Discussion

This survey was undertaken to gain an understanding of current orthotic service provision in the UK. Results highlighted the large variances across Trusts/HBs; these variances included appointment times, waiting times, product entitlements for patients and product lead times.

Variances in appointment times were evident between regions and between contracted and inhouse services, with all appointment times relatively short (average times between 18 and 41 min). This finding is confirmed by a recent study which examined foot orthotic provision in the United Kingdom25 ; reporting that the majority of orthotists (62%) had 15–30 min for clinical assessments and 15% reported having <15 min appointments. These appointment times were significantly lower than those reported for podiatrists and physiotherapists, who were 11.0 and 13.2 times more likely, respectively, to have 45–60 min appointments.25 It also supports previous research which reported that when orthotists were asked if they provided AFO–footwear combination tuning 27% said they did not tune due to a lack of time.26 These short appointment times, reported in the present survey and previous research, are below the recommended treatment times set out by BAPO; 20 min treatment blocks differentiated as: (1) initial assessment and analysis, (2) measurement and device specification, (3) trial evaluation of the device, (4) supply and final evaluation of the device, (5) review and fine tuning of treatment and (6) final review of treatment outcomes.27 They also advise that this treatment time may need to be increased to reflect the level of experience of the orthotist or the complexity of the case. The recommended treatment times are set by the BAPO Professional Affairs Committee which is a representative group including experienced senior clinicians from all four UK nations, with both NHS and contractor staff consulted. The committee also consider feedback received directly from members and statements made indirectly by clinicians in their biennial ‘Working Practices’ survey when setting the recommended treatment times. In light of this, while we could consider it as a negative that the survey showed that most Trusts/HBs did not have access to facilities for patient assessments, even simple video analysis, given the current short appointment times it would not be feasible for orthotists to use these facilities even if they could access them. As research has found that orthotists reported that they didn’t have adequate time within appointments to complete AFO-footwear combination tuning,26 and that orthotists have significantly shorter appointment times than podiatrists and physiotherapists,25 further research is required to establish if orthotists working in the NHS have sufficient time to complete their patient assessments and design or evaluate a treatment plan.

There were large variations across Trusts/HBs for urgent waiting times for adult and paediatric appointments which are consistent with previous research.9 The majority of Trusts/HBs reported lead times which were outside what has been recommended as maximum reasonable timescales; 10 working days for an AFO, 25 working days for bespoke footwear and 15 working days or stock footwear.28 This combined with differences in patient entitlement confirm, as previously reported,28 that service provision varies according to where you live; there is a need for a national standard to promote equity of care.

Combined long waiting times for appointments and lead times for footwear/orthoses means extended time before treatment is received; the present survey reports average and maximum waiting times for adult appointments of 7 and 34 weeks, respectively, in January 2017. The Medway FOI reported average and maximum waiting times of 9 and 51 weeks, respectively, in 2013–2014.13 For paediatric patients average and maximum waiting times were 5 and 20 weeks, respectively, in contrast to 7 and 52-week waiting times reported elsewhere in 2013–2014.13 Survey results showed that some Trusts/HBs appeared to not accommodate the needs of children. Waiting times of 20 weeks for routine and 8.2 weeks for urgent appointments are unacceptable, as are the long waiting times for supply of paediatric AFOs, usually provided to children with long-term disabling conditions, reported as up to 20 weeks.

Potential reasons for the long waiting times may be due to Trusts/HBs not including orthotic services in the 18-week RTT target or it could be due to a shortage of orthotists or a combination of both. Minimum waiting times are particularly important for children, as long waiting times mean they may have outgrown an orthotic device by the time they receive it and industry standard lead times for orthotic products are required. In addition, the Special Educational Needs and Disability code of practice,29 produced by the UK government, outlines duties for commissioning services to improve outcomes for children and young people who have special educational needs or disabilities, excessive waiting times affects the Trusts/HBs’ ability to provide orthotic services effectively to this patient group. There was an increase in the number of Trusts/HBs recording patient complaints and the DNA rate over the 5-year period, and the average DNA rate for orthotic services was consistent with the rate reported across the NHS.30

There was a high response rate (97%) to the question about monitoring patient satisfaction, with 80% of responding Trusts/HBs including patient satisfaction as a KPI could be perceived as positive and will help in the improvement of service provision. However, there were large variances across Trusts/HBs, most responders reported monitoring routine waiting times with a low number of Trusts/HBs monitoring inpatient and urgent waiting times and failed first fits.

While the introduction of local tariffs has been recommended9 most of the Trusts/HBs who responded were funded by a block contract (69%; 70/101). Many of the Trusts/HBs using a contracted service entered zero for the number of full-time orthotists who work within their Trusts/HBs. Possible explanations for this finding are that they did not consider this question relevant as their service was contracted, or that they do not know the number of orthotists who work within the service. Therefore, it appears that many Trusts/HBs do not hold information on the orthotists treating their patients. A positive response was that 77% of responding Trusts/HBs reported that their orthotists working with complex conditions had postgraduate training in orthotic management of these conditions. However, the lowest response rate (70%) for this question was from English Trusts/HBs with a contracted service, possibly indicating that these Trusts/HBs were not aware of the competency of the staff working with these patients. A lower response rate from Trusts/HBs with a contracted service was also evident for protected CPD time. A positive response was that 73% of responding Trusts/HBs reported providing protected CPD time for their orthotists, however it should be standard practice for all orthotists to receive protected CPD time across all Trusts/HBs.

It was reported in the NHS Quality Observatory13 that the volume of orthotic appointments and users was significantly under-reported within NHS systems; their review of Hospital Episode Statistics found 159 729 orthotics attendances were recorded for 2013–2014. However, in contrast the Medway NHS Foundation Trust FOI reported that the 38 Trusts who responded to the question treated 208 231 patients. In the present study, for the same year as presented in these previous reports (2013–14), the total volume of appointments and patients for the UK was significantly higher, at 618 953 and 421 515, respectively (table 3). There is also a vast discrepancy between reports on the volume of orthotic users (which are all people who use an orthosis, not only people attending orthotic services); with estimated figures of between 1.2 million15 and 2 million16 in England . This highlights the need for accurate information on the volume of patients attending orthotic services and on orthotic users in general; without this information it is not possible to provide and evaluate an effective orthotic service or to understand the scale of the need for orthoses.

For the questions which asked for information over the previous 5 years (2011–2016) there was an annual increase over the 5 years in the number of Trusts/HBs who provided responses, suggesting positive improvements in record keeping. However, this variance in response rate meant that it was not possible to directly compare across the years as it is not possible to determine if changes were as a result of changes within the orthotic services or as a result of the increased number of responses to the questions in the FOI. While in some instances it was possible to identify differences in service provision between regions, due to the low response rate for many questions it was not always possible to provide comparisons.

As previously discussed, a report by the NHS Quality Observatory13 highlighted the current challenges in obtaining accurate figures for orthotic service provision; as these is limited historical data on this service this hinders comparison with findings from the present survey. A study by Fox and Winson in 199431 reported that the annual NHS orthotics budget was approximately £38 million. While the method used to establish this figure differed to the method used within the present survey, it is postulated based on this information that the total budget for orthotic services doesn’t seem to increase in proportion to the overall NHS spend; which has increased by approximately 4% a over the lifetime of the NHS.32 Our results show £30.6 million in 2011–2012 within the responding Trusts/HBs, which increases to £40.6 in 2013–2014 and £48.6 in 2015–2016 (table 2). The lack of difference within the period from 1994 to 2016 is even more significant considering that this comparison does not take inflation into consideration. This highlights a clear lack of overall understanding of the expenses. In addition, without a clear picture of income and expenditure it is difficult to show the cost effectiveness of the service provision.

The response to use of outcome measure was very disappointing, with only 35% of responding Trusts/HBs (36/103) using outcome measures, implying that most Trusts/HBs have no formal method of measuring whether the orthotic intervention they have prescribed has been effective. For those Trusts/HBs who reported using outcome measures a wide selection of measures are stated as being used including various visual analogue scales, questionnaires and functional objective tests (eg, timed up and go). These findings are confirmed by recently published research conducted by BAPO; their survey of prosthetists and orthotists in the UK indicated that only 28% routinely used outcome measures, with no consistency in the outcome measures used.33 As previously reported,34 the use of a core set of patient-reported outcome measures would enable the assessment of the effectiveness of treatment interventions and would also facilitate audit.

The potential reasons for this finding are multifaceted, but the reported short appointment times and the lack of availability of essential equipment required to undertake accurate measurements in this survey could be important contributing factors. Previous research has reported that orthotists did not routinely provide AFO-footwear combination tuning, which includes essential aspects of orthotic provision such as static and dynamic alignments of orthoses, 27% said they did not tune due to a lack of time and they felt that they did not have the required equipment.26 While it is recognised that visual gait analysis is inaccurate35 36 and that video gait assessment should be routine clinical practice for orthotic provision37 most Trusts/HBs do not provide access to simple and inexpensive digital slow-motion video analysis.

In 2014, an NHS report stated that it was not possible to obtain accurate figures on the number of people in England accessing orthotics services, with this issue attributed to the complexity of pathways of care and poor availability and accessibility of data.13 While the data presented from this survey is limited by the low response rates for some questions, the information gained provides a valuable insight into orthotic service provision in the UK. While the response rate for this survey was low (61% of contacted Trusts/HBs responded), it received more replies than the Medway NHS Foundation Trust FOI request in 2014 which had a 29% response rate (55/188 organisations responded).9 Of the 20 Trusts/HBs who declined to reply 13 deemed that answering the request would cost in excess of £450 (Section 12 of the Freedom of Information Act38) which suggests there may be poor record keeping for orthotic service provision in these Trusts/HBs. Two Trusts/HBs declined due to commercial interests (Section 4338), yet as many other Trusts/HBs responded to the FOI request it is unclear why they considered that they could not respond to the survey. Five Trusts/HBs declined as they stated that their service was contracted to an external company. However, even if the service was contracted, one can argue that the Trusts/HBs are still responsible for overseeing the service and therefore should have access to the requested information.

While this survey confirms that many of the issues reported in previous reports on orthotic service provision8 9 20 are still evident there were also improvements in service provision identified. The projected population growth, ageing population and rising prevalence of obesity, diabetes, cardiovascular and peripheral vascular diseases will result in an increased demand for orthotics services in the future,9 and therefore, it is essential to ensure that services are capable of meeting current and future demands. Although the low number of responses received could be seen as a limitation of this report; to improve orthotic service provision first it is necessary to fully understand current provision. This has been argued since the late 1980s,39 however the change seems to be rather slow. Additional independent structured research and service evaluations sponsored by a competent authority (such as the Department of Health and Social Care) need to be commissioned which gather complete assessment of orthotic service provision across the UK.