Week in Public Services: 31st October 2022
This week: myth-busting about NHS reform; a new British Baccalaureate; and trouble (again) for Braverman
General
Let’s start this Week in Public Services with a bit of suggested reading/listening to satiate your policy needs until the now-delayed fiscal statement. Give my colleague Nick Davies a listen on The Bunker podcast for an overview of this year’s Performance Tracker, some great analysis of the state of public services, and a concise breakdown of the strains and stresses that’ll be influencing the government before the 17th November.
Speaking of, my colleagues Stuart Hoddinott, Matthew Fright and Thomas Pope all have whiplash after knocking up this paper at a pace completely incommensurate with its quality. It assesses whether the Chancellor should make spending cuts by recycling the austere methods of the post-2010 period, specifically: holding down pay, cutting staff, pushing staff to work harder, cutting capital spending, cutting preventative services, reducing service scope, and finding new revenue sources. The main headlines are: a) austerity + pandemic = public services are in a much more fragile position now than 2010, b) cutting pay while getting more out of staff is not practically or politically viable, c) cutting capital and preventative spending is counter-productive, d) sustainable efficiencies require capital investment and increased capacity, e) efficiencies are few and far between, f) if the government is intent on cuts to public services, better to outline the broad direction of travel and hammer out the specifics between 17th November and the spring budget.
This blog from the IFS about the rise of economic inactivity due to long-term illness took me a couple of reads to get my head round, but the insights are important. My previous assumption was that more people are leaving the workforce due to long-term illness, but the authors point out there are actually two things going on: more people are leaving the workforce, but predominantly to retire, not because they’re ill. At the same time, more people who are already inactive are reporting increases in long-term illness. This raises two questions for me: why did the pandemic cause a spike in retirements? Why are those who are long-term economically inactive reporting worse health outcomes?
Health and Care
The ri-shuffle leaves Steve Barclay back in charge of DHSC, reprising the role he held for those heady summer months between Johnson’s resignation and Truss’s appointment. So Coffey’s ABCD priorities are out, and Barclay’s “50 new surgical hubs” are back in. Coffey’s tenure was marked by her diktat against the oxford comma, and her apparent animus against any and all public health measures.
Speaking of public health, directors of public health have called on Sunak to protect spending in the area. Hopefully the appointment of a new government will mean the reversal of Coffey’s cancellation of many public health initiatives.
And if we were in any doubt about the value of public health spending, the Health Foundation have published analysis of the extent and distribution of cuts to the public health budget. They find that public health spending fell 24% per person in real times between 2015/16 and 2022/23, with the largest cuts falling on the most deprived areas. They also make a strong value for money argument for more public health spending: they show that public health interventions to achieve one additional Quality Adjusted Life Year cost £3,800 — only 28% of the £13,500 it costs the NHS to achieve the same outcome.
DHSC quietly published an update to the guidance for the RTT waiting list. Cutting through the jargon, the headline is that people on the elective waiting list who reject two offers of treatment dates can now be taken off the list and put into “a period of active monitoring”, effectively reducing the headline number awaiting care. Managing the list is obviously important and people who no longer need or want care should be removed, but there is a danger that this looks like the NHS gaming the system.
Nuffield Trust published a report on the importance of diversity in the NHS. They find that diversity across the service improves care for patients, reduces staff attrition and ultimately improves efficiency. The report expresses frustration with the lack of focus given to diversity and inclusion by senior leadership within the NHS, and calls for ICS’s to take on a coordination role for D&I initiatives.
In another of Nuffield Trust’s myth-busting exercises, Nigel Edwards looks at the idea that the NHS is resistant to reform because of its status as a “national religion”. The argument is that actually the NHS is reformed remarkably often and that, if anything, the services real problem is too much reform and over-centralisation of power. This is something I’ve wondered recently: how much does the political incentive for ministers to be seen to be “Doing Something” lead to resource-consuming and not particularly beneficial reform?
Interesting blog from Toby Nangle about Baumol’s cost disease in public services (and adult social care more specifically). I think his argument — that relying on productivity gains to deliver improved performance is unrealistic and that we are instead stuck in a trade-off between using productivity gains in the wider economy to fund improved care, and disinvesting in the service and accepting deteriorating quality — is broadly right, but would offer Steve Black’s blog from a few years ago as a counterpoint. I think there is a danger for policymakers to throw their hands up and invoke Baumol as a reason for not pursuing productivity improvements. But there are ways to improve productivity. If the NHS invested in improved IT systems, fixed the maintenance backlog, and shifted administrative work from doctors and nurses to managers, you’d probably find that productivity would improve. Until the government invests properly, however, the Baumol position is more likely to hold.
The Guardian reports that none of the £500m from the recently announced Adult Social Care Discharge Fund has been disbursed. This is concerning. The winter is rapidly bearing down on the NHS and any extra support needs to arrive sooner rather than later. Reading the article, I wondered how much of the delay might have been caused by political churn and instability — Coffey was unlikely to have been concerned in the last few weeks and Barclay will take time to get back up to speed (again).
Charlotte Wickens over at the King’s Fund has produced this report exploring ways to maximise the potential of diagnostics services, stressing the importance of an expanded workforce and capital investments. Indeed, hardly the most forthcoming inputs! She also includes an interesting analysis of the utility of new community diagnostic centres to increase the NHS’ diagnostic capability in line with demand — yet another example of the multifarious pitfalls that exist in an understaffed health system.
Children and Young People
Some new faces and some old in the DfE. Gillian Keegan (previously minister for care and mental health) is the new secretary of state, while Robert Halfon and Nick Gibb (whose return as schools minister means that order is restored in the universe) make up the ministerial team. Halfon’s appointment leaves an opening as chair of the education select committee — the second big committee opening after Hunt left the health and social care select committee.
For an indication of the new government’s intentions for education, the Times reports (£) that Sunak would like to introduce a “British baccalaureate” and launch a network of “elite technical institutions to transform vocational training”. Schools Week has this fantastic breakdown of how the proposed, I guess, BB(?) would work. According to Schools Week, the BB will run into at least a few of the perennial hurdles in public services. The compulsory study of maths would, for example, require hiring more teachers, something the government is currently struggling to do. Interestingly, another barrier might be Sunak’s own hires, with returning minister Nick Gibb unlikely to sign off on the plan.
Despite declines in expenditure from 2019 to 2021 on things like supply teachers, learning resources, and exam fees, and the resultant decrease in the percentage of local authority-maintained schools with negative reserves, the Guardian reports that 9 in 10 schools in England will be running deficits by September next year. As my colleague Philip Nye wrote in this year’s Performance Tracker, this could mean more strain on the budgets of local authorities as schools reach out to them for additional funds.
On a related note, the IFS has this useful piece on trends in education and sixth form spending. It concludes that the cuts Jeremy Hunt has signaled are on the horizon will be incredibly hard to make, with spending per student still sitting below the 2010 level. That the current fiscal plans alone imply a real-terms spending freeze, it’s difficult to see how and where schools will be able to make cuts without also biting into the scope and quality of education kids receive.
Law and order
Usually ministers receiving a new portfolio try to mark themselves apart from the previous incumbent, so let’s expect great things from the new Home Secretary, Suella Braverman. We shouldn’t hope for much given the state her predecessor left the department in…
A migrant processing centre in Manston is allegedly housing people in “wretched conditions”, according to the independent chief inspector of borders and immigration. With 3,000 people living in a max 1,600 person facility, it’s not surprising that cases of diphtheria have also been confirmed. What is surprising is that so many people were allowed to be kept in one short-term holding facility, staffed in part private staff without specialist training. It’s one of many issues — pushed by Tory members to boot — that’re piling up on Braverman.
While the seat’s still warm, she’d be well advised to dig into Baroness Casey’s interim report into misconduct in the Met, a force over which the Home Secretary has especial influence. The full report is yet to come, but Casey certainly hasn’t pulled her punches, finding (among other things):
- The Met takes too long to resolve misconduct allegations — your run-of-the-mill complainant can expect to have their complaint resolved a timely 350 days later (that is, if your case isn’t investigated by the Independent Office for Police Conduct, in which case you’ll be kicking your feet for an extra 50 days on average)
- If you’re a Met officer or staff member with multiple misconduct allegations following you around, you’ve got a 99.3% chance of not being dismissed from the force, while the dismissal rate for all officers and staff members facing a misconduct allegation is 5% (qualitative analysis also suggests that this is a source of great concern for members of the Met)
- Professional Standards Units (which handle many conduct and complaint cases) are often under-resourced and supported
These findings, regarding a force dogged by scandal, are unpleasant but unsurprising — tip of the iceberg for the new Home Secretary, who’ll also have her work cut out finding ways to raise charging rates, which continued falling over the last year (did I mention Performance Tracker has all you need to know?).
A forthcoming study by Dr Simon Cooper reports on the state of the relationship between Police and Crime Commissioners and their Chief Constables. It finds that Police and Crime Panels, which are designed to scrutinise the performance of Police and Crime Commissioners, are ‘toothless’ bodies to which PCCs can pay little attention. In other words, police accountability arguably rests on a 121 relationship between a constable and PCC. Watch this space for a full summary + analysis once the full article is published.
Local government
Despite Gove’s reinstalment as DLUHC Secretary, the future of levelling up may well depend largely on what we hear from the Chancellor in a couple of weeks time. If Sunak/Hunt are wondering what to prioritise, they’d be well advised to read this new report from UK in a Changing Europe, which studies the public’s opinion towards levelling up. Among the many interesting findings it reports, projects that can be delivered within two years are found to be far more popular than those with longer completion dates. With about that much time before the next election, might be see the shelving of longer-term projects in a bid to bolster the Conservatives’ less than, ehem, impressive electoral outlook.
County Council Network warn of the danger of cutting local authority (LA) budgets at a time of rising cost and demand pressures. Their advice reflects our findings from the neighbourhood services and adult social care chapters in this year’s PT, that LAs face extreme financial pressure this winter for three main reasons: rising demand for LA-provided services due to increasing poverty and pandemic backlogs, rising cost pressures in the form of higher wage demands and outsourced contract uplifts, and rising demand for social care. As we showed in our report earlier this year, when LAs feel the pinch, they end up prioritizing statutory and acute services at the expense of other services (such as libraries, subsidized bus routes, etc.)
It wasn’t just the CCN that raised the alarm this week about LA finances, Unison released the findings of their survey of 391 LAs, which shows that councils face a £3.2bn funding shortfall in 2022/23 — approximately 6% of LAs’ core spending power — with the rise in inflation and energy costs putting pressure on budgets. Worryingly, there are already reports of LAs cutting back services. For example, Wirral council have closed nine libraries and Gateshead Council are looking at closing two leisure centres. This is a really good thread from Jack Shaw explaining why comparison between LAs is difficult and why our understanding of the extent of the problem will evolve in coming months.
That’s all for this Week in Public Services — watch out for coming editions for some cutting-edge analysis as we roll towards the autumn statement!
