Editor Steve Hards frets about a dilemma for telehealth and telecare service purchasers.
Imagine that you are ‘a commissioner’ in a position to influence plans for local NHS or council spending, or you could be in a position of influence within an NHS trust, or a council.
You are acutely aware of past, current and impending funding pressures. Positive messages about telehealth and telecare technologies and their potential to facilitate changes in the way services are provided – and possibly to ease some of those funding pressures – have somehow penetrated your noisy environment.
You are reasonably convinced that services locally should ‘do something’ about it. You start convincing others. You build enough momentum to get to the point of someone drawing up a commissioning specification.
What do you put in it?
You reach agreement with local service providers about what you want to achieve in terms of service change and how much you are collectively prepared to invest on achieving those aims and over what timescale.
You now have to start specifying the competencies, qualifications and accreditations you want potential suppliers to have. Accreditations are particularly important because they are a shortcut to a significant area for due diligence, particularly in areas of technical expertise. You start to think through the options…
Option one. Limit bidders to companies on the Government Procurement Service’s (GPS) Telecare, Telehealth and Telecoaching Framework Agreement (FA).
But hang on, that’s over three years old and confining bidders to that, while an ‘easy’ route, will limit the field and exclude newer, possibly innovative companies that may have just what you require.
Also, if you have been reading Telecare Aware on the subject, you will also be wondering just whether being on the FA is any indication of good quality. There are doubts about what due diligence was done on the companies that made it through the tendering process by the original Buying Solutions (BS) organisation, which set up the FA. It was a flawed application process in which BS told tendering companies how to score well and therefore invited ‘creative’ responses.
Option two. Require Telecare Services Association (TSA) Code of Practice accreditation. If your plans include a telecare element then at least you will be certain that TSA accredited providers will work to a high standard. But the TSA’s telehealth provider accreditation will not be available until 2013. (TSA website.) You may also have a lurking concern that there may be providers who are perfectly responsible and ‘high quality’ that are not TSA accredited, because accreditation is only open to the TSA’s own members.
Option three. Alternatives to TSA accreditation? The recently-announced SSAIB UKAS-Approved Telecare Services Scheme (which started to be discussed three or four years ago) that is “run independently of any trade association, manufacturer or supplier interest” looks promising.
However, despite the claim in the press release that it is ‘prestigious’, what does it cover? In addition to the press release there is one other page on the SSAIB site and neither are particularly informative. If this scheme is a genuine alternative to the TSA accreditation one would expect a dedicated site promoting it, with full details and a general fanfare of launch publicity.
Option four. Give up worrying and fall into the reassuring arms of one of the major suppliers, particularly the market leader, Tunstall. The latter is on the FA, is TSA accredited and is the major player in the 3millionlives (3ML) initiative. It holds its market leader position by ticking commissioners’ boxes. Part of its marketing genius/leadership position is that it helps the commissioners decide what those boxes should be. And it can put out headlines such as: Tunstall Healthcare spearheads quality standards in telehealthcare. However, that press release refers to Tunstall attaining ISO/IEC 27001 certification regarding information security, not quality standards in general as you might suppose. Is it not reasonable to assume that all telecare service providers have high levels of security for users’ data? Hmm, perhaps we had better not go there!
These are not four confidence inspiring options, are they?
Ten years ago, council and NHS community equipment services (i.e. assistive technology in its general sense), with the support of the Department of Health (DH), their commercial suppliers and the industry body, the British Healthcare Trades Association (BHTA), began a process of service integration. By 2005 when the DH closed the shoe-string team that promoted the integration process, many of those services were making good progress in re-engineering themselves. DH followed that with a clumsy attempt to persuade community equipment services into the private sector. Now, it seems, the community equipment services industry has ‘come of age’.
It has taken accreditation seriously and produced a truly independent accreditation company, cleverly called CECOPS. Delving into the About Us page one finds that CECOPS is a form of social enterprise called a community interest company and it is run by some well known figures in the UK’s AT/disability field. Most importantly, the assessment process is contracted out to DNV Healthcare, a company with the credentials of working the NHS Litigation Authority for its risk management standards and with Macmillan Cancer Support.
Perhaps the time is ripe for TELECOPS?
Steve Hards
18 October 2012
UPDATE: Please note that comments go on to two pages.
Thanks for this Steve, an interesting read and I like the 5th option best but TELECOPS? not so sure about that branding …
… this conjures up images in my head of Cagney and Lacey or Bergerac (not that I watched either of them).
[i]These reminiscences of our younger days TV heroes are very powerful; I have recently been christened Ms Benn – I walk though the bus doors every morning and go on an adventure to somewhere new (dressing up not involved – honest!)
cue telecops music … man jumps from sporty car does a forward roll across the bonnet and presents the elderly person at number 12 with … (pan to close up of elderly person’s hand) … a GPS Locator.[/i]
Joking aside this does need a major rethink and a large dose of fresh air to get us out of the doldrums.
Steve
An issue for public sector commissioners (ie health trusts/CCGs and social care authorities) could be that legal advice on EU/UK tendering law may not allow a procurement specification to specifically identify membership of an organisation or compliance with a code or standard.
Adding these types of spec clauses may be open to legal challenges by providers who are able to meet requirements but do not have the appropriate registrations and accreditations.
This was an issue for Buying Solutions in the preparation of the 2010 framework.
Of course this would not preclude providers in pursuing accreditation/certification if they wish to demonstrate independent audit of their quality systems, IT systems, environmental systems etc.
NHS procurement may become even more interesting with ‘Any Qualified Provider’ arrangements. Service providers may need to look at CQC registration, Monitor regulations, meeting NHS terms and conditions etc.
Some observers also still see EU issues with the potential legal status of Clinical Commissioning Groups. Their status may be different from PCTs. There are some additional conflict of interest issues to work through where GPs (as a CCG) could effectively be commissioning services from themselves (eg enhanced services, diagnostics, minor injuries units).
It is also important to remember that a full EU tendering exercise could take many months to work through with an average estimated cost of £50-60k. This needs to be factored into overall costs.
Regards
Mike
Hi Mike,
Many thanks for throwing these observations into the mix! It’s no wonder that suppliers are finding it so difficult to sell into the NHS.
It is interesting that you are saying that whether to seek an accreditation or not is a provider choice that should not affect their ability to bid. And conversely, our hypothetical purchaser has to throw accreditations/memberships of organisations out of the formal tendering process…I wonder how many have breached that in recent years and what come-back excluded suppliers may have?
You neatly picked your way through the complications of the newly-shaken up NHS, which was one of the reasons I was deliberately vague about where in the system our hypothetical purchaser might be. However, the implications of the ‘Any Qualified Provider’ arrangements and the legal status of clinical commissioning groups had escaped me!
I take it that you are saying with your final paragraph that despite the shortcomings of the framework agreement, purchasing through it may be a better option than not doing so. Perhaps some of the £50-£60k saved can be used on increased due diligence on the selected providers.
Steve
Far too complex to undertake; and get it right.
It is designed not to work. Or to only work for a privileged few that will still give you what they say you need, not what you know you need, if you do in fact know what you need.
This just shows the need for a consumer led approach where the individual chooses, just like buying a TV or renting a house. Smaller companies will be swalloed by the bigger fish if they are to survive – corner shops and supermarkets etc. Alternatively smaller companies get their kit out together and hit the High Streets otherwise they will have great services but no market.
I cant help getting the image of ‘Telebobbies’ running around like the TellyTubbies scratching their heads as they try to ponder how to get on the GPS / FA.
E’ooo!! :-)
Managed services, outsourcing and commissioning are hot topics for local authorities at the moment. History would suggest that telecare services will in future be provided by independent or not-for-profit organisations – as is the case for residential care homes, and homecare services. These have been important factors in reducing the costs associated with care in the community, thereby helping the NHS to safely reduce the overall number of acute hospital beds despite the pressure of an ageing society.
The UK market is now awash with homecare provider organisations, but many struggle to find enough appropriately trained staff to satisfy contractual needs. Some offer excellence while others are a cause for concern – so monitoring of performance is essential.
The situation with telecare services is not so simple because the processes involved in organisation and delivery are more complex, and because measures of quality are not yet mature (even though the UK is a good few years ahead of the rest of the world). Are we then not in danger of jumping the gun and allowing market testing of telecare services before performance and cost base-lines have been established, and before the dangers of outsourcing have been studied objectively and independently?
This topic was so relevant to CUHTec members during the summer that it was included as a workshop during the Remixed conference in Newcastle in September. I have written up some of the key discussion points as a paper to appear in next month’s CUHTec Newsletter, which will be freely available to all members, both full and associate (associated membership is free to local authorities, housing associations and to primary and community care organisations). The paper concludes not only that commissioners need to develop more robust service specifications but also that service providers should have to work more closely with other preventive services in order to improve cost-effectiveness. Partnerships will be essential, many involving public organisations.
Thanks Steve for providing another timely soap-box article.
This is all rather scarey!
On the one hand, people are saying that managed services are inevitable, because councils must commission rather than provide services. On the other hand, we are being warned that establishing robust service specifications is too difficult, and we should accept that the big boys are going to come in and sweep up all the small local providers and replace them with a one-size-fits all model of telecare that probably wont save money or deliver good outcomes, because they aren’t interested in the finer points that actually affects quality of life?
Before we allow our beloved Directors of Social Care to listen to the inflated claims about numbers and savings that the big boy machines will churn out (without a scrap of evidence that would convince those of us at the coal face), can we simply not put some flags in the sand, and make sure that they know what managed services aren’t acceptible?
For a start:
1. Those that are run by equipment providers – for surely our experience with ICES tells us that they will only provide the equipment that makes them the most money
2. Those that are run by telecoms companies – because they will only offering services that use their networks (fixed or mobile)
3. Those that are run by logistics organisations – because they will only be interested in services that require a call centre.
Any others that we should exclude?
Are there any left?
Good discussion Steve
It will be up to commissioners to decide whether they use the framework or not as it is not mandatory. It is worth looking at the pros and cons carefully before making a decision.
I agree with the points about the barriers for small and innovative providers (although there are growing numbers of microproviders in social care with innovative service models to support personalisation and personal budgets).
The telecare framework could potentially be extended to 2014 as part of the 2010 contract. If the GPS see low takeup on any of the one year extensions (2012/13 and 2013/14), they could decide to wind it up or not go out again to tender in 2014. As a Government Dept they must also demonstrate cost-effectiveness – no sales = no framework. That could leave many organisations with difficult decisions to make in the next couple of years.
Of course, Scotland has an additional procurement arrangement which may better suit the needs of their health and social care services.
Going out to tender on your own without a lot of legal and technical expertise is not an easy business these days.
There is no perfect solution to procurement, but there are some new opportunities developing.
For instance, outcome-based specs could look for organisations that can improve the quality of life for 500 people with COPD in a defined community whilst reducing hospital visits by 20% – looking for innovation in how services are provided – telehealth and telecare could contribute.
I suspect that whilst CCGs are getting their act together, innovative organisations (including NFPs) will be partnering with providers to tackle the bigger issues ie up to 70% of the £100bn health budget is spent on managing long term conditions. Both ALIP and 3millionlives are encouraging new business models post-WSD to improve quality and drive down costs.
Also, we need to remember the development of 111 services (http://bit.ly/RcDe2Y) in England – health call centres covering local communities – are they future telecare, telehealth and disease management service providers?
As Kevin says ‘partnerships will be essential’ – but they may not be what we have been used to.
Mike
Steve
You can’t always believe fully what you read on web sites, but here are some further areas to think about as services are subject to market-testing, outsourcing, franchising, re-commissioning.
Devon children’s services – questions about the impact assessment – judicial review:
http://www.bbc.co.uk/news/uk-england-devon-19841048
http://www.bbc.co.uk/news/uk-england-devon-20006919
Cornwall proposed major programme of outsourcing and telehealth discussion:
http://www.computerweekly.com/blogs/public-sector/2012/10/cornwall-from-privatisation-to
The future of Gloucestershire’s community hospitals – press release:
http://stroudagainstcuts.co.uk/
West Coast Rail Franchise evaluation:
http://www.telegraph.co.uk/news/uknews/road-and-rail-transport/9584236/Why-the-West-Coast-franchise-is-a-great-Whitehall-railway-disaster
Commissioners and procurers of services really need to take good advice and have proper systems in place even with smaller contracts.
Mike Clark (@clarkmike)
Interesting partnerships – or strange bedfellows?
What if the pharmaceutical companies became involved – it would give them a good start in developing personalised medication? Or what about the software companies who analyse the “big data” – would we trust them to stick to stratification and prediction? Or even the insurance companies – life insurance might get a little more expensive if they knew that someone was accident prone or forgetful?
My fear is that these commercial giants will see that they can easily make a profit from the NHS – and why should telehealth will be any different? What if they offer then to do telecare for free in order to win a contract under the integrated care banner? They might be surprised to find how complex it is, and then ditch it after a year.
Maybe the tendering process for telecare could end up being more complicated than the one for the railway franchise.
I wonder what would happen if Virgin Care failed to win one?
Pharma companies have been involved in telephone-based disease management programmes in the United States (also UK example) for many years.
Pharma companies are involved in smartphone app development:
http://www.fiercemobilehealthcare.com/slideshows/10-big-pharma-smartphone-apps-patients-and-providers
As Jo indicates, there is great interest in big data and personalised medicine.
Making health data more widely available was announced in England in December 2011 (along with 3millionlives – see http://bit.ly/Rawxjo).
There is Pharma interest in the Telecare Framework, 3ML etc.
Overall Drug costs are being squeezed in England through the QIPP Programme (http://bit.ly/RawDaG), so you can expect Pharma to be looking at other areas. We are back to the fact that up to 70% of the healthcare budget in England is taken up by people with long term conditions.
Personalised medicine and genomics is playing a more significant part in identifying the possibility of earlier preventative action for some situations eg some cancers, heart and respiratory diseases, other long term conditions.
Big data analysis will be anonymised but individual genome mapping which indicates the possibility of heart disease or cancer in later life could impact on personal life insurance.
Big players will inevitably be interested in telecare and telehealth particularly where there are existing large databases of users, call centres etc.
As Jo suggests, future contracts could be badged as ‘integrated care’ or ‘managed services’ or disease management’ or ‘hospital at home’ etc – telecare and telehealth could play an important part in a range of health and well-being options that would be personalised.
For those interested in this area, it is useful to look at the developing role of Commissioning Support Units in England (which will become outsourced in time). Here is an example from the West Midlands – http://bit.ly/RaxqbE – CSUs may well become very influential as they will hold data/expertise for commissioning across a region (ie a number of CCGs).
Additionally, those interested may want to explore:
Value Based Pricing – there was a lot of coverage at the recent Healthcare Expo, and,
Accountable Care Organisations (part of Obamacare, http://bit.ly/RaxLv7) – some commentators think that the UK could have similar ACO type arrangements in time.
For those interested in ‘Any Qualified Provider’ – the list of 39 services that DH (England) have identified so far are listed at http://bit.ly/Ray4WO and covered further at http://bit.ly/Rayc8C
Really interesting discussion – and great that we are talking about the future and the implementation of digital healthcare initiatives as they are being developed in the UK.
It seems pretty clear that we are shifting rapidly from a culture of healthcare based on hospitals and doctors to a far more flexible and agile one based on prevention, self-care and informal care supported by technology at every stage.
With the new DALLAS projects and the Three Million Lives campaign we are telling the world that we are ahead of the game, and that our healthcare support and delivery organisations have shifted away from being box shifters and call handlers into something special that they can all learn from. The intensity of debate around the best partnerships could not be had in other countries. Hopefully this will convince stakeholders such as the pharmaceutical giants that this is the right country in which to invest and to find the right partners to ensure that our tele-services continue to be the best in the world.
The only thing I don’t like about ‘the future’ is that it is not NOW.
Partnerships don’t happen overnight. Organisations don’t know what their own departments are doing let alone what other organisations have to offer.
What is needed right now is a full Telehealth and Telecare service partnership that can be adopted regionally with interchangeable partners as needed depending on the service spec. Partners sign up for it and parts of the Terms of Reference revolve around fairplay and sharing.
Monitoring, compliance, evaluation, quality assurance, response, equipment, maintenance etc all under one umbrella corps. The UC is independent yet funded by all. Their decisions are based on the service spec and an air of fairness. One provider may have a whole contract to themselves whereas another contract may need 7 different providers.
PCTs/CCGs/LAs decide what exactly they want and then UC translates that into services. UC works with these organisations to ensure that what they want is what they are getting.
This can happen overnight or it can take years. Tendering is nigh on impossible at the minute because nobody knows exactly what they want – they just know that they need to have something.
[b]Getting around the EU regulations[/b]
I’ve heard that one way commissioners get around the EU’s ban on the restrictive practice of making membership of an organisation a requirement of a tendering company (Mike Clark’s first post on the first page of comments) is to give the membership/accreditation a huge influence in the second stage, the pre qualification questionnaire (PQQ). (General council PPQ example: [url]http://www.wandsworth.gov.uk/info/200095/tenders_and_contracts/1145/selling_to_the_council/6[/url])
If that is the normal practice, then it puts a such a value on TSA membership and accreditation it is no wonder that it sees no reason to relinquish control of the accreditation process to allow it to revert fully to its original role as an organisation representing the interests of its members.
In a circular kind of argument this IS in the interests of its members even if it is NOT in the interests of not-yet-member companies.
There are good uses for accreditation if its pros and cons are understood. But surely the procurement people have to take some responsibility and be accountable for their decisions rather than hiding behind a framework agreement and, when it goes wrong, washing their hands of blame because the supplier hoodwinked the framework.
Yikes! Another National Telecare and Telehealth framework agreement on the way ‘from January 2013’, and the old one not yet dead and buried.
Under-the-radar announcement by YPO (Who? It’s something to do with Yorkshire) [url]http://www.ypo.co.uk/index.jsp?t=services&c1=42&c2=54&service=4006[/url] with a stakeholder day in Wakefield on 26 November. “The YPO social care team is currently in the process of developing a new national framework agreement for the provision of telecare and telehealth solutions, and would like to invite you to join us for our information exchange stakeholder day on Monday 26th November.
The purpose of this day is to ensure that we are able maximise the benefit and suitability of the proposed framework agreement.
Register for free using the link below, or email procurementservices@ypo.co.uk for more information” Invitation link here: [url]http://www.surveymonkey.com/s/stakeholderregistration?dm_i=G5Z,10EEF,7WMOV4,32V87,1[/url]
[i]Heads-up thanks to a TA reader[/i]
Another one to factor in is the Northern Housing Consortium route which I have previously used when at Leeds. Allows for pre-procured access for those wishing to look at monitoring centre software and other bits. This was a very useful service as it meant that the tendering process did not have to be carried out by Leeds, we just went to speak to the supplier who had got onto the NHC framework and chose the one we preferred.