Equipment for older and disabled people: an analysis of the market Contents About Consumer Focus Executive summary Introduction Why these products matter 11 Market sizes and supply channels 13 Funding and provision – an overview 16 Mobility equipment 21 Community equipment 27 Ortheses and prostheses 31 Areas of consumer concern 33 Annex 1: NHS Supply Chain 41 Annex 2: Fair Access to Care Services 42 Organisations contacted 45 This scoping study was prepared for Consumer Focus by George and Linda Lennard Associates The work was undertaken in Spring 2010 www.georgeandlennard.org.uk Equipment for older and disabled people: an analysis of the market About Consumer Focus Consumer Focus is the statutory consumer champion for England, Wales, Scotland and (for postal consumers) Northern Ireland We operate across the whole of the economy, persuading businesses, public services and policy makers to put consumers at the heart of what they Consumer Focus tackles the issues that matter to consumers, and aims to give people a stronger voice We don’t just draw attention to problems – we work with consumers and with a range of organisations to champion creative solutions that make a difference to consumers’ lives We have a duty to represent the interests of vulnerable consumers People who use equipment like mobility scooters, wheelchairs and ‘simple aids to everyday living’ (SADLs) are among the most vulnerable in our society They might be making purchases of goods they are inexperienced with, they might be afflicted by discomfort or pain, they might have difficulties in accessing transport and using the internet Local authorities and Primary Care Trusts (PCTs) provide advice, assessments and equipment to people who meet local eligibility criteria but the availability of this help varies from area to area Often people have to wait for long periods before they can see staff to assess their needs and determine if they qualify for support We commissioned this research to better understand how the market is working for customers It is a time of change in these markets: the availability of direct provision of such equipment from local authorities and PCTs is increasingly under pressure, plus the Department of Health is promoting the use of vouchers or prescriptions in certain types of equipment to enable consumers to have greater choice The amount of money available to local government and the health service is likely to decline over the next few years This report highlights some of the problems in this market, many of which arise from lack of public money and shortages in the numbers of trained staff Consumer Focus has powers to investigate and refer markets that are not operating satisfactorily for consumers to the regulators and the Office of Fair Trading We are interested in seeing further analysis of the issues by the OFT Equipment for older and disabled people: an analysis of the market Executive summary The market This report is an exploratory study looking at the market for equipment and services designed primarily to enable independence for older people and disabled people in particular The market comprises a number of sectors covering a very wide range of equipment and products This study covers the purchasing and provision of mobility equipment (such as scooters and wheelchairs) and other types of equipment that are aids to daily living, as well as devices that are known as ortheses and prostheses – see the box below for brief descriptions A variety of terms are commonly employed to describe these types of products and equipment In this report, ‘community equipment’ is used as a general overarching term; in some cases, we use more specific terms in order to describe particular types of products where necessary Some decisions to obtain these products are made by people who may be in vulnerable circumstances, sometimes in times of crisis, for instance after an accident, or because of the onset of illness or disability Purchasing decisions are also made indirectly by relatives or carers There is a strong public services involvement especially by occupational therapists and other professionals who can assess need and provide advice, and by NHS bodies and local authorities who may purchase and provide products to people who qualify for such help In addition, ortheses, prostheses and cosmeses are usually provided by NHS-based services but there are also privately-run centres that offer these services Community equipment refers to a wide range of products that are primarily intended to help disabled people and older people with everyday living Examples include bath seats, can openers, hoists and standing frames but there are many other products that are available The term can also include mobility equipment such as wheelchairs, scooters and walking frames Ortheses are orthopaedic products that are externally applied and offer physical support, such as braces, sole inserts and limb support Prostheses can be described as ‘replacement parts’ such as artificial limbs, hip replacements, and breast reconstruction Cosmeses are designed to help preserve, restore or enhance physical appearance Why these products matter The products covered in this study are of vital importance for the health, safety and wellbeing of several million people They are also potentially useful for many more people who may not regard themselves as disabled Increasingly many of these products are being seen as consumer products rather than medical items, although some undoubtedly are of a specialist nature These products can play a significant role in enabling people to live more independently and to have a good quality of life Equipment for older and disabled people: an analysis of the market Markets There is a lack of comprehensive, reliable and up-to-date information in the public domain on the sizes of the various market sectors, and on the numbers of users of such equipment whether through private purchasing or public provision Another dimension of difficulty is that much of the purchasing of such equipment is carried out on behalf of consumers by statutory services such as local authorities and NHS bodies – information is not normally available on suppliers and contract terms However, public purchasing in England is carried out locally on a fragmented basis and therefore mainly lacks market power Published estimates of market sizes vary significantly Where statistics are available, definitions of the sectors may differ and it is not necessarily clear what types of equipment are included According to the British Healthcare Trades Association (BHTA), annual UK sales values are estimated as follows: Mobility products: £200 million Community equipment: £270 million Pressure area care products 1: £105 million Ortheses: £90 million Prostheses: £55 million These figures differ considerably from those provided in some commercial market reports, for example by Plimsoll Publishing which estimated the UK market for ‘disabled equipment’ at around £1.67 billion and the UK market for powered wheelchairs and scooters alone at around £800 million Another commercial market report by Keynote Ltd put the UK market for mobility equipment at £501 million It is also extremely difficult to secure firm information on the numbers of users of these products because of the inadequacies of published data and the wide range of products The Department of Health has estimated that there are at least seven million people who would benefit from community equipment of which three million equipment service users are supported by the State, leaving potentially at least four million people who, in theory, could be self-funding But these are estimates For such an important product area, it is remarkable that firmer figures on the value of the sectors, and numbers of people purchasing and using such equipment are not available in a comprehensive and robust form Key market features Reliable information on market shares and on the main market players is difficult to obtain From interviews for this study, it appears that there are a small number of global companies – mostly based outside the UK – which are especially prominent, as well as smaller, sometimes specialist, companies There is also reportedly a significant amount of takeover activity by the larger players Some of the larger companies provide a very wide range of products to public purchasers as well as to private consumers Includes equipment to relieve physical pressures when sleeping or sitting for example Equipment for older and disabled people: an analysis of the market This makes it especially difficult to arrive at a meaningful or useful estimate of market shares in particular sectors In some equipment areas, for example prostheses and ortheses, conventional market mechanisms are not very applicable in terms of consumer choice A related feature of this market is the difficulty of obtaining reliable and detailed data on costs and price issues This exploratory study identified concerns among some interviewees that the price levels of some products, particularly wheelchairs and scooters, appear higher than warranted Further investigation of this issue is required to ensure that consumers are getting a fair deal Retailing in this sector has traditionally been carried out by specialist private shops, some of which are chains However, consumers can also purchase some equipment by mail order and online, as well as from some charities Recently a number of generalist retailers have begun to offer fairly restricted ranges of these types of products Provision of equipment There is a mixture of public and private channels for consumers to obtain this type of equipment First, people can buy directly from suppliers/retailers using their own funds or by obtaining help from a specialist charity towards the purchase Some charities also provide equipment directly to consumers or on a loan basis In terms of public provision, once people have had their needs assessed and if they meet local eligibility criteria, they may be given equipment on loan by NHS bodies and local authorities via community equipment stores and services Or, as is the case with wheelchair provision in an increasing number of areas in England, they may be offered vouchers to obtain wheelchairs from approved private suppliers As far as other types of equipment are concerned, this is available on loan from NHS bodies or local authorities (once people’s needs have been assessed and they meet the eligibility criteria) However, in a number of areas in England which have adopted the Department of Health ‘Retail Model’, public provision of what are termed ‘simple aids to daily living’ (SADLs) is now being carried out by offering people prescriptions instead The prescriptions can be redeemed at accredited retailers Under the Retail Model prescription system and also the wheelchair voucher scheme, the products may belong to the consumer rather than being on loan, and people can also choose to top up to obtain a functionally similar model Consumers’ needs Consumers’ individual circumstances are an important factor that need to be taken into account In many situations, consumers may be buying equipment as ‘distress purchases’ Some are in vulnerable situations and unable to get out to shop around Purchasing from generalist retailers or via mail order, or on the internet where people have access, may be feasible for some products But many consumers may need expert advice and independent assessment of their needs They may also need to try out equipment, or have a home visit to ensure that the product meets their requirements Purchases are frequently made on someone’s behalf by friends and carers who may not be sufficiently informed about product suitability At the same time, many of these products are potentially of benefit to a wider range of people who may not regard themselves as disabled Equipment for older and disabled people: an analysis of the market Areas of potential consumer detriment a) Prices: concerns were raised by some of the people we interviewed about the retail prices of some of the equipment covered here such as wheelchairs and scooters However, the lack of publicly-available data is a barrier to further investigation, and there are also difficulties in making price comparisons between what are often individuallytailored products Some public purchasing is carried out centrally through the NHS but mostly it appears to be done on a local basis with weak purchasing power b) Information and need assessment: there appear to be problems for some consumers with being able to make informed price comparisons between products such as mobility equipment or more complex products, especially for those without internet access it can be difficult for consumers to obtain expert specialist advice and assessment prior to making private purchases or obtaining equipment through public provision c) Marketing and sales: it appears that some poor marketing practices exist according to anecdotal evidence but the scale is unknown The quality of sales advice is also critical as consumers may need specialist expert help, given the potential risks of unsuitable or unsafe products d) Waiting times: consumers often reportedly have to wait for considerable periods of time to obtain suitable equipment through public provision, for example for wheelchairs It is unclear whether this is due to the lack of trained professionals to make assessments, waiting times for the goods, or budgetary constraints There can also be long waiting times for orthotic and prosthetic services e) Postcode lotteries: eligibility criteria for public provision of community equipment vary between areas in England The range and types of equipment available locally may also be shaped by budgetary pressures rather than people’s needs These factors lead to inequities in public provision at local level f) Quality and design: if people not obtain the correct equipment to meet their individual needs, there can be risks to health and safety Poorly designed or poor quality equipment can also restrict people’s independence rather than enhancing it g) Regulation and consumer protection: existing regulatory and inspection arrangements for community equipment services need to be reviewed to ensure that they are sufficiently robust and comprehensive h) Market concentration: there appears to be a small number of global private companies in some of the market sectors, such as mobility equipment, who tend to dominate manufacturing and supply However, there is an absence of reliable publicly available data on market shares Equipment for older and disabled people: an analysis of the market Introduction Aims and context This report for Consumer Focus is based on an exploratory scoping study of private and statutory purchasing and provision of mobility equipment (such as scooters and wheelchairs) and other types of community equipment that are aids to daily living, as well as devices that are known as ortheses and prostheses The main objectives of this scoping study included:  to map the types of equipment and products that are of particular importance for disabled people’s health, safety and independent living where private purchasing, in whole or in part, is relatively common  to explore the size of the markets  to scope out possible areas of consumer detriment and market imperfections within these sectors and markets  to suggest specific sectors or sub-sectors where Consumer Focus may wish to consider making a super-complaint, and/or interventions on public policy issues An important part of the context for the study is the heavy emphasis in public policy on the promotion of individual budgets, self-directed care, personal budgets, and direct payments An integral part of this agenda is the idea and intention of developing greater consumer choice, and a ‘mixed economy’ of health and social care provision (with private funding augmenting public provision) These developments are affecting the provision of many of the products covered in this study that can be described as ‘community equipment’ More information on the types of products covered in this study is set out in sections to The sector (which should be characterised as a number of sectors) does not receive sufficient attention, in large part because it does not fit easily into any particular ‘mainstream’ health or social care category For example, while some products have a clear health-and-rehabilitation function, others are often intended to enable someone to live safely in their own home and locality instead of entering residential care Such products, and the arrangements which enable significant numbers of people to access and use them, are rightly regarded by many as major advances – not just in relation to technological development and design, but also in terms of people’s attitudes There are, undoubtedly, major benefits in regarding these aids or equipment as just another type of product with potentially wider use across the population On the other hand there are undoubtedly risks involved for people’s health, safety and well-being when purchasing privately Many consumers who buy or need these sorts of products are potentially vulnerable in some way In addition, depending on the nature of the product and people’s circumstances, consumers often require expert advice and assessment of their individual needs before making a decision It should be noted that, in some sectors or sub-sectors it is not meaningful, or useful, to view services and products through the lens of ‘markets’ For example, prosthetic limb services are generally regarded by professionals and the public alike as an NHS, or certainly a specialist professional/technical, service, with a strong bespoke element For most people the idea of ‘shopping around’ is not important (unless perhaps they are seeking sports-related equipment) Equipment for older and disabled people: an analysis of the market In the equipment sectors which we have been able to explore within the constraints of this scoping study, we have sought to identify issues of potential interest and concern to Consumer Focus, including market matters But it is also clear from the scoping study that there are broader areas of concern relating to people’s social care and health needs, the adequacy of provision, information, advice and consumer protection issues Within the confines of what was an exploratory study, we found much that was concerning, especially given the importance of these products to people, many of whom are at risk of being vulnerable or otherwise disadvantaged Some problems can be laid at the door of market features, including difficulties in finding out what suitable products are available and making informed choices But others derive from the fact that the services are not seen to fall within the mainstream health or social care category Our information sources were as comprehensive as possible given the time constraints for the study, and we believe that we have ‘captured’ important features of this sector, though not necessarily always with the degree of detail or depth which we would have liked to have achieved It should be noted that some information was provided by interviewees on an unattributable basis but this does not undermine the authoritative nature of their advice There is a significant number of individuals and organisations who we thank for their time and patience in answering our questions (see list at end of report) We were often heartened by their enthusiasm and commitment to improving the situation for disabled people and their families Importantly, several expressed a clear wish to work in partnership with Consumer Focus if we decide to pursue further work in this field Coverage The scope of this study had to be limited because of the vast range of products and equipment which are usually regarded as aids to independent living, and time constraints The product areas covered include mobility aids and equipment and other aids to daily living – often described as ‘community equipment’ The study also looked briefly at equipment which is usually described as prostheses (for example artificial limbs) and ortheses (for example external braces) The geographical focus of the study was on England unless otherwise stated Due to time constraints, the study did not specifically cover equipment and systems commonly regarded as telecare or telehealth In large part this is because of the sheer range of equipment involved (such as personal alarms, remote sensing of the temperature of rooms, remote monitoring of people’s medical condition, and intercoms) Hearing aids, building adaptations and additions, and spectacles and contact lenses also had to be excluded What we did This study involved a combination of desk research and interviews with a number of key stakeholders The desk research included government publications, reports by specialist organisations and material from the main trade association Some commercial market reports were also obtained but these proved of very limited use for the purposes of this study The interviewees included senior Department of Health officials, experts in a number of specialist charities and other organisations, and some individual professional experts including occupational therapists (see list at end of this report) Equipment for older and disabled people: an analysis of the market Structure of the report Section highlights the importance of these products and services, particularly to enable many disabled people and older people to live independently Issues relating to market sizes and supply channels are discussed in section An overview of some of the main channels for provision and funding arrangements is set out in section Matters relating to the market for and provision of mobility equipment are discussed in section Section explores issues regarding community equipment products and services (a term commonly used to cover what is in reality a wide range of often disparate products that are aids to daily living) Section briefly outlines some key points relating to the provision of ortheses (externally applied products which offer support designed to give stabilisation, immobilisation, relief and/or correction); prostheses (in very general terms ‘replacement parts’ such as but not only artificial limbs); and cosmeses (items to help preserve, restore or enhance physical appearance) Section highlights some key factors relating to consumers’ needs and circumstances, and sets out a number of potential areas of consumer concern in this field that merit further investigation Annex briefly outlines the NHS Supply Chain; and Annex details the Government’s Fair Access to Care Services guidance A list of organisations contacted and sources are provided at the end of this report Equipment for older and disabled people: an analysis of the market 10 This is not to say that companies’ product design activities and outcomes aren’t important, but for most people ‘choice’ is not very meaningful or realistic For example, we were told by the British Limbless Ex Servicemen Association, that peoples’ prime concerns were about NHS and NHS-based performance in arranging, fitting, maintaining and reviewing their needs The Audit Commission’s report cited above noted that at the time, despite the fact that there were three million users of these (and NHS audiology) services, the services were ‘a low priority’ Poor communication between different professionals was highlighted as an important issue in this area, often because their roles and responsibilities were unclear For example, in the prosthetics service there were examples of confusion between prosthetists and rehabilitation consultants, leading to duplication of effort The Commission also found a lack of clarity between the role of orthotists on the one hand and podiatrists and chiropodists on the other The report last year by the York Health Economics Consortium for the BHTA 20 pointed out that: ‘current estimates of the number of users of orthotic services are in excess of 1.2 million patients and include diabetic, stroke, orthopaedic and neuromuscular conditions.’ The York report added that: ‘demand on the service is increasing in line with both the ageing population and the complexity of the associated clinical conditions There is currently no agreed mechanism for relating the changes in funding to the changes in demand Orthotic services have generally received a very low priority in the NHS, hidden in secondary healthcare.’ Orthotic services were also found to feature procurement practices which were, ‘too dependent upon a “commodity product procurement” model’ (we assume this means that volume and cost considerations dominate purchasing decisions) And the report noted that: ‘the technology of orthoses can appear deceptively simple, such as foot insoles or orthoses made for back problems but the selection and fitting of the most appropriate device requires detailed knowledge of the functioning of the musculo-skeletal system Many orthotic devices have to be fitted specifically for the individual patient.’ Many of these points were also made to us by Diabetes UK, which maintained that problems with orthotic services stem from a lack of suitable specialist staff, and inadequate NHS budgets The York report cited above highlighted the fact that: ‘there were no incentives to trusts to reduce the waiting time for orthotics, as patients referred to the orthotic clinic have already been seen by a clinician and their treatment is deemed to have started This means that they are not in breach of the Department of Health target of a maximum of 18 weeks from referral to treatment.’ According to the British Limbless Ex Service Men's Association (BLESMA), the Ministry of Defence provides better prosthetic care and provision than the Department of Health BLESMA says that Headley Court – the Ministry of Defense’s rehabilitation centre – provides an outstanding prosthetic service to people serving in the Armed Forces and describes them as ‘the envy of the amputee community’ It goes on to make the point that other amputees have to rely on prosthetic provision delivered through local PCTs, which it describes as a postcode lottery 21 20 Orthotic service in the NHS: Improving service provision’, York Health Economics Consortium, BHTA, 2009 21 See BLESMA http://www.blesma.org/what-we-do.html#artificiallimbs Equipment for older and disabled people: an analysis of the market 32 Areas of consumer concern 8.1 Background factors An overarching area of consumer concern is whether current market and statutory mechanisms are meeting people’s needs for community equipment in fair and affordable ways However, the sector is characterised by a complex set of factors that tend to distinguish it from many other sectors and which need to be borne in mind when considering issues regarding potential consumer detriment First, the channels or routes available to consumers to obtain this equipment comprise a mixture of statutory provision, retail markets, plus some hybrid combinations of both statutory and private provision Secondly, there is a very wide range of products and equipment involved Some products are specialised and people may require expert advice and possibly also assessments of their needs before they buy or obtain the equipment However, other products have potentially widespread use and can be purchased like other consumer products without specialist advice Thirdly, some product areas are ‘medicalised’ in that they may not be regarded as mainstream consumer goods by professionals and the public In addition, consumers’ individual circumstances can vary widely Some people may be in especially vulnerable circumstances and need to obtain equipment very quickly and/or find it difficult to shop around (for instance, having just been discharged from hospital or struggling to live independently at home) There are related factors that must also be taken into account such as people’s knowledge, assumptions and expectations about what equipment is available, how to obtain it, and how to make the right choices Another consideration is that some may not regard themselves as disabled and possibly view these kinds of products as potentially stigmatising Others may take a much more pragmatic view and see products like these as no different from a pair of spectacles, for example Another area of complication is who is the consumer? For private purchases, as well as some consumers buying products for their own use, it is also common for other family members, friends and carers to be purchasing on someone else’s behalf Where products are purchased by statutory bodies, it is those organisations which are the proxy for the ultimate consumer or user 8.2 Prices and market power In many of the product areas that are the subject of this report, it appears that a number of globalised companies are major players in supplying the domestic market There are also smaller companies involved, some of whom are UK-based who may also specialise in niche product areas As stated previously, it is not possible to ascertain market shares with confidence or to judge whether retail prices are unduly high However, some interviewees raised concerns that prices of some types of equipment, such as wheelchairs and scooters, appear to be unjustifiably high In many of the product areas, public sector purchasing is a very significant feature and might be assumed to have the ability to exert pressure on suppliers in terms of prices and performance But, in reality, effective public purchasing power appears to be undermined by the very fragmented nature of much of the commissioning and purchasing arrangements Equipment for older and disabled people: an analysis of the market 33 In terms of retailing, the products are reportedly not high-volume items in general Most retailers have traditionally been ‘specialist’ suppliers Some generalist retailers are offering limited ranges of products but it is too early to judge what effect this might have on the market in terms of prices, consumer choice, and quality Consequently, here too, purchasing power is likely to be muted 8.3 Information and access For consumers who need or choose to purchase such products themselves, it is clear, from the interviews carried out for this study and from published material, that there are a number of potential barriers which can impede people’s ability to exercise informed choices and to access the products In the first place, people may well be unaware of the existence of many of the products as equipment may not be available on the High Street or have much of a public profile Secondly, it can be difficult to obtain informed and reliable information about what products are on offer, and their features and prices The still substantial number of people without internet access may not know of the existence of retailers or products, especially as specialist retailers tend to not to be located on main High Streets Some may rely on newspaper and magazine adverts and/or on recommendations from relatives or friends A survey of carried out by Ricability found that among interviewees: ‘Assistive technology was not a topic that was greatly discussed Few people knew much about it, and it only became an issue of interest when it became obvious that some sort of equipment was needed Even then, it appeared to be a ‘distress purchase’ – something that was acquired out of necessity rather than being actively desired For these reasons, and because the equipment was not usually seen in High Street outlets, it was widely assumed that information would have to be sought from health and social care staff – it was seen as technical equipment rather than as a consumer product For these reasons few people had a realistic idea of where to go for information about equipment.’ 22 However, there are expert sources of information These include the Disabled Living Foundation (DLF) which provides useful material through its website and telephone helpline It is currently working to improve the range of information on the website The DLF has a drop-in centre where people can try out products and, in addition, Assist UK has a network of Disabled Living Centres where people can get advice and try out equipment There are also other organisations, such as Ricability, the British Red Cross and Age UK, which provide information and advice But it cannot be assumed that people are aware of the existence of these bodies or of the services they offer 23 For those with internet access, it can appear to be easier to obtain product and price information However, online searching may not enable the consumer to have sufficient information about the suitability, or otherwise, of a product, for themselves, unless they can access suitably qualified advice 22 The revolution in equipment supply and what it means for information, Research report, Ricability, 2009 23 The charities FAST, the Disabled Living Foundation, Ricability and Assist UK have formed the ‘AT Alliance’ project The reason for doing so was concern about how people get information about community equipment and specialist adaptations The Department of Health-funded project has involved detailed research on ways in which people obtain information; databases and routes to information The organisations are collaborating to see how they can improve matters jointly The plan is for a portal website to have a limited launch this year, and to consult various organisations and get feedback The site will then be rolled out to the public, followed by a media launch in early 2011, together with publication of the final project report This will identify gaps in what information is available Some of the main gaps in information appear to especially affect communication aids, telecare, health equipment, and wheelchairs Equipment for older and disabled people: an analysis of the market 34 Similarly, it may also be difficult to make informed decisions on prices and value for money It should be noted that even some ‘simple’ products can cost £100 upwards, and some consumers may need multiple products A number of organisations, including charities and some sections of the industry, have serious concerns about online buying in this area, principally concerning the lack of assessment of individual needs, the appropriateness or otherwise of products bought in this way, and a lack of after-sales service facilities Moreover, some websites which ostensibly purport to or might be thought to be advisory are commercial This may well mean that consumers are presented with a restricted picture of available product ranges, and such sites are extremely unlikely to offer independent price comparisons Mail order purchasing offers an alternative channel for purchasing but the range of choice of products in a particular catalogue (hard copy or online) can be limited For some products, it is essential that consumers are able to handle and try them out before purchase (for example, wheelchairs) But some consumers may be unable physically to travel to and look around retail outlets And, as some interviewees pointed out, specialist retailers are often located away from High Streets and main shopping areas In addition, it is quite common for purchases to be made by (often stressed) family members, usually because the person is unwell or unable to visit retailers’ premises and try out the equipment This can lead to lead to inappropriate purchases Also the range of products stocked by retailers may be limited, particularly generalist retailers These issues apply to people who are purchasing privately and those who have been given prescriptions or vouchers For example, someone who has experienced an accident or other event which makes it difficult or painful to walk for a while might well ask a close relative to get an inexpensive wheelchair so that the injured person can at least get around their flat It would be perfectly understandable for the relative to get one online or from a generalist retailer But what neither the injured person nor their relative may have considered is the design and quality of the seating and backrest: if they spends a significant part of each day in the chair, and if this isn’t right for them, it is all too easy to develop a sore neck, backaches, and perhaps even pressure sores/ulcers 24 8.4 Marketing and sales For those deciding to, or having to, purchase privately, there can be other pitfalls in terms of potential misleading sales practices and also poor advice Based on a number of interviews for this study, it appears that there are instances of mis-selling in the community equipment sector, for instance through doorstep selling The scale of this is not known but it is an area that certainly requires further investigation For example, Which? carried out an ‘undercover investigation’ in 2008 into the techniques used to sell equipment for people with mobility problems in people’s homes For some disabled people this may be the only realistic way of purchasing 24 It has recently been announced by the Institute for Ageing and Health–Years Ahead Partnership that funding has been secured for a feasibility study aimed at establishing a recognised product accreditation and approval scheme for Independent Living products The aim of the scheme will be to encourage suppliers, manufacturers and retailers to consider the needs of the consumer, by ensuring that products, and services, are tested and accredited by the people they are designed for ahead of being launched (press release April 2010) Equipment for older and disabled people: an analysis of the market 35 Many unsettling examples of poor practice were uncovered: prices quoted for one product varied widely between different companies; only one out of 11 companies insisted on carrying out an assessment of the disabled person; and five company sales reps used the pressured selling technique of stating that only by deciding straightaway would the consumer get a ‘discount’ 25 A more general issue raised by a number of interviewees is the importance of expert advice and assistance so that the consumer can be assured that they are making the right choice, for example, in terms of comfort and functionality Inappropriate seating could lead to pressure ulcers; a wheelchair could be too heavy for the user or carer etc Poor sales advice can lead to a bad purchase which could adversely affect someone’s health and safety or that of a carer A recent Which? selling investigation into bath aids revealed poor levels of advice by staff in a number of retailers Only 39 per cent of High Street shops that were evaluated showed adequate product knowledge, and some specialist shops gave poor advice 26 The need for robust, fair and accessible complaints and redress mechanisms is vital, particularly as an increasing number of products are likely to be purchased privately or through prescriptions/vouchers At present, consumers can take up unresolved complaints with the BHTA if the company is a member of the Association; the BHTA also offers independent arbitration The BHTA’s Code of Practice for members has been granted Office of Fair Trading approval under the Consumer Codes Approval Scheme Among other matters, in signing up to the Code, BHTA members agree not to use highpressure selling techniques, and encourage a carer or advisor to be present during home visits 27 If something goes wrong with the process of obtaining ‘simple’ equipment or SADLs via the Retail Model, consumers need to take up complaints with the retailer, unless the problem arises from assessment in which case the prescriber (local authority and/or NHS body) is responsible The view of the Department of Health is that its role is to support policy implementation and local decision-making by local authorities and their health partners It has provided a range of tools and materials to implement the new model, including materials for undertaking accreditation and monitoring the developing marketplace 8.5 Assessment and support Due to the nature of much of the equipment and products and because of people’s individual needs and potential vulnerabilities, expert advice is frequently essential This is likely to include competent and specialist assessment of people’s individual needs Consequently those providing advice and assessments need to be knowledgeable and trained to advise on appropriate equipment As mentioned earlier in this report, people have a right to have their health and social care needs assessed by a relevant professional such as an occupational therapist, physiotherapist, audiologist etc However, a number of interviewees pointed out that people’s knowledge of their rights and what is on offer from local authorities and NHS bodies can be limited Professionals such as occupational therapists play a critical role in helping to ensure that people are properly assessed and advised about equipment that will meet their needs 25 Which? investigation into mobility aids, 2008 Which? Mobility aids selling investigation, May 2010 27 BHTA Code of Practice for the healthcare and assistive technology products and services industry, updated September 2009, British Healthcare Trades Association 26 Equipment for older and disabled people: an analysis of the market 36 However, concerns have been raised by organisations such as the Foundation for Assistive Technology (FAST) about the level of competence with respect to equipment assessment of some professionals As FAST has highlighted, the problem is exacerbated by the fact that the assistive technology workforce is made up of practitioners with diverse roles and disciplines working within a range of service provider organisations in statutory, third and private sectors 28 An additional or alternative route is for people to assess their needs themselves This can be done by using the AskSARA self-assessment tool developed by the Disabled Living Foundation and available on its website Other organisations are licensing AskSARA For example, many local authorities are reportedly using AskSARA to provide advice and information about daily living equipment Also some large retailers are using it to offer advice and guide customers to suitable products they supply Also, where consumers are buying privately, they may be able to get help from an ‘independent assessor’ This is a recent development that is linked to the Department of Health Retail Model The Department of Health envisages that ‘Independent Needs Assessors’ will provide assessment and advice to people who are purchasing community equipment privately (whose needs have not been assessed by a local authority or NHS service) An Independent Needs Assessor is someone who is not employed by a local authority or the NHS: they could be a private occupational therapist employed by a pharmacy chain for instance According to the Department of Health, they will be qualified in the same way as professionals who provide needs assessment services to local authorities and health partners, for example, people qualified in occupational therapy, physiotherapy, and rehabilitation services While the opportunity to obtain an independent assessment of their needs is welcome for consumers when purchasing privately, it is questionable whether, and how, consumers can find out about the existence of independent assessors It is also possible that people will have to pay for such assessments unless they can obtain advice from disability organisations or other specialist independent bodies Obviously this may well disadvantage people who cannot afford to pay Confusingly, as well as independent assessors, there are also what are known as ‘trusted assessors’ who are trained to a certain level in equipment but are not as qualified as occupational therapists They are usually employed by a local authority or NHS body as social workers or district nurses for example, and can make assessments of people’s needs in the course of their work They are meant to be aware of the need, where necessary, to pass over the responsibility for carrying out assessments to an occupational therapist Consequently, it seems likely that there are issues around people’s awareness of their rights to have their health and social care needs assessed, and how to ensure that they obtain expert assessment There are also question marks about the adequacy of professionals’ competence and knowledge of equipment 8.6 To buy or not to buy Bearing in mind the issues outlined above, it may not always be clear to consumers whether they should seek to buy such equipment privately or find out whether they might be entitled to help from local statutory services (such as local authorities and/or NHS bodies) 28 Assistive technology workforce development, FAST, 2007 Equipment for older and disabled people: an analysis of the market 37 Where consumers meet the eligibility criteria for State help, one consideration is whether or not they are happy to have a product on loan from community equipment services/stores, which may have been previously used On the other hand, there are benefits in that equipment on loan is maintained and repaired free of charge Moreover, if a product proves unsuitable, it is likely to be easier to get it replaced or adjusted than if it has been bought privately There are environmental considerations as well; equipment on loan may be recycled, although there will also be associated costs (such as decontamination) However, some interviewees also pointed out that the need to recycle equipment can lead services to purchase equipment that is simple and robust In some cases this may not be a problem But it can also mean that people are not offered more modern and sophisticated products, such as lightweight wheelchairs The range and types of products purchased and made available on loan may also be constrained by budgetary pressures in the public sector at local level rather than being shaped by people’s health and social care needs (see, for example, Audit Commission 29) A related problem expressed by interviewees is that community equipment and wheelchair services are frequently marginalised in policy-making and budget-setting Reportedly some senior managers involved in commissioning and purchasing at local level regard equipment services as just another supplies function, rather than recognising its fundamental importance for individuals and for other health and social care services It is also widely recognised that there are significant variations in the quality and performance of community equipment and wheelchair services at local level – this point was made by a number of interviewees and in the Audit Commission report cited above These variations will affect the adequacy of what is made available to consumers through State provision In addition, differences between locally-determined eligibility criteria can affect people’s entitlements to equipment, resulting in what are commonly described as postcode lotteries The Department of Health has to some extent recognised the inadequacies and inequities arising from such variations between local services For example, in March 2010, the Department of Health announced a pilot programme aimed at ending the wheelchair postcode lottery (Department of Health press release, 19 March 2010) Anecdotal evidence suggests that some local authorities and/or their health partners are cutting the items included in their local purchasing catalogues because of cost pressures In some areas, eligibility criteria for statutory help have been tightened for the same reason While in other areas, caps are being set on the prices of items included in local catalogues Although some of these may be low-cost items, they could be a burden for people on low incomes, especially if consumers need a number of these items for daily living There is also some evidence that in some areas people are being referred to the social fund for assistance with this type of equipment According to the Social Fund Commissioner’s annual report 2008/09, there has been an increase in the number of applications for aids, adaptations and specialist items, which are often for substantial amounts of money 30 In some of these cases social services had not conducted a proper assessment of need, and some had purported to discharge their statutory duties by referring the disabled person to the Fund The Commissioner’s report stated that: ‘It is clear from the cases we see that applicants are confused about who has responsibility for assessing and meeting their needs for aids and other specialist items 29 Fully equipped 2002: assisting independence, Audit Commission, 2002 The Social Fund Commissioner’s Annual Report 2008/2009, Independent Review Service for the Social Fund, 2009 30 Equipment for older and disabled people: an analysis of the market 38 It is unacceptable that people who are often in desperate situations and with urgent needs find themselves passed between their local authority and the Social Fund.’ In recent years, the Department of Health has sought to introduce a more consumer or user-centred approach across a wide range of health and social care provision, including some aspects of community equipment This can be seen in the introduction of vouchers and prescriptions for wheelchairs and some types of community equipment (SADLs) which are then owned by the consumer Some consumers are likely to welcome these options as it increases personal choice and reduces their dependency on what is available from local community equipment/wheelchair services (including being able to top-up the voucher or prescription) There can be other benefits to consumers being made more aware of the existence of other potentially useful products as well when they take the prescription to an accredited retailer However, so much depends on people’s own circumstances People may be seeking to obtain equipment in stressful or pressurised circumstances and not want the burden of having to go to a retailer and make a decision about products Secondly, many people are unable to physically get to a retailer because of health problems or disability, and therefore cannot make use of such an option unless the retailer agrees to visit them at home Some people may prefer to own a product, rather than have it on loan, while others may not want the onus of repair and maintenance costs In addition, there is the possibility that some retailers could press people to top-up vouchers or prescriptions unnecessarily Nevertheless, a significant feature of the Department of Health’s policies is its emphasis on the need to mainstream many of these products so that they become more visible and available in the marketplace, rather than being seen as medical items There are also moves by a number of generalist retailers to stock some community and mobility equipment These developments should help to reduce the stigma that can be associated with community equipment and help to normalise these products so that they viewed as a consumer product like any other It also represents a recognition that a number of these products are potentially useful to many people who would not regard themselves as disabled or ‘aged’ However, these developments raise questions about whether some consumers might simply be unaware of, or dismiss, potentially important statutory sources of advice and support, and may be spending money unnecessarily Linked to this point is the issue of whether people will obtain products which really meet their needs in terms of their health, safety and well-being For some products (like easy-grip kitchenware), people may not need expert advice or assessment of their needs and they can safely purchase in the marketplace, including from non-specialist retailers But at the same time ‘mainstreaming’ of some products could mean that people miss out on vital expert advice and help, which generalist retailers are unlikely to be able to offer 8.7 Consumer protection Almost all health and social care services, including domiciliary care, are formally inspected, monitored and regulated by the Care Quality Commission (CQC) But it is not clear how the CQC sees its role with respect to community equipment It is worth noting that the performance and adequacy of community equipment and wheelchair services are not specifically featured in the performance assessment frameworks, which to a large extent currently govern the nature of the CQC’s work Disquiet about the inadequacies of regulatory standards was highlighted by Brian Donnelly in a document sent to the Department of Health and the Care Quality Commission in 2009 Equipment for older and disabled people: an analysis of the market 39 It sought to highlight the seriousness of potential breaches in legislation, and that community equipment services are not currently subject to robust inspection or regulation regimes 31 The document recommended that a concordat arrangement is set up between the different regulatory bodies eg Health and Safety Executive, Medicines and Healthcare Products Regulatory Agency (MHRA) 32, Care and Social Services Inspectorate Wales (CSSIW) and the CQC with a view to establishing universal standards, and perhaps regulating and inspecting services There is also self-regulation In terms of company practices, all member companies of the BHTA are required to sign up to its Code of Practice (which has been granted OFT approval under the Consumer Codes Approval Scheme) 33 Ricability is currently investigating the standards of service provided by specialist retailers via a three-year project funded by the Department of Health and led by Assist UK, and through its monitoring of the BHTA Code of Practice As part of the former project, Ricability has compiled its own set of standards based on discussions with disabled consumers Both projects include anonymous investigations by disabled people trained by Ricability It has not been possible within the constraints of this scoping study to explore the above issues in detail but it does appear that consumer protection policies and practices, and regulatory arrangements and processes, merit further investigation to ensure that they are sufficiently robust and comprehensive 31 Community equipment services – England and Wales 2009 – The need for national minimum standards, Donnelly B, 2009 32 The Medicines and Healthcare Products Regulatory Agency (MHRA) has a formal enforcement role with respect to the efficacy and safety of ‘medical devices’ 33 It’s all about trust BHTA Code of Practice for the healthcare and assistive technology products and services industry, British Healthcare Trades Association, 2009 Equipment for older and disabled people: an analysis of the market 40 Annex 1: NHS Supply Chain The NHS Supply Chain has responsibility for the national framework agreements (NFAs) for the following assistive technologies: audiology, prosthetics and orthotics, electronic assistive technology, special seating and wheelchairs and accessories, but not for telecare or telehealth equipment and products The latter is the responsibility of Buying Solutions – formerly NHS Purchasing and Supply Agency – which is the national procurement partner for UK public services and is an Executive Agency of the Office of Government Commerce in the Treasury With respect to community equipment and wheelchairs the NHS Supply Chain is a major main player in the NHS regarding provision and purchase of equipment The Chain provides customer-focused healthcare products and services It is a 10-year contract, operated by DHL Logistics, on behalf of the NHS Business Services Authority Its stated aim is: ‘to provide more than £1 billion savings to the NHS over the next 10 years so that resources are released for NHS trusts and healthcare organisations to focus on quality frontline patient care, manage costs and achieve sustainable value.’ The NHS Supply Chain carries out ‘framework purchasing’ through Official Journal of the EU tendering processes which are intended to ensure fairness, transparency, and nondiscriminatory practice It says it keeps NHS organisations well-informed about tendering and framework contract activity and decisions, and says that the NHS can and does interact with it about specifications and decisions NHS organisations like PCTs can use the Chain’s catalogue for purchasing purposes, but they can purchase directly if they wish According to some interviewees, key aspects of the agreements it enters into with external suppliers are not in the public domain (because of commercial confidentiality considerations), nor is there any significant input from or relationship with end-users, ie patients or clients Note: The above is based on interviews with senior officials in the Department of Health, and was forwarded to them for checking, and further information was sought – but no reply had been received at the time of writing Equipment for older and disabled people: an analysis of the market 41 Annex 2: Fair Access to Care Services Official guidance on Fair Access to Care Services (FACS) is supposed to be followed by care managers and staff in local authorities (and by staff in partner health organisations) as part of the process of assessing people’s needs The brief description below is taken from Prioritising need in the context of Putting People First: A whole system approach to eligibility for social care: Guidance on Eligibility Criteria for Adult Social Care, England 2010, Department of Health 2010 – which supersedes the original FACS Guidance The FACS framework was introduced in 2003 to address inconsistencies across the country about who gets support, in order to provide a fairer and more transparent system for the allocation of social care services 34 The principle behind FACS was that there should be one single process to determine eligibility for social care support, based on risks to independence over time Its aim was to provide a framework to enable councils to stratify need for social care support in a way that is fair and proportionate to the impact it will have on individuals and the wider community, taking into account local budgetary considerations There is also parallel guidance for councils on the application of eligibility criteria for carers This is contained in the Practice Guidance to the Carers and Disabled Children Act 2002 There is evidence that, in recent years, financial pressures have influenced local authorities to shift their focus towards those groups with the highest needs Many councils have raised the level of their eligibility threshold, leading to concerns that some people who ought to be receiving support are now being ruled as ineligible At the same time as many councils have been seeking to manage their resources by tightening eligibility criteria, a programme for the significant transformation of social care services has been put into place This reform programme is described in the cross-sector agreement Putting people first: a shared vision and commitment to the transformation of adult social care 35 Putting people first sets out a shared ambition for radical reform of public services, promoting personalised support through the ability to exercise choice and control against a backdrop of strong and supportive local communities To broaden their focus beyond those with the highest needs, councils should ensure that the application of eligibility criteria is firmly situated within this wider context of personalisation, including a strong emphasis on prevention, early intervention and support for carers In practice, this may mean councils making adjustments where necessary to ensure a seamless approach between their personalisation programmes and the determination of eligibility for social care 34 Fair access to care services – guidance on eligibility criteria for adult social care, Department of Health 2003 35 Putting people first: a shared vision and commitment to the transformation of adult social care, Department of Health, 2007 Equipment for older and disabled people: an analysis of the market 42 The revised guidance aims to set social care eligibility criteria firmly within the context of both the new direction of policy established by Putting people first, and more generally within a broader theme of public service reform Priorities for this reform include greater choice and control, better access to public services and information, empowerment of people using services and their carers at local level and the definition of user satisfaction as a key measure of success: ‘In this way, Government can work to support its citizens’ aspirations for “public services to be on their side: fitting around their needs and lives, giving them security, control, information, and letting them know what they are entitled to.’ Eligibility criteria should be explicitly placed within a much broader context whereby public services in general are well placed to offer all individuals some level of support For example, people who not meet the eligibility threshold should still be able to expect adequate signposting to alternative sources of support Equipment for older and disabled people: an analysis of the market 43 Assessment of peoples’ needs Services categorise people’s levels of need according to whether they are ‘critical, substantial, moderate, or low’ These are defined as follows: Critical is supposed to be applied when life is or will be threatened, and/or:  significant health problems have developed or will develop  serious abuse or neglect has occurred or will occur  there is, or will be, an inability to carry out vital personal care or domestic routines  vital involvement in work, education or learning cannot or will not be sustained  vital social support systems and relationships cannot or will not be sustained  when vital family and other social roles and responsibilities cannot or will not be undertaken Substantial is supposed to be applied when there is, or will be, only partial choice and control over the immediate environment, and/or:  abuse or neglect has occurred or will occur  there is, or will be, an inability to carry out the majority of personal care or domestic routines  involvement in many aspects of work, education or learning cannot or will not be sustained  the majority of social support systems and relationships cannot or will not be sustained  when the majority of family and other social roles and responsibilities cannot or will not be undertaken Moderate is supposed to be applied when there is, or will be, an inability to carry out several personal care or domestic routines, and/or:  involvement in several aspects of work, education or learning cannot or will not be sustained  several social support systems and relationships cannot or will not be sustained  several family and other social roles and responsibilities cannot or will not be undertaken Low is supposed to be applied when there is, or will be, an inability to carry out one or two personal care or domestic routines, and/or:  involvement in one or two aspects of work, education or learning cannot or will not be sustained  one or two social support systems and relationships cannot or will not be sustained  one or two family and other social roles and responsibilities cannot or will not be undertaken Equipment for older and disabled people: an analysis of the market 44 Organisations contacted Ability Aware Age Concern (Age UK) Assist UK Association of Directors of Adult Social Services (Disability Network members) BLESMA British Healthcare Trades Association British Red Cross Care Quality Commission C F Hewerdine Ltd College of Occupational Therapists (housing group) Department of Health: Transforming Community Equipment Services Department of Health: Wheelchair Services Programme Department of Health: NHS Supply Chain Diabetes UK Disabled Living Foundation Foundation for Assistive Technology Motability Muscular Dystrophy Campaign National Association of Equipment Providers NHS Supply Chain (three senior contacts) Ricability RNID Spinal Injuries Association The Jennifer Trust Whizz-Kidz Equipment for older and disabled people: an analysis of the market 45 Equipment for older and disabled people: an analysis of the market For more information please contact Prashant Vaze on 020 7799 7919 or by email prashant.vaze@consumerfocus.org.uk www.consumerfocus.org.uk Copyright: Consumer Focus Published: November 2010 If you require this publication in Braille, large print or on audio CD please contact us For the deaf, hard of hearing or speech impaired, contact Consumer Focus via Text Relay: From a textphone, call 18001 020 7799 7900 From a telephone, call 18002 020 7799 7900 Consumer Focus 4th Floor Artillery House Artillery Row London SW1P 1RT Tel: 020 7799 7900 Fax: 020 7799 7901 Media Team: 020 7799 8004 / 8005 / 8006 ... Association The Jennifer Trust Whizz-Kidz Equipment for older and disabled people: an analysis of the market 45 Equipment for older and disabled people: an analysis of the market For more information... satisfactorily for consumers to the regulators and the Office of Fair Trading We are interested in seeing further analysis of the issues by the OFT Equipment for older and disabled people: an analysis of the. .. www.georgeandlennard.org.uk Equipment for older and disabled people: an analysis of the market About Consumer Focus Consumer Focus is the statutory consumer champion for England, Wales, Scotland and (for