Week in Public Services: 13th September 2022
This week: Truss’s new government; vacancy rates in health and social care; and financial difficulties in local government
General
A mere two months after Boris Johnson resigned, we have a new Prime Minister. Truss faces a considerable set of problems in public services, not least striking criminal barristers, rapidly declining NHS performance, and a rapid exodus from the adult social care workforce. Policy Exchange published a report with 16 ideas for the incoming PM on how to fix some of the worst problems in health and social care. Some good stuff and some not so good stuff, as Steve Black points out in this thread.
Away from new government watching, here is some vital reading about the cost of living crisis from the Resolution Foundation. One of the most shocking statistics in that piece (among many strong contenders) is that average real pay could be 9% lower in Q2 2023 than two years earlier, an amount which would wipe out all real-terms pay growth since 2003. One thing that puzzles me is the sharp uptick in average weekly earnings from Q2 2023 onwards (p.15). What’s driving that? Is there an assumption that energy prices come back down from then on? Or that wages start to rise again? Anyone with some insight, let me know.
Health and Care
We have a new Health and Social Care Secretary (who also takes on the role of Deputy PM): Thérèse Coffey. For anyone wondering who she is, The Guardian provides a succinct profile. More importantly, what’s on her to-do list? We offer our views on her priorities in the live blog that our sleep deprived Ministers team have been updating since last week. In terms of her views on health and social care, she has said her priorities can be summed up as ‘ABCD’ — Ambulances, backlogs, care, doctors and dentists — which, not to be a pedant, should surely be ABCDD? Let’s hope she pays a bit more attention to policy detail than headline-grabbing acronyms.
Apart from the new H&SC secretary, the headline this week has to be the high and rising number of NHS vacancies. This article from the Guardian is a nice summary of where we are. As you can see from the below chart vacancies across the NHS declined during the pandemic, echoing trends across the rest of public services. That decline, however, is now in a screeching reverse. The last quarter (between March and June 2022) saw a large increase in vacancies across all staffing groups and, most notably, in the ‘total’ category where the number of unfilled posts now stands at 9.7% of the workforce — the highest level in this time series.
Proportion of NHS workforce with unfilled roles, split by quarter
Source: Institute for Government analysis of NHS Digital, NHS vacancy statistics England
So what’s going on? As ever, it’s a combination of a few things. The Guardian article quotes Saffron Cordery (Chief Exec of NHS Providers) and Pat Cullen (Gen Sec of the RCN) as saying that it’s down to a poor pay deal this summer. That is certainly true, but there are other reasons. Stress is a leading cause: the proportion of people who resigned from the NHS citing work-life balance as a reason rose from 16.7% in 2019/20 to 18.7% in 2021/22 — it’s highest ever level. This is likely pandemic-related burnout, which doesn’t seem to be improving and anecdotally is creating a nasty feedback loop: stressed staff leave the workforce, leaving more work for the remaining staff, adding to stress and causing yet more staff to quit. Not a pretty picture.
Focusing on the ‘retention’ side of recruitment and retention, this article from Rachel Maxwell outlines a strategy for lowering student nurse attrition rates — a welcome tool given the estimated 33% (!) of student nurses who left nursing courses in 2020.
Seems that someone in government has finally decided to tackle the pension issue that drives doctors out of the NHS early. The Times reports that the government will change the system that currently penalises doctors as they get paid more — either by working extra hours or through salary increases. Good that this is being addressed, but it has seemed like low hanging fruit for a while now.
John Burn-Murdoch of the FT, estimates that there are currently 500 excess deaths per week due to the emergency care crisis in the NHS. It’s a stark piece of analysis but I think makes too strong a causal claim between high levels of mortality from certain causes — e.g. liver diseases and diabetes — and the poor state of urgent and emergency care. That is not to downplay the current crisis — things are truly bleak in emergency departments — but more to say that attributing excess deaths just to those factors is tough to prove.
Before he disappeared off to the backbenches, Steve Barclay had a great idea to “bust” the Covid backlog: 50 new surgical hubs. If you have a sense of déjà vu, it might be because the NHS made a similar announcement in the elective backlog delivery plan back in February, since when the NHS has opened 91 hubs. The question for the 50 new hubs is the same for as it was for the others: who is going to staff them?
Speaking of the backlog, the NHS released its July RTT update. The headline is that the NHS missed the first of its targets for clearing the backlog: no one waiting more than 2 years for treatment by the end of July. They almost got there, with only 2,885 still on the list at the end of the month. Though NHS England argue that the majority of these chose to defer treatment and others were too complex to clear off. Shameless plug of my own tweet thread on the topic here.
Really interesting report (and relevant thread) from the Health Foundation about public perceptions of health and social care. Some of it is unsurprising (general gloomy view about the current state of both services. What surprised me most was the lack of understanding of how social care works; 51% of those polled think the NHS provides the majority of social care and 45% think that it’s free at the point of use. This fits with a long-standing theory of mine (some nice confirmation bias then): the public doesn’t really know what local authorities do and mostly think it’s about filling potholes rather than also running, you know, one of the most important public services in the country.
Sobering article by Sarah Neville in the FT about the deterioration in population health due to Covid. One academic quoted in the article describes the effect being “as if everybody suddenly decided to take up smoking in one go”. Bad for all of us who have had Covid, but also a reminder that although the pandemic has receded in daily life, it will be a productivity drag on the NHS for the foreseeable future.
I missed this when it was first posted, but this blog post from Steve Black about the shortcomings of NHS strategy should be a must-read for Thérèse Coffey as well as everyone in NHSE. Chief among his criticisms is the tendency for NHS strategy to end up being a shopping list of vague aspirations — reduce elective wait times, hire more nurses, etc — without any analysis that actually identifies the underlying problems and allows the NHS to focus on areas that would actually improve performance. Through this lens, the “operational resilience framework” that NHSE recently released ahead of this winter looks to be more of the same.
We’ve seen the policy pendulum swing back and forth in health policy for a while now, are we about to see the same thing in adult social care? Potentially, argues Sally Warren, who thinks we might see a return to a national approach to social care policy, with the Health and Care Act 2022 granting the CQC the power to inspect the care functions of local authorities and the introduction of the Office for Local Government (hello Audit Commission 2.0).
Great blog by Simon Bottery discussing the King’s Fund finding that half of care workers earn less than entry level roles in supermarkets. One stunning quote in the piece from a care home manager: “I dread hearing Aldi opening up nearby, as I know I will lose staff”. As Simon points out, the solution likely involves properly funding local authorities to pay providers and, in turn, carers more — something the government currently has no interest in doing.
Recruitment and retention aren’t the only problem for care providers. Sky News reports that one care home provider — Sheffcare, which operates nine residential homes — has been told that their fuel bill will cost £1.16m a year, up from £90,000 in a typical year. This is obviously unsustainable. Providers already operate with relatively small margins and will not be able to absorb these kind of increases. At a time when there is already a shortage of care places, the social care system can’t continue to operate if a raft of providers leave the market.
Children and Young People
A lot of chatter about the large drop-off in independent school A-level results, with this chart from Chris Giles doing the rounds on Twitter. The story from that chart is that independent schools ‘gamed’ the system most in 2021, evidenced by that group of schools having the largest percentage point decline of A/A* grades.
But was that really the case? FFT Education Datalab argue that the data Chris uses are helpful, but should also be considered alongside what they term the “relative risk” of achieving an A/A* in 2021 compared to 2022. On that measure independent schools were firmly middle of the road, while further education establishments — a group excluded from Chris’ graphic — were in the top 2 on both metrics. More than anything an interesting story about data presentation.
Law and order
Great analysis from Matt Ashby about variation in “crime pressure” between different police forces — a metric for the amount of crime per officer, weighted by severity. Key takeaway for me is that crime pressure has risen 51% across England and Wales since 2010, though how much of that is due to officer cuts or worsening severity of crime is difficult to tell. Worth noting that pressure peaked in 2019, right before the start of the national recruitment drive.
Speaking of the recruitment drive, another of Matt’s threads shows how officer and support staff numbers vary by force compared to 2010. Of the 42 forces in England and Wales, only 17 have seen an increase in officers in that time, and 8 are still more than 10% lower, despite strong national recruitment numbers. The picture is worse for support roles: only 8 have more staff now and 23 have fewer. Shockingly the Met has cut 41.7% of its support staff in the last 12 years.
While on the topic of the Met, the force’s new commissioner — Mark Rowley — took up his post on the 12th of September. Before resigning, Priti Patel sent him a letter that nicely outlined some of the challenges he faces. They include: restoring trust in the service following a string of high profile scandals (we can add the shooting of unarmed Chris Kaba to start to that list), hitting the Met’s recruitment target by the end of March 2023, and responding to HMICFRS’ PEEL findings. Not an enviable in-tray.
Local government
It’s been a busy few weeks for the Department for Levelling Up, Housing, and Communities (DLUHC), which has been flexing its muscles in front of local authorities over financial and other shortcomings. Last month, the then DLUHC Secretary Greg Clark (not to be confused with the current Secretary Simon Clarke ) announced the government would effectively take control of Liverpool City Council.
This follows the publication of a report that, in the words of a DLUHC press release, revealed ‘serious shortcomings, particularly around financial management and senior leadership.’ The report doesn’t pull its punches, highlighting workforce capacity gaps, a weak risk management culture, and poor progress in addressing financial concerns.
Other local authorities are experiencing financial issues. Among them are Runnymede, Spelthorne, the recently unitarised Bournemouth, Christchurch and Poole, Thurrock Council, and Breckland council.
It’s concerning that local authorities are experiencing financial difficulties now, before the worst of the cost of living crisis bites this winter. This new analysis by the LGA and ADEPT, for example, revealed a 60% increase in the price of the salt needed to keep drivers safe during the winter, compounding the financial difficulties caused by, to take one other example, a nearly 40% increase in the price of running and maintaining street lights.
