Annals of the Royal College of Surgeons of England (1991) vol. 73, 176-177
The way ahead for the amputee W V James
FRCSEd
Director of Medical Services
Ian McCoII MS FRCS Vice-Chairman
Disablement Services Authority, London
The climate of care of disabled people has changed in the last decade. There is now more interest in 'the person' rather than 'the disease' and in the effects of disease on function. That climate of change led to the investigation of the problems of the amputee. This resulted in the DHSS Working Party that reported on the Artificial Limbs and Appliance Centres (ALACs) in England which reported its results in 1986 (1). As a result, the ALACs were removed from the DHSS and placed in an intermin Disablement Services Authority before being integrated with the National Health Service in 1991. That report revealed a general lack of awareness of the problems of the amputee. The NHS surgeon is usually separated from the amputee immediately after the patient is discharged from hospital and referred to the limb fitting centre. Surgeons are generally unaware of the effects of their surgery. Their training in amputation surgery is sketchy, and there is little knowledge of the type of amputation stump necessary to fit an artificial limb successfully. They also have little knowledge of prosthetics or of the rehabilitation of the amputee. Each district hospital only carries out five or ten amputations annually, thus individual surgeons have little opportunity to become versed in amputation surgery and the care of amputees. Because the ALAC service is quite separate from the NHS, surgeons have little opportunity to see the results of their operations after discharge from the surgical ward, and be aware of the effects of amputations on the lives of their patients. A survey showed that some amputations were carried out in a way that made it difficult or impossible to fit artificial legs success-
fully. The surgeon is unable to appreciate the importance of level selection on the type of limb to be provided. Many surgeons are unaware of the considerable advantages in retaining the knee joint, which conserves the energy so crucial to the elderly person with a low energy reserve. The knee joint also allows active control of the artificial lower leg, which is not available to the through- or Correspondence to: Professor Lord McColl MS FRCS, Department of Surgery, Guy's Hospital, London SE1 9RT
above-knee amputee, who has to swing the lower limb like a pendulum. They cannot see the importance of a properly fashioned and well-healed stump so necessary to achieve a well-fitting socket. To many, an amputation is only an occasional operation, without the opportunity to gain experience and expertise. For that reason, the working party suggested the surgeon should concentrate expertise in limb surgery units, or make arrangements to concentrate referrals for surgery. This is a strong argument for every district general hospital to have at least one surgeon with a special interest in amputation surgery. The care of the amputee starts even before the amputation with careful assessment of social needs and counselling. It involves the selection of the right level of amputation, the way in which the amputation is performed, and the immediate postoperative care. Some rehabilitation measures are anticipated and put in train. In order to increase the input of prosthetic expertise, the doctors and prosthetists in the Disablement Services Centre are being encouraged to be invited to see patients before operation, both to assist the surgeon in decisions on appropriate amputation levels and care, to explain and demonstrate the effects of the operation to the patient, and assist in the rehabilitation of the patient. That is now starting to take place, and more surgeons are making use of the Disablement Services Centre before operation. The awareness of the therapy needs of the amputee is also being increased, with the provision of training packages for therapists who will be able to care for amputees closer to their homes. There was concern about the ill-fitting limbs that were provided. This was associated with the standards of education required of prosthetists at that time, and also due to a shortage of prosthetists. The educational standards lagged behind those of Scotland and other developed countries. As an interim measure, the London School of Prosthetics was started, which provided an HND qualification, and the first 12 students qualified in 1988. However, the shortfall of qualified prosthetists is increasing, and it is also evident that the level of training should be to degree level. To that end, the Disablement
The way ahead for amputees
Services Authority is promoting the creation of a university course for 28 students in England. The limbs provided by the ALACs were largely of the traditional kind. They were mainly 'exoskeletal', where the weight is borne through the outer skin of the prosthesis. The sockets were frequently made of metal, and were fabricated as the result of rough measurements rather than from a cast of the stump, which was delicately modified to allow precise areas of weight bearing and pressure relief. The modular limb system was adopted, whereby the socket is attached to the foot by a central pillar, capable of adjustment and easy replacement of the socket. An outer plastic foam fairing provides cosmesis. Now, some 80% of amputees are provided with such modular limbs. The ALACs, many of them within the grounds of NHS hospitals, were separated from the health service, and working under the entirely different administrative and cultural background of the DHSS. The Disablement Services Authority, has the task of reorganising, upgrading, and integrating the service with the NHS by 1991.
177
The doctors in the ALACs were employed as civil servants in the DHSS, and even though ALACs were often within the gounds of hospitals, they were professionally separated from the NHS, and had skills mainly devoted to limb fitting and the supply of wheelchairs. It was decided to expand the role of the medical staff to include the rehabilitation of their patients, which in turn extended into the field of disability medicine. That being so, all Disablement Services Authority doctors who are to be transferred to the NHS and who are not already accredited, are undertaking an accreditation programme in disability medicine. Hopefully, this will allow the Disablement Services Centres and their medical staff to take part in the wider rehabilitation services within regions and provide a better service all round.
Reference 1 McColl Report. Review of Artificial Limb and Appliance Centre Services, Volumes I and II. London: DHSS, 1986.
The way ahead for the amputee W V James
FRCSEd
Director of Medical Services
Ian McCoII MS FRCS Vice-Chairman
Disablement Services Authority, London
The climate of care of disabled people has changed in the last decade. There is now more interest in 'the person' rather than 'the disease' and in the effects of disease on function. That climate of change led to the investigation of the problems of the amputee. This resulted in the DHSS Working Party that reported on the Artificial Limbs and Appliance Centres (ALACs) in England which reported its results in 1986 (1). As a result, the ALACs were removed from the DHSS and placed in an intermin Disablement Services Authority before being integrated with the National Health Service in 1991. That report revealed a general lack of awareness of the problems of the amputee. The NHS surgeon is usually separated from the amputee immediately after the patient is discharged from hospital and referred to the limb fitting centre. Surgeons are generally unaware of the effects of their surgery. Their training in amputation surgery is sketchy, and there is little knowledge of the type of amputation stump necessary to fit an artificial limb successfully. They also have little knowledge of prosthetics or of the rehabilitation of the amputee. Each district hospital only carries out five or ten amputations annually, thus individual surgeons have little opportunity to become versed in amputation surgery and the care of amputees. Because the ALAC service is quite separate from the NHS, surgeons have little opportunity to see the results of their operations after discharge from the surgical ward, and be aware of the effects of amputations on the lives of their patients. A survey showed that some amputations were carried out in a way that made it difficult or impossible to fit artificial legs success-
fully. The surgeon is unable to appreciate the importance of level selection on the type of limb to be provided. Many surgeons are unaware of the considerable advantages in retaining the knee joint, which conserves the energy so crucial to the elderly person with a low energy reserve. The knee joint also allows active control of the artificial lower leg, which is not available to the through- or Correspondence to: Professor Lord McColl MS FRCS, Department of Surgery, Guy's Hospital, London SE1 9RT
above-knee amputee, who has to swing the lower limb like a pendulum. They cannot see the importance of a properly fashioned and well-healed stump so necessary to achieve a well-fitting socket. To many, an amputation is only an occasional operation, without the opportunity to gain experience and expertise. For that reason, the working party suggested the surgeon should concentrate expertise in limb surgery units, or make arrangements to concentrate referrals for surgery. This is a strong argument for every district general hospital to have at least one surgeon with a special interest in amputation surgery. The care of the amputee starts even before the amputation with careful assessment of social needs and counselling. It involves the selection of the right level of amputation, the way in which the amputation is performed, and the immediate postoperative care. Some rehabilitation measures are anticipated and put in train. In order to increase the input of prosthetic expertise, the doctors and prosthetists in the Disablement Services Centre are being encouraged to be invited to see patients before operation, both to assist the surgeon in decisions on appropriate amputation levels and care, to explain and demonstrate the effects of the operation to the patient, and assist in the rehabilitation of the patient. That is now starting to take place, and more surgeons are making use of the Disablement Services Centre before operation. The awareness of the therapy needs of the amputee is also being increased, with the provision of training packages for therapists who will be able to care for amputees closer to their homes. There was concern about the ill-fitting limbs that were provided. This was associated with the standards of education required of prosthetists at that time, and also due to a shortage of prosthetists. The educational standards lagged behind those of Scotland and other developed countries. As an interim measure, the London School of Prosthetics was started, which provided an HND qualification, and the first 12 students qualified in 1988. However, the shortfall of qualified prosthetists is increasing, and it is also evident that the level of training should be to degree level. To that end, the Disablement
The way ahead for amputees
Services Authority is promoting the creation of a university course for 28 students in England. The limbs provided by the ALACs were largely of the traditional kind. They were mainly 'exoskeletal', where the weight is borne through the outer skin of the prosthesis. The sockets were frequently made of metal, and were fabricated as the result of rough measurements rather than from a cast of the stump, which was delicately modified to allow precise areas of weight bearing and pressure relief. The modular limb system was adopted, whereby the socket is attached to the foot by a central pillar, capable of adjustment and easy replacement of the socket. An outer plastic foam fairing provides cosmesis. Now, some 80% of amputees are provided with such modular limbs. The ALACs, many of them within the grounds of NHS hospitals, were separated from the health service, and working under the entirely different administrative and cultural background of the DHSS. The Disablement Services Authority, has the task of reorganising, upgrading, and integrating the service with the NHS by 1991.
177
The doctors in the ALACs were employed as civil servants in the DHSS, and even though ALACs were often within the gounds of hospitals, they were professionally separated from the NHS, and had skills mainly devoted to limb fitting and the supply of wheelchairs. It was decided to expand the role of the medical staff to include the rehabilitation of their patients, which in turn extended into the field of disability medicine. That being so, all Disablement Services Authority doctors who are to be transferred to the NHS and who are not already accredited, are undertaking an accreditation programme in disability medicine. Hopefully, this will allow the Disablement Services Centres and their medical staff to take part in the wider rehabilitation services within regions and provide a better service all round.
Reference 1 McColl Report. Review of Artificial Limb and Appliance Centre Services, Volumes I and II. London: DHSS, 1986.
