The week in public services — 11th September 2018
This week: Matt Hancock is enthusiastic for NHS apps; the Home Office doesn’t understand whether the police are financially sustainable; and cash for “uniformed youth groups”
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.
Cross public services
If we leave the EU without a deal, the Treasury expects further departments to find any the cash for any unexpected spending out of their existing budgets. Which means cuts to spending on other things. Cheery. On a totally different note, a thought-provoking blog from Julia Unwin about the disconnect between those who use and those who provide public services, and how using different language often exacerbates the gap.
Health and Social Care
In health, Matt Hancock’s enthusiasm for technology has translated into £200m new cash for NHS tech, though details on what are currently light on the ground. Some of that cash will probably come from the summer £20bn announcement: NHS Providers have set out five tests for the Government’s five-year plan to accompany the spending announcement from earlier this summer, including by increasing spending on public health and social care. Perhaps some of that £20bn will go into reversing the trend of selling off property. New figures show a 72% increase in the number of NHS sites deemed “surplus to requirements” over the last two years has led Labour to accuse the Government of “selling off the NHS family silver”.
And speaking of apps, Matt Hancock has also announced a “TalkHealthandCare” app for the NHS workforce, inviting them to send stories and ideas to the Government, in a speech about health and care. He hopes this will improve staff engagement — but proposals for NHS staff are significantly more detailed than those for social care. In any case, Hancock’s focus on staff is timely, as more hospital doctors, and more GPs, are choosing to retire early, according to a BMJ analysis of figures on why doctors claim their pensions. There is also new evidence of an ethnicity pay gap among hospital consultants.
In bigger trends, Public Health England have put together a “Health Profile for England” — an overview of the health of the population, and trends in illnesses. Inequalities persist and the number of people with diabetes is set to grow, but there are positive stories: we’re all living longer, and smoking prevalence has dropped by a quarter in the last seven years!
And last Tuesday, we hosted a debate on whether a hypothecated tax could fund the NHS. I will admit — I still don’t think so — but I found the arguments for hypothecation more persuasive than I thought I would, and different to what I was expecting. The differences between advocates of soft and hard hypothecation are as big as the difference between hypothecators and general tax advocates! If you missed it, you can catch up here.
Quite a lot of news for social care this week as well. Independent Age have looked at options to raise money for free personal care. Social care commentator Richard Humphries has argued that the different financial systems in local government and the NHS mean that health ministers have been able to avoid tough decisions about money and services which are common in local authorities.
And new research on direct payments in social care — where service users have some control over what services they buy with a personal budget set by a council — suggests they haven’t made a difference. The authors attribute this to: lack of clarity about the benefits of direct payment; a limited supply of services; and the impact on providers. Care homes are generally not fans of the direct payments, because of the possibility that service users would pay reduced fees, and spend the rest with other providers or individual care workers.
An interesting BBC piece about care homes explores the impact of receiving an “inadequate” or “requires improvement” from the Care Quality Commission on providers. Put simply: it raises the cost of raising capital (banking) and insurance. Providers are concerned that Care Quality Commission inspections are inconsistent. With the care homes most reliant on local authority clients already under significant financial pressure, the knock-on effects on quality could create a self-fulfilling vicious cycle of care home closures.
The Kings Fund have the best simple overview of adult social care ahead of the budget that I’ve seen. Your one choice line? “Recent press reports suggesting that zombie ideas like a tax-free care ISA are under consideration indicate that the hard choices that need to be made are being avoided yet again.” The Government’s public actions imply this is correct and true.
Neighbourhood services and local government
Northamptonshire has become the touchpoint in debates about local government. Northants Tory MP Andrew Lewer — not to the left of the party — has broken with Government lines on Northamptonshire’s financial failure in a New Statesman interview. He argues that financial problems were created by the Government’s approach to social care, that the two-tier local government system is broken, and that county councils should be reorganised on a unitary basis. Also in the NS, Anoosh Chakelian has detailed the consequences of cuts to youth clubs in Haringey.
If another council goes bust, where will it be? The BBC have analysed what they think are the most financially-pressured councils: Northamptonshire, East Sussex, Birmingham, Lancashire, Suffolk, Surrey, Torbay, West Sussex, Hartlepool, and Oxfordshire.
Of course, what’s driving pressure is largely social care for adults and children. Heather Jameson makes a dark — but realistic — prediction for local government. As councils spend more high-cost, targeted, social care services, council tax and charges for other services will rise. For local taxpayers who do not use children’s or adult social care, the next few years are going to seem like they’re getting “less for more”. The start of a legitimacy crisis?
On a different note, public health person Greg Fell has a great piece on the consequences of transferring the public health grant to local government. TL;DR — don’t think for a minute that there weren’t raids on the public health budget when it was back in the NHS.
Children and young people
In schools, the Education select committee has found that cuts to Ofsted’s budget led it to prioritise the cost of inspection over providing independent assurance. Ofsted has completed fewer inspections than planned, failed to meet its targets for how often schools should be inspected, and schools are being left longer between inspections. The committee recommends that the Department for Education reconsider its policy of exempting outstanding schools from reinspection.
The Department has issued new guidance on staffing and employment in schools, warning teachers not to use school resources for “party political purposes”, following the ‘School Cuts’ campaign before last year’s general election. In other ‘difficult-headlines-for-the-Government’ news, a survey of teachers by the National Association of Head Teachers has found that funding for schools supporting pupils with SEND has got worse, as 94% of respondents said it was harder to support SEND pupils now than it was two years ago:
In positive (sort of) news, new research from Stephen Gorard at Durham suggests that differences in educational outcomes between the north and south can be explained by the characteristics (demographic, economic) of pupils that attend — and that grammars and academies have limited impacts on performance. So geography matters less than generally thought — but so does school type. His book should be interesting.
In children’s services, a group of children’s charities and campaigners have called the Department for Education’s “myth-busting” guidance on child protection an attempt to encourage councils to shirk legal duties. It’s never an easy week being a Department for Education press officer.
In all fairness though, children’s services face increasing demand — and it looks doubtful if the Department can squeeze money out of the Treasury at either the budget or the Spending Review. So in the absence of more cash, trying to streamline child protection is one way of trying to make efficiencies — although it makes for a very queasy headline. Of course, if one could reduce demand for children’s social care, there would be less need to make efficiencies. Children’s minister Nadhim Zahawi says the Government is trying to reduce the number of children in care, following the recommendations of the Care Crisis review — but rejected ringfencing support for early help.
And in ‘who-checked-the-press-release-on-this!?’ news, Tracey Crouch, minister for sports and civil society, has announced a £5m scheme to create 5,500 extra places in “uniformed youth groups” (think guides and scouts, rather than mass participation youth clubs in authoritarian states). For context, spending on youth services fell 35% between 2010/11 and 2016/17, which this new initiative is arguably replicating.
Law and order
The NAO haven’t pulled any punches in their latest report on police funding. They conclude that the Home Office’s light-touch approach means they do not know if the police are financially sustainable. The Home Office has no long-term plan, a limited understanding of demand, and the funding formula used to distribute money to forces is ineffective, the NAO claim. My excellent colleague Benoit also pointed out a fantastic diagram in the report, showing how incredibly complex one seemingly-simple question is: who’s accountable for police performance?
I won’t delve into any more details — there is too much fascinating stuff — but this is essential reading on police funding and performance. Sajid Javid is in for a tough afternoon addressing the police superintendents conference. Rick Muir at the Police Foundation argues that the report exposes the Government’s total lack of strategy for policing.
There have also been several qualitative reports of pressure on the police over the last week. Gavin Thomas, chief superintendent of the Police Superintendents Association, argued that “routine police functions” now depend on “officers effectively giving their time for free by staying past their shift times or working on leave days”. And a Freedom of Information request has found that the Met Police have sold £1bn worth of property. Ken Marsh, chair of the Met Police Federation, says buildings have been sold in order to avoid cutting police numbers.
Further along the law-and-order-chain in courts, the Equality and Human Rights Commission, the equality watchdog, has announced it will conduct an inquiry into whether victims of discrimination are being denied justice due to legal aid cuts. Funding for almost all employment law cases was scrapped in the 2013 legal aid cuts, and a Buzzfeed investigation found that no-one with a discrimination complaint against an employer or business received legal aid in 2016/17. The watchdog is concerned that victims of discrimination who cannot fund their own lawyers could be being denied justice.
In prisons, the Ministry of Justice are consulting on proposals to give governors powers to design “programmes of incentives” — rewards prisoners are granted for good behaviour — for the prisons they govern. Russel Webster think the language and design of the scheme owes to David Gauke’s time at the Department for Work and Pensions.
In the same week, a fascinating review of the academic evidence commissioned by the Ministry of Justice found that “the crucial factor in maintaining order is the availability and the skills of unit staff”. Time to reconsider those prison staff cuts as well changing incentives in prisons? (Russel Webster also has a good write-up).
A lot of the political focus on prisons has followed the recent damning report on Birmingham. But pressures are widespread. The number of drug finds in Welsh prisons is increasing, for example, which the Prison Officers Association attribute to staff shortages rather than better detection. Hardeep Matharu has written a superb summary of the Rory Stewart’s comments on the Government’s response to the problems in HMP Birmingham, and what it means for private prisons.
Policy Exchange director Will Heaven argues that problems at HMP Birmingham, and other category B and C prisons, owe to the poor condition of prisons themselves — often actively dangerous and hazardous to health. 12 of the country’s 15 poorest-performing prisons were built during the 19th century.
Finally, in probation, the Ministry are consulting on reforms to ‘Transforming Rehabilitation’ — probation privatisation. They are looking specifically at whether payment by results is still useful, or whether a complex mechanism known as “guaranteed maximum price with target cost” would work better. With Chris Grayling still at the cabinet table, a total reversal on privatisation looks unlikely.