Q&A with Rob Kinsman and Mario Kreft MBE, Chair at Care Forum Wales

This is a transcript of the interview which ties in with our Business Outlook 2025 report. 

Rob: Hi, I'm Rob Kinsman and I am joined today by the Chair of Care Forum Wales, Mario Kreft. Mario celebrated recently 40 years of care home ownership at Pendine Park in North Wales, which comprises nine care homes and over 400 bed spaces. Welcome, Mario, thanks for joining us today.

You started Care Forum Wales in 1993, and I thought we'd just kick off with a bit of a conversation about the background of Care Forum Wales and its objectives.

Mario: I was Vice Chair of the National Care Homes Association here in London. There was really nothing in Wales at that time, and we thought devolution was going to come sooner than it did. We didn't expect John Major to win that election. So, we set it up with a particular focus on there being a Welsh government which, of course, now we have. I guess the objective was really to make sure that care providers not just had a voice but had an input into the legislation that was bound to follow, and I think the track record over 30 years has shown that.

Rob: You’ve got a really good buy-in from a lot of providers. Membership is really high, isn’t it?

Mario: Membership is high, but it can always be higher. We've got the best part of 500 people who are contributing. I think it's fair to say there are many more who get the benefits of Care Forum and believe in what it does, but don't necessarily pay the annual subscription. But I think you get that everywhere. So, I think, really, it's so far so good.

We’ve been quite successful. We celebrated our thirtieth year at the Senedd recently. The outgoing First Minister, Mark Drakeford, talked about the importance of the organisation and how it's vital for the Government that they can listen. I mean, we have that through other parts of the UK. Care Forum is a founder member of the Five Nations with our colleagues in Care England. Obviously, Scottish Care, Northern Ireland, and the Republic, and, I guess, it's just about integration.

Care providers, when they're not doing their job, are very much affected by legislation and change, and they make a choice. They either be part of that and make a difference in the contribution, or they just wait for somebody to tell them what to do or how high to jump, really, and we've seen that with ratings recently. Ratings will be coming into Wales from 1st April. They've been silent ratings for years. It's a quite different approach to what the CQC has done in England. I think they've learned from England and the mistakes that have been made here, and I think we're going to have a far, far better system. The evidence so far is that 70%+ of the homes are scoring very highly, which, that's great news.

Rob: There's a different regulator in Wales, the Care Inspectorate Wales, CIW, and, historically, it's not had a rating system. So, am I right in saying that they looked carefully at the CQC rating system and looked to replicate that with some improvements?

Mario: I don't think so much to replicate it. I don't think when it was brought in it was terribly well thought-out in England, and I think we've just looked at it and seen all the mistakes that were made and have got something that's meaningful because if it doesn't mean anything to the public. I mean, the best scoring system we've ever had, and it applies to any food hygiene business, is the scores on the doors. Wales was the first to make that mandatory, and you have to put it on the front of your shop or your kebab house or restaurant, and I think it does inform the public. When this works through, it will be a very, very positive thing, and, above all, it will show not just the quality of care in Wales, but the value for money.

Rob: One of the challenges in England with the CQC is the lack of actual visits to care homes. Have the CIW been able to go and inspect these care homes? How does that silent rating system work?

Mario: Well, one of the things that's very different, of course, is you pay an inspection fee here in England, it can be many thousands of pounds a year. Obviously, the big groups are paying an absolute fortune. In Wales, we don't pay anything, the standards come through the Welsh Government. They're inspected effectively by civil servants working for the Welsh Government, and they’ve recognised that there's no point in putting fees onto that because most people in Wales who receive a care service, be it domiciliary care or particularly in care homes, are publicly-funded. So, what is the point of putting more cost on providers to only have to pay more in fees?

Rob: There's a tie in there with the Government and the way they're buying into what needs to be offered as a service.

Mario: The Welsh Government, again, very much with the work that was being done in Wales by ourselves and others, recognise the need for social care workers to be registered. So, there's a registration system for everybody. There's also a Real Living Wage threshold. So, you know, it might not be enough. It probably isn't, but there's a minimum of £12.60 an hour going forward from April. But I think what the Government recognised was that it is a very, very important part of the health and social care economy and it supports the NHS.

The bit that you can never understand is the lack of joined-upness between health and social care. We've seen it recently with the amount of money that the Budget is putting into the NHS, and next to nothing really in comparison with social care. As somebody said, I think it was Lord Vaizey recently, you can't fix the NHS unless you fix social care. Now, it's not fixed in Wales by any manner of means, but there is an understanding it needs to be.

Rob: I think that's born out with the support the Government gave providers in Covid - very different levels of support in Wales than in England, and there was support up to 90% occupancy in Covid.

Mario: What we found in Covid was genuine support. In fact, you know, my colleagues in the Five Nations – Care England, Scotland, Ireland - were all very, very envious of the buy-in and the support that the care sector had in Wales. In the early days, I don't think Wales got it quite right. I don't think anybody did. But, you know, to basically fund you to 90% saved a lot of homes. What we saw then was a lot of providers being able to come out the other side, at least in a state that they were able to continue. So, we haven't seen the closures in Wales that we've seen in England, we've seen in Scotland. We have a government that is very, very supportive of the care sector because it understands how important it is to the NHS.

Rob: Post-Covid, there's been some really meaningful local authority fee increases. But, of course, this year we've got a potentially different challenge with the National Insurance increase in a couple of months’ time. You were quoted recently, I think, at the end of last year saying this poses a greater threat than Covid. What's your view on that?

Mario: The reason that I said that was because, very much at that time, we had no idea of any support coming from the central government, and the NI still is not supported. It's a 37% increase. It's going to affect everybody in all jobs right across the UK. I'm not an economist, but it doesn't sound like the cleverest thing in the world when you're trying to promote growth. But when you're trying to protect what is essentially a relatively fragile but vital industry, which is social care, the very last thing you want to do is put a tax on inputs. By all means, tax profits, but I think the point about Covid is very much that, going into Covid, we knew we had a very, very supportive government. With NI, which could be a tipping point for some, there doesn't seem to be any understanding, here in London, where these decisions are made, of how vital these social care services are. I think, from the point of view of the Treasury, we're governed by what happens in the southeast of England, probably in private homes where the profit per resident per week may well be more than the whole fee in other parts of the UK.

Wales is no different. 90% of the care in Wales is publicly funded. So, it makes no sense, and we've got a lot of hospice members in our membership. They are struggling. They're looking at cutting costs. It's not very sensible in our view.

Rob: In Wales, you do have a greater proportion of clients in care homes that are publicly funded, funded by the local authority, and we all know that there is a proportion of the care home residents across the UK that subsidise the sector by being self-funders, but there is just not that option in Wales.

Mario: It is an issue of the postcode lottery. A lot of people will have heard of Rhyl if they've never been there. There's a bridge in Rhyl and it's over the river Clwyd, which is a boundary of two counties. Crossing that bridge, you will get an entitlement to be a resident in a care home with nearly £10,000 between one local authority and the other.

So, we've been pushing this as being an issue about equality, because that's what it is. It's not about the fee for a care home provider. It is the entitlement that an individual has having had their needs assessed, having been financially assessed, and means-test effectively to receive that service that they obviously require. It’s very, very difficult to get public funding in a care home these days, any sort of public funding if you don't need it.

The care homes, as you know, have become very much, they've taken over from the long-stay hospital wards. We've got a lot of nursing homes. Dementia obviously is the big news story for the future with the amount of people living so much longer and becoming mentally impaired. So, what we've got to try and do is make sure there's at least a baseline.

And that's really what we've been calling for. We've got a national office now in Wales. It's another great step forward. But, at the moment, it's new, and a lot of people are impatient, but what we're always having to do is we've got to be patient. We've got to make sure that we work with people and what we want to do is not have a national fee for Wales.

We want a national baseline that really takes account of the real costs that you can provide high-quality care that's good for the residents, it's sustainable for the provider, and hopefully, they can actually to develop their services because that costs money, but, importantly, is good for the taxpayer. And I think this is where when we talk about the care sector, we've got to be very clear with what we're talking about. If we're talking about care homes and we're talking about those places where it's virtually 100% publicly funded, or is it privately funded completely, and they are so different. And most of the care in the UK relies, most of these care homes rely on a large proportion of publicly funded people. In Wales, that's no different, it’s 90%.

Rob: There's no other industry like it, is there? We've done an analysis of fees in Wales, and there's a disparity of over 30% between some regions and the cost to the provider is the same. So, what's your view on moving that forward and what does that look like in terms of that base fee, how realistic is that?

Mario: There's a lot of buy-in from all the political parties that it makes no sense for simply to walk over a bridge and the inequality to be £10,000 per person per year. That's ludicrous. You can see the same in South Wales. There’s a bridge down there in Newcastle Emlyn in Care Forum we call it the Newcastle Emlyn question, and, would you believe, the local authority there is building a home just down the road at £330,000 a bed. We need to get this joined up. But, you know, you have to be patient.

The one thing we know, we've got a population that's ageing. We know that dementia is becoming more and more prevalent in very old people, over 85-year-olds particularly, and, so, we see a real future for care homes. We see a real future for domiciliary care, and we hope that, increasingly, technology will enable people to remain in their own homes. But, you know, people get the wrong idea of this. The people that go into care homes, anywhere in the UK today, particularly in Wales, I know firsthand, are very, very in need of care. Very often nursing care in addition to social care. And they very often, I had a case recently, somebody had actually been cared for at home by their family for four years. They were all done, you know, and this person's 95, that is the way that we're going to see this develop more and more.

Rob: Christie & Co published a report last year which revealed, that by 2034, there's going to be a shortfall of over 9,000 beds in the sector in Wales, and there's no real visibility on any meaningful new beds coming on stream. So, how do we square that equation off when we've got an ageing population and a shortage of beds?

Mario: I would be very much arguing, and colleagues at Care Forum, that we need to stimulate the independent care sector. We know there are three new builds that are currently in various stages of development run by councils, and we know that each of those is either - we've just quoted 330,000, but the other two are just under a 300,000 bed - so, colossal. They will be nice, I'm sure. But that was all ideological, it was part of a previous First Minister's legacy project. Okay, that isn't going to be a solution. Wales doesn't have the money to replicate these homes.

We've seen, since Covid, building costs have skyrocketed for all building, and therefore we're going to have to find a way to increase these beds. One of the ways, I think would be very sensible, is to stimulate the market in such a way that those people in communities, because that's where these places are, and that's where they need to be, those people in communities are encouraged and incentivised to expand those services, because if you've already got a service, you might have 30, 40 beds, well, what's wrong with another 20? And you've got your workforce. I mean, we haven't talked about the workforce, but that's a key issue. You know, it's not sustainable to go to the Philippines and India and Africa and bring all these people in for all sorts of reasons, economic and political.

We've got very, very good care homes providing excellent services. We know that's a fact because Care Inspectorate Wales tells us that. So, surely, if we could incentivise providers who want to support their communities to either extend or even build in the locality, whatever, we need to keep those services close to where people want to live in the communities they want to live in, where possible, with the culture and the language that they're used to.

Rob: There's a lack of new builds coming on stream in Wales. The supply of beds is limited, so occupancy actually in Wales is higher than the UK average and has been for some time. So that supports the idea that these existing providers can expand their current services because the demand is there and occupancy is strong.

Mario: One of our members is actually the proof of the pudding really, just went out, took a big risk, borrowed a lot of money and increased their beds by 50%. But it was a very expensive way to do it because of the build. But what that has provided has been a fantastic community-based service that nobody would actually put a care home there.

It would never happen. The council wouldn't build a care home and, otherwise, people in that community would have to travel possibly an hour in either direction to find a service. Well, why would we do that when we can find a cleverer way of doing it?

Rob: So, we're actually seeing really strong investor demand across the UK for people to grow their care businesses, and, actually, that holds true for Wales as well. How much cross-border collaboration is there with Care Forum Wales and Care England, and is it realistic for providers to own a care home in England and also in Wales with a different regulator and that sort of thing?

Mario: Essentially, if you can do business in England, you can do business in Wales. I think nobody needs to be frightened of the different regulatory regime. To be perfectly candid, I think you'll find a very, very warm welcome, as the song goes, and I think the regulatory regime is a better regime. It's a fairer regime, and it's very supportive. So, it's not difficult to understand why people would be looking across the border at regional operators, of which there are many. If we're into that world where it is so expensive and such a risk to start up a brand new enterprise, if that's got to be 60, 70, 80 beds, say, we're talking significant amounts of money before we've even started.

The secret really is about building on what we have, and I think there are operators who have the opportunity, and I think, when you look at the demographics, and that's the key here, you know, Wales is a poorer country. Yes, that's a fact. But what you have in Wales, of course, is that opportunity because there is no real new build going on.

The things that appear to be in the pipeline are shelved because the fees don't make any sense post-Covid for building costs, but we know that demand is soaring. You know, you've only got to look at the NHS waiting lists that, despite all the money that's being put in, the waiting lists are high, the NHS is suffering as it is in parts of England. So, what we see is social care being part of that solution, so why wouldn't you want to straddle that border? If you can be a skilled operator in England, you can be in Wales and vice versa, in my view.

Rob: What's the local authority view on top-ups in Wales? So, if we're looking at sort of baseline local authority fees, is there a general consensus about the view on top-ups with local authorities?

Mario: Local authorities will, on the one hand, they’ll actually frown on them and, other parts of in that same authority, will be encouraging people to actually charge them to basically substitute some of their budget, and I think they're just going to become a way of life. It is the case that governments want to get closer to that fee, but that's why we want that baseline fee. I don't think there's anything wrong with a family choosing to have a better service or what have you, and finding some extra money to do that. But that should be if you need public funding, if you are so unwell, you should have a proper base fee.

I mean, if you can operate well, £10,000 per resident per bed less than the guy on the other side of the bridge, then you're running a tight ship, aren’t you. I think we're going to see a much better, much fairer spread of funding, and I think that's because Wales predominantly bases itself on equality, and this is one of the great inequalities that currently exists. I think having a care home fee between one place and another, well, it’s a care home fee, but when you talk a bit and put the narrative in it is the entitlement of that individual to receive a service they've been properly assessed for. That narrative changes the game.

Rob: What's your view in the immediate term in terms of the outlook for the sector?

Mario: I think the outlook is incredibly bright because it's the old case of supply and demand, isn't it. There is no shortage of need, and I think one of the scandals currently that we have in the UK is the amount of unmet need that isn't being recognised.

There is a conundrum, isn't there, here in this country where people work all their lives, most of their investment is their house, and they want to pass that down to the next generation. I don't think it is right that the state pays everything but, equally, the state should pay its fair amount because a lot of these people now would otherwise be in hospital.

What we've done recently is very interesting. We've been able to link the poorer fees, or the lower fees in Wales, to those areas where the hospital discharges are the highest. So, we've made this a political issue, and that's what I would say about the future. The more people that actually engage in the collective, it's not about a union, it's about an association.

It's about common ground. If you're dealing with something that is primarily going to be publicly funded, you can't just sit there and say, “Well, you know, I'm not happy” and complain all the time. You've got to go out, you've got to do something about it. But if you look at this positively, you look at the demographics, you look at the quality, you look at how people have been able to grow their workforces, register their workforces. You look at what will be coming out publicly soon about the quality of our care homes meeting and surpassing regulations. It's a great news story.

Rob: I think all the work you do at Care Forum Wales is fantastic, and it definitely provides one voice for the sector and the industry has definitely benefited as a result.

To watch the full video interview, click here.