Referral for Provision of an

Electrically Powered Wheelchair

Powered wheelchairs are provided by the NHS in Scotland to provide independent mobility for people who have a permanent and severe restriction to their mobility for medical reasons. To ensure that the equipment can be used safely and to ensure that we are as fair as possible in allocating scarce resources there are nationally agreed criteria which patients must meet to be eligible for provision of an NHS powered wheelchair. A copy of the criteria is attached at the end of this document.

Indoor (EPIC) or Indoor/Outdoor (EPIOC) Powered Wheelchair ?

The range of chairs supplied by the NHS falls into two broad categories:

EPICs (electrically powered indoor chairs) are generally smaller, less powerful and slightly slower devices which are only suitable for use indoors.

EPIOCs (electrically powered indoor / outdoor chairs) are heavier, more powerful, usually larger chairs which have features such as kerb-climbers which make them suitable for use outdoors as well as indoors but because of the increased size may make them difficult to use in some indoor environments.

Because of the increased risk to the user and to others when a chair is used outdoors, the criteria which apply to EPIOCs are rather stricter than those for EPICs.

This form and assessment clinics

To allow us to assess whether an individual meets the criteria for eligibility we require that the team who are responsible for the long – term care of the child and who have assessed the relevant aspects of the child’s abilities, should complete the appropriate sections of this form. To enable us to contact the appropriate individual in the event of a query, we have asked that each section should be initialled by the person responsible for that aspect of the assessment and that the names of all those involved should be entered at the end of the form. We will review the form and if it is likely that the child is eligible then we will arrange an appointment at a clinic where we can evaluate wheelchair driving skills and discuss the practical aspects of using a powered chair. It may also be necessary to arrange a home or school visit to check that there is a suitable environment for the use of the chair.

What happens next

When we have received and reviewed the form we will write back to the main contact person and to the child’s family with our initial decision. If we intend to proceed to an assessment clinic then we will offer an appointment date at this time. If we do not think that the child will be eligible then we will explain our reasons for this decision. If the child is not eligible we will also offer an appointment to assess whether an alternative solution to the problem may be appropriate.

The Child
Surname: / Health Board:
Forename(s): / G.P. (name, address):
Date of Birth:
Address:
Tel:
School: (name, address):
Postcode:
Parent’s daytime phone no: / Tel:
Principal Contact (please ensure that all those involved in this referral are listed at the end of the form)
Contact - Name: / Address:
Profession:
Signature:
Referral Date: / Tel: Fax:

Medical Condition

Please enter medical diagnosis or reason for mobility impairment – please include related conditions such as epilepsy which may affect driving ability.
Initial

Walking Ability (please tick)

Child is unable to stand 
Child can stand but cannot move 
Child can manage a few steps with assistance from another person 
Child can walk short distances using sticks or other walking aid (approximate distance ……………) 
Child can walk short distances unaided (approximate distance ……………) 
Child can walk longer distances but tires easily 
Child can walk longer distances but has other need for wheelchair (please explain below) 
Comments:
Initial

Wheelchair use (please tick)

Child has never had a wheelchair or buggy 
Child is using an attendant propelled wheelchair or buggy 
Child is using a self-propelled wheelchair but is unable to move wheels 
Child can turn chair around but cannot propel 
Child can propel chair for short distances only (approximate distance ……………) 
Child can propel chair for longer distances but is too slow 
Child can propel chair for longer distances but has other need for powered chair 
(please explain below)
Initial

Visual skills

Has the child had a recent visual assessment? Yes  No  If yes please comment on the following areas:
Visual acuity
Field of vision
Depth perception
Other relevant features
OR Child has no visual impairment  / Initial
Mobility and Driving Experience
Child has no experience of independent mobility 
Child has walked or crawled but is no longer able to do so 
Child has used a self-propelled wheelchair but is no longer able to do so 
Child has used a self-propelled wheelchair but this does not meet their needs 
Child has tried an electrically powered chair for a short time (please give details below) 
Child has used an electrically powered chair successfully (please give details below) 
Initial

Cognitive skills

Please describe any difficulty or delay and in particular any difficulties with cause & effect, problem solving or spatial relationship skills.
OR Cognitive skills are normal for age  / Initial

Disposition of child

Please indicate below any factors which might indicate whether the child will be safe (their own safety and that of others) and effective in using a powered wheelchair. For example: attentiveness, self-awareness, desire for independence.
Initial

Use of controls

Child has successfully used a standard joystick to control an electrically powered chair 
Child has successfully used another device to control an electrically powered chair (e.g. switches) 
Child uses a proportional joystick to control another device (e.g. computer game) 
Child uses switches or other joystick to control another device 
Child has not used switches or other electrical controls before 
Please describe:
Initial

Physical and seating requirements (detailed requirements will be assessed at clinic)

Approximate height of child ……………… (m)
Approximate weight of child ……………… (kg)

Sitting ability (please tick)

Child can sit unsupported in a moving vehicle 
Child can sit unsupported in a static seat (e.g. school chair) 
Child needs some support to maintain a sitting position (e.g. simple belts or cushions) 
Child needs extensive support to maintain a sitting position (e.g. special seating systems) 
If using supportive seating please describe below:
Initial

Environment

Where do you anticipate that the chair will be used regularly?
At home indoors 
Around the home outdoors (e.g. garden) 
At school indoors 
In the school playground 
Outside the home or school (e.g. shopping, playing with friends) 
Elsewhere – please note below 
In normal use will the chair have to cope with any of the following (please tick):
Uneven ground ; Access ramps ; Kerbs / steps ; Narrow doorways ; Manoeuvring in confined spaces 
Has an area with a power supply been identified where the chair can be stored and charged - Yes  No 
Has an individual been identified who will be responsible for maintaining the chair - Yes  No 
Initial

Training and Supervision

The child and family have experience in using a powered wheelchair and do not need training 
OR
A programme of training has been planned and will be organised by ...... 
OR
A training programme will be required before the child can use the wheelchair independently 
If the child is eligible for a powered wheelchair then the training arrangements will be discussed at the clinic.
AND
The child is capable of using the chair safely when unsupervised 
OR
The following named person will be responsible for ensuring that the chair is only used under supervision at all times
...... / Initial
Other relevant information / Initial
Persons responsible for making this referral (sections marked * must be completed)
Name / Role or profession / Signature
* / Principal contact - should be a member of the clinical team and available to attend a clinic and discuss the referral.
* / Paediatrician or GP supporting this application.
* / Parent or guardian - in signing this document you are agreeing that you have read and agreed to the attached document "Conditions of Supply"

The person named as principal contact should ensure that all sections of this form have been completed and that all of the team members involved are listed above.

Attached - Eligibility Criteria, Conditions of supply

Criteria for the provision of: / Last revision date
Electrically propelled indoor chairs (EPIC) / 2/10/1997
Patients must meet all the following criteria before they can be considered to be eligible for the provision of an electrically powered indoor wheelchair
1 / For medical reasons, be severely and permanently restricted in their mobility
2 / Be unable to walk
3 / Be unable to propel a manual wheelchair indoors
4 / Have no cognitive, spatial, visual or similar impairment (e.g. poorly controlled epilepsy) which would make their use of an EPIC a danger to themselves or other people
5 / Have demonstrated in a driving test that they have the physical and intellectual capability to control an EPIC safely and responsibly
6 / Have a residential environment compatible with the use of an EPIC and which includes a storage area with a power supply for a battery charger
7 / Be capable of ensuring that an EPIC is maintained adequately (charging on a daily basis, battery inspections etc.) either personally or by a carer
8 / Will derive significant improvement in their independence and quality of life through the use of an EPIC.
9 / Agree that the provision may be reviewed on a regular basis
Criteria for the provision of: / Last revision date
Electrically propelled indoor / outdoor chairs (EPIOC) / 2/10/1997
Patients must meet all the following criteria before they can be considered to be eligible for the provision of an electrically powered indoor / outdoor wheelchair
1 / For medical reasons, be severely and permanently restricted in their mobility
2 / Be unable to walk
3 / Be unable to propel a manual wheelchair
4 / Have no problems with visual, cognitive, visio-spatial or other higher cortical functions or other medical conditions, which would make them a danger to themselves, pedestrians or other road users
5 / Have the ability to comply with the DVLC requirements for motor vehicle drivers concerning epilepsy and other causes of loss of consciousness
6 / Have visual acuity of at least 6/24 (can read a car number plate at 40 feet) and have a field of vision of 120 degrees in a horizontal plane and 20 degrees above and below this plane (equivalent to class 3 vehicle visual standards)
7 / Have demonstrated in a driving test and by other means that they have the insight, intellectual capacity and dexterity to operate an EPIOC safely and responsibly on their own and without assistance
8 / Have a residential environment which is compatible with the use of an EPIOC and which includes a storage area with a power supply for a battery charger
9 / Have a local outside environment which is accessible by an EPIOC and compatible with its use (including static and dynamic stability)
10 / Be able to ensure that an EPIOC will be maintained adequately either personally or by a carer
11 / Have the capacity to derive significant improvement in their independence and quality of life through use of an EPIOC
12 / Agree that the provision may be reviewed on a regular basis

SMART Centre

Astley Ainslie Hospital

133 Grange Loan

EDINBURGH EH9 2HL

Tel 0131 537 9433

Fax 0131 537 9552

Conditions of Supply

The conditions under which the wheelchair/buggy is supplied are listed below.

Please read them carefully.

The WHEELCHAIR/BUGGY including all accessories:

a)  Will remain the property of Lothian Primary Care NHS Trust and must be returned when no longer required.

b)  Must not be disposed of, altered in any way, or have any attachment

fitted to it without prior written authority from etc.

c)  Must be kept clean and in good running order.

d)  Must be safeguarded against damage and loss at all times – we recommend that you insure it.

If it needs repaired, please phone ETC (0131 537 9433). We will make arrangements for the repairs to be carried out by our contractors, or authorise you to have the work done locally.

The wheelchair/buggy will be maintained and repaired free of charge by ETC if used under normal circumstances and within Great Britain. The wheelchair/buggy must be insured if you travel abroad.

Please notify ETC if you change your address or if you have no further use for the wheelchair/buggy.

CR1 (v2)