The Week in Public Services 23rd June 2020
This week: where all the A&E patients went; teaching during a recession; and new public service paradigms
General
Let’s start with a hypothetical. Suppose you have just woken up from six-month coma and are wondering what on earth is going on, and why the UK is doing so badly in combating Covid-19. What should you read to understand what’s happening? This summary by Trish Greenhalgh and Andrew Sentence would probably give you the most bang for your buck. They conclude that the problems are due to a mix of “too-little, too-late policymaking”, a decade of austerity weakening public services’ resilience, and following plans which were specific to flu.
Elsewhere, public health professor David McCoy tries to explain why England messed up testing so badly (tl;dr — centralisation and “ignoring well-established principles of good practice”). Of course (all together now) testing is nothing without a network of people to trace the contacts of those who test positive for Covid-19, so you should also read this excellent Tom Chivers article on contact-tracing, which concludes that even an imperfect contract tracing system would probably be the least bad of all options before a vaccine is available.
Looking at the bigger picture, I thought this Economist article framed the changes going in lots of different public services well. In the authors’ view, the UK governments’ response to coronavirus shows that “the state is getting back into the insurance business” — starting to reverse a series of changes where governments and employers asked citizens and employees to bear more risks from the 1980s onwards (think of the shift from defined benefit to defined contribution pension systems, from secure work to zero hours contracts etc.). Of course, the last major uninsured risk in public services is still funding social care in old age, where governments have famously prevaricated for the last 20 years…
But maybe the future won’t simply recreate the 20th century past. Simon Parker has written a great essay about the future of public administration and government. There’s a lot of different threads running through this, but I found it most interesting as one of the clearest answers to ‘if not new public management, then what?’ I’ve read. Worth reading.
Health and Social Care
So — given all the chatter — has the pandemic actually changed the public’s beliefs about the NHS and the government’s role in healthcare? New polling commissioned by the Health Foundation found that 86% of people now believe national government has a ‘great deal’ or ‘fair amount’ of responsibility for ensuring people generally stay healthy, up from 61% in 2018…let’s see whether that change is permanent (especially after people inevitably run into difficulties accessing routine care once lockdown restrictions start to lift).
One of the best things I read this week was this absolutely fascinating longread from Louella Vaughan, which tried to get to the bottom of a question that’s been vexing lots of NHS managers, clinicians, and policy wonks: where have all the A&E patients gone? Her conclusion is that “the drop in ED attendances is likely to be real, do not necessarily represent pent-up or deferred demand, and that aspects of this may be sustainable in the longer term”. If you’ve any interest in health policy, you should read the whole thing. I learned a tonne. Did you know that in some areas homeless people account for 8% of the patients attending A&Es, but make up around 30% of visits? And that some reductions in hospital work are associated with falls in mortality? (A review of doctors’ strikes held between 1976 and 2003 found a reduction in mortality, even where strikes lasted up to 17 weeks). Exactly. Read this.
Over in the world of technology, Policy Exchange’s Richard Sloggett has proposed a sensible framework for deciding which changes to keep and which to bin: evaluating, assessing need, investing, and commissioning. I agree on the need for evaluation (obviously). Here’s what it looks like on the ground. “Before Covid-19 came along 10%-20% of our outpatient appointments were done digitally, by video or telephone consultation. But by April and May that was 70%” — interesting reflections about what will change after the pandemic from former NHS improvement chief exec Jim Mackey. His conclusion falls firmly in the sensible middle ground: “there’s a binary perception that either the NHS needs more money and beds or it needs to transform itself [but] going forward and learning from Covid-19 it needs both”.
Paul Burstow has written a similar interesting blog on the use of technology in social care, suggesting there is scope for more technology-enabled-care to support vulnerable people stay independent at home.
In other news, the Care Quality Commission is restarting inspections. The Independent has interviewed the chief inspector of hospitals, Professor Ted Baker, who is most concerned about reports the CQC has had about patients being inappropriately detained under the Mental Health Act, and discharge to care homes. On which — David Oliver has published another good article, pointing out the counterfactual: if hospitals hadn’t discharged residents to care homes without testing them, hospitals might have been overwhelmed. And importantly, lots of other European countries which have had fewer overall deaths than the UK also had similar care home death rates, which is a point we often we seem to miss when talking about this.
Hospital chiefs in Devon are asking NHS England to extend the contract it put in place with the private sector to remain in place until the end of the financial year. NHS England has submitted a bid to the Treasury. But the Treasury is sceptical that extending a government contract to buy up capacity in the independent sector will be good value for money, and want to see more evidence before signing the proposal off — they want to know exactly how many patients will be treated. I am shocked! Shocked! Well, not that that shocked.
In adult social care, a new ADASS survey of local authority social care directors about how Covid-19 has affected social care budgets. A mere 4% of directors are confident that their budget will be sufficient to meet their statutory duties this year, down from (an already low) 35% this time last year…
Another consequence of the pandemic has been an increase in unpaid care — mainly poor women providing more care. Carers UK estimate that 4.5 million people have started to provide unpaid care during the pandemic — up from 9.1 million unpaid carers before the outbreak. They want the government to increase carers’ allowance.
Children and Young People
While the school reopening debate remains unresolved, the government have been doing other things. Principally, setting up a new tutoring scheme to help children who’ve lost out on schooling catch up over the summer. I can’t decide what to think about this. On the one hand — it’s a sensible proposal, with the backing of most education academics (even if some rightly question the distribution of the money, and why early years and students aged 16 and over have been excluded). On the other hand — implementing this seems to be going about as well as the government’s promise to reopen all primary schools by 1st June. According to this Guardian article, “most of the planning appears to have been led by No 10, with Department for Education officials virtually zooming back and forth with dismayed faces after having their input appraised in unflattering terms.” Not to mention that just under half of the 230,000 laptops the government is sending to help vulnerable pupils learn at home during the coronavirus pandemic have actually been sent out — two months after the scheme was launched. That doesn’t fill me with confidence about the tutoring plans.
In another debate I’ve been trying to follow, the Education Policy Institute have published their analysis of whether the upcoming recession (which, spoiler alert, shows signs of leading to 1980s or 1990s levels of unemployment) will solve teacher recruitment problems. In a neat simple model, they estimate that assume that Covid-19 could reduce recruitment shortages by between 20% and 40% each year over the next two years if it affects graduates in a similar way to the 2008 crisis. So: some good news (good is a doing a LOT of work there), but not enough to plug the recruitment gaps. Looks like it’s back to the drawing board to work on how to better retain teachers.
My two cents: it’s surely worth trying to ‘overrecruit’ teachers for the next few years given the current gaps. The government should be promoting teaching as a career to recent graduates hard, and making sure there are enough teacher training placements to accommodate a higher-than-normal of teacher trainees (my view in this is — mostly — nicked from Luke Sibieta’s comments on the excellent IFS Zooms In podcast).
In children’s social care, new research from Action for Children and the Early Intervention Foundation, based on interviews with early help professionals, found that “school closures, social distancing and lockdown measures have seriously affected the ability of services to support children and families at the time when they needed it most”. What might be done to improve support as restrictions are eased? The Institute of Public Care have looked at the data and intelligence councils should be gathering, and how to commission care more effectively.
Law and Order
Black Lives Matters protests and police debates aside (though if you want to read more on this — check out this thoughtful blog from Rick Muir, and this reading list), a quieter week.
There were rumours that the government could abolish some jury trials in order to reduce the backlog of cases in courts, which have gone down (extremely) badly with lawyers. There were almost certainly things I missed, however.
Local Government
Your regular reminder that this pandemic is wrecking local government finances from extra costs and lost income — this time, from the Mayor of London.
The government have, as they love to repeat, provided £3.2bn to local government to address the crisis. But now even the distribution (as well as the amount) of that funding is controversial. County councils appear to be getting a lot more of their costs covered compared to London boroughs and district councils. Always worth bearing in mind that councils are still obligated to balance their budgets over an entire financial year, and even those councils whose costs appear to have been covered (shire counties and metropolitan districts) will still have finance officers with headaches…
The Institute for Fiscal Studies is, as ever, on top of local government finance in England, and their latest briefing note shows that “on average, [councils] that are more reliant on revenues that look particularly vulnerable in the short term have higher reserves, but this is far from always the case”.
Contrarian take: despite the government saying it won’t cover councils’ lost income, a lot of the second tranche of emergency funding went to district councils, suggesting that the government has already implicitly acknowledged that “the crisis is expected to impact income more than spending”. Good point.
In more positive news, the New Local Government Network have published an interesting article with the assistant chief executive of Sunderland about how the pandemic has changed the pace of transformation in Sunderland, and some of its positive consequences.
That’s it for this week. Stay safe.
