke, when Secretary of State for Health, managed to find £1 million from somewhere for additional indoor/outdoor powered chairs in the northern and north-western health regions. It is worth quoting what he said when he announced this grant at the Manchester disablement services centre last May. After expressing his delight at being able to make the announcement, he said: During my visit today I have met severely disabled people who have been using these chairs during the pilot study. I have seen for myself the way in which they can improve the quality of life of many disabled people. Most of us take for granted the freedom to collect our children from school, go to the shops or visit friends but for the severely disabled that freedom does not usually exist. This additional money will help around 450 disabled people to enjoy some of that freedom". The problem is the difference between on the one hand, this extra 450 in two regions and the 200 under the pilot scheme and, on the other hand, the possible total, including the over-65s, for the country as a whole. We may be thinking in terms of numbers well in excess of 20,000.

When the functions of the DSA are transferred to the regional health authorities in April, there is to be a ring-fenced budget for the first two years. To judge from Mr. Clarke's statement, the Government were well aware of the merits of these chairs, and the DSA sought the inclusion of the sum of £53.25 million in the ring-fenced budget to allow for the general issue of these chairs from 1991–92 onwards. This was a good deal more than the previous total budget for wheelchairs.

In the event, I now understand that this bid has not been accepted. Although the ring-fenced budget which is to be handed over is to receive a welcome and substantial increase of rather more than 18 per cent. for 1991–92, the additional sums not only fall well short of what the DSA was asking for but carry with them, as I understand it, no requirement that they are to be used for indoor/outdoor powered chairs. The DSA tells me it hopes that some of the extra money will be devoted to this purpose, but there is evidently no obligation; and it is not to be forgotten that there are other pressing needs—notably the need for more provision for special seating in the ordinary types of wheelchair—which will cost a great deal of money.

Therefore, this evening there are many questions to be put to the Government. I should like to ask some of them and I am sure that other speakers will add to the list. The first is the obvious question of whether they think that the indoor/outdoor powered chair is a good idea and whether the provision of such chairs should be encouraged. Do they share the hope of the DSA that some of the extra money will be spent on those chairs? On what scale do they think that such chairs will in practice be issued on the financial allocations which are now to be made? How is it hoped to achieve a reasonable consistency between different parts of the country? Is any guidance being given about conditions, such as age limits and eyesight tests? Could there be different practices in those respects in different areas? Is there to be any continued research into devising the most satisfactory type of chair?

Further, on a practical point, can those who have been issued with chairs under the pilot scheme funded with Mr. Clarke's £1 million count on being able to keep them and on being able to have them properly serviced and maintained? Anything that the Minister can say of comfort on those issues will be most welcome and will reach a much wider audience than that present in the Chamber this evening.

I shall leave aside for the moment the problem of indoor/outdoor powered chairs. There is a great deal of anxiety about what will happen when the budget for the whole of the wheelchair and artificial limb services ceases to be ring fenced after 1993. There is a fear that there may be a serious risk that some of the money intended for those services will find itself diverted to competing needs. I have asked about prospects in the immediate future for indoor/outdoor powered chairs. I end my speech by going a little wide of my Question by asking what are the Government's plans from 1993 onwards for monitoring this valuable service? Further, how will they guarantee that those in need of limbs and chairs after 1993 will have those needs satisfactorily met?

8.23 p.m.

Lord Holderness

My Lords, I suspect that all noble Lords and noble Baronesses taking part in this debate will wish to join me in congratulating the noble Lord, Lord Allen, not only upon his persistence in the matter but also upon his success at the third attempt in getting a debate on his Question which the Government will be answering this evening.

Although tonight's debate takes place in the shadow of grave and difficult decisions that Her Majesty's Government must take, in a sense I am glad that it did not take place earlier. First, I believe that my noble friend Lord McColl would have been unable to take part on earlier occasions. We greatly look forward to hearing his contribution. Secondly, I believe that the noble Baronesses, Lady Masham of Ilton and Lady Darcy (de Knayth), who are sitting in front of me, would have had similar difficulties. We look forward to their contributions bearing in mind the special insight which they bring to the problem. Indeed, I look forward to hearing all the speeches which will be made during the course of the debate.

As the noble Lord, Lord Allen, has just said, we now know more about the Government's intentions. We also claim that the Disablement Services Authority, which was unanimous and most enthusiastic about these indoor/outdoor chairs, is now further advanced in its whole plan for the future organisation of the wheelchair service. I must declare an interest, in that I am chairman of the authority, which, as the noble Lord said, was a special health authority appointed in 1987 by no less a figure than the present Prime Minister (then serving the Government in a rather humbler capacity) with the remit to manage, to improve and eventually to hand over the service to the National Health Service.

In the report of his working party, which led to the appointment of this authority, my noble friend Lord McColl emphasised the need to provide an indoor/outdoor chair which at that early stage he clearly and wisely saw would transform the lives of men and women with most serious disabilities as well as helping many of them towards useful employment which they could not otherwise take. At the same time, he realised that this would reduce their need for care by providing them with greater mobility. I am sure that the House will be grateful to my noble friend, who is sitting behind me, for being willing to postpone an important journey abroad in order to take part in the debate.

As the noble Lord, Lord Allen, said, the two pilot studies carried out in the north of England convinced the Disablement Services Authority that the provision of such a chair is an objective which must be achieved as soon as possible. Certainly few reports which I have read have reached so unanimous and wholehearted a conclusion. Perhaps I may quote from paragraph 34 of the report. It reads: All the clients reported that the wheelchairs improved their lifestyles, giving them the independence and self-esteem to undertake a variety of activities that would not have been possible without an indoor/outdoor wheelchair". I sometimes think that it may be difficult for able-bodied people fully to appreciate the glorious access to freedom which this new provision will bring to a few thousand of our most needy fellow citizens. It is very easy to take mobility for granted, yet it is one of the most precious gifts enjoyed by human beings. Therefore, as the noble Lord, Lord Allen, said, the authority asked Her Majesty's Government for the resources necessary to provide the chairs. The bid was for a large sum of money—£53 million. The Government have not produced that amount, but they have replied in a rather different way. They have increased considerably in all the regions the allocation for the services which the authority is about to hand over, of which the wheelchair service is an important part.

From the beginning of next April, when the DSA comes to an end, it will be the duty of each regional health authority to try to distribute this increased sum among the districts in its region. By that time, each of those districts will be responsible for the wheelchair service. That has been the aim behind the policy of the Disablement Services Authority for nearly the whole of its short life. Soon after our appointment, members of the authority recognised the fact that the wheelchair service must be brought as close as possible to those who will use it.

I have been encouraged, from a number of visits I have paid to district health authorities now running the service, in the belief that we took the right decision. One hundred and eighty-three of the districts in England are now responsible and the remaining handful will be added before the end of March. So this devolution of responsibility is all but complete, and it is in the districts that the decision to provide indoor/outdoor chairs will be implemented.

Ever if district health authorities do not at first believe that they have enough resources to make this addition to the wheelchairs they are providing at present, I hope that sufficient will be put at the disposal of each district health authority to enable it to bring such a benefit to those in greatest need. Although it is obviously not for the Disablement Services Authority for much longer to provide any guidance at all, I hope that local health authorities will take into account what I might call the social benefit in any priorities they have to decide.

In conclusion, I need hardly add that it will be of great satisfaction to all members of my authority, as we finish the work we were appointed to do, if a large number of health authorities decide in the coming year to lay a firm foundation by means of this addition to the service, for which its most disabled users understandably feel they have already waited very patiently and for too long.

8.32 p.m.

Lord Banks

My Lords, I should like also to join in supporting the noble Lord, Lord Allen of Abbeydale, in raising this important subject this evening. It has been a great privilege also to hear the noble Lord, Lord Holderness, describe the arrangements which have been made for when the Disablement Services Authority, which currently has responsibility for the wheelchair and artificial limb services, transfers this responsibility to the regional health authorities, who will in turn devolve services no doubt to the district health authorities with, as the noble Lord, Lord Allen of Abbeydale, pointed out, a ring-fenced budget for the first two years.

Many health authorities have expressed concern that the level of funding for this service will be inadequate, particularly if the service is to be improved. There is concern also—the noble Lord, Lord Allen of Abbeydale, referred to this—that once the budget ceases to be ring-fenced in 1993 some of the money intended for the wheelchair and artificial limb services will be channelled into other health services which may, in the light of the National Health Service reforms, be given higher priority.

RADAR, the Royal Association for Disability and Rehabilitation, is concerned that this will mean that the wheelchair service will become another Cinderella service and that after 1993 limb and wheelchair users will have to fight high-profile, life-saving clinical services for cash-limited funds. It would appear that a continued ring-fenced budget for the wheelchair and artificial limb services is vital. With the wheelchair and limb budget not ring-fenced after 1993, how will the Government guarantee clients the best quality limbs and chairs which are needed after that?

An extremely important, but often ignored, aspect of the needs of people in wheelchairs is special seating. Again, the noble Lord, Lord Allen of Abbeydale, made some reference to this. Correct seating is of vital importance to people who use wheelchairs, affecting their independence, their health and their state of mind. Someone who is incorrectly seated may, for example, be unable to feed himself. In addition, extra pressure is put upon carers, who will frequently need to adjust the position of the person in the wheelchair. Such dependence upon others inevitably increases frustration and results in a loss of confidence. More worrying still, if incorrectly seated, people with deteriorating neurological conditions, such as multiple sclerosis, can become deformed and suffer an increase in spasticity, a predisposition to pressure sores and joint contractures. The treatment of an average pressure sore costs the National Health Service at least £30,000.

RADAR is extremely concerned about the lack of provision of special wheelchair seating. The Department of Health, in its February 1990 report to Parliament under Section 22 of the Chronically Sick and Disabled Persons Act 1970 recognises the importance of special seating. It says: There are significant increases in the number of projects concerning wheelchairs and seating, underlining the importance of optimising posture and mobility in order to achieve maximum independence and function for physically disabled people". Some of the language in that may seem a little out-dated, but we get the meaning very clearly. They are saying there is more to be done in optimising posture than has been done up to now. A report by the Leonard Cheshire Foundation, based on its residents, shows that over a third of them were badly seated or could be seated better. Information from sources such as the Leonard Cheshire Foundation and the Multiple Sclerosis Society suggests that some 70,000 to 100,000 people are in need of special seating. With wheelchair cushions alone costing from £35 to £350 each and with more sophisticated matrix seating costing around £800, the indications are that some £50 million would be required to provide an adequate service. This is a small sum in comparison with the potential cost to the health service of £3,000 million in the treatment of pressure sores because the correct seating had not been made available.

I understand that the Department of Health has recently allocated £1 million to the funding of special seating. I should like to ask the Minister whether that is correct. If so, this provides only between £10 to £14 per person, and is far from adequate. Will the Government recognise the savings to the National Health Service which would be made possible by the provision of an adequate budget for special seating? The Government are surely committed to improving the independence and mobility of disabled people. Will they back this commitment by making resources available for the provision of powered indoor/outdoor wheelchairs nationally for disabled people who need them and also for the provision of special seating for disabled people who need it? Will they also ensure that after 1993 the budget is used for the purpose for which it is intended?

8.39 p.m.

Baroness Darcy (de Knayth)

My Lords, I am delighted that my noble friend Lord Allen of Abbeydale has struck it lucky the third time round and I should also like to congratulate him on his persistence. I also wish to congratulate him very much on his clear, sympathetic and very comprehensive summary of the indoor/outdoor powered wheelchair situation. May I also say what a particular pleasure it is to follow the noble Lord, Lord Banks, and to have an opportunity to say how pleasing it is to hear his wise and measured words once again.

I am grateful for the kind remarks of the noble Lord, Lord Holderness, but, not being a regular powered wheelchair user, I wondered whether there was anything useful I could add to what the very knowledgeable noble Lord had said and also to what the noble Lord, Lord McColl, could tell us. However, I was spurred into taking part by the informed comments of the Joint Committee on the Mobility for Disabled People, of which I am a member, and by the memory of a magic sense of freedom when a few years ago the noble Lord, Lord McColl, arrived with a prototype of the Squirrel powered wheelchair and I traversed my garden and went over parts where I had never been before. It really did open up new vistas for me. The Squirrel then ran into financial difficulties, but I am delighted to hear that it is now to be developed by Shanning International, because I think it is a chair with great potential.

The Joint Committee on Mobility for Disabled People was delighted at the Disablement Service Authority's initiative in issuing a limited number of powered indoor/outdoor wheelchairs, at the outcome of that initiative, and at the agreement by the Secretary of State for Health to spend an extra £2 million on wheelchair and special seating in the Northern and North-Western Region.

It is generally agreed that the powered outdoor wheelchair currently available, the DSA model 28B, is unsatisfactory. My noble friend Lord Allen has already described it as cumbersome. It weighs over 14 stone without its user and it makes a Dalek look quite neat. It is very difficult to manoeuvre and it cannot cope with steps, thresholds, steep slopes or full-sized kerbs. I am told by a mobility centre that some users return the chair within weeks of issue because they simply cannot manage it. This is hardly appropriate mobility for the 1990s.

The most unsatisfactory aspect of model 28B, which my noble friend has already touched on, is the fact that it is attendant-operated. Mobility should lead to freedom, which goes hand in hand with independence. It also means that the helpers have time on their own too. Physical independence has spin-off benefits: one becomes more independent in other ways. This was a very cheering aspect that emerged from the pilot study. The noble Lord has already quoted paragraph 34. I wish to quote from paragraph 27, which says much the same thing; namely, that the conclusion of the regional staff was that overall the clients were delighted with this type of wheelchair because it considerably improved their outdoor mobility, giving them an improved degree of independence and markedly increasing their self-esteem. The vast majority of clients who participated in the Study were reported to be keen to retain their indoor/outdoor wheelchair. I very much hope—and the Joint Committee on Mobility for Disabled People stressed this too—that this limited issue will rapidly be expanded to cover the whole country. Very severely disabled people's quality of life should not depend so critically on where they live. I also feel strongly that people over 65 should be included, particularly those who are unable to apply for mobility allowance on account of their age.

As has already been mentioned, there is a great deal of concern about future funding when the responsibility for issuing wheelchairs is transferred to the regional health authorities. It will be ring-fenced for two years, but there are grave doubts about whether the funding is adequate to provide the range of wheelchairs and cushions urgently needed. I hope the Minister will be able to assure us that there will be no cutting back of existing services; rather, that the Government will improve the service and take account of modern wheelchair and cushion developments. The whole cushion service is at present under great pressure (there is no pun intended there), but it is crucial that the full range of satisfactory cushions remains available. This is an area in which I can speak with a little more experience and feeling.

It is a false economy, for example, to stop the issue of the more expensive cushions which are most effective in preventing pressure sores—they can cost about £250—because in the end, as the noble Lord, Lord Banks, has said, treating a pressure sore can cost £20,000 or more and mean the occupation of a hospital bed for perhaps 12 weeks, to say nothing of the disruption in the life of the patient and his or her family.

The noble Lord, Lord Banks, has already spoken at great length about special seating, but I should like to say a little about it because it is a very important subject The extra £1 million for special seating is very welcome, and the giving of that extra £1 million acknowledges the importance of special seating. As the noble Lord, Lord Banks, has said, incorrect postures can mean not only pressure sores but, for example, contractures leading to impaired mobility and loss of independence. RADAR and other organisations, including the Multiple Sclerosis Society and the Leonard Cheshire Foundation, are concerned about the under-provision of special seating. They say that funding is far from adequate.

Would the Minister agree to undertake a survey of the number of people in need of special seating so that future provision can meet their needs?

The Joint Committee on Mobility for Disabled People—who I think the Minister would agree is not given to over-reacting —says that it is very worried indeed about the prospects for the service throughout the country when ring-fenced funding ends in April 1993. It would like ring-fencing to continue. Without ring-fencing the wheelchair and cushion services will have to compete for funds with the glamour areas of transplant and heart surgery. The provision of independent mobility and correct seating and cushions may be unexciting, but it enables users to be healthier, more confident and more useful members of the community. It keeps them out of hospital. It makes very good sense practically and financially, as well as in terms of human happiness.

Therefore, I very much hope that the Minister will give some positive and encouraging assurances about the long-term future of the wheelchair service.

8.45 p.m.

Lord McColl of Dulwich

My Lords, along with many others I am grateful to the noble Lord, Lord Allen of Abbeydale, for initiating this timely debate on the subject of powered wheelchairs.

As your Lordships know, the Government became concerned with the services involved in the supply of artificial limbs, wheelchairs and other appliances, and asked me to chair a working party to examine their adequacy, quality and management. I was very fortunate to have the help of an exceptional group of people without whom I very much doubt whether we would have had any success at all. Among others, they included giants such as Mr. Duke Hussey, Sir Austen Bunch and Professor Brian Griffiths, soon to be Lord Griffiths.

It is no secret that there was a certain reluctance among, the disablement services, as they were then, to accept our diagnosis of what was wrong and to accept the treatment that we advised. The report was about to be put on that well-known dust-producing shelf when it was rescued by a junior Minister who really galvanised the machinery into instant action and, as a result, almost all the 49 recommendations were implemented. So impressive was his practical knowledge and concern for disabled people, and so outstanding was his ability to make decisions and actually implement them, that I confidently told many of my friends that he would be the next Prime Minister.

In response to our report, Mr. John Major announced in another place on 17th February 1987 some important improvements in wheelchair provision. Three new types of chair were to be developed, and the wheelchair service was to supply for the first time, as has already been mentioned, special seating systems for those who needed it. However, one of our concerns not covered by that announcement was the supply of indoor/outdoor powered chairs. As your Lordships know, those who need occupant-controlled powered chairs are supplied with them for indoor use only. The indoor/outdoor powered chair is more powerful, more robust and, of course, more expensive.

The question of cost has always prevented the services, while under direct government control, from supplying such chairs. When the Disablement Service Authority, of which I have the honour to be vice-chairman, took over the service it seized the nettle and conducted a pilot study in Newcastle and in Manchester. As we did not know how many of the chairs would be required, we drew up precise criteria for their issue which were simple to apply. From that study we concluded that to provide the chairs throughout England would cost £11 million. If the provision were extended to those above the age of 65, the total bill would be £53 million. As most of us are either moving towards 65 or have passed it, we are increasingly interested in the provisions for more elderly people.

As noble Lords know, by 1st April 1991 the disablement services will be devolved completely to the National Health Service. With its demise, the DSA is able to bequeath resources to its successor health authorities, showing an overall cash increase of more than 18 per cent. in 1991–92, compared with the 1990–91 regional budgets. Some regions will receive 20 per cent. more compared with this year. That gives local health authorities a real opportunity. We reckon that the cost to each district health authority of supplying indoor/outdoor wheelchairs on the criteria which we used in the pilot study would only be about £58,000. If the supply were extended to include those above the age of 65, the total cost to each district health authority would only be £278,000.

I know that some will say that against the background of demands from other parts of the health service now is not the time to proceed with this. To them I point out that the district health authorities have to consider all the needs of the population they serve. The Disablement Services Authority funding will be ring-fenced until 1993 and there is this large step-increase in resources between this year and next. When the district health authorities decide how to spend their wheelchair money next year, I trust that they will have near the top of their priorities these comparatively modest sums. After all, half the population will be disabled to a greater or lesser extent before they die. For most disabled people these chairs make all the difference.

In conclusion, I wish to pay special tribute to the civil servants and the National Health Service officials who have combined in this unique experiment of forming a special health authority with a life of less than four years, charged with taking over the disablement services from the DHSS, re-vamping them, greatly improving their quality and then transferring them to the National Health Service. They will be integrated with the service at district level for wheelchair provision and at supra-district level for artificial limb provision.

Great credit goes to the officials and members of the board, especially to our chairman, my noble friend Lord Holderness, who has been ably assisted by his chief executive, Mr. Melvyn Jeremiah, whose capacity for work seems endless. This has indeed been a success story with which I am proud to have been associated.

8.56 p.m.

Baroness Masham of Ilton

My Lords, I wish to thank my noble friend Lord Allen of Abbeydale for giving us the chance to say a few words on the subject of providing an indoor/outdoor electric wheelchair for severely disabled people ranging between the ages of five to 65 years. This is our third attempt to debate a subject which concerns giving a far greater quality of life to severely disabled people. The most precious quality for anyone is their independence. Until one has lost it, it is difficult to appreciate how important every added bit of independence is to the individual and those who may help him. Thanks should go to all those people who helped with the report. A special thanks should go to the noble Lord, Lord McColl, for the work he did on his report as well as on this one.

Debating this subject at the eleventh hour of the Gulf situation makes me think of the invasion of Normandy. It was because of the expected casualties at that time that the National Spinal Injuries Centre at Stoke Mandeville Hospital was set up for service personnel paralysed in the war. I hope and pray that there will not be a war because with every war come many long-term severely disabled people.

I am very concerned at this time with the closures or pending closures of centres which provide support and rehabilitation for physically disabled people. I have received several letters and a signed petition from the people living in and around Newcastle-upon-Tyne because their only day centre for severely physically disabled people, the Shield Field Day Centre, is threatened with closure as the social services department is short of funds. I have written to the Minister for Social Security and Disabled People and to the director of social services in Newcastle. I await replies. Closures have already happened. The noble Lord, Lord Banks, said that that was a fear. I wish that it were not, but I could give him examples of centres which have already closed.

It was Newcastle and Manchester which undertook this pilot study for indoor/outdoor wheelchairs. I wish to ask why these two cities were chosen. The most important point about the pilot study was that clients who reported said that the electric indoor/outdoor wheelchair enhanced the quality of their lives 100 per cent. One woman who knew that an electric wheelchair would give her the independence and quality of life she needed to remain in the community and stay independent wrote to me several years ago. I contacted her Member of Parliament, who happened to be Mr. Callaghan, now the noble Lord, Lord Callaghan. His secretary was most helpful, giving me the names of voluntary organisations in that part of Wales which I contacted. The lady received her wheelchair and she later wrote to me saying, "I feel I am a bird let out of a cage". She was free to visit the park and do her shopping in the local shops. Surely if there is such a thing as care in the community it must be about enabling people to do as much as they can for themselves. If they can do little, they should be enabled to survive without being incarcerated in their homes.

As founder and now president of the Spinal Injuries Association, I find that it would be totally impracticable for the high lesion tetra- or quadriplegics to use a chair which could not go inside and outside. The very severely disabled people are paralysed from the neck down. The Spinal Injuries Association states: The rules governing the issue of indoor/outdoor chairs mitigate very harshly against our more severely disabled members". When SIA surveyed the tetraplegic members in 1981 it was found that not one of these people used the chair issued by the DHSS. Their comments were that the DHSS chair was not reliable, not comfortable and not suitable for their lifestyle. A person paralysed from the neck down does not want to transfer in and out of a chair more than is strictly necessary; nor will his helper want to lift him in or out more than is necessary. Think of the helper's back when lifting a heavy, totally paralysed person. Thus a chair which will cope with both inside and outdoor conditions is absolutely vital for severely disabled people.

In 1989–90, the Spinal Injuries Association was given a most helpful grant by the Wolfson Foundation to help with mobility problems. It received over 200 applications and was able to assess about 80 people. After she received her wheelchair, one woman said: The wheelchair has taken the strain off our marriage. It gives me the chance to go out on my own and to give my husband a break. It was sheer chance that we received assistance from the Wolfson Fund. If I had not been a member of the Spinal Injuries Association I would still be totally dependent on my husband for my mobility". Organisations such as RADAR, the Multiple Sclerosis Society, the Leonard Cheshire Foundation and the SIA are worried about what will happen when the present service is integrated into the local health authorities' services, as has been mentioned by several of your Lordships. It is vital that there should be the expertise and funding for correct seating. An incorrect, cheap cushion can cause pressure sores, with disastrous and expensive results. The correct seating, as with the correct chair, for the individual is cost-effective in the long run, but its provision needs expert training and for interest to be shown by the professionals running the service.

In many health authority areas the needs of physically disabled people come a long way down the list of priorities. There are often district teams to deal with the problems of the mentally handicapped, but that is riot the case with the physically disabled. Expert advice should be available for all who need it. Disabled patients or clients are often shuttled from pillar to post as they have become a non-priority group. I hope that the Department of Health will not wash its hands of all responsibility, because clear guidelines on good practice and specialised needs should be circulated to all regions and districts.

The provision of an electric wheelchair for indoor/outdoor use is not the end of the matter. A good tack-up service is needed. These chairs need reliable and efficient servicing. There must be a breakdown procedure or people may be marooned in the middle of a supermarket or in an isolated lane. Each district should have a pool of chairs for that purpose. Will there be insurance and maintenance cover? There should be puncture-proof tyres, maintenance-free batteries and the correct seating for the individual, as I have said. The assessment staff should be trained. When assessment takes place, the individual user (the client) should be part of that assessment. The user's needs are the main point of the exercise. Training should be provided for the user and his or her helpers, if they have them. Safety straps should be provided so that users are not thrown out of the chairs when going up or down a kerb or bump. As stated in the report, there should be kerb climbers when needed.

To provide a good package there needs to be proper investment and training and an efficient service for all who need it. Many elderly people feel left out. I believe that many organisations for the elderly could do more for their disabled members. They often seem to forget their neediest members. I hope that Age Concern, the Distressed Gentlefolks Aid Association and other organisations will expand their help for disabled people.

I hope that the pilot study will be extended to all parts of the British Isles so that before too long the people who need these chairs and have no other means of obtaining them will be able to have a suitable chair of their choice.

9.4 p.m.

Earl Attlee

My Lords, it is, as always, a pleasure to follow the noble Baroness, Lady Masham. I must admit that had this Unstarred Question been tabled at the beginning of last year I should have been saying something different. I unfortunately broke my ankle in April and for several months I found out what it was like to be immobile. I was in a wheelchair twice. In one way that terrified me. I would be sitting looking at something when some well-meaning person would suddenly grab the chair. I would be swung around by someone I did not know. I did not know whether I could trust them. Normally I could not.

I hope the noble Baroness will not mind if I tell a little story. It was "white cane" day. She drove up in her car and got out with her wheelchair. I was there by arrangement so that I could help her up the kerb. A well-meaning young man brushed me aside and said that he would help. He grabbed the chair. He headed towards the kerb. I thought, "Oh, my God". Sure enough, he hit the kerb. The noble Baroness mentioned seat belts. My goodness, she needed one! She was jerked forward, and stopped just in time. Looking round at that keen, healthy young man she said in a pained voice, "Please, let Lord Attlee do it, he's an expert". I was pleased by that, although not because she called me an expert. I now realise why she said that.

I was once swung around in a wheelchair. Admittedly I was on board a ship. My right foot, which was heavily plastered, crashed into a pillar. Had it not been for the thick plaster, untold damage would have been done. I had some experience before that because I was a volunteer ambulance driver. I could do that work only at weekends, but I became used to loading and unloading wheelchairs and locking them into position in an ambulance. Therefore, when I read the report I was interested to see that people could load wheelchairs into cars. An ordinary wheelchair with somebody in it is difficult enough to manoeuvre and load into a vehicle when there is a ramp. How anyone can load it into a car beats me. I am glad, therefore, that this debate is not only about powered wheelchairs.

Like the noble Lord, Lord Allen of Abbeydale, I question why there is an age limit of 65, which is the age I shall reach next year. Why on earth does someone in a powered wheelchair have to meet the same eyesight requirements as someone who drives a car? In view of the speed at which the chairs will travel it is clear that one does not need to be able to see 30 yards ahead.

With the greatest respect to the noble Lords, Lord Holderness and Lord McColl, I do not like the report. This may be a personal view, but I dislike any report printed in proportional spacing with the letters crammed together so that an "n" and an "i" look like an "m". I found the report very hard to read.

Regarding the specification of the three wheelchairs, if one has to manoeuvre a wheelchair in and out of houses and up stairs one wants to know how much the chair weighs. The report gives all sorts of information about the wheelchairs but not their weight. I shall not ask the Minister to answer that question tonight because I have a feeling that she does not know the answer.

The noble Baroness, Lady Masham, mentioned batteries. Some wheelchairs are supplied only with dangerous lead acid batteries. The far safer and more powerful gell battery can be obtained, but at additional cost.

Like other speakers I am at a loss to understand why both of the centres where the trials were carried out are in the North. We talk about the North-South divide; there are many differences between the two halves of the country and it is a pity that the report was based on trials carried out only in the North.

Another criticism of the report relates to the number of people involved. While about 58 per cent. of those questioned may have thought that a particular wheelchair was very good, which sounds wonderful, trials involved only about 53 people. Only 6 per cent. thought that the chairs were bad. That is fine, but it means only about six people. Far too few people were questioned to make the statistics anything but airy-fairy.

I should like to conclude with two further points. The first concerns the cushions. It is intolerable that an expensive piece of equipment costing over £1,000 should have a standard seat. As the noble Lord, Lord Banks, said, if one does not have the correct seat one gets sores and can hurt one's spine.

I should like to underline one point concerning special seating. Here I have an interest, admittedly an emotional one. My wife's eldest brother suffers from an advanced stage of multiple sclerosis. My wife and I see him when we can and his mother visits him three or four times a week. When I look at him I wonder how his bottom and thighs feel when he sits all day in his wheelchair.

The report shows that there is a requirement for powered wheelchairs. Any wheelchair gives a certain amount of independence, but to use a muscle-powered wheelchair one needs strong arms, shoulders and hands. Many people who are severely disabled do not have the necessary muscle power. I hope that not only will the Government find sufficient money to provide powered wheelchairs for those who need them but that they will also review some of the unwise restrictions as to age and the need to have eyes like a hawk.

9.13 p.m.

Lady Kinloss

My Lords, at the third attempt the noble Lord, Lord Allen of Abbeydale, has at last been able to ask a most important question of the Government this evening. It is particularly important in view of the nearness of the transfer of the wheelchair and artificial limb services from the Disablement Services Authority to regional health authorities.

RADAR and others are concerned that in 1993, when the budget ceases to be ring-fenced, some of the money intended for wheelchair services and artificial limbs may be channelled into other health services. When the wheelchair and artificial limb budget is no longer ring-fenced after 1993, can the Minister say how the Government can guarantee clients the best quality limbs and chairs, especially those severely disabled people who need indoor/outdoor powered chairs?

The Spinal Injuries Association tells me, as my noble friend, Lady Masham has already said, that a person paralysed from the neck down does not want to transfer in and out of a chair more than is strictly necessary, so that a chair which can cope with indoor and outdoor conditions is absolutely necessary.

In paragraph 82 of the McColl Report it is estimated that there are about 400,000 users of wheelchairs. There are two distinct categories. About 85 per cent. may use chairs for a short time each day, or they may be temporary users of chairs. The second group consists of users who are so severely disabled that they spend many hours a week in their chairs and are totally reliant on their equipment. They make up about 15 per cent. of the total.

While the budget is still ring-fenced, the regional health authorities (or the district health authorities, if they are responsible) will have to decide where the money is to be spent. Will they hope to have perhaps six people in wheelchairs which are used by occasional users or one person who needs the much more expensive indoor/outdoor powered chair? After 1993, when the budget is no longer ring-fenced, how can we be reassured that the regional health authorities will still continue to provide the money for the most appropriate chair for the person's needs?

An extremely important but often ignored aspect of the needs of people in wheelchairs is the special seating which the noble Lord, Lord Banks, and my noble friend, Lady Darcy, have already mentioned. Correct seating is of vital importance to people who use wheelchairs, affecting their independence, health and state of mind. For example, somebody who is incorrectly seated may be unable to feed himself. This causes extreme pressure to be put on carers, who will frequently need to adjust the position of the person in the wheelchair. I am sure the Government would agree that such dependence upon others inevitably increases frustration and results in loss of confidence.

The Department of Health, in its recent report to Parliament (February 1990) under Section 22 of the Chronically Sick and Disabled Persons Act 1970, recognised the importance of special seating. The Government have recently allocated £1 million to special seating, for which they must be thanked, but can the Minister say how much it is costing the NHS to treat pressure sores which result from poor seating?

Perhaps I may ask the Minister one more question. Can she say what consultative mechanisms are planned so that disabled people may influence the wheelchair service in the future, particularly as regards the indoor/outdoor chairs? I hope the Minister can give us some hope when she replies tonight.

9.18 p.m.

Lord Ennals

My Lords, I believe that the whole House and probably all disabled people dependent on wheelchairs will be grateful to the noble Lord, Lord Allen of Abbeydale, for his persistence and for the way in which he presented his case.

I must declare an interest as one of the vice-presidents of RADAR and as President of the College of Occupational Therapists. I am very interested in this question. Not only do I want to add to the praise given to the noble Lord, Lord Allen, who has done so much for disabled people by raising issues in this House and by his other works: I want to express the thanks of all noble Lords for what the noble Lord, Lord Holderness, and the noble Lord, Lord McColl, have done during their period as Chairman and Vice-President of the Disablement Services Authority. I think the appointments, both of which were made by a young man who has since achieved prominence, were very imaginative. Perhaps it was intentional that this debate was delayed until Mr. Major had become Prime Minister and had the sort of authority which would enable some of the anxieties which have been expressed in all parts of the House to be laid to rest.

As the noble Lords, Lord Allen and Lord Holderness, have explained, in April 1991 the functions of the Disablement Services Authority in relation to wheelchairs and artificial limb services will be transferred to the regional health authorities. In turn they will pass on those responsibilities to district health authorities with, as the noble Lord, Lord Allen, said, a ring-fenced budget for the first two years.

With others, I warmly welcome the noble Lord, Lord Banks, back to his place. With his customary fervour he said how much many of the health authorities were concerned about what would happen in terms of the level of funding. We ought to look at the work that has been done by the Disablement Services Authority and at the decision that, after that work and that of the working party presided over by the noble Lord, Lord McColl, we ought to be looking with enthusiasm and hope for the consequences of its work being taken over by the National Health Service. It offers a great opportunity and means that services will be provided by health authorities at very near the level of the people who need those services.

However, it would be an absolute tragedy if, instead of that being a great opportunity to improve the services available for disabled people, it turned out to produce a reduction in the service or indeed not to provide the opportunity for the improvements which modern technology has made available. I know that many authorities are deeply concerned that the wheelchair service might become another Cinderella service and that noble Lords will constantly ask why the services are not being provided. It requires very great determination and will on the part of the Government to see that funds are made available to ensure that the service is properly provided.

As the noble Lord, Lord McColl, said, during 1989–90 the DSA carried out a pilot study in the north and north-west health authorities and 200 powered indoor/outdoor wheelchairs were issued to selected individuals. As was noted at the end of the study, those individuals were permitted to retain the wheelchairs and the Department of Health made available an additional £1 million for that purpose. As the noble Lord, Lord Allen, said, to provide that quality of service in wheelchairs for all those people who need them the DSA estimates that £53 million would be required.

I hope that in response to what several noble Lords have said the Minister will make a very clear statement about the funds that will be available. We ask these questions. With the wheelchair and limb budget not being ring-fenced after 1993 how will the Government guarantee that clients receive the best quality of limbs and chairs needed after that? What arrangements will be made to monitor the wheelchair service once it is integrated into the National Health Service? Is the Minister aware that the level of funding so far is inadequate to provide indoor/outdoor powered chairs and the special seating referred to by a number of noble Lords this evening?

Unless there is a massive increase in the budget, there is a danger that disabled people will be forced into self-propelled or inferior models which can themselves be disabling. We must ask the department what steps it will be taking to ensure regional parity of service so that the service received does not depend on the part of the country in which one lives. I must ask whether it is defensible that certain people in the north and north-west regions should now have possession of powered wheelchairs on the National Health Service and that such vehicles are not available for people with similar needs in other parts of the country. Are the Government prepared to make available the required resources in order to rectify that apparent injustice?

Currently, people who need powered wheelchairs have to buy them privately. Therefore, the precise number of people who own such wheelchairs is not available. However there are some half dozen or so manufacturers of those wheelchairs, each of whom regularly produces new models. It is highly unlikely that that would be the case if the demand were not substantial. At an average cost of £1,800 per chair, it is equally unlikely that people will buy them if they do not genuinely need them, particularly as disabled people tend to be in the lowest income bracket. It is part of the responsibility of the Government, and also of the National Health Service because it seeks to provide a service available to all at the point of need, to seek to provide the best quality mobility vehicles —that is, indoor/outdoor wheelchairs—for all disabled people regardless of their ability to pay. It would be sad if there were a degree of privilege, particularly as disabled people tend to be at the lowest end of the income bracket.

I shall not comment upon special seating because that was fully discussed by the noble Lord, Lord Banks. Under the new system assessment proposes to involve more occupational therapists and physiotherapists. I welcome that provided that the disabled people have a full say. However, we are faced with a grave shortage of occupational therapists and physiotherapists. The noble Baroness, Lady Masham, as a vice-president of the College of Occupational Therapists, is fully aware of that. Perhaps the Minister will recognise the acute shortage of occupational therapists and physiotherapists and say whether more can be done to meet the needs.

Reference was also made to the importance of consultation with disabled people. The Minister was asked about the consultation that she has had with disabled people and their organisations about the integration of the wheelchair service into the regional health authorities. If during the two years from April we discover a fear that after the end of ring-fencing the service might deteriorate will the Minister and the Secretary of State consider extending the period of ring-fencing in order to ensure that the service expands?

I am sure that we all welcome the new traffic lights that have been provided in Parliament Square opposite St. Margaret's Church. However, I have received many complaints from disabled people that the ramp there is so steep as to be dangerous. I hope that someone will hear this plea on behalf of wheelchair users. A sharp ramp can create great dangers, particularly in an area where there is a great deal of traffic. We look forward to hearing the Minister's reply to a short debate for which we are grateful to the noble Lord, Lord Allen of Abbeydale.

9.27 p.m.

Baroness Hooper

My Lords, I too congratulate the noble Lord, Lord Allen of Abbeydale, on his perseverance in raising this Question. I am glad that it has been a case of third time lucky. It is an important subject, as every speaker in the debate has recognised. Everyone can envisage the difference that powered wheelchairs must make to the life of disabled people who need them. We in this House are fortunate in having among us Members with first-hand experience who are sufficiently articulate to put the message across. I listened with interest and considerable sympathy to all the contributions this evening. I assure your Lordships that the Department of Health recognises that indoor/outdoor powered wheelchairs can considerably enhance the quality of life of some severely disabled people. We do what we can to encourage their use.

Perhaps I may first make some comments on the role of the Disablement Services Authority, although much has already been said. We have heard about its role and the excellent work it has carried out. I am very happy to join with the noble Lord, Lord Ennals, in taking this opportunity to acknowledge the work of my noble friend Lord Holderness and his team at the Disablement Services Authority.

As was envisaged at the outset, the authority will cease to exist from this April. However, arrangements have been made between the authority and local district health authorities to ensure a smooth takeover and a continued high level of commitment to those services in the National Health Service in the context of an integrated rehabilitation service. That includes the ring-fencing of services currently provided by the authority for the two years following its abolition. However, I feel sure that the services provided in that area will remain as a lasting tribute to the work of the Disablement Services Authority, which aims to meet quickly and cost-effectively the short-range mobility needs of people of all ages who have serious and permanent difficulties in walking.

To that end, the authority supplies over 250 types of wheelchair for users of all ages. These include two types of powered chair—a self-propelling indoor powered chair for people who cannot walk or propel an ordinary wheelchair and an attendant-controlled outdoor chair for those carers who cannot push a chair. The authority supplied over 8,400 of these powered chairs last year, which represents an increase of 9 per cent. on the previous year. Taking all kinds of wheelchair, almost 170,000 were issued last year—8 per cent. up on 1988–89.

As has been explained this evening, the committee chaired by the noble Lord, Lord McColl, took the view that occupant controlled indoor/outdoor powered wheelchairs would help to improve the independence and quality of life for severely disabled people and recommended that such chairs should be supplied by the NHS. Again, as the noble Lord said, following the authority's examination of that issue, a pilot study was carried out in northern and north-western regions during 1989–90. I understand that the DSA selected those two pilot sites as the disablement services centres in those areas already had the appropriate medical and technical expertise and the necessary administrative support to be able to run a successful pilot study. No North/South divide exaggeration was intended.

The final report of the study became available earlier this year. It found that such powered wheelchairs could significantly improve the quality of life of severely disabled people, which came as no surprise to a number of people. It also confirmed the validity of the prescription criteria as a basis for future supply, although the authority decided subsequently to remove the upper age limit of 65 which previously formed part of the criteria for eligibility. I should say to the noble Earl, Lord Attlee, that the conditions discussed were for use in the pilot schemes. Conditions for any future issues will be a matter for the National Health Service.

Mention has been made of the unsuccessful bid for additional funds to extend powered wheelchair provision in the 1990–91 spending round and the fact that the then Secretary of State was able to allocate an additional £1 million during the year. For 1991–92 we have made an increase in the funds earmarked for disabled services in general which exceeds not only the GDP forecast but also, admittedly by a small amount, the general growth allocations of regional health authorities. That has been done to help to ensure that money is there to meet the existing demand for special wheelchair seating.

It must be said that the difficulty, as always, in earmarking funds centrally is that we tend to look at our own special interests in feeling that earmarking would be helpful. However, in practice it means that the matters earmarked tend to build up, and the freedom of management in the regions is therefore constrained. As a result, a certain amount of local flexibility is lost. As noble Lords will be aware, local health authorities feel strongly about that.

The position of overall funding changes from year to year, as do the priorities within it. Therefore I must say at this point that we also remain free to consider the case again in subsequent years. I remind noble Lords that however good the case for funding, the cost of offering a powered chair immediately to everyone who could benefit would be very large. The typical cost of the limited range of wheelchairs used in the pilot study was mentioned as being between £1,500 and £2,000. Non-powered standard wheelchairs come out at a round £130. To move straight from the present pilot scheme to full provision for all those who need the wheelchairs would almost treble the cost of wheelchair services in the country from about £33 million to £86 million. Realistically, we are looking at a period of several years over which we hope that powered indoor/outdoor chairs may become progressively more widely available.

I should add that the Royal College of Physicians issued a timely report on their survey of health services for adults with physical disabilities. That report was published last November and will certainly be useful to all those concerned with planning and running services for disabled people.

In answer to the noble Lady, Lady Kinloss, I should also say on the point of consultation that all disablement services centres have been encouraged to set up user consultation arrangements to take account of the views of users. The DSA has also emphasised the importance of consultation. No one will have to give up a powered wheelchair that has already been issued. That was a point raised by the noble Lord, Lord Allen of Abbeydale. We continue to hope that those districts which have people with indoor/outdoor chairs from the DSA will find the resources necessary for maintenance.

Regarding the fears that ring-fenced budgets may be raided for other purposes after 1993, I must say that every group that comes to us fears that the National Health Service reforms will mean less funds for their group. With continuing growth in total spending, they cannot all be right. However, health authorities will be responsible for addressing all the health needs of their residents. There is no reason to fear that our reforms of the National Health Service will funnel a greater share of funds into the acute sector.

I appreciate that there is a cost to treating such things as pressure sores. However, in passing I must say that the estimate of £3,000 million given by the noble Lord, Lord Banks, for that cost is not a credible estimate. That represents almost one-eighth of all National Health Service expenditure. I may have misquoted the figure, but I shall look at Hansard to make sure.

Regarding the funding for special seating, part of the reason for the good increase in funding for these services is that we have specifically taken account of the growing demand for special seating. Whether or not we should have a survey of those needing special seating is a matter for individual health authorities. Again, they will have the responsibility of identifying the health needs of their residents and the obligation to act on them.

With regard to the assessment of wheelchair users, in the most difficult cases that will be carried out by multi-disciplinary teams which will include rehabilitation medicine consultants, OTs, physios and medical/technical officers. The noble Lord, Lord Ennals, and others referred to regional parity. The normal process of the National Health Service management executive reviews of regions and the collection of statistics identifies those regions whose performance is weakest. The number of occupational and physiotherapists has increased by a considerable amount in the past 10 years.

Perhaps the most predominant question that I have been asked this evening is what happens after ring-fencing ends in 1993. We believe that by 1993 the wheelchair and artificial limb services should be firmly entrenched in their local National Health Service within a developing consultant-led specialty of rehabilitation medicine. In any case the separation of purchasers and providers which our National Health Service reforms create will ensure that there is a serious examination by the purchaser of which health needs are greatest. There will be less scope for powerful hospital specialists to divert resources into what may be considered to be more glamorous areas. We will monitor their efforts by collecting statistics on activity and expenditure; by the National Health Service management executive's review of regions; by the appointment of persons of standing in every region in order to champion the causes of the disablement services and who will sound the alarm if problems arise anywhere.

There will also be one regional general manager and one regional director of public health specifically responsible for the services. The Department of Health will be in regular touch with these individuals. In any event any money earmarked centrally is by no means the whole picture. A health authority should not need to be told that a service such as these wheelchairs is worth special support. As I have said, we shall be monitoring the progress and, no doubt, if it becomes necessary, we may have to consider guidance which is another matter about which I was asked.

I hope that many will conclude that without these measures further funds should be allocated locally. During the period of ring-fencing the allocation which each district will get to purchase disablement services for its residents will be the minimum and not the maximum they can spend. Powered wheelchairs have been proved to represent an extremely good investment for some severely disabled persons. Clearly district health authorities will need to weigh the competing priorities they face very carefully. Given the obvious value of powered indoor and outdoor wheelchairs for those able to benefit from them, I hope and feel sure that districts will find ways of bringing the developments and advantages of ever-improving technology and making them more widely available and that this will not be a Cinderella service.

Lord Allen of Abbeydale

My Lords, there is one question which the noble Baroness has not answered in her very interesting speech. Is any general guidance being given about age limits and conditions of that kind or is there a risk that different practices will be followed in different areas?

Baroness Hooper

My Lords, I apologise to the noble Lord. I thought that I had touched on the fact that the criteria laid down in the pilot projects will not necessarily be followed throughout the national Health Service. We do not envisage issuing guidance, but if in the course of monitoring the progress of services we feel that guidance is necessary, we shall issue it.