The week in public services: 26th February 2020

This week: budget rumours; Ofsted controversies; and widening health inequalities

Budget chat

Budget rumours are back! Ahead of Rishi Sunak’s first fiscal event, spare a thought for the public finance wonks who had to go a whole 2019 with no budget to analyse. (Although the world really didn’t cave in without a budget — so maybe the Treasury shouldn’t tinker with fiscal policy quite so often? Yes, we have a report for that)

Ever since Sajid Javid resigned, there’s been lots of chat about fiscal rules — and whether Rishi Sunak will revise them. Michael Savage from the Observer has the politics covered, and the Tony Blair Global Institute have suggestions for an “all-weather fiscal framework” here.

Coming back to the (many) other decisions in this March’s budget, the Institute for Fiscal Studies have also published their classic pre-budget analysis. TL;DR — you want higher spending, you need to pay more taxes. IFS chief Paul Johnson’s helpful twitter summary is here; the whole analysis is here.

The Resolution Foundation have also fired off their opening salvo, concluding that Rishi Sunak will either have to raise taxes or bend the fiscal rules in order to meet the government’s ‘levelling up’ agenda. They estimate that it will cost £56bn by 2023/24 to reverse the day-to-day spending cuts in departments outside the Department of Health and Social Care. Sobering.

The scope for investment spending remains much bigger than day-to-day spending. Immodestly, I’d suggest a report I’ve written this week about why all governments struggle to spend their investment budgets, and what the Johnson should do about it (if you can’t self-promote in your own weekly blog, where can you do it!?)

Health and Social Care

The biggest story this week was the release of the ‘second Marmot review’ — looking at what’s happened to health inequalities in the UK between 2010 and 2020. There’s lots of analysis in the report, but the most shocking finding — I think — is that life expectancy for women in the most deprived parts of the country is actually falling. Falling.

(This article from the Education Policy Institute’s Mary Reader — about how the growing use of school exclusions fits into the picture of widening health inequality — is also very useful).

While funding for many preventative services has been cut, I would note that the Treasury has just given the Department of Health and Social Care an in-year funding increase of £400m to deal with ever-rising spending in acute care. Draw your own conclusions.

Elsewhere, a great paper from the IFS reviewing the existing academic evidence on how wages and other non-financial incentives affect medical labour supply. (Translation: does patient care improve when we pay doctors and nurses more, or change the way they are paid?)

I learned an absolute tonne, but the things I found most interesting:

• Medical labour supply is generally unresponsive to wages (but some research suggest pay affects the quality of care nurses provide)…
• …but “medical personnel do respond strongly to incentives” — in particular changes to how they are paid (e.g. contracts based on volume, quality, or targets).

Some research shows that the introduction of the ‘Quality Outcomes Framework’ (effectively performance-related pay for GPs) improved the ‘quality’ of general practice against the indicators GPs were measured against. The researchers think that the priority for further research is to look at what non-pay interventions could help recruit and retain enough medical staff — which sounds very sensible.

And remember the election pledge to have 50,000 extra nurses, by improving retention? The government is apparently unimpressed with NHS England’s proposals — because they don’t contain trajectories or milestones — which, to be fair, are the sort of things you normally expect in a plan. In the meantime, a worrying Royal College of Nursing survey suggests that seven-in-ten nurses are now looking after patients in hospital corridors — although their sample isn’t representative.

In general practice, there’s been a lot of debate between the government and the British Medical Association over the new general practice contract — about what GPs can reasonably be expected to deliver. This helpful Kings Fund explainer highlights the key areas of contention.

Bristol GP Zara Aziz makes an interesting point that the additional preparation, screening, and advice which GPs are providing to patients who suspect that they might have coronavirus is proving particularly difficult because general practice is “at a precipice and any small shifts in workload — whether through staff sickness or extra patients on the practice list — could send it into freefall”.

Nigel Edwards has written a good article (£) on the risks of another NHS reorganisation. Noting rumours about reintroducing higher-stakes accountability and stricter performance management, he notes that New Labour-style performance management worked up to a point — but came in a context of rising spending and enough staff. If you don’t have a Times subscription, you can read Nuffield Trust’s summary tweets here.

In adult social care, the Office for Statistics Regulation have analysed the shortcomings of Scottish social care statistics. On a quick skim, many of the problems are the same as with the English statistics…unmet need

Regardless of the data though — the publicly-funded adult social care system in England continues to slowly fall apart. Your regular reminder that the low fees paid by local authorities mean that most investment is going to build homes for self-funding clients — this time from the chief executive of Care England, Martin Green.

From a different angle, but underlining the same point, new research from the Centre for Economics and Business research, summarised here (£) in the Financial Times, also shows that only the 10% of pensioners with the highest incomes could afford to pay for their own care out of their disposable incomes.

Taking a longer view, Health Foundation chief executive Jen Dixon has written a good essay on what Dominic Cummings’ ideas — should he remain influential within government — might mean for NHS structure and management. She argues that his ideas imply “keeping a priority-setting Department of Health separate from professional management of the NHS, and for NHS trusts and GPs not to be throttled by too many central targets from NHS management HQ”. Let’s see if that happens in practice…

Children and Young People

The big debate last week was over the leaked Ofsted report about school funding. Amanda Spielman’s comments that “school funding can still be squandered when it is plentiful” riled a lot of feathers but I don’t think it’s actually that controversial. I wrote up what I thought were the most important points here.

A quiet-but-interesting debate about Ofsted has been going on among teachers and education researchers in The Guardian. Laura McInerney thinks that Ofsted is generally a force-for-good in highlighting school problems — even if the way it grades schools and the way its judgements are interpreted by schools could be much improved. Two letters in response argue that Ofsted is part of a “toxic accountability system”, and that the character of inspections has changed so much over recent years that it is no longer a force for improvement. Thought-provoking.

Elsewhere, the government has told councils in England which are spending more than they are allocated to provide services for children with special educational needs that they will have to reconsider their plans to shift money from their general schools budget to their special educational needs budget. The government says the extra £780m it gave to councils special educational needs budgets this year is enough; the councils disagree. This isn’t a new fight — I wrote about the increasing trend for councils to move money to their special educational needs budgets in last year’s Performance Tracker.

In children’s social care, the government are currently considering banning the use of independent and semi-independent placements for children under 16 in response to concerns about this ‘unregulated provision’ — that is, accommodation for children in care which is not classified as a children’s home and therefore not required to registered with Ofsted. This useful Commons Library briefing lays out the detail.

A series of Freedom-of-Information requests from the National Centre for Excellence in Residential Child Care show that — regulated or not — the average weekly cost of a children’s care home rose — faster than economywide prices between 2013 and 2019.

And last but not least, there is a new really interesting-sounding Nuffield-funded project to keep an eye on. This research which will attempt to quantify what influence headteachers have on their schools, and what effects they have on pupil outcomes. Looking forward to reading it!

Law and order

A useful new Crest report investigates how much the drug market is contributing to the rise in violent crime. There has been an increase in both the supply and purity of class A drugs, which appears to have driven the expansion of ‘county lines’ drug-dealing by gangs. Good summary of the findings here.

Meanwhile in prisons, Danny Shaw points out some worrying stats — the latest Ministry of Justice data show that there are 500 prison officers and 1000 more prisoners than there were a year ago…

The Times also claim to have seen internal Ministry of Justice forecasts that prisons could run out of space by the end-of-the-year due to sentencing reforms and a rise in the number of prisoners being recalled. My colleague Nick explained why the story matters, here.

The Prisoner Learning Alliance also released interesting new research on education in prisons. My biggest takeaway was that most senior managers responsible for prison education do not have an education background — and typically come from running another part of a prison.

Nuffield Trust have also released new research about hospital care in prison. Linking data on prisoners’ residences to their use of NHS services, it’s got lots of useful insights. The main things I learned were:

• Prisoners generally miss more hospital appointments than the general population
• 22% of pregnant prisoners missed midwife appointments and 30% of pregnant prisoners missed obstetric appointments in 2017/18
• Injury and poisoning were the most common reasons in prisoner admissions to hospital

Last but not least, I can highly recommend this podcast episode of Justice with the chief inspector of prisons, Peter Clark, which is incredibly informative!