Pick and mix order of the day as ‘hybrid' becomes the new retail model buzzword

Just as the NAEP Conference was getting underway, a report from trouble torn Iran appeared on a news programme. The reporter, suggesting that the country was in a degree of turmoil used the expression, ‘The future is the land of guesswork'. In a way, that could sum up where we are with the TCES programme and the retail model. Things are happening, that's for sure, but many of the things that are happening are resulting in different, new and unique solutions. So, lots to take in from a couple of days in Blackpool….

What's happening around the UK?

“We shouldn't get totally overawed by the statistics”

“We suspect that there are millions of pounds of redundant equipment in stores in Wales”

“If you look at the evidence, there are still massive concerns about the safety of the service”

TCES and the Retail Model has somewhat taken over the discussions as far as the English Community Equipment sector is concerned. But, of course, it is only England that is being affected by the changes currently.

There has been nothing to suggest that other areas of the UK will follow and indeed, other programmes of development are underway. Presentations brought the delegates up to date as to where both Scotland and Wales stood in terms of the debate on how to manage care services in the future.

Scotland's 65+ population is projected to rise by 21% between 2006 and 2016. By 2031 it will have risen by a substantial 62%. For the 85+ age group, a 38% rise is projected for 2016 while the rise in that age group up until 2031 is 144%. As Jane suggested to the audience, “It's large and it's heading our way!”

Jane posed the question “What do the figures actually mean?” She answered by saying; “If we were to continue with the existing model of care, then we just wouldn't be able to cope.” She explained that almost 50% of the funding in Scotland for health and social care expenditure is spent in hospitals and suggested that the hospital admissions and the way that they happen is something that needs to be focussed on. “When people do need hospital care, then it needs to happen in more of a planned way. We already know that if it is a planned care admission, then it is likely to be a shorter stay.”

She cautioned against over reaction though. “We shouldn't get totally overawed by the statistics because in Scotland, only 11% of the over 65 age group actually receive community care services. The vast majority of the others are either looking after themselves or being cared for by unpaid carers and that is the group that we have to focus on to see what we can do to help them be able to look after themselves. It does change though as the figure rises to 40% for the over 85 age group. The question is how we target that group to enable them to be a smaller proportion in terms of the care they need. Although the 144% figure is alarming, we know that the percentage requiring care will rise only about 2%. Having said that, we don't have the resources for that 2% increase so actually require fundamental change.”

Whatever the changes might be, it seems that the developments that are taking place in England are not on the radar across the border. Jane confirmed that, at this stage, Scotland would not be moving down the path of a retail model for equipment provision. Jane did however say that they had a ‘watching brief' when it came to the changes taking place in England and, it seems that some pressure is being put on those moulding the shape of future services as Jane reported; “Our user groups have been very forceful in saying to us that they want to be able to access equipment themselves and to be informed so that they are not making bad decisions. At this stage we would be taking that forward by providing information on a national basis.”

As was made clear at the conference 12 months ago, the ironic thing is that just as the powers that be in England are pressing on with the promotion of a programme that will result in the dismantling of the Community Equipment Services, in Wales a good deal of effort is being expanded in developing a system based on the best elements of the current English framework.

Steve Vaughan works for the Director of Social Services in Wales and is Head of Partnership. He told the delegates that he thought it important that the profile of Community Equipment Services is maintained in the light of everything that is happening elsewhere.

There are 11 partnerships operating in Wales and Steve explained that most had made good use of capital that has been available to them to develop services. “We are now starting to see the benefits that with improved services and improved delivery.” Over the past year the main focus of the work has been a commissioning framework for what he termed as ‘routine equipment' or small value items. This has included an extensive product evaluation across Wales in an exercise led by ‘Value Wales'. “It's the first time that clinicians have been able to physically examine such a wide range of equipment” he told the conference. “It has been agreed to standardise on a number of good quality products and this should reduce considerably the postcode lottery impact of the current service structure. Certain issues of poor quality and design were identified for the first time and will be addressed. It will know need some collective discipline on behalf of the Partnerships to make sure that it works.”

Steve also touched on the work that was being done in regards of the complex equipment and particularly with an emphasis on recycling issues. “We suspect that there are millions of pounds of redundant equipment in stores in Wales which can't be recycled at the local level and so what we are about to do is to explore an approach to this. A lot of work has already been done on the methodology. One option is the possibility of a national store that would provide credit notes for local stores. We think that this would be a particular benefit for children's equipment, a lot of which is complex by its nature. The funding for a feasibility study has now been agreed and a business case will be put together early in the New Year. The size and shape of any national store will be dependent on the results of the research, but I do think that it would make better use of resources and also provide more timely equipment for people.”

Steve also mentioned the work that is taking place around national minimum standards. He mentioned the report that has been written by Brian Donnelly on the subject, a copy of which can be downloaded from the THIIS website and which can be found in the TCES Update section. “If you look at the evidence, there are still massive concerns about the safety of the service” Steve explained. “The concerns about safety led us into the discussions about minimum standards and Brian has written a report that I believe is excellent and he has served us incredibly well by producing it.”

Steve also reported that there will be a review of the wheelchair services in Wales too.

Supplier's point of view

“This will be much harder for us to replicate in other areas of the country.”

For the first time at this year's conference, a supplier had an opportunity to address the delegates and put the commercial point of view. James Ibbotson, Managing Director of Sidhil put his head above the parapet.

He started his presentation by reminding delegates, if they needed reminding, that we are going through some pretty tough times and that the British economy was shrinking at a faster pace then at anytime in the last 30 years. “So” he said, “why do we bother?” But, as James pointed out, Sidhil's have been around quite a while – over 100 years in fact and was in business during the great depression and so has a good deal of experience trading through difficult periods.

Turning his attention to the future, James recognised that, although there is money in the system for products right now, in a year or so there will be an election and, whatever the result, there will have to be inroads made into the large debts that the country has.

And, as far as the changes to the system go, he said; “People want more choice and they expect to get it” he said. “But, what does choice mean? It means different things to different people.” He suggested that there was a difference between ‘clinical' and ‘lifestyle' needs and that these related to different products. “That is very hard to predict” he told the audience. And, developing the argument that choice has to be managed to make it efficient he asked; “Do people really want pink commodes?”

On the creation of new products he explained just how long it can take to go through the development process and the steps that the company went through before committing to investment. He quoted the example of the latest bed that took over a year to develop from start to finish. “It's important to get it right at the beginning because it's expensive if you get it wrong.”

Of course, what everyone would like to see is for prices to come down and more products being developed with all the additional features that customers are starting to expect to see. But as there is pressure on prices, there is less money to invest in development, that is, unless the volumes increase. He explained that, if prices drop 5%, then the company has to sell a lot more than 5% extra to generate the same revenue.

“Which” he said, “brings us to TCES. The national tariff is driving down prices that are lower than the previous averages. That's great for the customer, but it will have an impact on innovation. Other things like producing retail packaging and delivering in smaller volumes will incur extra costs that we will not be able to pass on. It's not clear what is happening to the national delivery service for the complex aids to daily living (CADL's) and everyone we talk to seems to believe something slightly different and so we are confused. Our hope is that we will see higher volumes.”

Sidhil has been very involved with the development of the retail model in Cheshire and James suggested that, although much has been learnt in an area that is reasonably local to the company base, there are questions regarding how easy it would be for the same system to work elsewhere. He explained; “We have been supplying and installing products in Cheshire and we have learnt a lot doing so. This will be much harder for us to replicate in other areas of the country.”

There are challenges we face as a UK manufacturer but the positives outweigh the negatives and we are proud to be a UK manufacturer. We believe that it is the future of our business and we hope that other suppliers will follow our lead.

And so, an insight into the challenges that are facing suppliers, both in terms of the market conditions and also the demands that the new models will be placing on them.

And now, the retail perspective

“I believe that TCES has been an abject failure”

“Naturally I see it as being good for us, good for the health service and good for the customer”

From the suppliers to the retail side of the marketplace as Mike Williams of Ableworld and Joe Cavanagh, who has been involved in the industry for many years, talked about the issues from the other side of the fence.

Mike has been one of the main supporters of first the Cheshire pilot and, for over a year, the fully operational model. Joe spent a number of years heading up some of the biggest companies in the marketplace before spending the last few years as a consultant. What makes his views more interesting though, is that he is also on the board of the new social enterprise set up by Cheshire (Ability Aware) as part of the retail model. Being close to the coalface in that regard should give him a unique insight into the way the model is performing.

His views were clear and forthright. “I believe that TCES has been an abject failure” he said, “and that it has failed to deliver what it promised. We have seen slippage of over two years and, as a tax payer, I think that it is very questionable as to what has been achieved. The model is all about driving down costs but one of its failings is that it won't deliver savings. It may meet the longer term strategic aim of normalising products.”

The fact that Joe doesn't believe that the model will make savings is an interesting one. Initially, the model was ‘sold' by the DoH team on the basis of savings, some of which were quoted as being significant. Elsewhere in the conference there was an example of another area that had been encouraged to take a look at the retail model with an indication that savings of over a £1 million a year were achievable. However, the area is not going down the full retail model path as their own financial investigations couldn't find the savings that had been suggested. Of course, you can present figures in a number of different ways and it may well be that the savings are there, but only if a level of action is taken that, at this moment in time, doesn't appeal to the people who are making the decisions.

“Transparency” is a word that has been used more than most in the media recently in relation to the MP's expenses and there is no doubt that a little dose of transparency would make the TCES retail model issue a lot clearer too. There seems to be a lack of credible and transparent facts and figures released from the areas that have had the opportunity to take a look and become active. At the time of writing, no figures have been forthcoming and that is fuelling a level of mistrust and could well be slowing the process down.

In Joe's opinion, the fact that Mike was around to get involved in the development of the retail model was a stroke of luck. “Cheshire was very fortunate to have Mike in the area as, in most parts of the country, there just aren't retailers like Mike and that's why the retail model is doomed to failure as it was first presented.”

Because he has little faith that there are enough companies willing, ready and able to put the effort in to make the model work as it is working in Cheshire, Joe sees a different scenario. “I think that the emerging strategy will see a lot more social enterprises take shape.”

As has been well reported in THIIS over the past year or so, Mike is a strong supporter of the model and has been right from the very start. He saw an opportunity early on and explained that after looking into the ways that the process worked previously, he was in little doubt that changes could be made for the better. “What surprised me was that every Loan Store was being charged different prices and, in my view, very high prices. We were given a price structure and have been able to take that and go out to talk to suppliers and make a reasonable profit. There are three or four suppliers that have risen to the challenge. Naturally I see it as being good for us, good for the health service and good for the customer. I can't understand the negative views that other retailers have and it is basically free marketing for my company.”

And updates from some other areas….

“When we did start to test and validate the figures we found that it just wasn't achievable”

“Don't get pressurised into something that doesn't feel right or that there is no evidence to say to do”

From the suppliers and retailers to a current service. Martin Kennard presented the perspective as seen through the eyes of a Community Equipment Provider.

In Leeds, the expenditure on equipment in 2008-2009 will be £1,875.075 with running costs of £1,000,167. The value of equipment on loan is put at £10,409,326. The number of items issued in 2008-2009 is 71,592 and 50,244 have been collected. The products have been supplied to 16,089 adults and 705 children.

Martin explained to the conference that Leeds, like many areas of the UK has gone through a process assessing options for the future. This has involved Leeds Metropolitan University, wide stakeholder involvement and a number of experts.

The result is that Leeds is retaining the in-house joint purchasing service and providing much of the equipment as it does currently. In the question and answer session that followed Martin's presentation, the word ‘hybrid' was mentioned for the first time at the conference and it is clear that areas such as Leeds are taking a look at the retail model and the developments in places such as Cheshire, taking bits from that but deciding to maintain part of all of their existing services. Each seems to be developing in a different way, which is going to be a challenge for anyone hoping to keep track of the marketplace. Measuring just what is working and what is working most effectively, could also be difficult too.

In the parameters of the Leeds ‘hybrid', there will be some work done to develop a ‘retailer' option for some of the lower cost items but Martin also told the conference that they would be exploring the option for an in-house social enterprise arm of the main service which would offer a retail sales and hire service. This is the sort of development that has existing retailers confused, worried and in some cases a little angry. There's no doubt that the social enterprise option is one that is becoming more popular by the month and many areas see this as being very ‘doable'. How this fits in with developing a retail option through existing local businesses is less clear. There's little doubt that a social enterprise providing a ‘retail' option will be seen by many in business as a competitor and one that may well have significant advantages over a high street outfit. Whether they can work together in the long term isn't clear and we won't know the answer to that for some time to come.

Laura Fortune, Programme Manager for Adult Care Services in Hertfordshire explained that figures had been given that showed a potential saving of some £1.2 million a year. This was split across two budgets and Laura said; “The prospect of £600,000 saving from two budgets was an exciting prospect.” However, as she pointed out, “there was some scepticism about the savings”.

Hertfordshire decided to take a closer look at the figures themselves as Laura explained; “Rather than simply saying, yes, we will do whatever you say, we decided to go down the road of a feasibility study. We looked at our existing services so that we could compare and contrast them with the DoH model.”

Laura also explained that, as part of the overall review, there were very tentative discussions about a regional distribution centre, which took place with a few colleagues in east Anglia, but these have not got very far down the line at present.

The four month feasibility study gave them some interesting results. “When we did start to test and validate the figures we found that it just wasn't achievable. The savings would not have been achieved as stated.” She also suggested that the National Catalogue offered little benefit either. “As far as the National Catalogue and product tariff goes, it was more expensive than Hertfordshire are buying at now. Unless we could identify efficiencies, we felt that we were limited in what we could do with the model. Having said that, we didn't really want to throw away the good bits and the advantages.”

The result is that there will be changes in Hertfordshire. “By taking a look at our existing services we have come up with a new model. We are starting to talk to the local retailers and aiming to go down the prescription route with a focus on our direct payments.”

However, she did mention that it isn't going to be an easy thing to do, especially in the climate of recession. “Since we started to talk to the retailers in our area, we have lost two of them already since they have closed their businesses.” In her presentation, Laura had also mentioned ‘an under developed retail sector' as one of the reasons that the model wasn't taken up in full. As already mentioned, it is likely that other areas could find a similar thing as the established, experienced and trusted retail outlets in the traditional mobility and homecare marketplace are sometimes few and far between and not able to support a full retail model programme at present. That, of course, is why the DoH is so keen to attract new players into the marketplace. The danger, one would assume, is that a new model could be supported by new companies with little experience ‘learning on the job' and would that be the best way forward?

The Hertfordshire example is a good one in terms of the reticence to go ‘all the way' as Cheshire has done. The more that areas pick and chose elements, the more that will encourage others to do so too and could make selling the ‘full version' ever more challenging.

In relation to the Complex Aids to Daily Living (CADL) issue and specifically a regional solution, Laura suggested that it has to be looked at carefully, particularly in terms of a rural area. Sighting Norfolk and Suffolk she stated “It could take four or five hours to get across that region at times. There are a lot of practical issues to take into consideration. It's all about timing and whether there is an appetite for it.”

Like most people, Laura was realistic in terms of an admission that doing nothing is not an option. “If we carry on doing what we are doing, then the budget will go through the roof.” However, she cautioned against taking a decision without a careful look by telling colleagues; “Don't get pressurised into something that doesn't feel right or that there is no evidence to say to do.”

The DoH point of view

“We have a lot of interest from the independent pharmacies”

“Our view is very much that, we have created opportunities and the question is, how creative can you be about filling the space”

“This is not ‘big bang', it's a phased approach”

Like the presentation given by the DoH at Naidex a few weeks ago, the starting theme of the update was how TCES fitted into the bigger picture in terms of the ‘Putting People First' initiative that has been around for some time.

As Lynne explained. ‘Putting People First' is one of the major policy objectives of health and social care and she re-iterated that TCES was all about choice and control and empowering individuals to self help. She commented that people were looking for help to understand what their choices were.

She also mentioned the new entrants to the retail marketplace. It isn't clear whether the likes of ASDA, Homebase or B&Q reacted because of the TCES developments or whether they were always going to be moving into the market. The DoH team are clearly keen to link the market activity to their encouragement.

Lynne reported that the DoH had received a lot of interest from the independent retailers that were already in the marketplace. However, it was the independent pharmacies that she highlighted as being more recently enthused. “We have a lot of interest from the independent pharmacies” she said. “If you take away the chains such as Boots, Lloyds and the Co-op, then there are about 6,500 independent businesses in England and they are extremely interested. They see this as a logical extension to the services that they already provide.”

On the subject of Boots, Lynne reported that the company was involved in TCES. “Boots is working with us in our targeted area in the North West and have been writing prescriptions for the retail model for the past few days, which is excellent news.”

Clearly the trend is for areas to pick and choose elements of the ‘retail model' but it seems that Lynne and her team are pretty relaxed about this. Although the impression might have been, in the early stages, that there were firm guidelines regarding what the model might look like, maybe it's more of a case of making progress in terms on alternative delivery in whatever shape that might take and that suits a particular area. As Lynne stated; “Our view is very much that, we have created opportunities and the question is, how creative can you be about filling the space.”

There has been a question mark about just how many areas are willing to ‘get creative' and the map that the DoH has on the website, showing the level of interest in engaging with TCES, has been the subject of constant conjecture.

Lynne was aware that her presentation at NAEP last year, showing the level of engagement with each individual area, had caused what she described as ‘a little flutter'. “I realise that some of you, at that time, had not realised that we were talking to your Directors of Adult Social Services or the Chief Executives within the PCT.”

She explained that there were different levels in terms of how they are shown on the map and that can range from simply having financial and activity data from the area. As she pointed out, it doesn't necessarily mean that they are active in terms of looking at the model. Indeed, there are different colours for those areas that have requested details from the DoH but not responded and those who have sent in data. In terms of being active at a level that would indicate real involvement, it seems that those areas coloured ‘pink' are the ones to keep an eye on. Lynne reported that the latest area to move into this category is Southwark.

Lynne added that her target was to get 10 leading sites to have passed ‘start up readiness' and to have launched their projects by the end of September. Southwark is one of those sites and so there are nine others to progress. Seven of these sites are in London, one is in the eastern region, close to London and three are in the North West.

You can view the map on the website at www.dhcarenetworks.org.uk/csed

Lynne also mentioned that a prescription piloting solution was also being piloted and that there were a couple of different solutions for this. “We are looking to pilot this next month and it is using software from some of the companies that you are working with now and taking it to the next level.”

In addition, work is also starting on what Lynne described as ‘a cluster solution' which basically means getting regions to work more closely together. As the main impetus for the TCES programme has been in the North West so far, that is the area that is being developed in this way. “It's all about having the strategic conversation about can we work together and collaborate and instead of having six or seven different services, should we start looking at having one and becoming a cluster solution. It's going to interesting to hear what their views are and where they are currently and what the timelines should be.”

Lynne explained the process if areas (or sites) were interested in looking at taking TCES development further. There are a number of steps and, clearly, over the last two years, a complex and comprehensive programme has been set up for people to follow. There seems to be far more support available than maybe there was in the early days of this programme, with toolkits for project managers, induction courses and strategic briefings.

She confirmed that there was plenty of steps to go through before even considering to go live with a retail model approach by saying “This is not ‘big bang', it's a phased approach.” Many people will welcome an approach which takes things in small, planned steps which engages individuals effectively. It is different from the initial approach which was a good deal less subtle and managed to alienate a number of people in the early days.”

As part of that planned process, the DoH is working with a few areas at a time. And, as Lynne reported, the next group of 10 sites to work with have been identified and oversubscribed. “We have some 21 organisations that want to be in our ‘top ten' the next time around and so we already know that we have people who want to be involved.”

So, it seems that the programme has evolved and developed into a much more cohesive operation. Communication had been poor though in the past and getting the message across is still difficult as Lynne admitted. “We are very conscious that we can communicate more and better”. A new communications manager is now on board to help in that respect.

In the question and answer session, the first question was regarding the wheelchair review and what is currently happening. Lynne answered; “We have some very positive news about children's wheelchairs. There is a commitment for Whizz Kidz to work with NHS London. Tower Hamlets has a model of service that has been very successful and we are looking at implementing that model across London and hopefully, it will be scaleable to roll out across England. We have also allocated some money to see whether the scheme that is for children (up to the age of 25) can actually also be scaled up for everyone else (i.e.adults). We are doing our very best to progress the work with wheelchairs.”

Another question centred on the length of time that TCES has been around and the questioner suggested that, in his opinion, the performance on delivery had been poor. “There has been tremendous slippage in terms of the TCES programme being delivered. How long is the programme going to run?” He asked.

Lynne replied by saying; “The DoH is very pleased with what we are doing and realise, as I am sure that you do, that it sometimes takes the Community Equipment Services a little time to embrace new ideas. We did have some slippage last year in terms of the Complex Aids for Daily Living (CADL's). We had hoped that we would have had a national solution for CADL's but we presented to ADASS (Association of Directors of Adult Social Services) a number of options and the option they preferred is a regional solution.

She also gave an insight into the length of time that she and her team might be involved. “My team was funded to the end of March and I went to John Bolton (the Department of Health's director of strategic finance, social care, local government and care partnerships) with my proposed workplan in January (09) and I suggested that the programme ended at the end of March (09) and that we spent the last few months handing over to regional implementation structures. It wasn't thought though, that the regional structures were going to be mature enough for us to hand over all our knowledge and all our materials.”

Lynne explained that she had been told that if she hits the target of the 10 new sites by the end of September (as previously mentioned) then another full year of the programme may be forthcoming. “D Day for us is the 30^th September as that's when we will know whether we will be closing the programme down and transferring the information or not.”

She also explained that there was a focus on London in terms of additional funding that the team had requested. “We have been quite active in putting in bids for funding and have asked for six project managers that would help accelerate the implementation of TCES across London.” She explained that, with the current small team, working in the phased way that they are, it would take four years to implement TCES in London.

The fact that the existing DoH team may ‘hand over the reigns' and indeed, had suggested doing so earlier this year was surprising news to many delegates. There's no doubt that there have been plenty of disagreements about the development plans and the way in which they have been presented, however, it seemed like a curious move to many people.

The overriding view was that, if the decision was taken to release control over development from a central source, then the programme would most likely simply fade away. Whether you agree or disagree with the developments, that surely is the worst of all scenarios for the programme and could leave some areas that have embraced change out on a limb.

Finally…

The past couple of years have been both interesting and difficult ones for anyone involved in the supply of community equipment. Interesting because the debate around change is both incredibly important and also complex. Difficult because few people really like that much change and working out where you are in the whole scheme of things is near on impossible as the goalposts keep changing. It's fair to say that there have been plenty of argument surrounding how the initial plans were introduced and communicated and not everyone is convinced that things have got any better in that regard. Clearly there is a ‘trust' issue and until full and transparent figures are made available, then there will still be plenty of sniping going on.

The issues are so complex and so important that maybe it isn't such a surprise that the ‘model' is evolving so much and that ideas introduced with some fanfare have been tweaked, changed or even dropped. A good example of that is the recent announcement that the CEDAB (Community Equipment Dispenser Accrediation Body) is being scrapped after less than a year in operation. The body produce the criteria that should be met by retailers that wanted to be part of the retail model and was supposed to be the policing outfit in terms of which businesses could take part in the retail model throughout England. But, no more – it's going to be dealt with locally by each individual area. Changes like that are frustrating to many and are jumped on by some as evidence that the programme is simply lurching from one position to another and that some of the ideas floated are unworkable.

The big difference though is that areas are now looking more closely at what they are doing and working out what they would like to be doing. As one delegate stated; “A service (community equipment service) has to become a business to survive.” It is likely that we will see more existing services dipping a toe in the commerical marketplace. The TCES retail model has kick started much of that debate and no matter what, things will be different in the future. Exactly in what way, we are still to find out.