I am a bread maker. I know which ingredients I need to make the perfect loaf. I know how long it takes. I know how much the ingredients cost, how much of my time I need to put in, and how many loaves I need to sell at what price to make a living.

As a bread maker, I know my customers. I know if I make really great bread I can sell at a price higher than that in the supermarkets because my customers appreciate great bread. If the cost of the ingredients goes up, I can raise my prices and my customers might not like it but they will understand. I can still make a living.

In the NHS the life of a bread maker is much more complicated. When I sell my bread to the NHS, I am not selling it to my customers (the people who eat my bread). I am selling it to “commissioners”, who are buying that bread on behalf of patients. The job of commissioners is to make sure patients get the best possible value for the money invested by the government in the NHS, and they take this very seriously indeed.

Problems arise when the cost of my ingredients go up. I say to the commissioners, “the cost of flour has gone up, and so I will have to raise my prices”. But according to the commissioners this is my problem. They insist that I make more bread for less money, despite the rise in the cost of ingredients.

So what do I do? I can either make lower quality bread, putting less care and attention into each loaf. Or I can work longer and longer hours making bread, and pay myself less and less money to offset the rise in the cost of ingredients. Eventually, I have to do both.

I go back to the commissioners and say that I can’t carry on. My bread is no longer of the same quality and I am close to burnout.

Finally, they listen. They say they understand the problems I am facing. They say they are going to give me more money for my bread. On one condition: that I make bread 7 days a week. Patients should have fresh bread 7 days a week they tell me, and that is what they want in return for the extra money.

I say, “But I need the extra money because my costs have gone up. My costs will go up even more if I have to make bread 7 days a week. My business will still be in trouble”. “Money is tight for everyone” the commissioners reply, “we need a return for the extra money we are investing”.

I don’t understand this logic. If flour costs more, I need more money to make bread. I cannot absorb the cost and still make great bread and still make a living that will support my family. Sometimes costs go up. Sometimes people have to pay more for the exact same thing. When I sell directly to customers they understand this.

I agree with commissioners that patients should have fresh bread 7 days a week. I am happy to work with my fellow bread makers to work out a way that we can do this between us, and as long as we are reimbursed for the costs of doing it then we can provide it. But not now. Not while my business is facing such severe challenges. If commissioners paid more money so that I could meet the costs of making bread, and I could get my business back on track, then I would be at a point where I could work out how to make fresh bread available 7 days a week. But not right now.

I would be happy to agree to change the way I make bread in return for extra money. I would be happy to explore how I could find different types of labour, work with other bread makers and other organisations, and find ways that would enable me to still make great bread at lower costs. If the commissioner would invest extra money to help me make these changes I would be up for the challenge.

But if nothing changes, I do not think I will be able to make bread for the NHS any more.