Week in Public Services: 15th February 2023
This week: delayed discharge disappointment; a tussle over childcare; and council tax rises
General
One of the most important debates since the Rishuffle last week has been how to pronounce new departments’ acronyms. Are you team Dez-Nez, Dee-Snez, or (insanely) Dess-No? Answers on a postcard addressed to “Team ministers, IfG towers”. Good luck to colleagues in the trenches of that discussion. If I’m honest I’m still trying to work out DLUHC. I hear Duh-Luck and Dee-Luck in pretty equal measure and have plumped for flitting between the two noncommittally. Enlightenment on the issue is welcome.
The “bombshell” this week was the publication of a range of government expenses by Labour. After a lot of trailing, it was somewhat…underwhelming. I just don’t get this — much of the spending was on things such as hotels and meals out when politicians are travelling. Labour might be in power soon and what are they going to do, have ministers sleep on friends’ sofas? Not travel to summits at all? This is all pretty necessary stuff. I know they’re a political party and this is a political attack line, but it feels like the most likely response from the public will just be “all politicians are as bad as each other”. And like clockwork, the Tories then shone the spotlight on Angela Rayner’s own expenses a matter of hours later. Anyway, Tim Durrant has more coherent and reasoned thoughts than me here.
Linking to two threads from the IfG ministers team in one week? This blog risks become “Week in Team Ministers”. (Luckily that doesn’t have the same ring to it).
Quick, let’s talk about strikes, before things get too team ministers-y.
The Guardian reports that the number of days lost to strike action in 2022 was higher than any year since 1989–2.4m last year compared to 4.1m in 1989. Given declining union membership since the 1980s, this feels like a pretty stark demonstration of the discontent in the British workforce. And as ever things look likely to worsen in the coming weeks with the RCN now asking members working in emergency departments, intensive care, and cancer wards to join a series of 48-hour (up from 12-hour) strikes in the coming weeks.
This Mariana Mazzucto interview in the FT (£) also caught my attention. The focus of the interview is her and Rosie Collington’s new book, the Big Con, which argues that management consultants have no place in government. One of their key arguments — that the use of consultants means that the civil service never builds up its own expertise — is a very IfG-ish point and one I tend to agree with.
But she also heads into other areas, making the case that government needs to be more ambitious and is often hampered by Treasury cost-benefit analyses. That point resonates given government and HMT reluctance to invest in services. How would, for example, investing in the NHS improve population health outcomes? Or how would expanding lifelong learning impact productivity? The lack of answers to these questions seems to mean that they are ultimately dismissed or side-lined.
Health and care
The IFS have another report out looking at the state of the waiting list one year on from the launch of the backlog recovery plan. A key insight here is that elective activity actually only needs to increase by 20.9% compared to pre-pandemic trends, rather than the previously targeted 30%. The difference is driven by fewer people joining the list, with advice and guidance meaning that more people receive treatment in primary care. Despite that lower activity number, the authors (and this author) are pessimistic of the NHS’s chance of hitting that level of activity by 2024/25.
Speaking of the elective waiting list, results for December were published this week. The headline is a slight rise (15k) in the number of incomplete pathways, following an unexpected decline in November. Some thoughts about the causes in my thread.
We also now have delayed discharge data to 5 February, 4 weeks on from the government’s announcement of an additional £250m of funding to speed up hospital discharge. So, did it work? The HSJ points out that total numbers have stayed more or less the same with a -1.7% decline in total numbers and -0.2% for those in hospital more than 21 days.
But those totals mask a lot of variance between ICSs, with 17 (40.5%) seeing an increase in the number of people remaining in hospital at the end of the day, despite being eligible for discharge. Of those, two had delayed discharges rise by more than 40% (Bedfordshire, Luton, and Milton Keynes ICS and Birmingham and Solihull ICS) while Frimley Health and Care ICS rose by 89.2%.
In some ways this shouldn’t be that surprising. I pointed out in my report a few weeks ago, that this type of short-term, emergency funding is unlikely to have the desired impact for a range of reasons. It could also be that the effects of this funding will be seen over the next few months, but that will still mean it didn’t alleviate pressure during winter as intended. The government should really be investing money well in advance for it to be spent most effectively. We’ll have to see if they learn their lesson next winter.
More analysis of ICSs, this time from the House of Commons Public Accounts Committee (PAC). They find that effective implementation of ICSs is at risk due to short-term pressures of the ongoing crisis. There is also valid (in my opinion) criticism of the lack of focus from national policy makers on preventing ill-health. They also highlight the lack of oversight of ICSs — a topic that is the focus of the Hewitt Review. Interesting thread from Sally Warren reviewing the report.
RCN have a new report looking at which factors impact retention of nurses and what the government should be doing. The data around the types of nurses that are leaving the service is concerning: 20% of nurses with less than 10 years’ experience left the Nursing and Midwifery Council’s register in the 12 months to September 2022. In terms of reasons for leaving, 70% of those thinking about leaving claimed that “feeling undervalued” was a contributing factor. It does feel hard to see how much of this will be resolved without a more generous pay deal, though the report points out that isn’t the only driver.
Dr Gordon Caldwell posted a document recounting experiences of poor integration of IT systems and processes in hospitals that hamper productivity from his 40 year career in the NHS. As Steve Black points out, it’s hard not to agree with the view that investing in these areas could improve performance in the service after going through the list.
The Observer published a story about NHS staff, in particular consultants, operating private providers that the NHS is commissioning for elective activity. A lot of the article is a bit hysterical, calling this “backdoor privatisation”, which it is clearly not — the NHS has always used independent providers, and while the amount of procedures have increased, it is still a fraction of total activity. And those providers have always to some extent been staffed by moonlighting NHS staff. What’s more interesting to me is the conflict-of-interest point; there should clearly be better processes in place to prevent hospitals in which consultants have senior leadership roles commissioning care from private providers run by those same consultants. But that isn’t insurmountable.
On the same article, Alison Moore argues that doctors will continue to take more work in the independent sector for as long as the current pension rules disincentivise them from increasing their NHS hours.
The Times ran a piece (£) over the weekend profiling a number of GPs and GP support staff. A couple of interesting (though anecdotal) points. First, it describes the implementation of “immediate triage” in December last year. I think this is a good example of how — despite a lot of commentary about how sclerotic the NHS is — the service is actually responding quite innovatively to the ongoing crisis, albeit in a diffused and disconnected way meaning there is likely duplication of efforts. Second, it supports other anecdotal reports we’ve had of worsening acuity of patients.
The Local Government Chronicle (LGC) reports that of the 52 attendees at the prime minister’s NHS Recovery forum, only 13% had “working knowledge” of the adult social care sector. There were no representatives from the LGA, SOLACE, or ADASS either at the meeting, despite social care and delayed discharge being one of four focuses for the discussion. While this is in some ways not surprising — the forum was for NHS recovery — I think it is right for local government leaders to complain. Adult social care has received disproportionate levels of blame for delayed discharge this winter and that narrative is unlikely to be challenged without representatives from the sector in the room.
Children and young people
John Dickens at Schoolsweek published a great tracker showing which of the 42 policies announced in the schools white paper has survived. By his estimate 11 have been delivered, 8 are on track, and 5 are delayed, with the remainder scrapped or unclear. This includes two key academy proposals on academisation and plans for council spin-off MATs which John outlines in more detail here.
FFT Datalab published analysis of school attendance during the teacher strike on 1 February. Overall, secondary schools saw much lower rates of attendance than primary schools, and disadvantaged pupils were more likely to be absent than their peers. Though it should be noted on this second point, the difference in attendance between more and less disadvantaged pupils is similar to the proportion on non-strike days.
Academy trust finances were under scrutiny last week with a report from the Kreston academies group. A Schoolsweek story shows fewer trusts are in deficit but a small number of standalone primary schools are struggling with large deficits due to capital and maintenance costs. But hold off on those micro violins — 11% of trusts have more than 20% of their income in reserves, a threshold criticised recently by PAC, and more trusts are taking a higher “top slice” of funding from school income. In other reserves related news, Schoolsweek also report that government has permitted councils seeking multibillion pound bailouts in the SEND sector to take “surplus reserves” from schools to plug their funding gap.
The government published its State of the Nation 2022 — children and young people’s wellbeing report. It shows that wellbeing recovered to near pre-pandemic levels by 2021, and has remained relatively fixed in 2022. Yet as TES highlights there has been inconsistent recovery in mental and physical health, with schools concerned about the volume of mental health work they now face. Worth perhaps then looking at the Help at Hand service from the Children’s Commissioner.
This week Westminster saw a very public tussle between DfE and the Treasury over childcare provision proposals. For context, the UK has the highest childcare costs in the OECD and calls to reform the system as we get close to the next election. Even the CBI are now lobbying for greater childcare provision. DfE’s reported solution was a 30-hours-a-week entitlement to parents with three year olds. The Treasury appears to be unmoved, pouring cold water on the £6bn proposal and is considering other options.
Finally as the children’s social care sector continues to process the government’s long term strategy, the LGA have this excellent summary. See also this great coverage from Schoolsweek which includes critical commentary on the speed of reform from the former children’s commissioner Anne Longfield and Josh MacAlister. In linked news, Community Care reports on a new national workload action groups aimed at reducing unnecessary burdens on practitioners.
Law and order
A pretty slim week on the legals I’m afraid. We’re saving our energy in that department for our analysis of Yvette Cooper’s speech at the Institute for Government tomorrow, which you can find here.
Kirsty Brimelow, Richard Atkinson and Zoe Byrne gave evidence to the Home Affairs Committee for their policing priorities enquiry. Kirsty Brimelow (Chair of the Criminal Bar Association) kicked off with a particularly interesting account of the effects of inexperienced police officers on demands on legal staff. Particularly in the case of fraud investigations where prosecution counsels are apparently becoming involved at earlier stages of cases to make up for shortfalls in the investigative capacity of new officers.
Although this is news to no-one, Wayne Couzens has finally pleaded guilty to a series of alleged indecent exposures, one of which occurred only days before he murdered Sarah Everard. This write-up analyses what we can infer about police performance. It’s damning to learn that nothing was done on several occasions despite full details of these incidents being passed to the police. First, it’s a particularly stark example of the all-too-common failure of forces to recognise patterns of behaviour associated with certain crime types. Jennifer Grant (a criminologist at Portsmouth) argues that we need to take indecent exposure more seriously, and potentially as the first sign of escalating behaviour.
This example of the procedural shortcomings when investigating sexual assault by an officer astounded me. In her evidence session, Zoe Byrne recounted an incident in which an officer was accused of rape, with the case then being investigated by the suspect’s own colleagues. How is a victim supposed to expect a fair investigation if the police do not address these sorts of basic procedural issues?
Local government
It looks like central government has granted special dispensation for Croydon, Thurrock, and Slough councils to raise council tax by more than the precept, following major financial mismanagement in all three authorities. Thurrock and Slough will raise rates by an additional 5% and Croydon by an additional 10%. While the councils clearly need additional funding to drag them out of their financial holes, it seems absurd to shift the burden onto residents. And as Gareth Davies points out here, Thurrock will only raise £3.75m to fill a budget blackhole of £500m — a small amount for the government, but a heavy burden for residents during a cost of living crisis. On another note, what’s the point of the requirement for a referendum on council tax rises if central government can circumvent it? It appears that councils can’t raise rates by more than the precept unless they’ve overseen gross financial incompetence, in which case, no problem. This is a ludicrous decision by central government and all to save them a measly amount of money.
Among local authorities that haven’t cratered their finances through mismanagement, the Local Government Chronicle reports that 7 in 10 have decided to raise council tax by the maximum allowed under the precept. These findings from LGC were mirrored by research from the County Councils Network which found among the 84 councils to have published their 2023/24 budget proposals, 75% have proposed to increase council by the maximum amount. This is a substantially higher than in 2020/21, when only 45% increased council tax by the maximum, but still well below the government’s assumption in the Autumn Statement that 95% of authorities would. Given so few councils are using the maximum precept, can the government now drop the pretence that it is putting an additional £7.5bn into adult social care over the next two years?
Along with the machinery of government (MoG) changes announced next week, Jeremy Pocklington is moving on from his role as Perm Sec at DLUHC. He’ll be replaced by the current Perm Sec of DCMS (Sarah Healey), whose old job he will be filling.
The FT reports that HMT has taken increased control of DLUHC’s finances, with the Treasury now having to approve all capital spending decisions. This is apparently because of concerns about DLUHC’s ability to deliver value for money. This looks distinctly like another nail in the coffin of levelling up.
Really interesting piece from the Bennett Institute which attempts to value public parks. As with other goods that are provided for free, this is a difficult task given the, you know, lack of a price. Instead, researchers carried out three surveys in February 2020, May 2020, and February 2021 across different regions of the country, asking them how much they’d need to be paid to go without a park for 12 months. They found that the value of parks increased throughout that time, likely because people used parks more frequently during lockdowns. I’d be really interested to know how (or if) this has changed since the end of lockdown. From a public services perspective, this is really important work as it provides a more concrete “cost” incurred by a local authority if it closed a park in its area, which, while unlikely to prevent cuts, at least improves a value for money conversation.
