An independent provider in the Wealden area

154. In considering our recommendations, we have referred to our ‘NHS Complaint Standards’ which is a toolkit for good complaint handling. They refer to our Principles for Remedy which say organisations should take steps to provide an appropriate and proportionate remedy for injustice or hardship caused by maladministration or poor service. They say organisations should put things right and return the affected person to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately. To decide on a level of financial remedy, we review cases where the person has experienced a similar injustice, along with our severity of injustice scale.

155. To put things right for D and Miss C, we recommend that within one month of the date of our final report, AJM should:

• write to D and Miss C to acknowledge the significant failings in its management of repairs, communication and record keeping. It should apologise that those failings have had such a profound impact on the quality of D’s day to day life, causing him substantial social isolation, frustration, and loss of opportunity to engage in educational activities. It should also apologise for the significant emotional impact of these events on Miss C.

• pay the family £3,700 in recognition of the impact caused and send us evidence it has done this.

Systemic recommendations

156. Our Principles for Remedy say organisations should continuously improve and learn from complaints to make sure poor service is not repeated. We propose making the following recommendations to drive improvements in AJM’s service and help prevent other wheelchair users and families from experiencing similar problems to those seen in Miss C’s complaint.

157. For each of the recommendations below, AJM should produce a specific, measurable, achievable, realistic and time limited action plan within three months of the date of our final report. It should aim to implement the action plan within a further three months. The action plan should fully explain: • the specific actions taken or planned to prevent each of the failings from happening again • the names of the person or team responsible for completing each action • when the actions will begin, and when they will be completed • how it will make sure that the actions comply with relevant standards • how AJM will ensure the actions have been successfully completed • how AJM will measure the impact of those actions • how AJM will monitor and audit the actions taken to make sure improvements to its service are maintained.

158. AJM should share the action plan with us for comment before finalising it. AJM may wish to consult its stakeholders on the action plan where it considers that would be beneficial.

Recommendation 1

159. Most of the cases we have seen, including Ms C’s complaint, involve delay in AJM handing over suitable equipment or repairing equipment adequately. We have also seen cases where AJM failed to provide suitable equipment first time, even after a long wait. Many of the delays appear to be a consequence of AJM’s decision to operate queues and how it managed the queues. AJM does not appear to have had robust procedures for reviewing and reprioritising people waiting in the queues.

160. AJM’s customer surveys show waiting times were the most frequently reported reason for service dissatisfaction and ‘very poor’ ratings. In survey reports to ICBs, AJM said it was taking actions to address waiting times and communication. However, later surveys show these issues did not improve.

161. In this case, delay led to a significant injustice to D and his family. So, we recommend that AJM’s action plan includes measures to improve waiting times for equipment and repairs. As part of this process, AJM should: • review its approach to queues or waiting lists, including the reasons for operating them and the impact they have on service users and waiting times • create robust procedures and criteria aiming to reduce or eliminate waiting lists where possible • produce a clear policy statement setting out circumstances in which it will need to operate a waiting list, where this cannot be reasonably avoided, that it can share with ICBs and service users • develop robust procedures to oversee and manage any unavoidable waiting list to • ensure service users are appropriately categorised, reviewed and reprioritised appropriately. The procedures should avoid anyone getting stuck in the middle of the queue. They should be capable of being shared with service users and also with ICBs as part of any contractual obligations and service users • outline how it will keep clear records of the operation of waiting lists.

Recommendation 2

162. AJM has not been able to adequately explain the supplier’s role (if any) in the delay in providing equipment or show how it expedited or resolved matters with suppliers.

AJM told us it has significant stock holdings. AJM’s prescriber of equipment policy allows generic prescribing of stock and enables its stock team to select a close technical equivalent where appropriate. This should result in suitable equipment being ordered or handed over in the shortest time possible. However, that does not appear to have happened in D’s case.

163. Contracts between AJM and the ICBs all say that AJM should have stock control processes and procedures in place with suppliers to meet the timescales in the contract. However, during our investigation, AJM told us it did not have SLAs with suppliers at the relevant times. It also told us it did not know the average waiting times for the delivery of different pieces of equipment. So, we recommend that AJM’s action plan includes that it: • ensures it has agreements with all suppliers in line with its contracts with ICBs and information it provides in tenders • reviews its SLAs with suppliers to ensure they are adequate to meet timescales for providing equipment set out in contracts with ICBs • identifies how it will make any necessary improvements.

Recommendation 3

164. AJM did not manage Miss C’s expectations well or provide clear and complete information about what was happening with D’s wheelchair. We have seen this in other cases too. AJM’s records have gaps where contacts with service users might be expected and/or poor accounts of what happened. In some cases, information we obtained from other sources such as suppliers did not align with AJM’s records, raising questions about their accuracy.

AJM’s customer surveys show poor communication was a regularly occurring concern across all areas. In every survey report to ICBs, AJM said it was taking actions to address poor communication. However, the surveys show these issues persisted.

165. The lack of appropriate and accurate information caused frustration and distress to Ms C and her family. So, we recommend that AJM’s action plan: • reviews the work it has been doing and assesses whether this is sufficient to ensure it communicates with people in a clear, helpful, effective and timely manner in future, in line with our Principles of Good Administration. AJM should identify any further activity needed and incorporate this into its action plan. AJM should consider how it can involve its service users and other relevant stakeholders in deciding what further action to take.

• considers why the information Ms C received in October 2024 was inaccurate • identifies how it will ensure the information it gives to service users is accurate and transparent in future.

Recommendation 4

166. Our investigation has been hampered by the lack of contemporaneous records to explain what AJM did. This also affected the service provided to complainants as AJM was apparently unable to provide people with correct or consistent information about what was happening. As such we recommend AJM should: • review its systems for recording clinical information and contacts with service users so that in future it has reliable and usable records of its activities and communication, in line with our Principles of Good Administration. AJM should ensure its recordkeeping allows it to provide accurate information to service users such as updates on delivery times for their equipment and reasons for delays. The records should also ensure AJM can comply with contractual transition/exit arrangements in terms of furnishing commissioners and/or incoming providers with accurate information on work in progress.

167. For each of these four recommendations AJM should allow us to comment on the reviews and draft action plan before sending them to Miss C, the ICB and NHS England.

168. Once AJM has implemented the action plan, it should send us evidence of this.

6. Miss C complains that AJM, commissioned by North West London ICB, failed to provide a wheelchair service to her son, D, between 13 May 2024 and January 2025. Miss C says AJM: • delayed sending the original wheelchair to the manufacturer for two months • returned the original wheelchair not fully repaired • scheduled the pickup of a temporary wheelchair without delivering another wheelchair • provided a temporary wheelchair which was not fit for D, an active user • provided a temporary wheelchair which required numerous repairs • did not keep her updated on the status of the wheelchair delivery or the parts ordered.

7. Miss C said D could not participate in school activities in his temporary manual wheelchair. Miss C said D participates in sports and other school outings, but this was not possible between 13 May 2024 and 30 January 2025 as someone had to push his wheelchair all the time.

8. Miss C says D was distressed when the AJM engineer arrived at his school to pick up his temporary wheelchair without delivering another wheelchair. Miss C explains D is paralysed from the waist down and unable to move without a wheelchair.

9. Miss C says she lost confidence in the service AJM provides. She says her son received a better service with a previous provider.

10. Miss C would like a financial remedy and service improvements.

11. D has spina bifida (when the spine and spinal cord do not fully develop in the womb). The symptoms of spina bifida include paralysis, incontinence and a build-up of fluid on the brain, which can damage the brain and cause learning difficulties. Due to this, D is paralysed from the waist down and is unable to walk or move around without a wheelchair. He has used a wheelchair since he was 18 months old.

12. AJM reassessed D’s needs in August 2023, when he was 11 years old. AJM assessed D as an active user (a person that requires support to participate in outdoors activities, sports and who lives a dynamic day-to day life) and prescribed a wheelchair that could fulfil this requirement.

13. On 26 October 2023, AJM provided D with a light frame Quickie Life wheelchair. This is a light frame wheelchair that enables users to use the wheelchair for prolonged periods of time, meaning D could mobilise without the aid of others.

14. On 13 May 2024, Miss C and D attended AJM’s wheelchair clinic because he was having ongoing issues with the wheelchair. AJM decided to send the wheelchair back to the manufacturer because it needed repair and was under warranty. AJM provided a temporary manual wheelchair for D. Miss C said she was told the repairs would take 12 weeks.

Delays in sending the prescription wheelchair back to the manufacturer

19. AJM’s clinic notes dated 13 May 2024 say the prescription wheelchair was returned to the manufacturer for the following reasons: • ‘slow puncture in right hand side back wheel’ • ‘left hand side castor no longer spinning’ ‘bar under seat broken’ • ‘top belt for backrest has broken.’

20. AJM’s records show the manufacturer picked up the prescription wheelchair on 31 July 2024. There is no explanation in the records about why it took AJM more than two months to return the chair to the manufacturer.

21. Our Principles of Good Administration say: ‘Public bodies should create and maintain reliable and usable records as evidence of their activities. They should manage records in line with recognised standards to ensure that they can be retrieved and that they are kept for as long as there is a statutory duty or business need.’

22. AJM’s contract with the ICB says it should keep: ‘Accurate and up to date records on assessment, provision, re-assessment, discharges, repairs & maintenance…’

23. In line with our Principles and the contract, AJM should have kept adequate records to show what happened. It did not do that. Without those records, we have relied on other evidence including the contract between AJM and the ICB, and what AJM told us about the reasons for the delay.

24. AJM told us that it procures equipment based on clinical priority, with orders placed for those with the greatest need first. It said this means some service users may experience delay. However, it is not clear to us how this explains the delay in arranging for a manufacturer to collect and repair equipment that is under warranty.

25. Schedule 2 of the contract says: ‘Core support processes and services will be aligned to deliver care in ways which minimise avoidable delays and non-value adding activities’. The contract says repairs should be carried out within a maximum of five working days.

26. The timescales in the contract indicate the urgency with which repairs should be treated. Our Principles say organisations should keep to published service standards or explain why they cannot. Taking so long to return the chair to the manufacturer is not in line with the timescales in the contract, and there is no evidence AJM did anything to minimise the delay or explain the reason for it. We consider this was a failing.

The prescription wheelchair was returned not fully repaired

27. Miss C said AJM returned the wheelchair to D in January 2025, but it was not fully repaired.

28. The manufacturer’s records show that AJM discussed the repairs needed with the manufacturer in July 2024. The emails we have seen between AJM and the manufacturer indicate AJM sent the wheelchair back to the manufacturer because of a bent or broken frame. The emails are corroborated by photos AJM took showing problems with the frame and bolts.

29. AJM has not provided any evidence showing it asked the manufacturer to carry out any other repairs. It has not provided evidence about how it planned to carry out the other repairs needed to the wheelchair, like the castor wheels.

30. AJM’s records show that on 11 September 2024, the manufacturer informed AJM it was waiting for parts to complete the necessary repairs. We do not know what parts. At the time, the manufacturer anticipated the parts would be shipped from its warehouse in Germany during week commencing 16 September 2024.

31. The manufacturer’s records show it repaired the frame of the wheelchair and dispatched this to AJM on 8 October 2024.

32. Contrary to the manufacturer’s records, on 8 October 2024 AJM emailed Miss C explaining it had received an update from the manufacturer. We have not seen that update. AJM reported that the manufacturer had said it was still waiting for parts to be shipped from its German branch to the UK and was unable to provide an estimated delivery date. AJM also stated the manufacturer had reassured AJM that the order had been escalated to higher management for urgent dispatch.

33. We have not seen any evidence of what happened after 8 October. AJM does not appear to have done anything with the chair it had received back from the manufacturer. In an email Miss C sent to AJM in December 2024, she said a member of staff had told her, ‘the chair has come back in the same condition, with parts to be fitted by the engineers at AJM’. She said the chair had not been replaced as promised, and the front castor wheels that are needed for proper functioning had not been ordered, causing further delay. Miss C asked why AJM had not ordered parts in the first place and replaced them itself. She said they were now seven months in and still waiting for parts.

34. AJM’s records indicate the castor wheels were ordered as an emergency on 16 December 2024 with the order completed on 30 December 2024.

35. In a response to Miss C in January 2025, AJM said the manufacturer had repaired the wheelchair frame but would not replace the whole chair as they did not consider it was beyond repair.

36. AJM confirmed to us it carried out eight further repairs to the prescription wheelchair between January and July 2025.

37. Given the limited records provided to us, it is difficult to understand what AJM did to address the problems with D’s wheelchair reported in May 2024. It is clear Miss C was expecting the wheelchair to be replaced. This did not happen. There is no evidence AJM even asked for that. Based on the communications between AJM and the manufacturer in July 2024, we can see AJM would have known the chair was not going to be replaced then.

38. Further, AJM appear to have only discussed repairs to the frame with the manufacturer. AJM therefore must also have known in July 2024 that it would have to do the other repairs. It could have planned to do those promptly on receipt of the chair or sought an alternative. We consider there was a missed opportunity for AJM to review its stock and order any necessary parts between July and October 2024 to minimise the overall repair timeframe.

39. AJM did not give us any more information about why it missed this opportunity in D’s case. However, during our investigation, AJM told us it ordered parts and equipment centrally. It said it operated waiting lists/queues for procurement in several service centres. It explained that it budgets monthly at each of its service centres and it will not order or purchase equipment or parts for repairs if doing so puts it over budget. Service users therefore wait in the queue until AJM is satisfied that purchasing their equipment will not mean the service centre is over budget for the month the purchase is made.

40. AJM said waiting lists/queues are unavoidable due to the way wheelchair services are commissioned and resourced generally. We looked at the way North West London ICB commissioned and funded its wheelchair service to see if it contributed to the delay with D’s wheelchair. Below, we explain why we did not find that was the case.

41. Nevertheless, we accept there may be times when an organisation cannot meet its service standards for unavoidable reasons. To decide whether AJM’s delays amounted to maladministration or poor service, we looked at how it managed the delay in line with our Principles. These say that organisations should: • meet their published service standards and commitments and do what they say they are going to do, or let customers know if they cannot • make sure measures taken to manage a service are proportionate and fair • give information that is clear, accurate and timely • give reasons for decisions (such as the place someone has in a queue).

42. AJM told us that it made sure service users remained well while they were waiting for equipment by triaging all referrals to its services in line with the national levels of need used by NHSE in the National Wheelchair Data Collection and National Currencies. AJM’s process is set out in its Duty Triage Policy. Priority is determined by the referrer (usually the service user’s GP), and the complexity of the equipment needed.

43. Versions of the Duty Triage Policy dated February 2024 onwards explain when and how AJM re-prioritises service users who are waiting. It says re-prioritisation is triggered once someone has been waiting 13 weeks or more, or when they contact the service to ask for an update or report new information. The policy says reprioritisation should include an assessment of clinical harm. Before February 2024, AJM had no documented re-prioritisation process.

44. We asked AJM for any records it had of reprioritisation and the risk matrix used to determine priority, but it did not have this either generally, or for D. AJM told us the prioritisation process was an ‘organic discussion’ within each service centre. AJM told us it carefully managed the queue by clinical priority, through a process of risk assessment and triage carried out on a regular basis – sometimes daily and always weekly. We have no other information from AJM that explains the reprioritisation process or the factors staff might take into account when reprioritising the queue. We do not know what factors AJM took into account in D’s case. AJM told us that people who do not have the highest level of need often fall further down the queue as those with higher priority take precedence. We do not know if this happened to D.

45. AJM also said that low need service users can often be allocated equipment from available or reconditioned stock, which removes them from the queue quicker. This is because no significant budget or staff time is needed to obtain and hand over the equipment, so it will do that straight away. D is not low need - this may mean resources directed towards lower need users were not available for him.

46. AJM cannot account for the decision in D’s case or show that, more generally, it took all relevant considerations into account when operating the queue - such as the potential for clinical harm where people are stuck in the middle of the queue. AJM has not provided any justification as to why it directs staff time and equipment towards larger volumes of lower complexity and lower cost items rather than smaller volumes of medium complexity and more expensive equipment. AJM has not evidenced that when it placed D in the queue (which we can only assume it did) it planned resources effectively to meet its service standards, in line with our Principles.

47. AJM told also us that, more generally, problems with suppliers can impact on queues and waiting times for equipment. However, it was unable to provide records or evidence about the ordering process for the parts for D’s wheelchair showing delays by the supplier.

48. We looked at whether there was any more general evidence that might show such delays may have had an impact on D. We asked AJM for evidence of past problems with suppliers, waiting times and any service level agreements (SLAs) it had. AJM told us it did not have SLAs with suppliers in the past and did not know the average wait times for equipment. AJM sent us its Prescriber of Equipment Policy which sets out the steps for prescribing and ordering equipment, selecting stock etc. The policy describes how staff can prescribe generically in low complexity cases. It also describes how staff should select a technically equivalent item if the prescribed equipment is not available. AJM does not appear to have had a similar process for expediting more complex equipment. That, and the absence of supplier SLAs means it would be unlikely to obtain more complex equipment as quickly and cheaply as lower complexity equipment, as required by its contract with the ICB.

49. For these reasons, we do not think AJM has shown that it acted in line with our Principles to manage or prevent D’s long wait. It cannot explain its decision about D’s relative priority in its queue (if he was indeed in the queue), or show us any records relating to this or that it understood the potential harm D might be experiencing. It cannot show it had stock and procurement processes that minimised waiting times. We consider this to be a failing. We will consider the impact of this later.

Temporary loan wheelchair not fit for an active user

50. Miss C complains AJM provided a temporary loan wheelchair that was not fit for D while it was arranging repairs to the prescription wheelchair. In her complaints to AJM, Miss C said the loan wheelchair was unsuitable for an active user.

51. Miss C said she enquired if the loan wheelchair came with a cushion suitable for children at risk of developing pressure ulcers. AJM said it did not. Miss C pointed out that AJM assessed her son just a couple of months before as requiring a cushion suitable for children prone to pressure ulcers. Miss C says she took the cushion from D’s prescription wheelchair to ensure his needs were met.

52. We have limited documentation of the appointment on 13 May 2024. However, we have seen no reason to doubt Miss C’s account that it was she who ensured D had a cushion that was safe for him in the loan wheelchair.

53. D’s prescribed wheelchair was a Quickie Life RT, which is a lightweight adjustable chair for active teens. The loan wheelchair was a basic model. AJM’s records note that it was not suitable for D’s needs because he is an active user. AJM’s records also note that the loan wheelchair was slightly too small for D, that he found it difficult to self-propel so had to be pushed around school, and that he was finding this very frustrating. So, it is not in dispute that the wheelchair did not meet his needs.

54. The contract says: ‘in the unlikely event the wheelchair needs to be removed for completion of repairs, AJM might be able to provide the service user with a replacement wheelchair; typically, this will be a standard model so will not necessarily be the same model or size as your issued wheelchair.’

55. We accept that AJM is not required to provide an identical model to the one needing repair. However, the contract also expects repairs should be carried out within five working days. D was in the loan wheelchair for around nine months.

56. The contract also says: ‘Users of wheelchairs… are able to maximise their mobility through the provision of a wheelchair that meets their clinical needs.’ It says the service will maximise independence and autonomy and enable children and young people to access ‘wider developmental activities in the community’.

57. We saw no evidence of AJM taking steps to try to provide a more suitable chair for D while his own awaited repair. We consider that leaving D in a chair that did not meet his needs for such a long time was not in line with the contract. We consider this was a failing.

Loan wheelchair repairs

58. On 20 August 2024, an AJM engineer raised the following repairs needed for the loan wheelchair: no arm rest, stoppers, brakes and front castor wheel problems.

59. On 11 September AJM said it was actively checking its other depots to see if the required parts could be sourced more quickly.

60. On 24 October AJM said it was still sourcing the remaining parts including the anti- tippers and the brakes, which were expected to be delivered to the depot by 25 October.

61. According to AJM’s records, AJM carried out the remainder of the repairs to the manual wheelchair in December 2024.

62. The contract says repairs should take place within five working days. Based on evidence we have seen, the repairs actually took about 15 weeks, between August and December 2024.

63. The contract also says where repair or replacement is not an immediate option, procedures must be in place to ensure the service user is made safe until the equipment can be repaired.

64. We know Miss C reported on 20 August 2024 that she felt concerned about her son’s safety as the parts that needed to be changed were the anti-tippers and the brakes. We saw no evidence of AJM acting with urgency to ensure D was safe, as it should have done in line with the contract.

65. In an email to Miss C in September 2024, AJM said it could not provide a more suitable chair but it was ‘continuing to explore all options to expedite the repair process [for the loan chair]’.

66. We have not received any evidence of when the parts for the loan wheelchair were ordered or the efforts AJM made to chase the parts to try to meet the timescales in the contract. The only information AJM provided is the communication record with Miss C. There is no evidence AJM was exploring all options or attempting to expedite the repair or, for the reasons described in the previous section, that AJM was managing this delay in line with our Principles.

67. As such, we consider AJM failed to ensure the temporary chair was repaired promptly in line with the contract or manage the delay in line with the Principles. We consider this was a failing.

AJM scheduled the collection of the temporary wheelchair without delivering another wheelchair

68. Miss C complained AJM scheduled the collection of the loan wheelchair before delivering the prescription wheelchair. She explains this put unnecessary stress on her and D. She says the collection of the manual wheelchair was booked at D’s school and he was severely distressed by the prospect of being left without any wheelchair, as he understood he would be left completely immobile.

69. When Miss C informed AJM about this, it accepted this first pick up appointment was made in error and it left the manual wheelchair in D’s possession until it handed over the prescription wheelchair later the same day.

70. Based on AJM’s complaint file and Miss C’s account, AJM arranged the collection of the manual wheelchair from D’s school before the return of his prescription wheelchair. D told us he felt vulnerable and scared as he was about to be left without any wheelchair.

71. The contract states: ‘all aspects of service provision should be carried out in the most appropriate environment in order for the user and assessor to achieve a fully informed outcome. Treating and caring for people in safe environment and protecting them from avoidable harm.’ Arranging to collect the loan wheelchair from D’s school without returning the prescription chair at the same time was not in line with this.

72. D and Miss C were very distressed when the engineer attended the collection appointment without a replacement wheelchair. We recognise this led to unnecessary anxiety.

73. We are pleased to see AJM acted quickly and remedied the error the same day. We are also pleased to see AJM apologised. However, AJM did not explain how it would prevent a similar error in future.

74. Our Principles say: ‘When mistakes happen, public bodies should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. Putting things right may include reviewing any decisions found to be incorrect; and reviewing and amending any policies and procedures…’

75. We consider that fully remedying this mistake should have included explaining how similar mistakes would be prevented, to avoid causing the same distress again.

Communication

76. Miss C complains AJM did not provide updates on the prescription wheelchair repairs or the parts ordered for the loan wheelchair.

77. AJM only communicated the extent of the manufacturer repair (and that there was not to be a replacement) to Miss C in December 2024, despite knowing that since July 2024. The information AJM gave Miss C on 8 October 2024 also appears to have been incorrect. AJM has no records to show how it obtained the update it gave on 8 October. We consider there was a lack of suitable record keeping that would have enabled AJM to provide clear and correct information to Miss C.

78. Based on the records provided about the loan wheelchair, it appears AJM only offered an update either when it had the parts and was ready to undertake the repair, or when Miss C reached out.

79. The contract key performance indicators include that AJM should provide ‘clear communications about repairs’ and provide updates (such as estimated delivery dates) within 3 working days.

80. The contract also says AJM must ‘work with the user, their carer and referrer in the provision of the wheelchair to meet the identified need and ensure clear communication pathways are followed to update the same on developments.’

81. Our Principles say that organisations should do what they say they are going to do or explain why they cannot. They say that organisations should give information that is clear, accurate and timely. AJM did not do any of these things and has provided no explanation as to why it could not. Our Principles also say organisations should ‘behave helpfully’, ‘deal with customers in a co-ordinated way with other providers to ensure their needs are met’ and ‘create and maintain reliable and usable records as evidence of their activities’. The absence of useable records and the delay in communicating or and giving accurate information to Miss C does not meet this standard.

82. Based on the evidence we have seen, AJM did not clearly communicate about the repairs in line with the contract or our Principles. We consider this was a failing.

Summary of failings by AJM

83. In summary, we consider there were the following failings in the service AJM provided: • AJM failed to keep adequate records relating to the repairs • AJM did not ensure D’s wheelchair was promptly returned to the manufacturer for repair in May 2024 • AJM did not adequately manage this repair, so it needed to organise additional repairs after the wheelchair was returned by the manufacturer • AJM left D to use a loan wheelchair which did not meet his needs for around nine months • AJM failed to promptly repair the loan wheelchair and did not ensure D was safe while the repair was completed • AJM organised collecting the loan wheelchair without arranging to deliver D’s permanent chair • AJM failed to adequately communicate about the repairs.

North West London ICB

84. ICBs are responsible for commissioning wheelchairs services in their local areas. To ensure an effective service is in place, ICBs should: • assess the needs of their population and set an adequate budget • oversee the contract to monitor performance and address any issues with the service provider.

85. We have looked at what North West London ICB did when it commissioned AJM to provide the wheelchair service to see whether any actions or omissions contributed to the problems Miss C and D experienced.

Needs assessment

86. The NHS Constitution requires the NHS to assess the health needs of local communities and put services in place to meet them. The Operating Model for Wheelchair Services and other national guidance says commissioners should set the parameters for the service according to the Model Service Specification, reflect the requirements of service users in that, and accurately identify the level of service provision required, including the level of unmet need.

87. The contract started on 1 April 2024. The ICB told us it decided to commission a full integrated wheelchair service (a service that provides everything from triage of referrals to assessment of need and provision of equipment).

88. The contract the ICB wrote includes the service pathway and national and local KPI (key performance indicator) reporting requirements. The service specification in the contract closely follows the pathways in the national Model Service Specification and the Operating Model. The maximum times for different activities within the wheelchair provision pathway, and for completion of the entire pathway, reflect the times in the Operating Model. We saw therefore that the ICB took account of relevant national guidance when describing the service to be provided.

89. During the procurement process in 2022 and 2023, we saw the ICB took the actions described below to complete its needs assessment for the service.

• According to statutory guidance, the ICB used the joint strategic needs assessment (JSNA), produced by the local health and wellbeing board, who are responsible for identifying the needs of the population more generally. In this instance the ICB used the JSNA to look at its population and predicted a rise in demand for the wheelchair service. The JSNA sets out that the area had high health needs, poverty and related conditions, with 16% of the population having a long-term condition and 21% having a complex health need. There was no wheelchair specific information in it.

• The ICB produced a business case looking at relevant factors in its decision making about the scope and budget for the service which included: • A consideration of local and national activity data for the previous years in the relevant areas, and a specific acknowledgement of the paucity of the national data set and issues with the national currencies.

• Projected activity for the term of the contract split by complexity of need. The ICB said it was aware of increased demand/levels of need. It cited a 60% increase in volume of referrals between November 2021 and November 2022. In other documents it identified this as a post covid uplift.

• The ICB considered the new scale and scope of the service meant it was commissioning a model that allowed for increased efficiencies that would potentially offset any costs of an increase in activity.

• The ICB undertook a market engagement exercise in September 2023. The document used in the presentation for potential providers said that it was an opportunity for providers to ask the ICB for more information. Headline information in the presentation included the total activity predicted by the ICB and noted there may be an increase in complexity of referrals.

90. Following those activities, the contract the ICB wrote sets out the estimated work the provider should complete each year for referrals, assessments, and repairs in the ‘indicative activity plan’ or IAP.

91. The IAP was not split by complexity of need, but that information was available to providers as part of the procurement process.

92. The IAP factored in a growth rate. This is in line with CECOPS which says commissioners should take account of expected growth to manage future demand on the service.

93. As such, the ICB appears to have done most of what the guidance might expect when setting its activity. It: • evaluated information on existing service provision, including number of users, number of referrals, potential complexity • reflected the requirements of users in the specification of the service to be provided • gave clear and agreed activity tolerance levels that providers are expected to operate within.

94. However, based on the evidence we have seen, the ICB’s service planning mainly relied on historic data. Historic data alone may not accurately reflect current levels of need since it is dependent on the rigour and completeness of previous data collection and reporting. Furthermore, historic data is unlikely to be capable of identifying unmet need.

95. While the ICB does not appear to have fully followed the guidance here, we recognise this is difficult for ICBs to do more generally. Our commissioning adviser confirmed that there is currently no mature, standardised methodology to enable ICBs to accurately quantify unmet need. As there are mitigating factors at national level, we do not consider the ICB’s departures from the guidance amount to failings.

Budget setting

96. In line with the Operating Model and CECOPS, ICBs should ensure wheelchair services are adequately funded to meet the expected needs of all service users. The Operating Model specifies that commissioners should seek value for money, taking into account whole life costs and ‘invest to save’ opportunities. NHSE’s tariff and currency guidance suggests ICBs should be assessing the activity required and using benchmarked tariffs to calculate the budget for the service.

97. CECOPS says there should be a schedule showing a breakdown of activities and types of equipment with related costs. We saw that the ICB’s business case and draft contract specify the number of referrals, assessments, prescriptions, repairs, collections and deliveries to be completed each year. The IAP also specifies the number of referrals, assessments and repairs to be completed. However, those documents contain no information about the costs for each unit of activity.

98. The ICB commissioned the service on a block contract. That meant there was a fixed payment for the entire duration of it. We saw no calculations by the ICB for a cost per referral based on specific activities or equipment types, as might be expected from the guidance to reach that block contract figure. We do not know how it was set, beyond it apparently tracking the funding for the previous wheelchair service that it was replacing.

99. While the block contract price does not appear to have been costed from the activities in the IAP, we saw that the ICB acknowledged there were problems with the data on costs and undertook a benchmarking exercise with other local ICBs to consider the adequacy of its budget on a cost per referral basis (reached by dividing its budget by the number of predicted referrals). Its business case also includes a consideration of the appropriateness of the budget and value for money.

100. The ICB business case explains the plan was to move to an integrated wheelchair service provided by one supplier, to gain benefits from standardising the service specifications and from the provider making use of economies of scale. The ICB said it was aware of increased demand/levels of need. It cited a 60% increase in volume from November 2021 to November 2022. In other documents it says this was potentially a post covid uplift. The ICB concluded it was commissioning a model that allowed for increased efficiencies that would potentially offset an increase in activity and costs. While the block contract price was not calculated in the way national guidance sets out, the ICB appears to have taken relevant considerations into account when it set the budget.

101. Further, AJM had to submit its calculations on costs as part of the tender. It must therefore have thought the budget was adequate to provide the service at the time it signed the contract to commence on 1 April 2024. AJM agreed to the contract at its bid price, which was less than the budget envelope set by the ICB.

102. The ICB told us that AJM was awarded the contact following a competitive process and was aware of the funding available.

103. AJM told us that while it agreed to the original budget, its operating costs rose significantly during contracts due to inflation, product costs and rising pay from around 2021. The external economic picture supports AJM’s comments to some extent. Bank of England data for March 2022 to March 2025 shows the cost of goods and services rose by an average of 3.59% per year. NHSE’s benchmark prices for wheelchair equipment also increased over the same period, although this data is not directly comparable year on year because of how it is collected.

104. AJM told us:

‘Every year providers must absorb nationally agreed NHS pay awards, increases in National Living Wage, National Insurance changes, inflation in clinical supplies, increases in wheelchair and component prices from manufacturers, transport costs and wider operating inflation. While the cost of delivering each wheelchair episode continues to rise, the funding available to deliver that activity remains effectively unchanged. The consequence is inevitable margin erosion over the life of the contract. A contract that may have been financially sustainable at commencement can become progressively less sustainable each successive year, despite activity remaining broadly in line with plan.’

105. We recognise that recent years have been challenging for all private businesses. We acknowledge that high levels of inflation likely caused challenges for AJM with block payments for non-equipment costs. Staff pay increases in the NHS are generally funded by central government. AJM’s staff, while providing an NHS service, are not NHS staff for pay purposes. AJM must set its own pay and budget for that. We can see it is likely that AJM would need to maintain pay at levels broadly equivalent to the NHS to retain staff. We can also see how this would put pressure on a block contract.

106. In 2017, NHS England said part of the purpose of the National Currency guidance was to help ICBs to start to move away from block contracts and towards payments based on actual activity. AJM has also pointed us to NHSE guidance on deconstructing block contracts published in June 2026. The guidance provides instructions to commissioners on the collection and analysis of data to better understand how block contract values map onto indicative prices for specific activities. While we acknowledge the ongoing work in this area, we found no statutory guidance in place at the time, and it appears that ICBs had discretion about whether to use block contracts. We have not seen any evidence to show ICBs should not be using block contracts. We therefore looked at what the ICB did, and whether it should have done anything differently, in response to rising prices.

107. We saw no requirements for commissioners to increase the value of locally agreed contracts in response to rising prices. However, in line with the Ombudsman’s Principle of ‘taking all relevant considerations into account’, we would expect the ICB to have considered any information AJM provided in respect of the affordability of the contract over time.

108. AJM told us it informed ICBs that additional costs were affecting its margins, but they refused to provide more funding. AJM said it could not reduce its fixed costs or staffing costs because the number of staff needed were set by the national currencies and safe staffing levels. AJM told us it could only control its equipment spend which involved creating queues/waiting lists.

109. We have reviewed contract management meetings and activity monitoring discussions between AJM and the ICB from 2024 and 2025. We saw no evidence in those that AJM said the budget was not adequate because it had more work to do than expected. In fact, the evidence shows AJM acknowledged that activity was less than predicted because of inaccurate recording by the previous provider (we explain this in more detail below).

110. AJM did raise the issue of cost pressures and inflation with the ICB during an activity discussion on 22 September 2025. That is after the period of the complaint Miss C has made.

111. We saw no other contract variation requests or anything to show that AJM reported unsustainable financial pressures. The general conditions to the NHS standard contract (which was the contract AJM signed) provide a framework for disputes that can be used by either party. AJM could have used this to challenge the adequacy of the budget if it chose to. Therefore, it appears that AJM considered the service was still affordable despite rising costs.

112. We acknowledge AJM’s concern about the impact of block contracts, especially in times of high inflation. In this case however, we saw no evidence that the ICB failed to act in relation to the budget for the service during the relevant period.

Evidence about the activity of the North-West London Wheelchair Service

113. We have looked at whether the activity AJM had to deliver was significantly different from what it had expected and therefore budgeted for when it agreed the contract. A significant discrepancy may mean the ICB was partly responsible for AJM’s decision to operate a queue, and therefore D’s experience.

114. AJM sent us activity reports for 2024/5. We used this data to compare the actual activity delivered by AJM, with the expected activity set out in the IAP in the contract. Based on the data available, we saw that the average number of referrals received per month for North West London ICB was lower than planned. AJM suggested to PHSO that the complexity of work was different to expected, but we have seen no information to confirm that or information showing whether, or how, this affected AJM operationally or financially. Nor have we seen evidence that AJM raised this with the ICB.

115. Based on this, we do not think the evidence supports a picture of AJM being financially disadvantaged by having to undertake significantly more work than it might have expected. We have not seen the ICB were therefore responsible for the need for a queue that D may have been affected by. As noted previously, if AJM had significant concerns about the budget or the work it had to deliver, it could have used the framework for disputes within the NHS contract. We have not seen evidence AJM used this mechanism, or that it demonstrated to the ICB that the activity prediction was wrong – other than highlighting that the previous provider had over-recorded the work it was doing.

Contract management

116. Given AJM was operating a business model that, on the face of things, was causing people like Miss C and D to experience significant delays, we looked at whether the ICB should have exercised more robust contract management over AJM.

117. Commissioners have ultimate responsibility for holding providers to account when there are problems with the quality of service. The main standard ICBs must meet when managing contracts and disputes is the terms of the NHS standard contract. However, ICBs have a significant amount of discretion in how they do this. We found no national guidance to help ICBs to decide when to take informal action to address service delivery problems, and when to resort to formal contractual levers. The Standard NHS contract only says that formal contractual levers should be used when there has been or there is likely to be a breach of contract.

118. We also found the provider market for wheelchair services is small, leaving commissioners with few alternative choices and a greater need to improve the existing service, rather than impose penalties or end the contract. We took that into account when looking at what the ICB did. We also took account of the service conditions to the NHS contract which say services should continue to be provided to the people who need them, even where there are disagreements about activity or budget.

119. During our investigation, we observed that the ICB was unable to use the routes that would usually be available to commissioners to address poor quality services. This is because AJM is an independent provider and is not defined as a healthcare provider. Guidance from the National Quality Board on escalating quality issues to a national level within NHSE does not apply to independent providers. Providers that are not healthcare providers are not regulated by the Care Quality Commission.

120. ICBs can escalate matters to NHSE regional teams in line with their own risk framework if they need support. North West London ICB did not do that. However, we heard from this ICB and others, as well as NHSE, that the regional teams may also lack the specialism in wheelchair services to provide any significant support. While we do not think the absence of formal escalation routes relieves the ICB of its governance obligations, we can see this is likely to add significant challenges for all commissioners when attempting to address quality concerns.

121. We also note that the Operating Model says that commissioners should seek to support supplier and provider markets to improve quality in the short and long term. The ICB told us that this, combined with a lack of providers, informed its choices about how to manage the contract with AJM – taking more informal action first to try and improve quality in the existing service rather than penalising one of the few remaining providers.

122. We note that the national procurement guidance emphasises that commissioners should be using commissioning (i.e. during procurement, rather than contract management) to increase efficiency and quality. We have not seen the ICB consciously did this. However, market shaping through strategic commissioning to improve the provider market has only recently become an explicit expectation under the NHS Strategic Commissioning Framework, published in 2025. We have heard from ICBs and national organisations that, as such, ICBs may not have the required skills or experience for this yet. Further, it was not a requirement at the time of events, so we have not used it as a standard.

123. When managing the contract, the ICB held contract management meetings with AJM every two months where various issues were discussed including reporting, quality and performance. We have not seen the monthly performance data returns the ICB looked at. AJM has provided some KPI reports for the relevant period. They do not show significant breaches of the targets.

124. However, the contract management meeting notes show growing concern from the ICB in attempting to reconcile the data AJM was providing with other information from complaints teams and other partners.

125. Between June 2024 and the end of September 2024, the ICB noted an increase in complaints and an increase of plus 18-week waiters. The ICB also appeared to have problems interpreting the data and asked AJM to include reporting trends (i.e. looking back over several months).

126. Between October 2024 and the end of December 2024 the ICB fed back to AJM that complaints from Special Educational Needs Partners (SENP) and Children and Young People (CYP) had increased. The ICB also told AJM it was concerned about repairs data because AJM’s figures looked good yet stakeholders on the ground were not happy. The ICB did a comparison of data between August and September 2024 which showed delays in assessments and in repairs. AJM said this was due to referral data not being good enough and having to go back to referrers for more information. It also said there had been supplier delays.

127. In April 2025, the ICB made formal information requests to AJM about activity under section 28 of the NHS contract. In particular, the ICB noted a drop in performance between March and April 2025 in respect of waiting times for appointments, repair times, repairs fixed at first appointment and times to case closed. The ICB also noted a growing number of people waiting more than 52 weeks and people waiting a long time for appointments.

128. AJM said delays were due to a shortage of field staff and said that it would ‘optimise stock movements’. AJM said it had been operating with three clinical posts missing and three admin roles missing. It also said the longest waits were for specialist seating. It said it was recruiting and prioritising appointments for the longest wait times.

129. In May 2025, the ICB made another formal information request. It asked AJM to explain the generally deteriorating performance between April and May 2025.

130. AJM said it still had staff shortages, it said there had been a spike in demand in early May and there were delays in parts availability. It said it was taking corrective actions (as above) and stability would be achieved in August. AJM committed to clearing the backlog by September 2025.

131. The ICB made yet more formal requests in June 2025. It was concerned about:

• breaches of the KPIs of equipment provided in timescale and emergency repairs.

• the increase in 52 week waits • a general drop in performance of appointment times, repairs fixed at first appointment and waiting times for assessment and delivery (not in all areas) • the number of suspensions AJM was making because of poor referral information (around a quarter of all referrals were rejected by AJM pending more information).

132. AJM said that the issues were due to staff shortages/holidays, increased demand, and equipment delays by manufacturers. It said it was working with manufacturers.

133. AJM did not clear its backlog of long waiters by September 2025, as agreed, and in October 2025, the ICB started two task and finish groups (groups of the ICB to set up and resolve particular quality issues in a contract) – one on long waiters and data accuracy, and the other on complaints escalation.

134. The output of these groups culminated in the ICB issuing a contract performance notice to AJM on 4 December 2025. This is beyond the date of the complaint this report refers to, and after we started our investigation. However, it is useful to note that the CPN included concerns about: • long waits and poor outcomes • issues with complaints and variability in how complaints are recorded and responded to • serious concerns about the accuracy of data quality following audit and meetings where AJM was unable to reconcile its own figures • communication with service users.

135. The ICB said that despite trying to discuss these issues with AJM, the responses it had received lacked sufficient detail, clarity and clear timelines.

136. As a result of this process, the ICB is, at the time of writing, looking at the results of a joint investigation (i.e. between the ICB and AJM) into what happened. This is beyond the scope of our investigation.

137. Given this series of events, we have looked at whether the ICB should have done anything differently or sooner. We wanted to look at whether D’s experience may have been different if the ICB had taken the actions it did any sooner.

138. In reaching a conclusion, we have considered our Principles of getting it right and acting fairly and proportionately. This includes acting in accordance with guidance, taking relevant considerations into account, and acting proportionately, particularly when applying penalties.

139. While the ICB could have acted differently, we do not think its approach here or the timing of the approaches fall short of the Principles. The ICB attempted collaborative work first, which would appear to be proportionate and in accordance with the guidance. It took steps to understand all the data and reasons for delays and long waits. In particular, in the first six months of the contract the ICB spoke to AJM a number of times about accuracy of reporting and the data.

140. The ICB began to use formal contractual processes in April 2025 when it had evidence of poor performance. Formal contractual processes are for when the ICB has evidence that there may be a breach of contract. We saw no reason to conclude that evidence was available such that the ICB should have done more sooner.

141. On balance, we do not think that the ICB materially failed to consider something relevant it had access to, or that it should have weighed the facts it had differently, or done something differently. The relevant facts about what was proportionate here, included the service level data (which did not show a significant breach of targets), the expectation for ICBs to work collaboratively to help improve quality, and to consider the impact of formal action on service users. We are also mindful of the lack of a robust governance structure and the adequacy of resourcing within ICBs and NHSE to provide effective specialist support in these situations. All this would suggest that a graduated approach, as happened here, was appropriate and in accordance with the guidance.

142. For the reasons explained above, we do not consider any actions or omissions by the ICB caused or contributed to the failings we found with the service provided to Miss C and D.

Wider issues affecting wheelchair commissioning and provision

143. We have received other complaints from a number of regions that are similar to Miss C’s case. Across our investigations, we have seen issues at a national level which mean that, in practice, it is a considerable challenge for ICBs to fulfil all the requirements of national guidance, which service users and providers like AJM reasonably expect them to do. In particular, we noted: • a lack of available data about the wheelchair population (locally and nationally), particularly in relation to people who are not currently registered with an NHS wheelchair service or who need equipment that NHS wheelchair services do not provide • a lack of robust data collection metrics defined at a national level that can be used for the local commissioning and planning of services • a lack of robust data returns and national level analysis of data that can be used for benchmarking between ICBs locally • no regulation of independent providers like AJM who are not deemed to be providing • healthcare • an absence of formal national escalation routes or robust governance routes, equivalent to those available in relation to NHS providers, for when independent providers are not performing well • a lack of choice of providers in the market, which mean ICB have few alternatives available to them where existing providers are persistently underperforming despite robust contract management.

144. We intend to comment further on these issues in future work.

Impact

145. D is not mobile at all without a wheelchair. The wheelchair is an essential item to ensure his wellbeing and enable him to take part in everyday life.

146. Miss C told us D was significantly affected by the prolonged period without his permanent chair. She said the temporary chair was so much harder to propel so he tired after 10-15 minutes and it caused increased physical strain. Needing support to push him significantly affected his independence. D found this upsetting as he strongly dislikes others pushing his chair. Transfers in and out of the temporary chair were challenging because it did not fit him properly.

147. Miss C said not having a suitable wheelchair compromised family life enormously and they were not able to do normal everyday activities. She said D could not take part in the sports he loves, leaving him feeling upset and isolated, with a profound effect on his mental wellbeing.

148. D told us he could not participate in school activities and sports, and he could not move independently to go and see his friends. He says the lack of social interaction led to him feeling down for a long period of time.

149. The contract states AJM must achieve specific service user outcomes including: • providing quality of life for the service user with regard to the social model of disability and ‘whole life’ needs • enabling children and young people to access both education and empowers access to • wider developmental activities in the community • supporting independence and user autonomy.

150. Sadly, the delays in repairs and the lack of a wheelchair designed for an active user led to a missed opportunity to meet the service user outcomes for D.

151. We found D suffered significant unnecessary hardship and distress as a result of the continuous delays he faced with getting a suitable wheelchair delivered that met his needs.

152. Miss C told us she had to continuously chase the repairs to the two wheelchairs and she found the process distressing. She also told us she found it very upsetting to see her son’s mental health deteriorate as he was unable to mobilise independently.

153. As such, we also consider Miss C experienced unnecessary distress and anxiety for a prolonged period. This is an injustice to her.