David Griffiths: We Need To Talk About Money...

I was in the audience for a conference last year when there was a standing ovation for the announcement that the Welsh Government, in response to some well publicised examples of bad practice and excessive profits, were moving towards no longer allowing private sector companies to provide residential care for young people with complex support needs.

And I’m a fan of the increasing recognition of the role of voluntary, community and social enterprise organisations in delivering public services.

So, managing a private company I was a little wary of writing about money at a time when there is a lot of pressure on the system.

But, as a large employer, working with many British manufacturers, and increasingly hearing directly from people who rely on community equipment to live their lives, I decided it was too important to ignore.

Across the board, Medequip’s costs have gone up. In every substantive part of our business things cost more now than they did before, in some areas a lot more.

We’ve committed to the Living Wage and have a developing programme of co-production and community engagement activity. Add to this the requirements to achieve carbon and other sustainability targets, the drive to make services more personalised, and the extra activity needed to support the NHS.

What you get is a perfect storm. An immeasurable force meeting an immoveable object. At least that’s what it feels like from my side of the discussion.

The contracts we sign have a variety of clauses on how the commissioning organisation will deal with inflationary increases and it seems commissioning organisations have a variety of models for budget setting and dealing with increases in activity.

But my view is that, if the health and social care system is serious about delivering the kinds of outcomes described in the ADASS report Time to act: a roadmap to reform care and support in England and the NHS Long Term Plan then some things must change.

Budget can be a noun, budget can be a verb, or budget can be an adjective. What budget is not, is fixed. It can set the parameters, it can set the tone, and it can be used as a planning tool.

Too often I see historically set budgets for community equipment services being used by Local Authorities and the NHS as a sort of doctrine with little evidence of its origin and development.

Commissioners may not have the capacity or authority to conduct a zero-based budget exercise, but why not do some benchmarking?

As a national provider, working with a wide range of Local Authority and NHS commissioners, we can offer a range of anonymised benchmarking data that can help in local decision making about effective use of public money.

Transparency, by definition, must work both ways. If I show you mine, you show me yours. Entering negotiations with public sector organisations can sometimes feel like entering a parallel universe. A sort of do as we say, not as we do type of situation.

Medequip is very transparent about its costs, profits and pricing and works very hard to be efficient. Indeed, the reason over 60% of community equipment services in England have been outsourced has been because of evidence and feedback that the private sector can run these services more efficiently.

I see plenty of evidence of public conversations about how community equipment, assistive technology, the voluntary, community and social enterprise sector, and a host of other things can save money in the system. The trouble is they seem to be happening outside of the budget setting process or driving the discussions about inflationary uplifts.

Innovation is a bit of a buzz word right now. In my experience of working with the public sector it’s often a synonym for cheaper, and, with some exceptions, often requires “other” organisations to work differently, not one’s own.

I’d also say much of the system has got used to thinking about, or for, the people who use the services, rather than with them. What Medequip and I are learning from the work we are doing to involve people is that we might all be seeing what we have always seen. Involving people helps us question why things are the way they are. That’s when innovation happens.

For example, I get it that public sector organisations are different, big and complex but we see a diverse range of approaches to dealing with the challenge of internal overheads and the actual cost of the in-house activities that form part of the overall cost of the system.

It is often political views and history that determine how community equipment and other services are provided, rather than evidence-based assessments of costs and outcomes.

For example, why are we discussing shaving a few pounds off the cost of an activity or pieces of equipment when a private or VCSE organisation could save many pounds in the costs of doing assessments and reviews by adding these tasks to existing community-based services. The Trusted Assessor model can work for external organisations too.

There are also different approaches to borrowing, use of investments and reserves, and the use of joint funding arrangements between health and social care.

Now we have a growing body of Local Authority inspection reports from the Care Quality Commission, we can also begin to see the variations in efficiency and effectiveness across the range of themes and outcomes used in these inspections.

All of which has an impact on the budgets.

All of which has an impact on discussions with providers on uplifts.

Partnerships work best when each partner is motivated to help the other partner succeed. That requires each partner to value and respect the other.

I see that this can be a challenge for people in the different parts of the statutory sector of the health and social care system. The Integrated Care Systems are a work in progress, more developed in some areas than others.

I know Local Authorities were frustrated by the option within the NHS of cross-subsidy or bailing out of NHS Trusts in deficit, by those that had managed to stay within budget.

For Medequip, we feel the same frustration with the current arrangements for discussions with Local Authorities and the NHS about inflationary uplifts and other cost pressures.

Aren’t the well-run Local Authorities and NHS organisations effectively subsidising the less well-run?

Partnership becomes even more of a challenge when you introduce values-based differences of opinion on whether the risk of profit and loss should be held privately, or publicly. All sorts of personal and organisational issues are at play.

But we have the system that we have, and as I have said previously, Medequip is determined to be a significant partner to the statutory organisations in health and social care. Our mission is to keep people independent and I am proud of the way this business is run to achieve that.

So, we will enter discussions requesting inflationary uplifts and other cost issues, respectfully, transparently and with a sense of responsibility for our role in the system.

My hope in writing this is that if you are reading this in a Town Hall, or NHS office, you come to your next meeting with us in the same way.