The week in public services — 11th December 2018

This week: the social care Green Paper reportedly goes missing; the nuclear option on NHS finances; and the health wonk’s holy grail

This is a non-comprehensive overview of what is going on in public services by the Performance Tracker team at @instituteforgov. Did we miss something important? Let us know below.

Public Spending

Austerity, as we all now know, is ending. At least as a piece of political rhetoric. Which is timely, Ipsos Mori reckon, as 62% of people now think the Government should extend services — even if that means tax rises. So the Government’s clearly managed to pick up on public sentiment.

But look closer, and the polling reveals deeper problems. Only 15% of people are “personally willing to accept less from public services” in order to pay off the national debt — down from 47% in 2010. In the past, concern about public services has decreased as government spending increased. But increasing demand from an ageing population — particularly for care — mean that increasing spending on public services may well not result in people feeling like they’re getting more. It’s not clear that another round of top-up spending can manage the public’s expectations of services and taxes this time…

Health and Social Care

Change at the top! Julian Kelly, the man who until now was literally in charge of Britain’s nuclear submarines — and formerly of the Treasury, is in charge of NHS finances.

But that doesn’t appear to have had any change yet. Hear me out — and stop me if you’ve heard this one before. The head of NHS England is in debates with the Treasury about what tangible improvements the NHS can deliver for a cash boost. Nope, not the 2015 Spending Review, or even 2010 — it’s the latest negotiations.

Why does this always seems to play out in the public eye? For that, you can praise/blame [delete as appropriate] the 2012 Health and Social Care Act. The Act created NHS England as an independent body, separate from the Department of Health, intended to end “political interference in the NHS”. Has it? A mixed success, according to Nick Timmins.

Whenever the long-term plan does come out, Paul Corrigan has an interesting blog on what it should(n’t) do. Beware the temptation to revert to top-down command & control from NHS England and NHS Improvement, he argues. One of way assessing whether more central control would help, would be to compare the performance of foundation and non-foundation Trusts, he asserts.

But — sorry, I can’t help it — the inner geek in me is screaming that Foundation Trusts differ from non-Foundation Trusts in a range of ways other than the freedoms they have from NHSE and NHSI. With a higher level of earned autonomy, one would expect Foundation Trusts to have had underlying better financial management in the first place. If they were to perform better, that might not reflect the autonomy they’ve been given but rather different underlying characteristics. So we might add to Paul’s blog — beware also: simple (and potentially misleading) comparisons.

In any case, the NHS long-term plan is not the only game in town — we’ve also got the social care green paper on the way before the end of the year (stop laughing). Or have we? An unconfirmed story in the Daily Mail reports that the green paper now won’t be published until January at the earliest. The Mail is unhappy that “tens of thousands of older Britons face sky-high social care bills that deny their children much of their inheritance”; I look forward to their embrace of tax rises to fund a more generous cap on costs.

What do the public think about health and social care? Ipsos Mori have looked at that. Most of the findings are as you’d expect — people love but are pessimistic about the NHS; social care is poorly understood. My most surprising takeaway, however, was that 49% think 2018’s promised extra NHS funding is enough to maintain the current level of NHS services, but not to lead to improvement. Would we call that realism about what funding can deliver — or just cynicism?

Speaking of realism — remember the halcyon days of the early coalition years when the favoured policy wonks thought the only way to make health and social care sustainable was to integrate both? It was always worth asking what evidence there was that health and social care integration would either save money or improve services. What should the ‘vision statement’ for high quality integrated care have been? The Local Government Association have asked the Oxford Brookes Institute of Public Care to have a look.

In other new evaluation-based news, the Government has released the results of the review into the Disabled Facilities Grant — “a capital grant paid to local authorities in England to meet, or contribute towards, the cost of adapting a person’s home” — which has made 45(!) recommendations.

It’s not all bad news though — financially-troubled care provider Allied Healthcare has been bought by Health Care Resourcing Group, a healthcare recruitment agency. This means local authorities will no longer have to search out alternative care providers to take over contracts they had with Allied — although many are likely to have found alternative providers by now.

And in ever better news, NHS Digital have started publishing data on GP appointments, covering November 2017 to October 2018. Appointments captured from booking systems may underestimate the amount of work that GPs do, but given that we know so little about the services practitioners provide, this is a good starting point. As Sarah from Nuffield Trust says: this. Is. Good. News.

Law and order

We repeat loudly and often in Performance Tracker that prisons are a public service in genuine crisis — where it is hard to see any evidence that any possible efficiencies can reconcile the level of spending allocated with the Government’s ambitions for service quality. The Prison Inspectorate’s report on HMP Birmingham backs this up, and makes for frankly sobering reading: “exceptionally violent and fundamentally unsafe […] many frightened and vulnerable prisoners ‘self-isolated’ in locked cells but could not escape the bullying and intimidation as urine and faeces were thrown through their door panels”.

Children and Young People

New. Survey. Numbers! The latest Department for Education-commissioned survey of local authority children’s service leaders is out. My main takeaways: 93% of respondents had initiatives to improve social worker’s recruitment and retention rates — unsurprising given well-documented workforce problems. If there are any children’s social care policy wonks reading this — it’s all in our Performance Tracker chapter.

Most respondents thoughts social worker pay, and costs of providing services for looked after children and child protection had increased over the last three years. Which is interesting — although doesn’t accord with our finding that on average local authorities have squeezed spending on full-time social workers.

It could be that councils hired fewer expensive experienced workers and recruited less-expensive newly qualified ones, meaning that cost per social worker decreased whilst pay for different social work pay bands increased. Rest assured, your friendly researchers at Performance Tracker will be trying to work out why we seem to have a discrepancy.

Also, only 22% of social workers were supportive of the department’s new assessment and accreditation process. Not great considering that was supposed to help improve recruitment and retention…

In other policy news, the outcome of the Department’s review into improving educational outcomes for looked after children is also out, resulting in new advice for teachers and social workers. If you’re interested in the evidence base, you can check out the Department’s literature review and data analysis here and here — the latter of which contains some fascinating diagrams on children’s movements through the child protection and care system.

Neighbourhood services and local government

Seven weeks ago, the Ministry for Housing, Communities and Local Government accepted the recommendations of the independent Hudson review. The review called for local government finance settlements — the annual statement confirming how much money is available to local government — to be brought forward in order to give local authorities more time to set and scrutinise their budgets. The Ministry said it would aim to publish its provisional settlement on the 6th December.

On the 6th December, Secretary of State James Brokenshire announced that the provisional statement had been delayed…in order to allow enough time for parliamentary debate on the meaningful vote. Which is now not going ahead. So the Government has managed to create a shorter, more panicked, financial planning window for councils to plan next year’s budget the week before Christmas, or perhaps even January, for no discernible reason. Great. Local authority people are — justifiably — pretty hacked off.

Meanwhile, new CIPFA data highlights ongoing library closures in England. But the more interesting point is increasing reliance on volunteers, which indicates the subtle cost-shifting going on across public services. As Performance Tracker shows, the Government is asking people to contribute more to public services outside the tax system — either through volunteering, charging for services (e.g. removing legal aid), or subsidising state provision (e.g. self-funders in care homes paying more than publicly-funded clients). These measures may save money in the short-term, but they are political choices about service provision. Without involving the public in an open discussion about the line between public and individual responsibilities and costs, these measures are likely to generate resentment, and are unlikely to last.

CIPFA are also in the news following their proposed local government financial RAG rating. No-one wants to be in the red, or at the bottom of the ranking. But they appear to have found a way forward, looking at larger number of measures, and not providing a single colour result. Greater transparency on local authority financial sustainability can only be a good thing — especially as Somerset council is apparently not far off issuing a Section 114 notice, which would restrict in-year spending.

Last but definitely not least, this moving longread about increasing use of emergency accommodation by Jen Williams at the Manchester Evening news. We don’t cover homelessness or housing services in Performance Tracker — but it is essential reading.



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Graham Atkins

Graham Atkins


Senior Researcher @instituteforgov: public services, infrastructure, other things. Too often found running silly distances in sillier weather.