The History of the Limb Service Within the UK
The Artificial Limb Service was first set up by the War Office during the First World War. Artificial limb ‘Shops’ had been set up at Roehampton and the Charterhouse Hospital (near Smithfield). Some 25, 000 amputees had been treated at the 900 bed hospital for the war wounded. Many other Limb Fitting Centres were also started in the country during the 1914-1918 war, e.g. Cardiff and Manchester.
In 1932 the Limb Fitting Service came under the Ministry of Pensions. In 1948, with the advent of the National Health Service, amputees other than the war wounded, were accepted as patients at the Centres. In 1953, the Service was transferred to the Ministry of Health and subsequently to the Department of Health and Social Security. Further Centres known as Artificial Limb and Appliance Centres (ALAC), were opened (29 in England and 3 in Wales), and all were run by the Department of Health & Social Services (DHSS), and later by the Department of Health (DoH).
Advances in technology and materials, fabrications and concepts of modular prostheses allowed local production of artificial limbs. Though the service was first set up to serve the relatively young war wounded soldiers, by the 1960s the majority of new amputees were patients who had lost their limbs due to causes other than trauma – mostly elderly patients with vascular disease who often had inter-current illness and disabilities.
The service was NHS based from the early 1950s, leading to the establishment of the Dundee Limb Fitting Centre in 1964. In 1970, the Denny Report recommended further improvements and encouraged the adoption of a holistic approach to Rehabilitation.
In response to the ‘McColl’ Report published in 1986, the management of the Artificial Limb and Appliance Service was transferred to the Disablement Services Authority, a special health authority set up to run the service in March 1991 and with the responsibility to oversea the transfer of the ALAC services to the National Health Service Regions by 1st April, 1991.
Since 1991 the Prosthetic and Amputee Rehabilitation services have been provided through NHS Trust Hospitals, either as regional, supra-district or local visiting services. In the last decade there have been considerable developments with an increase in the range of prostheses available. There have also been changes in the models for both delivery of the service and contracts with prosthetic companies. The funding of prosthetic services was ring fenced for a period of two years only. Prosthetic services now have to compete with all other NHS services for funding. This has lead to a variation of services across the country.
Prosthetic Rehabilitation is now an integral part of Rehabilitation Medicine and is a core subject in the specialist training curriculum. The Amputee Medical Rehabilitation Society (AMRS), formed in 1990 with a membership consisting of almost all the Consultants in Rehabilitation Medicine practicing Amputee Rehabilitation in close collaboration with the British Society of Rehabilitation Medicine (BSRM) has been in the forefront of many of these changes. The ARMS merged in 2001 with the BSRM to become the Special Interest Group in Amputee Medicine (SIGMA).
The training of prosthetists has changed – all are now graduates. Prosthetics has developed as a profession under the aegis of the British Association of Prosthetists and Orthotists (BAPO) formed in 1995 after the amalgamation of the Association of Prosthetists and Orthotists (APO) and the British Institute of Surgical Technicians (BIST).
The therapists have their own special interest groups: BACPAR (British Association of Chartered Physiotherapists in Amputee Rehabilitation) and LLPOT (Lower Limb Prosthetic Occupational Therapist) and ULPOT (Upper Limb Prosthetic Occupational Therapist) formerly attached to CIGOWP (Clinical Interest Group Occupational Therapists for Wheelchair and Prosthetics) group which dissolved in August 2003. LLPOT and ULPOT are now attached to OTTO (Occupational Therapists in Trauma and Orthopaedics).
There is also a National Forum for Amputee Rehabilitation Counsellors (NFARC) and a Nurse Amputee Network and Special Interest Group (NAN).
The Rehabilitation Engineers have the Prosthetics and Orthotics Interest group (POIG) of RESMaG (Rehabilitation Engineers Management Group) and also the Rehabilitation Engineering and Biomechanics Special Interest Group (REBSIG) of the Institute of Physics and Engineering Medicine. The two interest groups work closely and have liaison membership on their committees.
The Prosthetic Service Managers have a well established network existing to facilitate communications and to share innovations and ideas. They meet twice yearly – once at a joint conference with the Prosthetic Service Provider Companies within the British Healthcare Trade Association (BHTA) and once independently. The Procurement and Supplies Agency (PASA) of the Department of Health and User Representatives are invited to both meetings.
All stakeholders including users, BHTA, clinical groups, managers and commissioner representatives have been bought together under the auspices of the Prosthetic Strategic Supply Group chaired by PASA. This has a clinical sub-group, The Amputee Rehabilitation Clinical Forum, which is currently looking to recommend outcome measures and prescription guidelines for national use.
References:
The Scottish Home and Health department. The future of the artificial limb service. Report of a working party set up by the Secretary of State. (Chair Denny M) 1970.
McColl 1. Review of Artificial Limb and Appliance Services Department of Health & Social Security. HMSO, 1986.
Prosthetic Advisory Group to Minister for the Disabled. A Report of the Working Party (Chair carter-Jones, L). College of Occupational Therapists; 1994
This section was reproduced with consent from the Amputee and Prosthetic Rehabilitation – Standards and Guidelines (2nd Edition). A Report of The Working Party of the British Society of Rehabilitation Medicine.
