The week in public services — 4th October 2018
This week: what we learned at party conferences, emergency cash for social care, and…an inflexible PFI contract in Northamptonshire.
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.
A bumper week this week: a roundup of public services news from the last two weeks, and the news from party conferences! But first…
The announcement we’ve all been waiting for
The budget date! Put Monday 29th October in your diaries. The budget is that exciting time of year for fiscal nerds where the Westminster bubble debate how much the Government is spending, what it’s spending on, how much it’s taxing, and where it’s raising revenues from. That is unless it gets derailed by Brexit, of course. Patrick Maguire thinks that looks likely, as both the DUP and the Conservative European Research Group want Hammond to show “optimism about Brexit” — setting the stage for some late October political theatrics between the October and November EU summits.
Also ahead of the budget: the British Social Attitudes survey found that a larger share of people think the Government should increase tax and public spending than have done for fifteen years. So if Hammond does increase taxes to fund the NHS spending boost, we should all love it, apparently… (H/T Chris Giles)
But the big political story over the last two weeks has been watching the Westminster lobby take public transport up North to cover the Labour and Conservative conferences. Train troubles aside, the conferences revealed quite a bit about the parties’ views on public services, even if there wasn’t much in the way of announcements. Emily spent the start of the last two weeks in Liverpool and Birmingham, talking about public service performance and pressures.
Your correspondent in the North West and Midlands writes…
At Labour, there was a lot of anger on the state of public services, but not many announcements from the podium. Jeremy Corbyn pledged to extend free childcare to 30 hours, to two-years olds (as well as currently eligible three- and four-year-olds), and remove the means test. Angela Raynor promised no more academies or free schools, and to restrict the freedoms of existing ones on admissions and high pay. Jon Ashworth promised further investment in GPs and public health.
A major theme that came out in fringe discussions I was involved in, was the consequences of squeezing preventative services (like public health and youth clubs) to pay for acute services (hospitals and schools). No one knows how or when the consequences of those decisions might bite, but that question (and the opposite — at what point does investment in such services lead to savings in acute spending) could do with an answer. Maybe by a think tank…
At the Conservative conference, Damian Hinds is reported to have said that the Department for Education does not have that many levers to really reduce teachers’ workloads, which he claims are driven by school-level policies on marking and data collection.
And Hardeep Matharu has the best single summary of David Gauke’s Conservative party conference speech. Aside from announcing the creation of a new unit to monitor prison money laundering, there were no new policies and Gauke mainly emphasised rehabilitation; very little on the pressures in prisons. Rory Stewart, the prisons minister, spoke at a panel on “How will the Government change prisons for the better?” organised by the Howard League. He seems on top of his brief, with sensible ideas to focus first on prison ‘basics’ — safety, hygiene etc. His speech and Q&A summarised, here.
Compared to last year, May’s speech was well-received but heavy on tone and light on policy substance. The relevant stuff for the public services world:
· The NHS will develop a new cancer strategy, lowering the screening age for bowel cancer, presumably using some of the £20bn announced in the summer
· Local authorities will be allowed to borrow against their housing assets and their income streams (council rents) to build new homes
Dan Bentley has outlined a couple of details to be ironed out with the housing announcement (right to buy and the land market could still constrain councils’ borrowing), here.
More broadly, there was also an atmosphere of serious concern among Conservative councillors I spoke to about the state of local government finances. There was anger that extra funding had been pledged to the NHS when, they argued, the last eight years showed how much more efficiently local authorities could use those funds.
Beyond that, though, public services were not the main event at Conservative conference. That worries me. If the government is going to ask for further savings from public services in the 2019 spending review, it’s going to need a clear vision of what cheaper public services look like. As far as I could tell, there was none of that on display this week.
Health and Social Care
NHS England is under pressure from hospital bosses to ditch particular service targets which they think are unhelpful — such as the requirement to give patients non-urgent surgery within 18 weeks of being referred by their GP.
Speaking of targets, David Buck from the Kings Fund argues that the new 10 year NHS plan must address health inequalities by: focusing on multi-morbidity; working with — and potentially funding — partners such as local councils; learning from past successes (such as the Health Inequalities National Support Team); and using the NHS’ purchasing power to address wider determinants of health.
“Integrated care systems” will be at the heart of the November NHS cash plan though, says Chris Ham from the Kings Fund. Where they are making progress, they are doing so despite NHS structures rather than because of them, he argues. Full report here.
Another new report from the Nuffield Trust looks at ways to improve efficiency in small acute hospitals — which are typically less efficient than larger acute hospitals, but often politically difficult to close. They often struggle to recruit enough staff. Nuffield recommend that: NHS England and NHS Improvement’s regional bodies do more to help small hospitals transfer patients they cannot treat; Health Education England develops new policies on allocating trainees to smaller hospitals; and NHS England reviews national standards designed primarily for larger hospitals.
In any case — reforming healthcare — changing the way services are delivered, or deciding where individual responsibility ends and the state has a role — is hard. It’s even harder if those debating in Parliament don’t understand the terms of the debate. A third of MPs did not understand what “accountable care systems” are, and 52% said they didn’t understand what “systems approaches” are.
And do regulatory bodies actually improve healthcare? A new joint King’s Fund and Manchester business school report on the impact of the Care Quality Commission found evidence of eight types of impact, although it found only “small and mixed” quantitative effects — changes in provider performance or patient choice — in response to CQC ratings. They found larger impacts in acute and mental healthcare, where there were existing support network for improvement, and less in GPs and adult social care.
An interesting article on The Conversation reflects on what Australia could learn from the Care Quality Commission’s introduction of ratings for care homes in England. TL;DR: ratings improve quality but rarely affect where people choose to go. Homes with lower rates of staff turnover and fewer staff vacancies tend to perform better.
Elsewhere in social care, a survey of carers by the Local Government Association (LGA) and Carers UK has found unpaid carers under stress, with 20% having not received a carer’s assessment — a way of identifying their support needs. The LGA wants these assessments to be part of any long-term funding settlement for adult social care.
A new report from Frank Field, aided by trade union Unison, finds that care workers are “cutting short visits to frail elderly people, or working unpaid overtime to keep up with huge workloads”, based on interviews with 98 care workers.
Finally: last week, we heard rumours that Conservatives might offer an emergency cash injection for social care at Conference, following concerns that social care hadn’t fully recovered from the rise in demand during the summer heatwave. Matt Hancock announced £240m for “social care packages to support the NHS” the following Tuesday. Sometimes the rumour mill is right.
I’ve tried to put that number in context — is it a big increase? How many more care packages could it buy? — here. Local authorities and social care professionals are grateful for the money, but (rightly) concerned that they won’t be able to spend it as well as they could without a longer-term plan to give financial certainty and allow them to spend on invest-to-save projects, or invest in workforce training through long-term contracts with providers, for example.
And if it comes with targets to relieve pressure on the NHS, it may not be spent on the biggest pressures facing social care. Jess Studdert from the New Local Government Network has a good — heavily sarcasm-laden — blog on the announcement.
My own take on the announcement — that it is not only the amount, but also the way this money has been given out at the 11th hour, that is a problem — is here.
Whether through the Fair Funding review, the Green Paper, or our preferred option of an independent inquiry, let’s hope we are moving away from emergency cash injections and towards a longer-term financial settlement which will allow local authorities to invest to address real problems —like care worker retention.
Neighbourhood services and local government
The County Councils Network have estimated that county councils need to make £1bn of savings, arguably dividing the previously-unified council ask for more money across the country.
The New Local Government Network have blogged on what a ‘no deal’ Brexit means for councils. TL;DR: pressure on trading standards; more demand for services such as social care if there is a destabilising economic shock; and possibly more cuts if public finances take a hit.
More in the list of councils under financial pressure:
· Torbay council’s chief exec has said recent budgets cuts have “slashed services to the core”
· Kensington and Chelsea have overspent their revenue by £18m this year, meaning they will have to draw on reserves
· Some of Northamptonshire’s financial problems could owe to…an inflexible PFI contract. Quelle surprise.
You can read the full details here (pp. 19–21) — the whole “stabilisation plan” is a revealing case study about what options councils actually have to make savings — what they’re doing, and what they can invest in under the financial constraints they operate under. It’s really notable that a lot of proposed savings in “changes in service policy & delivery” look to be service cuts — notably in highways and school transport.
Other fascinating info: Northamptonshire has the “highest spend [on children’s social care] per head of population of all English counties”. And the consequences of lack of clarity on the Fair Funding review and the Spending Review are really hammering local authorities ability to plan: “there may be additional funding for Adult Social Care and Children’s Services [in 2019] but this cannot be built into plans.”
Council finance directors echoed similar fears for their councils at a gathering helpfully written up by Room 151.
Children and young people
A good BBC article from Hannah Richardson on the headteachers’ funding protest last Friday — possibly the first sighting of protestors with signs citing Institute for Fiscal Studies research? After schools minister Nick Gibb quoted a figure on education spending which included university and private school fees to rebuff claims about public sector spending on schools on the Today programme, the Department for Education is being investigated by the UK Statistics Authority.
More prosaically, there may also be technical trouble on the horizon in schools. The Government’s plan to fund most of the increase in school teacher wages may fall short because of assumptions about teacher: student ratios in schools, SchoolsWeek reports.
It’s not only wages that are complicated: so are public service pensions. In fact, the Government is now increasing pension benefits three years after introducing reforms to try to reduce spending on pensions. I had to read it twice but this great House of Commons Library blog squares the circle: it’s all about changes to the discount rate.
Over in children’s social care, an Action for Children analysis of new children’s services budget estimates for 2018/19 finds that the pattern of cutting spending on non-statutory, preventative, services such as children’s centres whilst increasing spending on acute interventions such as safeguarding continues. The new budget data is here.
The New York Times have an interesting longread on child poverty in 21st century Britain.
More positively, the What Works centre for children’s social care has announced it will use some of its money to fund projects which devolve budgets to individual social workers, and which base social workers in schools. Luke Stevenson has also written a very good article on Frontline, and different routes into social work.
Looking beyond England, the annual IFS lecture was really interesting this year — on what evidence from Canada and the US tells us about the impact of expanding access to care and other early interventions for children. You can rewatch Professor Janet Curie’s lecture, here.
Law and order
Her Majesty’s Courts and Tribunal Services have published an update on their courts reform projects, including a helpful list of planned projects and their timelines.
Beyond the Courts, the Financial Times have a good longread on the consequences of cuts to legal aid, including a great stat about alternative dispute resolutions (read: mediation services) which were supposed to reduce demand for legal aid. “The number of mediations initiated actually fell from 13,600 in 2012–13, just before LASPO [the Legal Aid, Sentencing and Punishment of Offenders Act] came in, to 6,300 in 2017–18.” TL;DR: there is significant anecdotal evidence of cuts to legal aid putting justice under major strain.
Theresa May caused a stir by arguing that there is no causal link between police numbers and levels of crime — generating a flurry of angry pushback from police commentators and membership bodies — which seems to have died down quite quickly. Especially after Sajid Javid announced the Government will take a “public health approach” to knife crime — focusing on root causes — as per the Scottish Government’s approach. Dr Zubaida Haque has set out an excellent seven questions to ask Sajid Javid about his new “public health approach” to tackling knife crime.
Last but not least, an interesting analysis of spice, the synthetic cannabinoid drugs, in The Economist — including an analysis of their impact in prisons. “Prisons’ drug-testing kits do not detect synthetic cannabinoids, so many drug users switch to spice in order to hide their habit”, they claim.
