Opinion: Service provision - a cautionary tale

Peter Cardy, chief executive of Macmillan Cancer Relief

Reading last week's feature on Australian outsourcing took me back ten years to the time when the MS Society was reconsidering its future.

Services for people with MS were so dire that we were considering trying to become a major provider of outpatient care - a huge undertaking, but theoretically possible in the purchaser-provider NHS model that then existed.

Plus ca change...

I went on an intensive visit to two Australian MS charities that did most of their work under contract to their respective state governments.

I envied their ability to provide comprehensive services to the entire MS population, including using the Flying Doctor Service to reach disabled people in remote places.

Their array of services was formidable: housing, transport, day care, assessment, medical, nursing and drug treatments. Halfway through my visit, I began my report recommending that we try to emulate this in the UK.

But when I began to realise what I didn't understand and ask the right questions, I started to see things in a different light. For example, full cost recovery existed in one state but had suffered cuts in the other.

To maintain service levels, increased fundraising had to subsidise services for which the state had previously accepted responsibility but which it had later outsourced, changing the terms. This put the charity in a dilemma: they could reject the new contract, but whoever picked it up would not have specialist MS knowledge. Besides, their only rationale was to serve people with MS.

The dilemmas were different in the full cost recovery state. Here, the Government outsourced services for population categories, not diagnostic groups. So in successive tendering rounds, for example, the day-care contract shifted from people with MS, to neurological diseases, to all adult disabilities.

To maintain the service to people with MS, it had to widen the scope to the point that the charity's objects were being stretched to vanishing point. The charity's effort was inexorably dragged towards maintaining its services and therefore its income, and away from innovation.

The lesson was an old one - the payer calls the tune. I reported back to my board, and we turned away from providing to the riskier direction of independence, innovation and influence. Much may have changed since then, but the warning remains to look behind the superficial attractions of models imported from a different cultural environment.

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