Week in Public Services: 15th December 2022

This week: public sector strikes; reducing the elective waiting list; and trouble at Strangeways

General

Let it be known that neither sleet, snow, devastating defeats nor sweeping strikes will stand in the way of Week in Public Services — welcome back!

Let’s start with this article from Martin Wolf exploring the arguments for keeping public-sector pay down (that it’ll cause wage-price spirals, that the government can’t afford it, or that public sector pay is too high anyway). I’m puzzled by the first claim since (as per Martin) I’m not sure where the ‘prices’ exactly are in the public sector — I suppose you could make the case for economy-wide inflation, but then you’ve got to ask: where is the money coming from? Hint: it’s possible that taxes pay for it. Finally, public sector pay actually sits below private sector pay.

Tony Yates in the New Statesman makes a similar argument and sums up the situation we find ourselves in succinctly: “The real problem we are facing is the literal cost of living […] has gone up relative to everything else […]. Inflation was our chosen solution, not the problem. It was the least painful way for an unavoidable lowering in the real standard of living to happen.” Philip Aldrick makes an excellent point in this article: not reaching an agreement with public sector workers is also likely to end up being inflationary as repeated supply shocks drive prices up.

The ultimate message is that, when it comes to pay, you’ve got to consider whether it helps or hinders service delivery. We made a similar argument in May, arguing that pay increases should be based on recruitment and retention pressures (interesting add-on: anyone else noticed how wage-spiral advocates forget that the Bank of England exists?).

This platform doesn’t exist just to shamelessly plug Institute for Government work, but in this time of strikes and uncertainty, why not get some clarity with this explainer from Peter Hourston and Gemma Tetlow on public sector pay — a useful resource for understanding the profile of the public sector, how pay is set, and where pay levels currently stand.

Health and care

Sally Warren appeared on this Prospect podcast alongside Melanie Phillips to discuss alternative healthcare funding models. The debate was, to put it mildly, one-sided, with Melanie Philips arguing for shifting to an insurance model. As ever, there was no explanation of how changing the source of NHS funding would improve performance. Philips gestured towards improving patient choice, but choice requires capacity — a problem solved by the quantum of funding, not its source. On the other side, Sally Warren was excellent, calmly and expertly shut down the more outlandish claims. Definitely worth a listen if you like hearing an expert debunk unevidenced arguments.

Analysis by the HSJ (£, but Matt Discombe has a summary thread) shows the pilot trusts that adopted the test bundle of A&E metrics saw the fastest deterioration in wait times compared to trusts that retained the 4-hour target. Steve Black claims that trusts found it hard to manage A&Es because the new targets were so vague. Luckily, NHSE has backed away from ditching the 4-hour target.

Riveting report from the King’s Fund assessing which strategies worked in reducing the elective waiting list from the late 90s onwards and the lessons we should draw now. They split interventions into three categories: increasing supply, managing demand, and “management of waiting lists”, which includes two further, more nebulous sub-categories: “cultural and environmental factors” and “operational and practical factors”. The evidence from the lit review (by the authors’ own admission) is somewhat weak, including for interventions — such as separation of “hot” and “cold” activity — that the NHS is currently pursuing. There is also little evaluation from a value-for-money perspective, making it hard to determine where limited budgets are best directed.

What does all this mean for actually tackling the waiting list? I think one of the key insights from the report is that the political and economic context is markedly different now than in 1997. On the political side, Sunak’s is a government in its waning months, mustering coalitions on an issue-by-issue basis. In contrast, the early Blair governments had a clear vision, heaps of political capital, and a mechanism — the Prime Minister’s Delivery Unit (PMDU) — for pursuing Blair’s personal interests. The economy was also in a better state then, with rising tax receipts allowing for sustained investment in the health service. The level of investment to reduce waiting times is obviously a political choice, but the point is that it was an easier political choice to make in the late 90s when the fiscal picture looked rosier than it does now.

So what can we do given this context? The first type of intervention — expansion of supply — seems to me the most likely to have a considerable impact on waiting list numbers, and is explicitly mentioned as such in the qualitative work. But the context outlined in the previous paragraph essentially rules that out; the government is not willing to make the level of sustained investment necessary to substantially increase the supply of care. How about demand management? Well, arguably the NHS is already managing a lot of demand out of the system. They are discouraging referrals from primary care, either officially through extended use of Advice & Guidance (see p.7 of this NAO report for more) or through informally rejecting referrals. They are also more aggressively removing people from the waiting list, through more stringent validation removal criteria. A lot of this I think explains the IFS claim that 7.6m people are missing from the elective waiting list.

That leaves “waiting list management”. Among interventions that worked was close performance management of NHS chief executives by the Department for Health (DH) and the Prime Minister’s Delivery Unit and the deployment of the National Patient Access Team to hospitals that were behind the curve. On the former, interviewees described the immense pressure that DH applied to those in the NHS, galvanising improvement. It should be noted, however, that this did often lead to gaming of targets and manipulation of data. The potential effectiveness of this as an intervention is also brought into question by this claim in the report:

“Experts acknowledged that performance management was effective to some degree but that it was not sufficient by itself to deliver the 18-week target. For one thing, they pointed out the increases in NHS funding, which meant that while the […] target was challenging, over time belief grew that it was possible” p.52

In other words, don’t expect to rely solely on interventions from that third category, it will likely not have the same effect on a workforce demoralised by a financially unsupportive government.

The findings that close management of the NHS by DH helped reduce waiting times, makes this Times (£) report that Steve Barclay is making space in the DHSC offices for senior members of NHSE that much more interesting. Is this a deliberate attempt to ape some of the measures that worked in the New Labour years? One risk seems to me to be that while it will bring senior leaders in DHSC and NHSE closer, it will add distance between NHSE management and their own teams, who remain in South London.

On a slightly different note, the King’s Fund report must be politically embarrassing for the government as it was actually DHSC who commissioned the think tank to carry out the research. That makes lines like “cuts to NHS spending were part of the story of growing waiting times” and the repeated praise for New Labour painful for the government.

Speaking of New Labour, the government published the terms of reference for Patricia Hewitt’s review of the oversight and governance of ICSs. Amazingly the review is expected to publish interim findings by the 16th of December (!!!), a mere 10 days after the terms of reference were published. Astoundingly, the final report is due by the 15th of March. Speedy stuff.

A few other NHS things:

· BMA report on IT systems. One incredible statistic: the NHS loses 13.5 million working hours per year due to inadequate IT systems and equipment, though I would love to have some context for that number.

· Another report on Integrated Care Systems (ICSs) this week, this time from NHS Confederation. This is intended to clarify how ICS leaders can deliver on the goal of supporting social and economic development

· New IFS paper on NHS resourcing and performance. Nicely summarises the productivity problem that the service is facing, and echoes a lot of the work from Performance Tracker

The House of Lords Adult Social Care committee delivered their report on the sector and it’s a big one, at 150 pages. The paper aims to put people at the centre of care, encouraging co-production between carers and users of social care services, and the goal of users living what the authors describe as a “gloriously, ordinary life”.

Vic Rayner — Chief Executive of the National Care Forum — argues that ICSs should prioritise commissioning care from not-for-profit providers. Vic claims she was inspired by the Welsh government’s aim to eliminate profit from the children’s social care market — an initiative I hadn’t heard about, but which makes for interesting reading.

Children and young people

Gillian Keegan last week confirmed to the Education Select Committee that the Schools Bill — designed to reform the academy system — has been dropped. Keegan says that measures from the bill are still a priority including a register of children not in schools. An unsurprising move in some senses after opposition from the Lords and removing 18 clauses from the Bill in the summer. For full analysis of where this leaves the government’s reforms see this long read from Tom Belger.

Schools Week has a neat summary of Keegan’s other priorities, including: a physics and maths teacher apprenticeship, limited prospect of new grammar schools under her tenure, and DfE contingency plans to address strikes — including potentially measures similar to the pandemic to ensure continuing education for key workers’ children.

Fascinating interview with Nick Gibb. My reaction to the piece is mixed. On one hand, he is a man truly committed to his cause and, according to civil servants, an unusually diligent minister. On the other hand, his singular focus on phonics is almost manic. He also repeatedly claims that “more progressive” schools perform worse, without defining what makes a school progressive, or providing evidence that this is the case.

DfE eyes will no doubt have been paying attention to the strikes in Scotland as the SSTA and NASUWT unions on 24 November which saw almost all schools close. Despite this, and the planned strike action by the EISj and SSTA in January and February, Holyrood appears to be holding firm to its fourth pay offer to teachers.

The Education Policy Institute has a concerning report on the digital divide. In addition to describing the skills gap between students and the labour market, it also cites troubling trends for apprenticeships in the ICT sector and, no surprises, the challenges recruiting teachers to fill specialist ICT roles.

Schools Week has a really interesting article on the use of Integrated Curriculum Financial Planning (ICFP) to drive efficiencies in schools spending. The author claims the approach has the potential to save £1bn per year, though also notes concerns that it is just cost-cutting by another name.

Ofsted warned in its annual report that the workforce crisis in children’s education and care is hindering recovery from the pandemic. As Sian Griffiths noted on twitter some children are being placed on part-time timetables. Perhaps the area of greatest concern was the under provision of SEND services. Over half of all local authorities reviewed by Ofsted are reported to have significant weaknesses in their provision. For example as the BBC reports — only 60% of all Education Health and Care (EHC) plans are being issued within the maximum 20 week threshold.

Mirroring the debate held in the Commons, the House of Lords last week debated the MacAlister review. The discussion saw calls for less delay and to uphold the financial package suggested by the review. A notable intervention came from Lady Blake — former lead member for children’s services at Leeds — calling for urgent action on foster carers. In response the government promised a comprehensive implementation strategy due in the early new year… like many others… we watch this space.

Mithran Samuel has an in depth report on the children’s care sector in Wales — the only UK nation to have not commissioned a review of its social care services. Instead the Senedd is moving ahead with actions to improve safeguarding following a child practices review into the tragic death of Logan Mwangi.

Damning review of the Children’s and Families Act 2014 from the House of Lords. There are a lot of very quotable lines from the report, but the one that sums it up best is: “The […] Act has ultimately failed in meaningfully improving the lives of children and young people. Instead, it has […] languished as a result of a lack of implementation, inadequate scrutiny and incessant churn amongst ministers and officials”. Ouch.

Law and order

We’ve spoken a lot about police accountability in recent weeks — to settle any remaining queries, see this explainer I’ve written on the topic (no doubt the best summary you’ll find describing what police accountability is, what institutions support it, and where it currently falls short).

We really are — apologies in advance — in the pick of et these days, with the Public and Commercial Services Union announcing more strike action among HMCTS staff over the rollout of the Common Platform. The Platform is intended to be a shared interface to allow all parts of the criminal justice system to access and record the full details of cases, but its rollout has been dogged by issues like protective orders not reaching the police and warrants not reaching prisons. The strike involves court associates, so I can’t imagine this’ll do court backlogs any good. That being said, it looks like the platform itself was already seeing to that, with bugs causing case delays.

An exciting new inquiry into staffing issues in the prison system has been launched by the Justice Committee, looking specifically into why prisons are struggling to retain staff, the implications this has for prisoners themselves, and (crucially) how to improve staffing. Shortages in this sector are no joke — we reported this year that some prisons keep prisoners indoors for up to 22 hours a day thanks to staff shortages, while high turnover means fewer staff with the experience to manage potentially unsafe environments adequately.

We reported here on the government’s anti-fraud efforts. Julian Goldsmith has written this piece on the Economic Crime and Corporate Transparency Bill (which makes tackling economic crime — in part — the responsibility of legal regulators) currently working its way through parliament. Goldsmith makes intriguing point: take away ‘economic’ and you’re left with a very stark case of the government asking regulators to tackle crime instead of the police (Anyone fancy being locked in Ofcom HQ for stealing a phone?). Right or wrong, it seems indicative of the desperation with which the government is trying to adapt to the UK’s largest — and one of the least-investigated — crime types.

The prison place shortages we reported on last week might be set to worsen — at least they will if Manchester city council gets its way. Councillor Bev Craig told the MoJ that Strangeways prison is “not suitable for the significant remodelling or expansion it would need to meet modern day requirements for a prison…” (and no, I’m not about to reveal that that’s a quote lifted from 1990). While it seems like the proposal to move the inmates elsewhere is tied up with a desire to rid the area (the prison sits on an unambiguously named ‘counterfeit street’) of its general crime-y vibe in light of a new college campus opening in the neighbourhood, it’s unfortunately not surprising to read reports of rat infestations in parts of the prison.

I’d missed this, but similar issues are currently being mirrored at HMP Bullingdon, with the whole cast of staff shortages, overcrowding, and prison instability all in attendance. It is promising, however, to see that healthcare for prisoners has been classed good and improving in this Independent Monitoring Boards report.

Upstream in the crime sector, the Justice Select Committee put questions to the government’s prospective chair of the Judicial Appointments Commission last week, who signalled her intention to increase the diversity of applications to judicial roles. Diversity in this context refers both ethnic diversity (it won’t surprise you to learn about the very low proportion of black judges) and the pools from which judges are recruited (they’re usually barristers before, who are increasingly diversifying their portfolios given substantial decreases in legal aid). Given the scale of the crown court backlog, attempts to increase recruitment on both fronts are more than welcome — this is definitely a metric we’ll be keeping an eye on!

Hot off the heels of the Manston controversy, this EIN piece summarises a recent inspection report of Derwentside’s women’s immigration removal centre. It found several instances of sub-standard practice, including lack of consistent care provision for self-harm/suicide risks. And with poor data-recording practices, the true scale of the problems faced by detainees (many of whom have felt unsafe and have experienced unjustified personal intrusions) may be hidden.

Local government

The House of Commons Library released a review of statutory homelessness in England. It’s a very good overview of the duties that authorities owe, but also has some interesting insights. One standout thing for me was that the number of households owed a prevention order fell by a third between April and June 2020 as the government poured money into the “Everyone In” scheme.

This is a great stat from Jack Shaw and while only a single data point, highlights the squeeze that authorities face: the money that Cornwall County Council forecasts to raise from the 5% increase in council tax in 2024/25 (£14.9m) covers only about two-thirds of contract inflation for the same year (£21.4m).

· The government released the local government finance policy statement for 2023/24 to 2024/25. That’s a mouthful, but it’s basically how the government intends to distribute funding to local authorities. A few interesting things:

· First, it’s a two year settlement!!! (Though there is a slight caveat on this, in that it seems to be more directional than fixed for 2024/25, but that shouldn’t stop us from celebrating a genuinely good outcome for local government)

· The government aims to give all local authorities “at least a 3% increase in their Core Spending Power”. This will mean topping up those local authorities that aren’t as able to raise revenue from council tax as others

· There is also an awareness that shire districts won’t benefit from the social care precept so the government is extending the New Homes Bonus for at least one more year (it’s been “one more year” for a while now, so we’ll see how long that holds)

· It included a warning shot about levels of local authority reserves: “The government notes the significant increase in some local authority reserves over the 2 years of the pandemic. We encourage local authorities to consider how they can use their reserves”. Looks like the trend we observed in Performance Tracker has not gone unnoticed by government. It will be interesting to see if reserves have stayed high when the final revenue outturns come out later this month.

· The revenue support grant will rise in line with inflation — a pretty massive concession from the government

Overall, this seems like a good settlement to me, and one that addresses the concerns that we raised in our autumn statement analysis.

Institute for Government colleagues released a report comparing the sources of funding at a sub-national government level for a range of countries. The thing that stands out the most is how centralised the British state is, with local government having almost no tax-raising abilities beyond property taxes, be that council tax or business rates. Really great report, though I am biased.