Essex Cares is one answer to the changing face of community equipment provision. However, as we have highlighted before, this is most definitely not going to be a ‘one solution fits all' scenario and we are most likely to end up with a whole range of services across England and then, maybe, across the UK. To reinforce that point that there are different options when it comes to community equipment delivery, we had another way to go presented at the NAEP conference.
Liza Alexandra is the Community Equipment Service Manager at The One Stop Resource Centre, Trafford Provider Services in Manchester. She has a wide range of operational experience across both the NHS and social care setting having worked in both for over 20 year's in project management, business analysis and service management roles. She is leading a project to develop and implement a hybrid model around the transformation/retail agenda. Unlike some others, Liza's plan looks to retain and build upon the strengths of what she believes is a successful ICES loan store whilst introducing personalisation and choice.
Liza sees transformation within the NHS itself, taking a more business like approach with the added benefit of retaining funds and generating income back into the service and said in the introduction to her presentation that the TCES model as promoted by the DoH ‘just wasn't right for Trafford'. I asked her to expand on that statement.
“We took part in the original pilot as a micro site, and I just felt that the TCES team hadn't really looked closely at a working ICES store and that the background and understanding wasn't that deep” she explained. “We had a completely different operational service to that of the lead sites Oldham and Cheshire models that had approached provision in a different way. I think the focus of attention was on what wasn't working rather than what was working. I think they saw us as ‘just a store' and that there were 138 of us around the country, but, actually, we were more than just a store and lots of other equipment services are more than simply a store and are integrated into other services too. For example, we also provide transport services across the community involving X-Rays and samples. It isn't just a case of shutting down a warehouse, there are interlinked services here and I am not sure that they fully understood that.”
Like many others, one of the points that Liza felt presented a major opportunity rather than a barrier was refurbishing. “We are not a huge area” she said, “but we refurbish around £1 million worth of equipment each year and we cannot just write that off by giving it away and replacing it. The fact is that our store does work in its current form but the retail model argument did give us an opportunity to look at what we were doing, particularly as we knew that personalisation and choice was going to become such a big issue. Our aim was to develop the service that we have right now and to make it future proof. From our discussions we decided that what we actually needed was a hybrid model.”
She explained the thinking behind the Trafford concept. “We brought together the commissioners, operational managers and clinicians and talked about the pros and cons of the service and what we needed to do to meet the mandatory agendas. We were also very aware that budgets were getting tighter and so although we wanted the service to benefit the patients, we didn't want to shoot ourselves in the foot as a PCT by giving away all our assets and getting nothing back. We didn't want to be in a position where we had to cut back on the products that we were able to offer in the future.”
To Liza and her team, the solution seemed clear. “Let's just cut out the middleman, in this case the high street retailer” she explained. “We have the knowledge, we have expertise so we didn't see any reasons why we shouldn't sell direct. The retailers seem to be the additional link in the chain and, as such, are creating additional costs. We also felt that forcing ownership of equipment onto people wasn't actually giving them any choice at all and the emphasis on need from a clinical viewpoint had been lost a little. There are a lot of people with changing needs that are constantly being re-assessed and we didn't believe that the retail model as it was presented focussed on that. The model didn't support any green issues either with a lot of people needing equipment for only a short while after they have come out of hospital.”
And so, Liza's vision is all about what is there at present and making it stronger. “We are looking to build on the ICES store and retain the benefits of having an ICES store. Our aim is to build on what we have got as we know that what we have works and I think it works in a lot of areas around England. If people want the loan, then they can have the loan. If they want the choice to purchase something, then they can do that too but we will do it through a personal health budget. They can come and buy off ourselves or they can go to a retailer down the road and, if they want to ‘top up', then they can do that too.”
She believes that some of the rationale first introduced for the retail model didn't bear much weight, one being the top ups that retailers would achieve. “One of the things that came out from the pilots was that the number of people actually ‘topping up' was very small indeed. It was people choosing to have a toilet seat with a lid on rather that a standard product and, for me, that didn't really justify the big change. I can understand someone maybe choosing, for example, to have a chrome grabrail rather than a white one - but most people are really poorly when they get to the stage of having some equipment through the service and it's down to clinical need and I just thought that aspect had been missed. If people do have a short term need, then we want to look at hiring products so that people don't have to invest.”
On one of Liza's slides, she stated that she believed the service needs to be thinking more like the private sector and, although she doesn't agree with the involvement of the retailers as is the case in some models, she understands that her own service has to get a bit more ‘savvy' when it comes to dealing with the public. “A lot of things are going out to tender these days and there is evidence of state services losing contracts to the private sector which is fair enough. But we need to be thinking like the private sector ourselves and become more competitive.”
At present, her plan falls short of opening a full retail showroom as she explained. “Our original plan was that we were going to provide for both the state funded and self funders, but we have a little more work to do around the commercial aspects and in the direction of the self funders and so, for the first stage, we will be focussing on state users only. Hopefully, as we move ahead, we will be able to introduce provision for self funders too. We know the market is there as we already get people coming into our store and asking whether we are able to sell them anything. I do see that route available to us; it's just the timing of it.”
And, as we have heard from a number of people from the public sector, there is a strong awareness that these types of plans might well be treading on some pretty sensitive toes if a full retail service was to appear eventually. “We have to be fair and that's the advice we have been given under competition law. The pricing needs to be in line with what's out there in the high street and we wouldn't be there to undercut anyone or put anyone out of business, we wouldn't be interested in things like stairlifts or scooters. The driving goal isn't to make a profit; it is to meet a need without putting people at risk. I know that there have been some issues with retailers being a little keen when it comes to overselling, but I guess that's how they have been sold it by the TCES team in terms of increased footfall and the ability to be able to sell more products to more people. We would like to keep it in-house for a number of reasons and one of them is to allow funds to be regenerated back into the system and that has got to be better for state services. It just makes sense to me not to lose the income and to maintain something that is sustainable.”
Liza accepts that there will be a number of different visions and ideas. “There are similarities between a lot of us, but we are tackling things in very different ways because there is no mandatory route to go down, it's very much left to local decisions and that makes it very difficult for people to develop systems to support equipment providers too.”
So, would she have preferred something to have been tested more rigorously before being rolled out?
“My background is in project management” she told me “and, as such, I am not adverse to change at all. But, I felt that everything was to such tight deadlines, with limited flexibility and as a result the risks were too high to progress further at this stage. I don't believe that is the right way to do a project. My preferred approach is that if you think something isn't right, then you either put the brakes on it or you change the timescale. I think I would have liked to have seen a lot more background work and visited a lot more stores. The Glasgow store is a good example of something that works well around the original ICES agenda.”
“Until and if the new Government puts something mandatory in place, we'll have a whole mishmash across the country” she believes. “The coalition document talked about increased use of personal budgets and direct payments and so, in my mind, any service has got to be developed around meeting those agendas. Having a paper prescription in your hand isn't going to be the answer because people are going to have cash in their pockets.”
Liza's project is almost ready to move forward. “I have prepared a business case for the hybrid model. We have sought legal advice as we want to be doing this right and we are hoping to get something approved before the end of the year because we are ready to go and chomping at the bit.”
Liza is just as enthusiastic about the way she wants to go forward as Gary is in Essex. They are different ideas but both will impact on the marketplace and will be looked at closely by others in the future.