Week in Public Services: 14th November 2022

This week: nurses vote for strike action; delay of social care reform; and analysis of high pupil absences

General

In ‘fiscal hole’ news, the Guardian reports that Hunt and Sunak plan to announce tax rises and spending cuts totalling £60bn in this week’s autumn statement. Of this £60bn, there will reportedly be “at least” £35bn of spending cuts, though scant detail of where we can expect those cuts to fall. My atrocious record forecasting anything in British politics prevents me from speculating on what the government will cut, but I would urge the PM and chancellor to have another read of our “Lessons from the 2010s” paper before coming to any final decisions.

While we’re talking about the ‘fiscal hole’, this piece from Giles Wilkes is an excellent reassessment of the received wisdom being bandied around Westminster and the press at the moment. The argument — that the ‘fiscal hole’ is not an objective fact, but rather the result of uncertain forecasts and the government’s own fiscal rules — is helpful to keep in mind when we inevitably hear Sunak and Hunt talk about the inevitability of fiscal belt tightening. Well worth a read.

Reform published their annual State of the State report. The major thing that stood out to me was the section discussing public sector reform. The report argues that there is an appetite for more reform of public services, given limited political bandwidth to think about it in recent years. But the content is vague, full of claims that the state needs to be smaller, without making clear what that means, or which services should be either privatised or cut altogether. I would even argue the opposite to what this section implies: reform has carried on apace in public services — ICSs on a statutory footing, further rollout of MATs, adult social care reform, outsourcing and then insourcing of probation services — while the scope of the state has actually been limited by a decade of austerity. For an example, you need look no further than local government services during the 2010s, where bus subsidies dropped to zero in many authorities, a third of libraries closed, and more than half of councils closed children’s centres. That’s before you get to adult social care, where rationing means that 17% fewer people aged above 65 received long term care in 2020/21 than in 2014/15. Obviously the extent of state provision of services should be open to debate, but that debate should start from an honest and realistic picture of where we are, rather than unattributed (and wrong) claims that the state has grown too big.

Health and Care

Steve Brine has been elected the new chair of the health and social care select committee. He was parliamentary under secretary of state in the DHSC for public health and primary care between 2017 and 2019 — two areas of the health and care system in need of attention. Here’s his statement on the appointment, in which he says he wants to build on the work of the previous chair (that’s one Jeremy Hunt. He’ll probably find that one of the largest stumbling blocks to achieving his goals is going to be Hunt himself, in his new role as Chancellor.

The biggest health news of the week is that members of the Royal College of Nursing (RCN) have voted to undertake industrial action before Christmas. This will likely take the form of non-emergency and intensive care nurses walking out and will result in fewer elective procedures and restricted care in other areas. However, the headline hides variation in how the vote split across regions and trust type, as Dave West points out in this tweet. The result is that 95% of trusts in the South West, 63% in the North West and only 26% in London will strike, with variation driven mostly by difficulties meeting turnout thresholds in trusts. There is likely to be an eventual backlash against this decision, but it is hard to overstate the abysmal state of nursing retention in the NHS: 11.8% of nursing roles are vacant and one in nine nurses left the services in the 12 months to June 2022. While the NHS is doing a good job at recruiting more nurses (mostly relying on foreign-trained recruits) we know that greater nursing experience leads to better outcomes for patients — constantly backfilling vacant spots with new recruits is not a like-for-like exchange. If the strikes help improve retention, then it will benefit patients in the long term.

NHS Confederation published an evaluation of the first three years of primary care networks (PCNs). Their assessment is that PCNs have been a success overall, despite conception in less than ideal conditions. They highlight delivery of the majority of the vaccine programme and the hiring of an additional 19,000 direct patient care (DPC) staff (so far) as major wins. On this latter point, the report claims that additional staff are helping to plug the gap left by GPs leaving the service. I feel instinctively sceptical of that last claim. As it stands, the NHS does not publish data on DPC activity. So my questions for NHS Confederation are: what are those DPC staff doing? Can you be sure they’re filling gaps left by departing GPs? Some other things that jumped out: a lack of estate space and IT infrastructure is limiting PCN effectiveness. Running a PCN and training ARRS staff is increasing the workloads of practice managers and clinical directors (many of whom are GPs). A lot of really great insights in this report.

The King’s Fund published a blog looking at the relationship between social care providers and integrated care systems (ICSs). They found that the mismatch in size between ICSs and providers (which, by the way went both ways — both that providers were too small and too big) made communication difficult. The authors identify the development of integrated care strategies over the coming months as an opportunity for the sectors to work together.

Interesting analysis by Louella Vaughn and John Browne about the effect of centralising acute care into fewer, but larger hospitals. They find that there were some benefits for small groups of patients, but no overall improvement in the in-hospital mortality trend and an actual worsening in the 30-day mortality rate. Potentially a swing in the debate back towards increased decentralisation of healthcare?

Important work from Nuffield Trust looking at the ethnic disparities in healthcare. They found that those of Asian ethnicity experienced the largest drop in activity in the first year of the pandemic — a 49% decline, compared to 44% for those of white and black ethnicity. An accompanying blog from Nigel Edwards and Dr Habib Naqvi delves into potential explanations and call for more data to better understand the phenomenon — a familiar refrain for any IfG researcher.

The NHS estimates that there are 5.5 million people on the elective waiting list, with 7 million incomplete pathways — meaning that a number of people are waiting for two or more procedures or are mistakenly on the list twice. Good to have an answer to a question that has been bothering me.

Chief exec of the NHS — Amanda Pritchard — has said that ICBs will have to “rationalise roles and processes” to find efficiency savings, directly echoing government rhetoric on spending cuts. Steve Barclay also claimed that the NHS “doesn’t need any more money” and that the £6–7bn funding gap in the service will be filled with efficiency savings. The NHS is, reportedly, not very happy with the health and social care secretary.

Fascinating clip (relevant section is from 46:30) from PM about bed allocation in Maidstone and Tunbridge Wells trust. A few things that jumped out at me:

· This is a clear example of investment in an IT system improving productivity in a hospital. Nurses are no longer “walking around wards, finding empty beds”, instead they can focus on care and let bed planning happen centrally

· Good management makes a difference. Having efficient operations running in the background facilitates good care, and improves outcomes

· This system has been national guidance for a while, so why haven’t hospitals adopted it more widely? The interviewee says that it takes a long time to set this up because “hospitals are like juggernauts and it takes time to turn them around”.

· This is a clear example of good practice, but it is unclear how, if at all, this is being transferred to other hospitals. Would be interested to hear if other trusts are learning from this example

· The team took a whole-hospital view of emergency care — it isn’t just an A&E problem, but one that should be dealt with all across the hospital

More good work from Radio 4, this time looking at how the Queen Elizabeth hospital in King’s Lynn is struggling with an estate that is literally falling down around their ears, and the effect that is having on hospital activity. Relevant clip is from 1:35:30. Shockingly, four out of seven operating theatres are currently closed, inevitably resulting in missed procedures. The trust is spending tens of millions to keep the building on life support (sorry) while they wait to hear if they have won a bid for a new hospital as part of the New Hospital Programme.

An interesting case study of the impact of a rising maintenance backlogs on hospital activity: the HSJ reports that the Princess Alexandra Hospital Trust are struggling to meet elective backlog recovery targets due to maintenance issues including “sewage overflow, outdated electrics and [leaking] theatre roofs”. Also worth noting that the trust was promised a new hospital under the New Hospitals Programme, which now looks set to be scaled back. A full-blown parable for the outdated NHS estate.

Talk of the New Hospital Programme got me curious about the government’s progress on its manifesto promises. Way back in 2019 that document promised “20 hospital upgrades and 40 new hospitals” by 2030. According to minutes from NHS England’s October board meeting, 40 hospitals have been identified for building. Of those, one has been completed and seven more are under construction. However, of the 40, 13 are labelled rebuilds, three more are a mix of new builds and refurbishments, and one more is a replacement for an “ageing” hospital. Not quite meeting the manifesto promise then.

Rumours have been swirling for a while that the government was planning to delay implementation of the lifetime cap on social care costs, and the Times reported (£) this week that Sunak and Hunt now plan to delay introduction until 2025. The article raises a suspicion that the government is using this as a way to “kill off” the reforms. For their part, the government are framing this as “we shouldn’t pay for wealthy people to keep their homes” (NB: directly contradicting every Tory government since 2010). Is this the right thing to do? Simon Bottery makes a compelling case for going ahead with the reforms here, and I largely agree with him: 1 in 7 people facing catastrophic care costs is not something we should accept. In addition, the amounts are relatively small: £1bn in the first year, rising to £2bn in the years after that. Compared to the “fiscal hole” this is not so much. Having said that, there is a case for a delay of a year or so as government works out how to properly fund the reforms, in partnership with local authorities. Key to that would be launching the reforms in the five ‘trailblazer’ authorities in January, as initially planned, and learning from their experiences.

We know that delayed transfer of patients from hospitals into social care is a problem, but this is a really good (anecdotal) example of the phenomenon in action: a woman in Norfolk spent five months in hospital having been declared fit for discharge due to a lack social care staff able to deliver care.

Children and Young People

This blog from SchoolDash and the Teacher Development Trust highlights the squeeze on school budgets from unfunded salary increases. This is a fair point — and is a problem that is not unique to schools — but the question I have in response is: what’s the alternative? No one is arguing that it’s good that schools are spending less on things like teacher training, schools maintenance or administrative supplies. But the counterfactual — not increasing wages in a tight labour market with rising inflation — would likely lead to worsening retention in a service that already struggles with keeping staff. The real problem to me is that the government is approving staff pay rises without properly funding them, inevitably leading to trade-offs in spending decisions. The same is happening in the NHS. The part of the post I found more interesting was the section on staff development spending, which fell 60% in real terms between 2018 and 2021.

Analysis from Education Datalab shows that teacher anxiety actually fell during the first wave of the pandemic. Digging a bit deeper, head teachers experienced far higher levels of anxiety than their colleagues throughout the pandemic, with the highest spike coming in January 2021, when the government was flip-flopping on whether or not to open schools.

Education Datalab also released a report showing that school attendance is higher this academic year than last. This is reassuring but maybe not surprising — high Covid rates still drove increased absences last year. The part that concerned me was the fact that absence levels have still not returned to pre-pandemic levels raising questions as to why, when Covid has more or less become endemic. This article in the FT attempts to shed light on the phenomenon. There are a range of issues at play here, according to the authors. First, persistent absence is more common amongst free school meal (FSM) children than peers (one-third vs one-fifth). Second, rising incidences of mental health issues amongst children after Covid is contributing to absenteeism: 1/6 children aged 6–16 had a likely mental health condition in 2021, compared to 1/9 in 2017. Nadhim Zahawi’s (remember him?) planned response — a “zero tolerance policy” that will see parents fined if their child is absent — demonstrates a lack of understanding of the core problem and risks criminalising already vulnerable families.

Refreshing to see the children’s care sector feature in John Lewis’s Christmas advert. The video has led many prominent figures to speak about their own experiences in the sector. See, for example, this interview with Lemn Sissay on the Today programme. Visibility of children and their experience matters, particularly in the context of findings from the Bright Spots programme calling for greater trust, co-production and listening to the views of children in care (also echoing this report from the Children’s Commissioner earlier this year).

The MacAlister review drew similar conclusions earlier this year, and the government is reportedly now ‘carefully considering’ its recommendations. In the meantime, the Association of Directors of Children’s Services published its interim report on safeguarding pressures. One of the most worrying findings is the estimated £778m budget gap — a deficit which is driven by high inflation and “exorbitant charges for children’s home placements”. The use of the word “exorbitant” in that last sentence is not an aberration; the report is strong in its language. Later, the report casts doubts on local authorities’ ability to deliver an effective service while funding the service with “short-termist and selective funding pots” and while contending with “private organisations profiteering on the back of vulnerable children”. Punchy stuff.

Two reports on vulnerable adolescents came out recently. The first from the Longfield Commission calls for a new Sure Start Plus for teenagers, which envisages a multi-agency response to provide bespoke assistance to families and children who need it. The second from the NAO found the government lacks a clear plan to assist vulnerable adolescents.

Finally, new research from Elaine Drayton and Christine Farquharson of the IFS shows that adjusting for inflation, that government funding for free childcare for young Children in England will be 8% lower in 2024–25 than it was in 2021–22. For more on challenges facing the sector see Claer Barrett’s recent article in the FT.

Law and order

The big news in law and order this week is the publication of His Majesty’s Inspectorate of Constabulary’s (HMIC) report on vetting, misconduct, and misogyny in the police. Prompted by the killing of Sarah Everard by a serving officer, it’s a pretty shocking read. It’s worth pointing out that the report finds that most police meet and exceed professional standards of behaviour, and that prejudicial and improper behaviour has declined. However, the report also finds:

· Poor practice at the recruitment stage, with forces adopting inconsistent processes that means some applications never face scrutiny

· Forces are not legally required to carry out certain professional vetting processes

· Some forces did not have enough staff to act on the risks found while vetting (with vetting units often under-resourced)

· Cases of sound vetting decisions being overturned without clear justification

· Poor evidence and information sharing between forces, raising the risk that one force may not even be aware if one of its officers is arrested by another force

· Failures by forces to establish whether reports of prejudicial and improper behaviour are part of wider behavioural patterns, and leniency in assessments cases

The extent of police abuse of powers raises a number of concerns. First, about the government’s police uplift programme, which has pressured forces to find more recruits than they could responsibly assess. Second, while many problems can be traced back to a lack of resource, a lot of the issues come down to relatively simple procedural and legal shortfalls around, for example, lack of a codified recruitment process across all forces, or lack of basic information sharing.

Local government

Some unions (though not Unite) have accepted a pay offer that equates to a 10.5% increase in the wages of the lowest-paid staff. Unions stress that this is still a real terms pay cut.

Worrying news that some local authorities are voluntarily topping up Homes for Ukraine payments with an additional £100-£250 per month. These payments are reportedly to encourage those who are hosting Ukrainian refugees to carry on doing so beyond the six-month window of the original scheme, amid concerns that some Ukrainians may become homeless in the coming months.

Thanks for sticking with us — a lot to cover in the last couple of weeks. Watch out for our coverage of the autumn statement at the end of the week.