Week in Public Services: 11th April 2023
This week: declining satisfaction with the NHS; a numberless workforce plan; and teachers reject the government’s pay offer
General
With industrial action rumbling on — no, it isn’t over, as much as the government wishes it was — this piece (free to read) on Sam Freedman’s substack is really worth a read. Sam outlines some issues causing staff shortages across the public sector and what he thinks the government can do about it. One thing that hadn’t occurred to me was the pension point; public sector pay packages generally offer more generous pension packages than private sector jobs, but offset that with less generous salaries now (Ben Zaranko responded with an enlightening thread about the differences between private and public sector pension contributions).
The problem is that humans are notoriously bad at valuing future benefits, meaning that public sector workers likely undervalue their compensation and would prefer some of that cash now. Luckily, as Sam argues, shifting money into salaries is something the government can do! Though whether they actually will is a different matter. Another interesting point is the lack of flexibility — particularly the inability to work from home — that these jobs do not offer employees. One thing occurred to me as I read this; one supposed benefit of virtual wards is that they allow staff to work remotely — a rare perk in the NHS. Maybe there are other innovations — remote teaching? — that would allow more public sector staff to work from home.
I found this research from Resolution Foundation about public investment fascinating. The report argues that public investment in the UK has been far below optimal levels throughout this century, averaging only 2.5% of GDP compared to the OECD average of 3.7%. What’s maybe more surprising and indicative of poor decision making is the volatility of public investment, which is the second highest among advanced economies. High volatility might not sound like that big a problem, but uncertainty about future investment makes it hard for those managing public investment projects to plan ahead — look at the constant back and forth about HS2 for a prime example. The other target of Resolution Foundation’s ire is the much benighted (recently, at least) fiscal frameworks, which disincentivise any spending that contributes towards net debt.
This unwillingness to invest has ramifications for public services. We reported in Performance Tracker about the record maintenance backlogs in hospitals, schools, and prisons. But it isn’t just in the deteriorating estate that we see evidence of underinvestment, but also the lack of equipment, poor IT systems, and an estate that is too small for purpose (whatever happened to those 40 new hospitals?)
Health and care
The King’s Fund and Nuffield Trust published their annual analysis of the British Social Attitude’s survey of public satisfaction with the NHS. The results are not good. Only 29% of people were satisfied with the NHS in 2022, down from 36% in 2021, itself a significant drop. 2022 was also the first year that more than half of respondents reported being dissatisfied with the NHS. The areas of highest dissatisfaction were with waiting times for GP and hospital appointments, staff shortages, and government spending on the NHS.
If you thought satisfaction with the NHS is bad, then the results for adult social care will really shock you: only 14% of people reported satisfaction with the service, though this experienced a smaller fall (from 15%) compared to 2021. What’s quite interesting with social care is that the range of satisfaction by characteristic (age, gender, ethnicity, etc.) is much wider than with the NHS; only 30% of Asian respondents and 45% of Black respondents were dissatisfied with the service, compared to the population total of 57%.
One final point of interest is the percentage of respondents who have had contact with different parts of the NHS and social care in the last year. The only part of the NHS where contact declined was general practice, with 84% of people reporting contact with the service in 2022, compared to 86% in 2021. That surprised me; anecdotally, unmet demand has been at historic levels in primary care. Though it could be that fewer, sicker people are using GP services more, even though they represent a smaller portion of the population.
James Illman brings us the NHS England estimate that the service was forced to reschedule 175,000 appointments and procedures during the junior doctors’ strike a few weeks’ ago. That amount is apparently more than the ~140k that were rescheduled due to all other NHS industrial action. This is really interesting and doesn’t bode well for the upcoming 4-day strike starting today. It’s hard to prove, but I suspect it also gives an insight into the nurses’ and ambulance workers’ deal struck a few weeks ago; the government realised that the service would not be able to sustain more industrial action from those staff groups as well as junior doctors.
On the topic of reduced activity, the second of the government’s three backlog recovery targets is coming up at the end of April, this one to clear all 78-week waiters off the list. But James Illman reports that the NHS is going to miss this target, with approximately 11k people expected to be left on the 78+ week waiting list. The NHS are apparently trying to blame this miss on industrial action, but James doesn’t let them off so easily, pointing out that the combined number of missed appointments from strike action is about 4,000 — which would still leave them missing the target by 7,000.
A glimpse into internal government wrangling over the NHS’s work force plan, as the Guardian reports on leaked headline numbers from DHSC. I say wrangling, because the Treasury (led by that erstwhile supporter of a workforce plan, Jeremy Hunt) is attempting to keep the plan as vague as possible, with little to no detail on numbers, which does rather seem to defeat the point of a workforce plan. The headline from this leak is that there will be a shortage of 571,000 staff by 2036. You read that right: 571,000. Given the current workforce is about 1.4m people, that is quite astounding. I would love to know a bit more about how they came to that number as I struggle to believe it, partly because I don’t think it would ever be politically tenable for a government to let the service reach that point. Though maybe that’s naïve. The other thing that stood out is that the projection includes an assumption that there will be “no improvement in productivity”. Given the recent decline in NHS productivity, this seems like a particularly pessimistic assumption.
One last point on this: the plan seems to focus heavily on recruitment. I think this is a mistake. The NHS is actually pretty good at recruiting staff, albeit with a large proportion coming from abroad, it is instead historically bad retention that is driving much of the workforce crisis. There could therefore be some easy wins for the government if it committed to improving pay and conditions for existing staff.
Pritesh Mistry pointed out this interesting split of how NHSE expects to spend its budget on virtual wards. The standout is staff costs, which account for 85% of spending. It’d be interesting to know how this compares to standard ward costs, but you have to imagine that it would be higher, given that there are more costs that come with being in a physical hospital.
Obviously not the UK, but this paper assesses the difference in quality between privately and publicly owned ambulances in Sweden. As they point out, there is relatively broad agreement that privatising services reduces cost, but a lot more ambiguity about the effect on quality. They find that private ambulances perform better on contracted metrics — for example, response times — but perform worse on noncontracted metrics which includes mortality. They find a 1.4% higher risk of death within 3 years if a private ambulance is dispatched. The causal mechanism here is that to cut costs, the firm reduces quality. But a three year mortality window seems very large to me.
The Tony Blair Institute for Global Change published a report on population health. Much of it is a very good recap of existing evidence on the importance of preventative health measures, but I think it is the latter sections which lay out the recommendations that is more interesting (though it does trigger the “OBR-type independent watchdog” klaxon). Central to those recommendations is the shift in how we view health; from something that needs to be topped up when someone is ill to a national asset that should be invested in and protected. This is much the same as the recent rhetoric around childcare — we should be treating these outcomes as crucial to our economic functioning, to then encourage the government to divert investment towards them.
The Health Foundation have this fascinating bit of analysis, comparing GP experiences in 10 countries. There are caveats about the comparability of primary care across different countries and health systems, but the picture is still pretty bleak for the UK. British GPs reported: the highest level of stress compared to other countries, that they spent the joint shortest appointment length, and half of GPs think that the quality of care they deliver has worsened since the pandemic, a result second only to New Zealand. There were some surprises though: the UK provides by far the most remote appointments, 60% compared to New Zealand on about 35% as the next country.
This piece (£) by Rachel Sylvester in the Times is an excellent accompaniment to the above data, as it paints a very vivid picture of a service that has been pushed to its limit.
Last word on GPs: Pulse reports that the NHS is going to add GP burnout to the Quality Outcomes Framework (QOF) starting from April. This will involve practices drawing up plans to improve stress outcomes, undertaking risk assessments for each role in the surgery, and participating in “peer review meetings”. If that all sounds like work, it’s because it is. And given that high workloads is one of the key contributors to GPs’ stress, it does look slightly like the NHS’s steps to reduce burnout could end up increasing it. There were some excellent responses on GP twitter.
We mentioned the lack of news about the funding outlined in the adult social care white paper a few weeks ago. Well, it turns out that the government has been quiet for a reason: Dave West reports that it has now cancelled £550m of planned investment in the workforce proposed in that white paper. So just to clarify, the government has now delayed its landmark charging reform and cancelled the investment outlined in the other white paper published in the autumn of 2021. I think we can safely say that adult social care has not been fixed “once and for all”. For more, have a look at my blog for the IfG.
An interesting piece in the Guardian shows that £1 in every 5 that local authorities spend on care homes go to those rated inadequate by the CQC. According to the CQC, there are 14,925 care homes in England, of which only 236 (1.6%) are rated as inadequate, making that 20% proportion reported by the Guardian even more astonishing. Maybe this is because inadequate homes are also the cheapest and therefore more attractive to local authorities with limited budgets.
On a related note, the government has directed the CQC to assess the quality of care provided by local authorities, starting from April. This will result in the CQC giving local authorities a rating of either ‘inadequate’, ‘requires improvement’, ‘good’, or ‘outstanding’, though ADASS are sceptical about the usefulness of single-word ratings, instead preferring a “narrative judgement”. There is some benefit to this, and previous IfG work shows that local authorities take poor OFSTED ratings very seriously. But surely much of the reliance on poor quality care is due to heavily squeezed local authority budgets — something which is unlikely to change. In that context, what levers will poorly-rated councils have to improve care in their area?
Children and young people
This work from the Universities of York, Exeter, and Oxford is interesting, though raises some questions for me. Their research shows that one-third of care leavers were not in work by the time they were 21, compared to 2.4% of the wider population. Digging a little deeper though, and these results don’t seem so surprising; the majority of care leavers were defined as economically inactive due to disability or caring responsibilities. That makes the comparison with the wider population potentially a bit misleading. Wouldn’t a better comparison be those with similarly complex needs who didn’t enter care at any point?
Strong words from the Association of Directors of Children’s Services who claim that the government’s ‘illegal migration bill’ will drive children “into the arms” of trafficking and criminal gangs. A quick reminder that the government’s current asylum system is already arguably causing these problems.
The House of Lords public services committee has launched an inquiry into the government’s children’s social care strategy, in particular whether it addresses the needs identified in the MacAlister review.
Community Care reports that Social Work England has convened a working group to explore ideas to improve recruitment and retention of social workers. Concerningly for those in the children’s social care service, there is no representation from the DfE, despite DHSC being granted input for adult social care.
Social workers who responded to the British Association of Social Workers’ survey, relayed that demand for their services had increased during the cost of living crisis. Unsurprisingly, this has meant a greater workload of social workers, with 57.8% of respondents saying that they could not manage their workloads, up from 37.8% in 2022.
Turning again to great reporting from Community Care — councils are increasingly referring children from residential to foster care. This change is reportedly due to increased progress that children are making in residential placements but also cost concerns from councils.
The big news in schools since our last edition has been the government offer of a pay deal for striking teachers (this from my colleague Philip Nye is an excellent summary of the deal and how it compares to the NHS offer)…and the subsequent rejection of that deal by every union that has so far balloted members. The extent of the rejection is quite astounding; 98% of NEU members voted against the deal. Concerningly for the government, this rejection likely means more strikes are coming.
Slightly less high profile, but no less important is this report from SchoolsWeek which shows that more than a third of maintained schools reported incidents of financial mismanagement over the last two years. Embarrassingly for the DfE, this comes in the wake of the department’s abandonment in 2020 of reforms that would have mandated three-year audits of maintained schools.
Back to a favourite topic of Week in Public Services: the schools maintenance backlog. This time, the permanent secretary of the DfE admitted in an appearance before the Public Accounts Committee (PAC) that the schools rebuilding programme will not “eliminate the risk” of a crumbling estate. Other topics touched on in that hearing include the national tutoring programme (Director General Graham Archer claimed that the fact that 13% of schools did not take part was the programme’s “biggest disappointment”) and that it will take longer than expected to close the attainment gap. Worth a longer read.
Schoolsweek report on a £1bn package to bail out twenty council’s SEND budgets. While the government has stipulated some conditions, it speaks to the need for significant reforms in this area — for more on these recent SEND action plan, see this report from Samantha Booth at Schoolsweek.
Law and order
Labour have proposed (£) rolling out what they call “community courts” that will decide how to punish anti-social behaviour with community sentences, with the goal of taking pressure off magistrates’ courts. But as Penelope Gibbs points out, anti-social behaviour is not dealt with in magistrates’ courts.
The fact that the Met is struggling financially is definitely headline grabbing stuff, but the framing of this story is terrible. The Times leads with the stat that the Met spends £440k on mounting certificates and frames designed to recognise and reward officers. I hate these stories. £440k it is just over 0.01% of the Met’s £3.24bn budget. So while the Met may well be in financial difficulties, it is not due to this particular programme which may actually improve staff morale. A more likely suspect for the difficulty in making ends meet is likely the 10.1% increase in officer salaries that Rowley argues is needed to improve recruitment and retention in the service.
This story from the BBC provides some data about the burden on police forces from dealing with mental health call outs. FOI requests to 48 UK police forces led to 21 responses, all of which showed an increase in mental health incidents between 2017 and 2022. One particularly shocking stat is the 313% increase in incidents in Merseyside in that time.
This is a truly depressing story from Sima Kotecha, who reports on an FOI revealing that 1,621 rape and serious sexual assault cases were dropped between 2017 and 2022 because alleged victims decided not to pursue the case after the defendant had been charged. The Law Society and the Criminal Bar claimed this was largely due to waits in the court system (thanks to inadequate numbers of barristers and poor funding), which cause “mental turmoil” for the alleged victim. This is a reasonable explanation. Overall wait times have dramatically worsened in the crown courts since 2017, and MoJ data reveals that the median number of days from an offence being committed to a court result for rape has grown by 485 days since 2017. That being said, it’d be interesting to look under the hood of the FOI. If wait times are to blame, we would expect year-on-year drop-outs to increase accordingly.
Local government
Bin news! The BBC reports that the government plans to standardise some waste collection across the country by mandating that all local authorities collect the same six types of recycling waste, with the aim of increasing recycling rates. Local authorities are not happy with the proposals, though this is relatively unsurprising, as they generally don’t like any interference from central government. But I struggle to sympathise with them on this. If the changes are fully funded (granted, that’s a big ‘if’) it will surely be a good thing to have a consistent set of policies across the country, not only for citizens actually doing the recycling, but also for companies that produce packaging. Currently it’s impossible to know from one council to the next what is and isn’t accepted. It’ll be interesting to see if it has an impact on recycling rates, which have flatlined for more than a decade.
New Transport Committee report on the progress delivering “bus back better”. Reader, you will be shocked to learn that delivery falls short of the three word proposal. The Committee are keen on the many good ideas and ambitions in the proposals, but extra funding will be needed to deliver the priority bus routes, demand responsive services and 4,000 zero emission busses on the road by the end of the Parliament.
Research by the Fawcett Society and Democracy Club shows that fewer than 5% of local authorities have achieved gender parity. This is particularly interesting, as Simon Bottery points out, in light of the role that authorities have in commissioning adult social care — a service where the majority of both users and staff are women. Makes you wonder what perspectives decision makers in councils are missing due to their lack of diversity.
