Week in Public Services: 12th April 2024
This week: Lansley 2.0?; yet more benefits from Sure Start; and some rare good news in prisons
General
Westminster has been rocked by a honey trap scandal, with a range of MPs, staffers, and journalists approached by a mysterious person sending explicit pictures. Readers who have been worried about the IfG can rest easy. Much like French spies, we are immune to honey trap tactics. The only things that might tempt an IfG-er into a web of online intrigue and deception would be the promise of some previously unpublished civil service data, or gossip about the abolition of OHID.
The Bennett Institute published a new report as part of their review of public sector productivity. It recommends a focus on technological rollout across public services and improved HR practices to increase staff satisfaction, retention, and effectiveness. The first of these is a pretty well-trodden path, so I won’t spend too much time on it.
The second part was more interesting. I liked their argument that it’s harder to evaluate staff performance in the public sector than it is in the private sector. Lazy comparisons between the private and public sector are a big pet peeve of mine, and this is a prime reason why. It’s relatively easy to know how a company (and consequently its employees) is doing: Profit down = bad. Profit up = good. But it’s much more difficult in the public sector when there are multiple — sometimes competing — goals, which are often difficult to measure. The other problem is that it can be hard to attribute the improvement of a metric to a particular team or individual working in the public sector. How then should the government evaluate performance among public sector workers? And if it wants to implement performance-related reward packages, how should it go about doing so? The paper doesn’t offer any concreate answers, but rather poses a set of questions policy makers should ask themselves.
Health and social care
Buckle in, this is going to be a long one. Reform had a report out last week proposing a major structural change to the NHS. They make two broad recommendations: 1) abolish NHS England and 2) devolve much more responsibility for health. On the first, I broadly agree with their analysis that NHSE is overly centralised, largely unaccountable and often duplicates work with DHSC. Very happy for NHSE’s role to be slimmed down. All good so far.
The second part is where I have some real issues. I’m very much in favour of more local control over service design and delivery; we make a similar argument in our upcoming report about prevention. But some of the proposals baffled me. The report is incredibly critical of the ICS structure. And to some extent, fair enough! There hasn’t been a major shift towards more localised service delivery since ICSs were created. The report therefore proposes abolishing them and either giving more health powers to combined authorities or a model in which local authorities commission all out of hospital care and combined authorities commission secondary care.
On the first — they’ve just abolished ICSs and then effectively recreated them, just with slightly more direct links to a combined authority. On the second, I really don’t think that LAs should have responsibility for out of hospital care. I worry that it would come to completely dominate attention, and distract them from other — already neglected — services. That’s before you even begin to unpick the mess of local authority financing and capacity.
I understand the frustration with ICSs, but I think they could achieve a lot of what this report wants. It’s worth remembering that since ICSs were put on a statutory footing less than two (2) years ago, they have been constantly firefighting. They’ve dealt with strikes, had their management budgets cut by a third, and been subjected to constant pressure on national targets from NHSE. No wonder they haven’t radically reformed the longstanding healthcare delivery model in their downtime!
The thought of a massive structural reorganisation will send shivers through many in the NHS; the unaddressed spectre of Lansley haunted this report. So rather than burn a lot of political capital and time on a reorganisation which may or may not improve outcomes, why not use the existing ICS structure and then do a lot of the (really interesting and exciting) financial rewiring, like copayments, that the report suggests? That would be far less difficult to do and may achieve 95% of what the report wants, without turning the entirety of the NHS and local government on its head.
The government made hay out of its announcement of £3.4bn of digital and tech funding for the NHS at the spring budget. There are questions about whether that money is truly additional. But taking the government at its word, would that level of investment make a meaningful difference to the NHS? Pritesh Mistry from the King’s Fund answers that question. He argues that it isn’t enough to just allocate the funding, the NHS also needs to protect it and then spend it effectively. I also love his fact that the NHS spent £2bn in 2022 alone rolling out electronic patient records. That gives a real sense of the scale of the challenge in modernising the NHS’s IT system. In that context, £3.4bn (even if it is real) is barely going to touch the sides.
More King’s Fund work, this time about the difficulties that people in more deprived parts of the country have accessing care. Maybe unsurprisingly, the report finds that greater levels of poverty are associated with far worse health outcomes, partly through a lack of access and partly due to poorer wider determinants of health. I found their chart which details what people do when they cannot access care in general practice fascinating: the most deprived quintile is more than twice as likely than the next closest quintile to access care elsewhere, with vastly more people going to A&E than other parts of the population. That supports what we hear anecdotally, which is that when people cannot access care, they are constantly pushed to more acute parts of the health and care system.
That led me to some slightly older Health Foundation work which attempts to measure continuity of care in general practice. Using data from both the GP patient survey and electronic patient records, they find that — with the exception of the pandemic — continuity of care generally fell. They also found that continuity of care tends to fall the more frequently a patient visits their GP. This maybe isn’t that surprising — it’s less likely that your preferred GP will be free if you’re going a lot. But those people might also be going more frequently because they need the most intensive care, in which case they’re losing out from not seeing the same GP consistently.
This was a fascinating paper about the difficulties that ICSs are having in addressing health inequalities. Three things stood out to me: vague policy and goals from the centre leave ICSs unsure what to focus on; relatedly, ICSs have few levers to pull to address wider determinants of health e.g. housing; finally, short-term pressures like ambulance delays dominate ICS attention at the expense of focus on health inequalities. On the first point, there is an extent to which ICSs should be determining their own priorities and working towards those. The point of ICSs is to adapt high level goals to the needs and characteristics of the local population. Having said that, if there is no direction at all, they are to some extent flying blind.
In what is now becoming a weekly guest spot in this blog, Max Warner and George Stoye have another report out, this time on nurse career progression in the NHS. They find that nurses are progressing more quickly than they used to, with a nurse starting in 2016 more likely to be a band 6 after four years than their counterpart who started in 2012. They hypothesise that one reason might be that as pay was held down throughout the 2010s, the NHS promoted staff more quickly to provide them with pay progression. If true, this would reflect a similar trend that the IfG has observed in civil service pay.
Helen Salisbury uses this piece to articulate something I’ve been mulling for a while: the recent expansion in non-GP roles in primary care — for example, pharmacists, nurse practitioners, and physician associates — marks a substantial shift in the NHS’s primary care model. But it’s a shift that’s happened relatively quietly and which significantly changes a GP’s role. GPs are now increasingly managers of a multi-disciplinary team that carries out the majority of interaction with patients. Meanwhile, GPs themselves are encouraged to carry out less clinical work themselves. Helen’s very negative about this change but I’m still not fully sure what the implications are. Interested to hear other GPs’ thoughts.
Camille Oung from Nuffield Trust has a snappy overview of the strategies that other countries have used to improve recruitment and retention in adult social care. Included are measures such as: increased professionalisation, improved access to training for staff, and sector-wide pay increases. She emphasises, however, that piecemeal policies are much less effective than comprehensive and coordinated reform.
I missed this at the end of February, but the King’s Fund published a report on the state of mental health in the UK. Some of the headlines — increasing prevalence of mental health conditions — won’t be that surprising. What’s more surprising is that the NHS is hitting a lot of its access targets. Needless to say, that’s a stark difference with the rest of the NHS. Despite that, the King’s Fund argue that funding increases have not been sufficient to meet demand and that, unsurprisingly, there has been a lack of capital investment.
Children and young people
The IFS released their latest paper on Sure Start, this one looking at the impact of the programme on educational outcomes. They find that the programme improved school performance for children starting from age seven and becoming stronger for 11-year-olds. This effect continues into secondary school, with Sure Start linked to an increase in GCSE results equal to 0.8 grades. They also found that outcomes improved more for children from disadvantaged backgrounds: GCSE results of disadvantaged children who lived near a centre improved by three grades.
They also found a connection between Sure Start and SEND requirements. Among five-year-olds, Sure Start actually increased the number of children receiving SEND support, which the authors attribute to children being diagnosed earlier. However, for 11- and 16-year-olds there is a drop in numbers, which more than offsets the initial increase. Given the current pressure of SEND need on councils’ budgets (more on that below), it’s interesting to consider what might have happened if the government had chosen to grow, rather than cut the programme from 2010 onwards.
*Industrial action klaxon*: the NEU has warned that it will be balloting its members, with the potential to walk out in September. This is an interesting one to me, as the teachers’ strike was the negotiation that the government managed to resolve most amicably last year. Both sides seemed eager to come to an agreement, with teachers reportedly getting pretty fed up of the drama and reduced pay from striking. Maybe some of this can be explained by a change of management at the NEU, as Daniel Kebede took over from Mary Bousted and Kevin Courtney in September 2023.
Interesting poll from Teacher Tapp which shows a declining proportion of teachers would advise their 21 year old selves to go into teaching: 34% in April 2024 down from 58% in June 2018. You know things must be bad because the profession that teachers would predominatly now recommend to their younger selves is accounting.
Law and order
Unusually, some good news from the prison estate: the government’s emergency measures to reduce the prison population appear to be working. The latest population figures show a drop of around 1,000 over the last two months, to just under 87,000. Prisoners are currently being released up to 60 days early and sentencing hearings are being delayed to try and manage serious overcrowding in prisons. But the government’s longer-term plans to address the crisis won’t work — read our new comment piece on the forthcoming Sentencing Bill to learn why.
Ongoing prison problems haven’t stopped the government from announcing a new standalone offence of assaulting a retail worker, promising ‘tougher punishments’. The new offence will have a maximum penalty of six months in prison — curiously, the same maximum sentence for assault on a retail worker currently. Offenders are also unlikely to be sent to prison at all, as the Sentencing Bill will introduce a presumption to suspend all prison sentences under 12 months.
Local government
Another week, another report of a local authority being forced to make difficult cuts to balance its books, this time in Newcastle. This quote from the council leader, Nick Kemp, could have come from most local authorities in the country at this point: “Sadly after 14 years of austerity there is no low hanging fruit left and many of the decisions we have taken to balance the budget have been painful”.
Bristol city council has been accepted onto the government’s Safety Valve programme. That means the government will write off its £54m SEND overspend in return for the local authority “reforming” the service (reform in this case is arguably just the council making it harder for people to access the service they need). What is astounding to me is that speed at which Bristol’s SEND spending is growing. Bristol forecast that, without intervention, their overspend (which is cumulative, but still) will grow from £56m this year to £114m in 2028. The value of their entire dedicated schools grant is only £220m in 2024/25! The overspend is therefore already a quarter of their entire budget, potentially rising to more than half in four years. That is astounding to me, but is not atypical; councils like Devon and Cheshire East are already running deficits worth more than 30% of their dedicated schools grant. What can account for that type of growth in SEND need? Answers on a (digital) postcard and sent to my Twitter DMs.
For more on SEND deficits, my colleague Philip Nye wrote this blog post a couple of months ago.
