Week in Public Services: 18th January 2024
This week: what to expect in 2024; good news on the elective waiting list; and Ofsted under new management
General
New year, new government? That could still be a long way off. Sunak has seemingly confirmed that the election will not be until the autumn at least. For what it’s worth, my date in the IfG election sweepstakes is December 12, though I now think that’s a little late.
Whenever the election will be, it is still some way off. There are a lot of issues in public services that will grab headlines before then. In no particular order, here are the stories that I think will be the biggest this year:
1. Industrial action. This is an easy one. The junior doctors just concluded the longest ever walkout and 58% of consultants in the HCSA union voted to reject the government’s pay offer. If that result is replicated in the BMA ballot, it will mean consultants go back on strike. The big question for me is whether or not nurses and other NHS staff will re-ballot, given that their pay deal now looks paltry compared to what the government offered doctors. Nurses on the picket line weeks before an election is not a good look.
2. RAAC. The story that crumbles on. The MoJ closed the magistrates court in Blackpool this month and that is unlikely to be the last public building to be closed. This is probably quite a damaging one for the government, as a consistent stream of surveys will mean more closures of schools, courts, hospitals, prisons, etc.
3. New GP contract. This is a bit of a nerdy one. But the five year contract that started in 2019 expires this March. The BMA is negotiating a new one, though it is likely to only be a one-year holdover. That doesn’t mean there isn’t the potential for a few fireworks.
4. Local government section 114 notices. More on this below, but the government is desperate to stop the steady drip of bankruptcies and seems willing to let councils sell their assets to prevent any more headlines.
5. Unrealistic spending plans. Both parties have signed up to post 2024/25 spending plans. Those are, frankly, a fantasy that no government would countenance. Is either party going to be honest with the electorate about the trade-offs they’d involve? The optimist in me hopes so, but the realist in me suspects that it’s too electorally risky to be the party that says spending is too low.
Right before the new year the IPPR published a report on public service reform, which naturally excites us all here. The report pours cold water on hopes that an incoming government can quickly turnaround performance; they predict that it will likely take at least 10 years for the NHS to return to 2010 levels of performance, even with an increase in investment. It’s not all gloom though. The report argues that we need a ‘smarter state’, with public service reform moving away from new public management techniques like top-down targets to the ‘3 Ps’: prevention, personalisation and productivity.
It’s a really thorough report and makes a compelling case for a deep-rooted change in how public services operate. I’m especially interested in the first P, prevention, which focuses on how to shift spending away from acute services and towards preventative services (a question we’re working on ourselves at the IfG currently, so watch this space). The report recommends the creation of a new prevention spending category, PIE (similar to the proposal for PDEL that Demos and the Health Foundation made last year), but I’m somewhat sceptical that this will result in the Treasury actually setting aside funding specifically for prevention. I’ve got even greater reservations about another of their recommendations for greater automation in public services: AI. They estimate that implementing AI could save the government £24 billion a year. But for AI to really have an impact on public service productivity, you would need to have well-functioning IT systems first.
Health and care
For an optimistic start to 2024, it’s worth reading this blog from Paul Corrigan. He argues that pessimism about the impossibility of reform in the NHS is unfounded, partly because he was involved in New Labour reforms that massively improved NHS performance in the noughties. He argues that if the government wants to shift NHS spending towards prevention, it should create a financial structure that incentivises that behaviour.
In the last edition of Week in Public Services, we shared a Times article which described a productivity-enhancing procedure of running concurrent operating theatres in St Guy’s and St Thomas’. I wondered at the time why this process isn’t used more widely and it seems that Steve Black had the same question. He identifies a few reasons in this article. At the margin is a lack of incentives for individual doctors to take on more NHS work, particularly when it might reduce their private income. Steve argues that more impactful than that is a cultural resistance to new ways of working. Finally, a lack of operational (that’s how the hospital is run, not surgical operations) managers makes it difficult to identify and implement these kind of changes.
This is an interesting study about the safety of remote GP appointments. The authors’ first finding was that there were very few serious safety incidents that arose from remote encounters; they identified 95 between 2015 and 2023. In the context of the hundreds of millions of telephone appointments that GPs have delivered since the start of the pandemic, that does seem low. Where incidents did occur, the researchers identified difficulties communicating and subsequent lack of rapport and information as key drivers of error. That’s interesting work in the context of a sharp rise in the proportion of appointments delivered either online or by video in 2023.
Last week was the monthly NHS activity data release. The big news is that the elective waiting list fell by 96k, to 7.61m. That’s the largest (non-Covid) fall since December 2010, though obviously still leaves the list very high. It’s also worth pointing out that November is a month in which the list typically sees large falls (as the chart below shows). But we should still be celebrating some good news in the NHS. Even better is that the improvement is driven by an uptick in activity. Though as Charles Tallack points out in this great thread, the main driver of the fall is relatively low levels of additions to the list. We talked about this in last year’s Performance Tracker, and identified increased use of demand diversion methods like Advice & Guidance as a key driver.
This story has caused a bit of a hubbub on medic Twitter. A GP surgery in Surrey made three of its 11 salaried GPs redundant. They claimed that this was due to changing demand and by taking advantage of “the wider team”, by which they mean new pharmacists, advanced nurse practitioners, and other additional roles reimbursement scheme (ARRS, still the worst acronym in the NHS) staff. That last point is the one that has proved controversial. Some on Twitter argued that this is evidence that practices are increasingly inclined to replace salaried GPs (whose salaries are paid for out of the general GP contract) with ARRS staff (whose salaries are covered under the ARRS scheme). I have no idea if this is a wider trend or not, but there is an argument that having separate funding pots creates strange incentives.
As ever, Steve Black provided some balance to the discussion by pointing out that this particular surgery had a relatively high number of salaried GPs compared to the size of its patient list. He argued that it might actually be a benefit for the area as a whole, as the GPs who had been made redundant might go to a practice with many more patients per GP, thus evening out some of the disparities.
The Institute of Health Inequality (led by Michael Marmot) released a short report into disparities in pre-pandemic excess deaths across England. The main finding is that over a million people died earlier than expected when compared with mortality rates in the most affluent areas. The disparity caused by deprivation is stark: over 220,000 more excess deaths occurred between 2011 and 2019 in the most deprived decile than in the least deprived. Marmot described the findings as a “dismal state of affairs”, with the UK even being an example of what not to do on health inequality.
This is a fantastically well researched and written article in the FT (£) about mental health provision in the NHS. They point out that increasing amounts of care is being outsourced to the private sector, because of a lack of public provision. In contrast to other areas of NHS outsourced NHS care (e.g. electives), it is generally the more complex cases that end up with private providers. That creates some worrying incentives. The authors report this chilling quote: “[private providers] do have an inevitable business interest to keep people in [long stay] beds”. There’s lots more in there, so worth a read.
This is more of a policy-world article, but one I nonetheless found really interesting. Thea Stein, the chief executive of Nuffield Trust, published a blog post looking at why policy discussions about NHS productivity are often not that constructive. Her points are really good. People in the policy world might publish what we hope is constructive research. But for those working in delivery bodies like NHSE, that research can come across as an accusation and attack. That makes them less receptive to our work and means we’re often talking past one another. Food for thought.
Children and young people
Sam Freedman gives his view of what’s in store for education in 2024. He argues that education is not likely to be a key battleground in the election. If Labour wins, Sam expects that there will be a flurry of reviews, in lieu of substantive policy, combined with a headline-grabbing announcement on VAT for private school fees. But he is pessimistic about Labour’s ability to quickly address any of the major issues in schools — a crumbling estate, deepening pupil poverty, persistent post-Covid absence, and deteriorating mental health — in a constrained fiscal environment. Cheery reading.
Sam’s also suggested how Ofsted could reform school inspections in this report, right on time for the new chief inspector Sir Martyn Oliver. With Ofsted coming in for a lot of critique in recent months, he’s given several practical recommendations about how to improve the inspection process. He calls on Ofsted to respond as soon as possible to the coroner’s report, expand training for inspectors, and commission an independent report on its inspections as the first steps to restore trust with schools. Sam raises the important point that the DfE is ultimately responsible for implementing longstanding changes to inspections — especially surrounding the ‘requires improvement’ judgement — and that the department should grant sufficient funding for Ofsted to improve inspection quality.
Right on cue, Sir Martyn Oliver jumped into the new year and his new role with a media round, declaring his intention for inspectors to be “far more empathetic” and announcing a halt to non-emergency school inspections for much of January while inspectors receive training in wellbeing and mental health. He also stated that he would be “more open, less defensive, to accept the criticism” from teachers — all easy things to say in the first week in a new job.
Tes Magazine reports that the DfE is seeking to boost international recruitment of teachers to fill the high number of vacancies in the sector. With one in 10 state school teachers leaving their jobs in the last academic year and the number of trainee secondary school teachers well below target, the DfE told an expert advisory group that it aims to assist schools to “make the initial short steps that can make them more likely to recruit internationally.” Reaction to this is mixed: the chief executive of the National Institute of Teaching doesn’t dispute the merits of international recruitment to address shortfalls, but makes the equally valid point that schools benefit most from teachers “who stay long enough”. Increasing recruitment solves one problem affecting the education sector, but retaining teachers in the classroom is just as important, if not more, and there’s very little indication on how the department will address the reasons they leave (though I could point them in a helpful direction here).
This follows a similar pattern to the health and social care sector, which has increasingly relied on international recruitment to fill workforce gaps. School leaders should be wary about becoming too reliant on international staff, as last year proved that that source can be cut off very suddenly, depending on political whims.
Law and order
2023 was another grim year for prisons in England. The prison population reached its highest level since 2011 (see our last Performance Tracker for the full details) and the extent of overcrowding has led to more focus on addressing reoffending. Just before the new year the chief inspector of prisons, Charlie Taylor, called for a “fundamental reorientation” towards rehabilitation and education as the only realistic means to reduce reoffending. The Independent points out that one of the major barriers to rehabilitation is homelessness: despite a government support scheme running since 2021, over 11,600 inmates became homeless immediately upon leaving prison. The lack of a stable address raised the likelihood of breaching licence conditions and being recalled back to prison. Transform Justice had a great podcast on the same topic.
I found this thread comparing the Met and the New York police department (NYPD) quite interesting. The author points out that New York has far more police stations than London — a gap which has grown since the start of austerity in 2010. The NYPD also has more officers per resident than the Met (425 vs 375, respectively) but more than double the number of staff per head (224 vs 111). That latter stat is an interesting indicator as to the lack of support that frontline officers receive, leaving them with more admin work than they should have to do. Finally, victim satisfaction with the NYPD (putting aside likely difficulties with comparing) is much higher than with the Met: 92% vs 66%.
The government is pushing ahead with its Rwanda policy (despite the PM not believing that the plan would) and the Times now reports (£) that Sunak plans to deploy 150 judges and free up courtroom space to fast-track migrant appeals against deportation. This announcement immediately hit a snag in the form of a reminder from the Judicial Office that any deployment of judges is a matter solely for the judiciary and not the prime minister. The lady chief justice reiterated this. Even if the prime minster had the power to do so, it would only worsen the existing backlog of cases across the courts system, which as former lord chancellor Jack Straw points out (helpfully referencing us) reached record levels for crown courts last year.
Local government
The government slipped out a consultation alongside last month’s local government finance settlement which proposes greater flexibility for local authorities to use capital budgets and receipts to meet spending pressures. This sounds technical but is very important. Currently, local authorities have to seek permission from central government if they want to shift spending from their capital to their day-to-day budget. That’s known as a ‘capitalisation direction’. Generally, the government is loathe to grant those directions, though it has increasingly done so in response to the rise in section 114 notices. These new powers would allow local authorities to go ahead and do that without asking the government.
I’m in two minds about this. On one hand, I’m generally in favour of less ringfencing and more flexibility for how local authorities use their limited budgets. On the other, I’m very sceptical about the sustainability of using capital budgets or the proceeds from the sale of assets as a way of funding ongoing day-to-day spending. Not to put too fine a point on it, but you can only sell a building once, while the demand for social care is not going away any time soon. If I was being cynical (difficult to imagine, I know) I might see this as the government’s way of preventing any more s114 notices between now and the election, without having to commit any more money or meaningfully reforming the sector. Jack Shaw has a much more thorough and thoughtful take in a blog for UK in a Changing Europe.
Somerset council has warned that unless the government grants them permission for a 10% council tax increase in 2024/25 and/or a capitalisation direction, they will have to issue a s114 notice. This raises a couple of interesting questions. Well, interesting to me at least. Normally the government only grants those measures if an authority has issued a s114. But if government refuses to grant them to Somerset before they issue a s114, would it then almost instantly change its position after Somerset issues a s114? If they grant them beforehand, then does that render a s114 almost meaningless? Could it lead to a spate of authorities reaping the “benefits” of a s114, without ever having to issue one?
