The Week in Public Services: 27th October 2020

This week: government concessions to reality; working out what to do for 2021 exams; and busting ageing population myths


Big news in Whitehall: the government conceded to reality last week and confirmed that this year’s Spending Review — where the government sets out how much it plans to spend, and what on — will only cover one year, rather than the normal multiyear arrangement. We at the IfG think this is the right choice given the amount of uncertainty about the demands public services face and how much money the government can expect from tax revenues: setting fixed budgets that are likely to be out of date in a few months isn’t especially useful.

This decision should, however, have come much earlier as my colleague Gemma set out last week: “by pressing ahead for so long with the original plan for a spending review, the government will have diverted officials’ attention away from dealing with other pressing demands. Civil servants’ and ministers’ time could have been better spent if the government had acknowledged earlier that it was not possible to carry out an effective multiyear spending review this autumn”. We have been calling for this since July…

Elsewhere, last week’s antics in Greater Manchester prompted a lot of commentariat soul-searching about devolution in England and across the UK. These three pieces are, in my view, the most worth reading:

  • This Financial Times longread on whether Covid-19 will break the UK: “the crisis has homed in on frailties in the UK’s institutions, pulling at the seams of the union […] the question still to be answered is whether an overhaul can deliver a leaner, fitter and still whole United Kingdom or whether Covid-19 has highlighted fundamental comorbidities in the nation’s body politic”
  • This New Local report which argues for a new paradigm for managing public services based on local decision-making, self-governance, and autonomy (lead report author Simon Kaye wrote an interesting thread on what Eleanor Ostrom would have to say about the antics in Greater Manchester)
  • Alex’s take on England’s “patchwork quilt governance” of devolution

Last but not least: after I complained about how ideology was making the debate about how to manage coronavirus dumb a few weeks ago, this is a smart blog from behavioural economist Pete Lunn which avoids the annoying ‘let the virus rip’ vs ‘lockdown forever’ framing and considers measures any government could support to encourage economic activity and reduce social isolation while limiting the spread of the virus. Always worth highlighting better work!

Health and Social Care

In social care, the latest skills for care datafest on the state of the social care workforce on the eve of the pandemic was published last week. If you don’t fancy wading through the data tables, Simon Bottery has summarised the main points here.

What Simon didn’t mention, however, was the fascinating analysis that Skills for Care have done on their usual metrics — sickness absence, job numbers, vacancies etc. — since the pandemic has started. The vacancy rate fell from 8.6% to 7% between the 2019/20 data and March to August 2020. I initially thought that this might be because it’s got easier to recruit care workers (which would be good), but the report notes that “it could be the case that the fall in [care home] occupancy has served to reduce the shortfall in workforce supply”, rather than more staff having been hired. Still searching for a silver lining!

The latest report from the Health and Social Care Committee on social care funding and workforce concludes that “the case for making a sustained investment in social care has never been stronger–the toll the pandemic has taken on this sector means that social care is no longer a hidden problem, but one that the country as a whole understands”. While it might not have all the reforms campaigners have asked for, it’s a start. I think Simon is right to welcome it; some progress towards reform is better than none.

Over in the NHS, the Health Service Journal have been analysing cases of Covid-19 in hospitals in the northwest — there are now more Covid-19 patients in some hospitals (e.g. Liverpool University hospitals) than in the Spring, but the Trusts have not yet opened critical care surge capacity because they are concerned that moving staff to emergency rotas and stopping routine elective surgeries would cause substantial patient harm. On which note… a new Nuffield Trust blog from Rachel Hutchings looks at how Covid-19 service restrictions affected cardiovascular services and patients with heart disease.

In more immediate news, Trusts are complaining that adapting hospitals to higher numbers of coronavirus patients is harder because clinical commissioning groups haven’t given them enough money to expand critical care wards. (The clinical commissioning groups in turn say that NHS England won’t give it to them, who in turn say the Treasury is holding out). To reup something I wrote two weeks ago: “throughout the crisis NHS England and Improvement have sensibly flexed the targets regime to allow hospitals to focus on patient needs. With the second wave upon us, they need to flex it again, and quickly.” Substitute ‘targets’ for ‘financial regime’; I think the same applies.

In other news, the Care Quality Commission have published a report — commissioned by Matt Hancock — looking at the use of restraint, seclusion and segregation in care services for people with a mental health condition, a learning disability, and autistic people. They recommend prioritising support for community-based care (avoiding hospitals), better staff training, and better oversight and accountability.

A new NHS Providers briefing has looked at innovations to support staff wellbeing — such as free car parking and the rollout of the ‘digital staff passport’ which allowed staff to start new posts faster — which were introduced during the pandemic. Lots of interesting points, including some that I’d overlooked. They call for a “national steer” on HR software requirements, for example, to ensure that Trusts know they are buying software which will be interoperable locally.

In wonk world, Billy Palmer has been looking at how the UKs test-and-trace system compares to other countries and Pritesh Mistry wrote a thoughtful blog about health data, concluding that “ the system will only work optimally if patients feel safe providing and sharing their data. Without improved protocols there is a real risk that the sense of trust and safety will be further eroded”.

And how about some non-coronavirus content for a change? Here’s a controversial argument: what if the UKs ageing population isn’t the main cause of higher health spending? What if, instead, it’s mostly about proximity to death and the rising costs of end-of-life care? That is, in essence, the argument from Greg Fell, the director of public health at Sheffield.

You might wonder why you should care — if demand is going up roughly 3–4% each year, then the NHS needs more money to provide the same level of service — so why does it matter whether it’s the rising costs of tech and drugs, the ageing population, or a bigger population? An understandable view, but a mistaken one. The ageing population hypothesis implies that there isn’t much we can do about the ever-growing amounts of money we spend on healthcare. If, instead, it’s more to do with healthcare costs and utilisation, there are more policy levers which the government can use to address those. Not to mention that this also changes the political tone of arguments about NHS spending — from ‘why should I pay for those old people?’ to ‘what level of service do we want to afford people dying?’.

I first came across Greg banging this drum at the Nuffield Trust annual conference earlier this year. I remember looking at his slides and thinking ‘sure, but what about [factor X/Y/Z]?’ Reading these blogs properly made me rethink how important growing healthcare usage, particularly in the last few years of someone’s life, has been in explaining rising costs. In short: Greg gives a great presentation and talks a lot of sense — give him a follow.

And to finish with something totally different: an extract about US healthcare reform from Barack Obama’s upcoming memoir. I’ve been rereading Nick Timmins’ Five Giants recently, and this extract really reminded me of the debates over the creation of the NHS and the small-p politics of legislative horse-trading and taking on entrenched interests. It’s a thriller, at least as far as political memoirs about passing major bills goes. Worth sitting down with a cup of coffee with this one.

Children and Young People

A helpful Briefing Room episode last week covered the ongoing 2021 exams debate by looking at what is going on across the four nations. The episode covered their divergent approaches — from England going ahead as-is to Scotland cancelling the National 5 (equivalent to GCSE ) exams. There are no easy solutions, but the expert guests on the show thought that reducing the content of exams and/or introducing greater exam question choice might work. The experts were particularly worried about future labour market opportunities for students if different kind of grades were awarded (which regular readers will recall was Chris Cook’s suggestion last week). What really stands out, though, is the lack of communication with schools, and the lack of a (published) Plan B if things don’t go as planned. Meanwhile, SchoolsWeek have been digging into this year’s exams fiasco and discovered that Gavin Williamson in fact did meet with Ofqual in the two days prior to the announcement of exam results.

And while the debate over whether to extend free schools meal continues to eat up this government’s political attention and bandwidth, this Laura McInerney column covers the other important gaps in the government’s support for education at home — families who cannot afford wifi.

In research news, the National Foundation for Education Research have summarised their research into how Covid affected school leaders and teachers for SchoolsWeek, and Luke Sibieta and Simon Burgess have written a particularly useful summary on how schools can best use their resources to respond to learning losses during the pandemic.

And to finish with some non-covid news, Sam Sims has written a great blog politely, systematically, demolishing arguments that it is possible to devise an 11+ exam which meets all the criteria people want for it. “The 11 Plus can either be an accurate measure of academic potential that is unfair. Or a socially fair test that is inaccurate. It cannot be both.”

Law and Order

In policing news, The Guardian report that the police are fielding responses to a rapidly growing number of incidents involving people suffering from a mental health crisis. This is partly due to deteriorations in people’s mental health during the pandemic but was rising before the pandemic as well. There were 213,513 incidents in 2015 compared to 301,144 incidents in 2019.

A new Crest report has analysed police legitimacy in policing the pandemic and found that “the public in our focus groups felt the police were neither visible enough nor robust enough to deter rule-breaking […] unevenness in police visibility and interventions across different areas and communities was observed by many in our groups, and it raised concerns not only on effectiveness but also fairness, with some feeling the rules pressed harder on some communities than others” (if you don’t fancy the whole paper, summary thread here).

In prisons, the Prisons Inspectorate’s annual report is out which (unsurprisingly) this year includes an annex about Covid-19 and the Prison Service’s response. While, as is usual of most reviews of the government’s actions during the first wave, the Inspectorate found the way that the prison service enforced social distancing quickly impressive, they are worried about the longer-term consequences of a more restrictive prison regime.

The Inspectorate also published a critical report about short-term holding facilities at Dover, which was particularly critical of Tug Haven: “the reception facilities at Tug Haven were very poor and those at KIU were unsuitable for the large number of detainees who frequently had lengthy stays. There was no ready access to showers or lockable toilets with seats and lids. Many detainees at Tug Haven were not sufficiently protected from the cold, basic supplies including clothing were running out and detainees were often crowded into spaces where social distancing was not possible. Managers agreed that the environment was not acceptable but not enough progress had been made towards improving the situation, which was especially poor in view of the risks posed by COVID-19.”

Local Government

Less news this week. I did, however, discover this Nesta paper about what Covid-19 has revealed about local government in England (h/t Jono Bone), which is full of lots of fascinating examples of councils innovating during the pandemic — from crowdsourcing data about walking and cycling safety to create live dashboards of referrals and requests for support.

The Housing, Communities, and Local Government select committee have also started an inquiry into local government finance and the Spending Review.



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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.