The week in public services: 25th October 2019

This week: the government quietly ditches plans to close Victorian prisons; the holes in hospital building plans; and how rising costs swallowed £790m for social care

Sorry for the delay! It’s been crunch time for this year’s Performance Tracker — so week in public services has fallen by the wayside. But, do or die, we always publish the latest on public services news in the end. Here’s what’s been happening over the last two weeks:

Covering a range of public services, Reform’s State of the State report came out — and it contains some interesting insights from civil servants and frontline professionals about current pressures and what the government might focus on after promising to end austerity.

Health and Social Care

Right, it has been a busy few weeks! First off — an excellent round-up of what we really learned about the two main parties’ approach to health policy from the conferences (remember those?), from my colleague Freddie Wilkinson. TL;DR — party conferences don’t make for well thought-out policies. Richard Sloggett (until recently Matt Hancock’s SpAd) has also written a revealing piece on the conferences — about the shifting party politics of healthcare too. Worth checking out for one Tory view on public services.

Nodding back to Labour conference, the Nuffield Trust have handily analysed what personal care social care is: what it includes, and what it excludes. A good analysis of what Labour’s free personal care pledge really means.

This week, there was some new adult social care data — and it showed that fewer people received care than last year (despite the public sector spending £790m more on social care…) because of how quickly the price of care is rising. I tweeted the most important stories so you don’t have to read the data tables.

But while the cost of homecare (and the fees local authorities pay to homecare providers) has increased over the last three years, there are still big pressures on homecare providers — as David Brindle shows here. Walsall council has moved to paying for homecare by the minute.

Focussing on the Conservative’s plan for new hospitals, Siva from the King’s Fund notes that there are four things that seem not-quite-right with the announcement:

· the late timing

· the lack of transparency on how sites were selected

· the scope of the plan (i.e. what about primary care?)

· how the sites will be delivered given the financial and labour market pressures on construction firms in light of Brexit

Siva also analysed what the latest ‘ERIC’ (that’s the Estates Return Information Collection, non-NHS nerds) data shows about the rising critical maintenance backlog in the NHS — which now risks endangering patient safety in hospitals. Great blogs.

As well as these concerns, Nigel Evans at the Nuffield Trust argues that the NHS as a whole needs to invest more in capital and service planning skills. His words — there are too few “people who know about the development of really good modern buildings — the building notes that inform development are so out of date that they contain specifications for a ward smoking room”…

If that wasn’t enough capital analysis for you, the Heath Foundation have released new analysis on capital spending and assets in the NHS compared to other countries…England does not come out well.

Meanwhile, NHS providers published a new report on the state of the NHS. Despite the additional money in the spending settlement, 91% of NHS Trust chief executives responding to the survey said that “we need more public debate about the future direction of the NHS” — i.e. to recognise the trade-offs that hospitals feel forced to make due to rising demand.

How, if at all, can the Government deliver general practice services with “too few GPs”? Very good briefing from Dr Rebecca Rosen — always worth reading on general practice.

The sceptical among you may ask: why don’t we just recruit enough GPs? A good question. The answer is that we’re struggling to retain existing GPs due to workload pressures, and it’s hard to recruit more doctors into general practice (despite the government’s target to increase the number of GPs by 5000, the number of full-time equivalent GPs has actually fallen). There’s also a long ‘lag’ between pumping in money to hire GPs, and that money translating into more GPs — so even if you could do it by massively increasing payment or offering vastly better employment terms, there would be some time in the immediate future where general practice would not have enough GPs.

Could greater use of digital consultations help square the circle by enabling existing GPs see more patients? Possibly — but we must be careful not to focus solely on these, which tend to work only for younger patients who prioritise convenience — and don’t have long-term conditions.

So, what’s Rebecca’s answer? She thinks we should, as far as possible, try to ringfence the £4.5bn committed to primary and community care to invest in capital, running costs, and staff development for the ‘other staff’ (nurses, physiotherapists etc.) who work in general practice — all of whom are likely to play a bigger role in general practice if we cannot recruit more full-time GPs in the future.

Elsewhere, a Kings Fund analysis has shown that removing the nurse bursary led to a fall in the number of people applying for the pre-registration training programme to become learning disability nurses. The removal of the maintenance grant appears to have hit learning disability nurses particularly hard because many candidates are mature students, who may have more family and financial commitments than younger students (and be less willing to take on additional financial obligations). The NHS long-term plan committed to improve services for young people with autism and learning disabilities — but this will be hard to do if the NHS cannot recruit enough nurses to provide these services.

In a blog that seems particularly timely now, Dan Wellings and Ruth Robertson try to answer ‘what would the public think about health and social care if a general election were held tomorrow’? They find that booking a GP appointment is one of the biggest irritations. There’s also no sign of much change since the funding boost. The authors note that “public opinion on the NHS has a large turning circle” — which is probably not the news the government wanted to hear ahead of an upcoming election.

Richard Murray argues that, whatever the outcome of the election, the next government must avoid the temptation to reorganise the NHS (again). Given the scale of workforce pressures and the clear problems in social care, 2019 is an even less hospitable time for reform than 2012 was for Lansley.

About those workforce pressures: a great investigative piece from Shaun Lintern found that the gap between the number of nurses hospitals think they need, and the number of staff they have, has grown since 2014. Massive credit to Shaun for FoI’ing the data that the government stopped collecting (see here). Roy Lilley has written about some very worrying concerns about NHS Trusts ‘downbanding’ nurses — that is, moving them down pay bands while they continue to do the same work. And Helen Gilburt has (correctly) pointed out that it will be very hard to improve mental health care unless the NHS has the staff to do it — based on a great analysis on board papers for 53 NHS mental health Trusts. And all that is before we get on to pension tax changes, which half of NHS Trusts with the biggest referral-to-treatment time pressures cited as a factor decreasing performance in their most recent board paper (!)

In the academic world, a fascinating paper from Ben Goldacre and colleagues analyses when GPs adapt to new innovations in medicine and technology, and which ones adapt quickest. They think there is scope, using methods from other fields, to help raise the speed of adaptation for all GPs. If you don’t fancy the language of abstracts and journals, they have also written a great summary thread.

Looking at a bigger theme, a good article from Nick Triggle explores why the trend of ever-increasing life expectancy has slowed since 2011. TL;DR — there have been few major medical breakthroughs in the last few years, and reductions in government spending may have played a role. A lovely essay from Rich Taunt explores how central government can better support the NHS to improve policy. I like his idea that the Treasury should think of itself as HR and not HQ.

In Brexit news, Mark Dayan has analysed what Johnson’s new withdrawal agreement could mean for the NHS. The main change from May’s deal? The scope for a harder Brexit now that the Northern Irish backstop (and the customs union between the UK and EU) has been removed — but everything still all depends on the kind of deal the government would choose to pursue in the second phase of the negotiations…

Last but not least, the content of this weekly update are rarely positive — so it’s heartening to able to share some good news for a change! An interesting blog from Siva at the King’s Fund looks at how Norwich and Norfolk hospital managed to see and treat patients aged 65 and over more quickly and effectively, by creating an Older Person’s Emergency Department staffed with geriatric specialists next to A&E. As always, lots of idiosyncratic factors, but some hopeful lessons.

Children and Young People

It’s not been quiet in schools, either…the Department for Education released the results of the 2019 teacher workload survey, which found that teachers and ‘middle leaders’ in schools reported working fewer hours in 2019 than in 2016.

Good news, right? Given that we’ve got a worsening teacher retention problem and all. Well… a good new blog from James Zucollo at the Education Policy Institute poses a few questions about that. It’s not straightforward to work out what is happening to teacher workloads, and that poses a problem for policy-makers. The more I read about this, the more I think the Department for Education needs to sit down and think whether their additional teacher workload survey is worth continuing, as it’s so out of whack on the number of hours teachers work, and whether hours are increasing, decreasing, or not changing. Do we really need four different ways to measure the amount of time teachers work? Worth reading. (It also features a great chart).

Elsewhere, the Department has now confirmed school funding allocations so we can see where in the country that new schools money is going. To understand what this means in context, check out this summary of school funding trends from the House of Commons library.

The big story doing the rounds (rightfully) is the Education Select committee’s report in the support available to children with special educational needs and disabilities. Their verdict on the 2014 reforms is pretty damning: “at times unlawful practice, bureaucratic nightmares, buckpassing and a lack of accountability, strained resources and adversarial experiences”. They recommend a boost in funding a much tighter inspection regime with “clear consequences for failure”. They conclude that “for some, Parliament might as well not have bothered to legislate.”

A surprising relation to this story: the Royal National College for the blind is struggling to meet its costs, and is running a deficit because it depends on local authorities paying for residential places, which pressures on their budgets means they are struggling to do.

Over in the land of academia, interesting new research from Simon Burgess and colleagues at Bristol which found that schools where teachers observing their peers raised student achievement faster and further than schools where teachers did not observe their peers. The mechanism for how — whether teachers at the front of the classroom feel under pressure or whether the observers learn something they can put back into their own classrooms — is less clear.

Law and Order

Interesting Public Accounts Committee report on serious and organised crime — its scope, cost, and how well the Government is dealing with it. They conclude that public bodies are “focused on pursuing criminals after the crime has been committed […] at the expense of doing work to ‘prevent’ crime from happening in the first place”.

Meanwhile, secretary of State for the Home Office Priti Patel has pledged to create a new police unit within the British Transport Police to tackle county lines (typically drug smuggling involving children) crime, funded by reprioritising money already in the Home Office budget.

The Government has confirmed which forces will see the rise in police officers — though the formula for working out force recruitment targets is based on an old formula…which the government expects to update soon. Some of those who ‘lose out’ from the formula may be compensated again later. Nice explanation from Gavin Hales, here.

In prisons, Rob Allen gave a very helpful summary of what the party conferences revealed about prisons policy.

Since then, the government has decided that its sentencing reforms extending how much of a violent or sexual offenders’ sentence has to be spent in prisons (from half up to two-thirds) will only apply to those getting seven-year sentences, rather than four. That independent sentencing review has apparently concluded and will not be published publicly.

To recap: the government changed its position between the Queens Speech and last week’s committee hearing and doesn’t plan to release the content of the sentencing review to the public. Rob Allen is (rightfully) very unimpressed. The Ministry of Justice’s own impact assessment of the increasing sentencing for serious offenders is that it will cost £710m (with a net cost of £680m once the reduction in probation costs is taken into account). This is not a good way of developing policy.

Worth reading alongside this Justice select committee evidence session with Robert Buckland and permanent secretary Richard Heaton. According to Heaton, the increase in police officer numbers “is very difficult to calculate because we do not yet know whether the police will be pursuing high-level crime, low-level crime or crime that results in imprisonment [but] that is the major factor” expecting to increase the number of people in prison beyond the current projections.

In response to that, plans to close some Victorian prisons have been ditched, which the Prison Reform Trust reckons that the government has “quietly abandoned the policy that would have made the biggest difference [to improving prison conditions]”.

In a way lots of this was predictable — but it’s somewhat galling to put it all in one place at once.

Meanwhile, the prison population is ageing, and prison officers are having to take on some of the responsibilities of care workers. Should we be thinking about building secure care homes, rather than prisons? Good analysis of the data and prison officers’ experiences from the BBC, here.

Given all of this, it’s perhaps not surprising that an independent commission for justice in Wales has called for devolution of justice powers from Westminster to Cardiff…

Finally in justice for this week — a great essay from Frederick Wilmot-Smith on the introduction of online courts for some civil claims, prospects of extension, and how they could affect justice — both procedural (did we follow a just process?) and substantive (did we reach a just outcome?). Thought-provoking.

Local Government

Crossover episode! Why bin collection data could help councils and general practitioners identify the most in-need (seriously!).

Finally, an excellent thread from Gareth Davies at the Bureau of Investigative Journalism on how the increase in the interest rate charged by the Public Works Loan Board (the main source of council finance) will affect councils. Martin Wheatley argued that this looked to be a blunt solution to an ill-defined problem. The rise could crowd out worthwhile council investments in social housing and infrastructure, as well as constrain unwarranted property speculation. I agree — the spending data suggest that unwarranted property speculation is not a widespread phenomenon.

There’s some evidence it might not even work. A survey of chief finance officers by Room151 found that only 13% of them are planning to scale back capital projects as a result of the announcement. Some finance directors worry that using other, more expensive, sources of finance for these deals will simply reduce the amount of money they have to spend on local public services…



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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.