Week in Public Services: 1st December 2022
This week: final call for autumn statement analysis; GP contract renegotiation; and local authority financial mismanagement
General
I know, I know, the autumn statement was two weeks ago now, practically ancient history in Westminster terms. But we here at the IfG just can’t seem to let go. We published a report last week, in partnership with CIPFA, on what the statement means for public services, as an early Christmas present to all of you (now it’s December I had to get a Christmas reference in somehow). No doubt you’ll all read it from title to endnotes, but a brief summary nonetheless:
· Increases in overall spending are front-loaded, and are followed by low/negative allocations from 2023–25
· The govt’s inflation measure understates the costs departments will face (thanks to the famed GDP deflator, which we wrote about in more detail in last week’s edition)
· Increasing pay in line with private sector wages seems like a good way to stave off recruitment and retention issues, but means less money for the non-wage cost pressures (ambulances/maintenance/beds etc)
· Services receiving more money — hospitals/GPs/schools/local govt — will be able to meet demographic demand and inflationary pressures but little else, with performance levels unlikely to return to pre-pandemic levels even with additional funding
· Demand for criminal justice services will outstrip spending by a hefty margin, which is bad news for prisons and courts in particular, which face enormous backlogs and staffing pressures
The Institute’s own Gemma Tetlow also appeared on this IFS podcast to discuss the autumn statement. It’s a whirlwind all-you-need-to-know tour of the current fiscal landscape, with some useful dives into the near-past. Particularly informative is the discussion at about 13 mins, in which Gemma provides a concise summary of the very human cost of public service cuts — a much needed lesson for the £22 billion in cuts pencilled in from 2025/26 to 2027/28.
The markets seemed placated by the autumn statement, moving very little in its aftermath. But in case you were wondering what the most important audience — and by that I only half-ironically mean Tory members — thought of the statement, polling from Conservative Home shows approval ratings for Sunak and Hunt dropped substantially after the autumn statement: from +50% and +30% for Sunak and Hunt respectively in October, to +9% and -10% in November. Yikes. I don’t want to tempt fate by idly wondering if the Tories could try to install their fourth PM in one year over the next month.
Away from the autumn statement, the FT published a free to read article called “Backlog Britain”, looking at, unsurprisingly, high and rising backlogs in public services. A lot of the work reflects what we found in Performance Tracker, including the elective backlog, cancer wait times, and the courts backlog (that’s only a slight note of bitterness at the lack of a citation) but also extends into other areas including children and adolescent mental health, social security claims, and the asylum applications (another area where an IfG colleague has written an excellent explainer and accompanying thread).
Health and care
There seems to be a lot more chatter in the press these days about a number of zombie ideas for improving the NHS, for example: charging for GP appointments, reducing the number of NHS managers, privatisation of the NHS, and calls for always-undefined reform. I would spend time responding to each of these “ideas”, but don’t want to inflict an aneurysm on myself or a 20,000 word blog post on you. Luckily this thread from Nigel Edwards provides some measures that could actually make a difference. Well worth a read, and useful for when a boozy uncle inevitably suggests privatising the NHS this Christmas.
The NHS has reportedly (£) told secondary trusts to “be robust” when assessing GP referrals, in other words: rejecting more GP referrals. This isn’t surprising, given the finding in the NAO’s report that demand is being managed out of secondary care into primary care, but does show that the NHS’s priority remains keeping people off the elective waiting list, even if it means adding pressure to primary care. This tweet from Craig Nikolic sums the absurdity up nicely.
The FT wrote up this profile (£) about how Addenbrooke’s hospital is improving productivity. Their improvement measures fall into two buckets: better work allocation among staff; and technological innovation. As an example of the former, the hospital trained nurses to read endoscopy scans — a task that would previously have fallen to consultants. The result was more people treated within targeted timeframes. On the latter example, a doctors created a video consultation system that allowed primary and secondary care to consult before a referral was made. The result was both less GP time spent on referral letters and fewer unnecessary referrals into hospital. Now just need to roll these changes out across the NHS.
Bill Morgan (now a №10 SPAD) published his report exploring the reasons for persistent workforce shortages in the NHS. Most of the findings — HMT’s concerns about cost, professional bodies protecting existing members’ interests, difficulties in forecasting both demand and technological advances — will not be new to anyone who has been paying attention to the debate in recent years. As solutions, he suggests making workforce forecasts more transparent (something Hunt committed to in the autumn statement), an independent body (*OBR klaxon*) for workforce planning, and accepting more international recruitment. All of these are sensible recommendations and his caveats about the difficulties in implementing them are largely correct. But overall I think the report is too narrow in its focus. Morgan acknowledges that adult social care staffing is outside the scope of the report, but even within the NHS, attention remains firmly on secondary care. General practice is only mentioned twice (both times in passing) in the report, and there is no mention of community care. Primary care in particular should be an easier part of the NHS to plan for, given that there is a single specialty (GPs) and little likelihood that they are going to be innovated out of existence. Yet, there is no engagement with the question of why there is still a workforce crisis in that profession.
Given the above paper’s recommendations, the House of Commons Library report on NHS staff from overseas is interesting reading. One thing that jumped out to me is that the number of EU staff has actually grown since 2016 (though the authors do say this could be because we now know more people’s nationalities), and has remained relatively flat as a proportion of total staff (5.5% in June 2016 compared to 5.3% in June 2022). This does reverse the trend of an increasing proportion of EU national working in the service before the referendum, but certainly does not show an exodus that we might have expected given the increased difficulties of working in the UK. Maybe even more shocking is the precipitous decline in the proportion of staff from the UK between June 20218 and 2022: a decline from 87.3% to 83.5%, which reflects a trend we spotted in Performance Tracker.
Similarly, this piece by the Nuffield Trust looks at the effect of Brexit on workforce recruitment from EU/European Free Trade Association countries. While the authors pin slowing recruitment in various specialisms on Brexit, 2014/15 seems to be when recruitment trends start slowing. Take doctor specialists, whose numbers grew by about 6.3% per year from 2010 to 2014, compared to around 3% per year from 2016 to 2019. A big slowdown, sure, but the deciding moment seems to be from 2014 to 2016, where growth was about 2.4% per year. As the authors acknowledge, it’s interesting to consider the effect the campaign itself may have had on medical recruitment.
Thought provoking blog post from Sally Warren about the leadership role politicians can take on health issues. The catalyst is Labour agreeing with the government on delaying the ban on buy-one-get-one-free deals — a policy designed to combat obesity — because the public don’t support it. Sally points out that politicians ended up lagging public opinion in the 2000s as they repeatedly underestimated the public’s appetite for a ban on smoking indoors. Her point is a good one: Labour could make political hay by taking a stance on obesity that is potentially unpopular now, but could be in the mainstream of public opinion very soon.
James Illman reports that the government is ditching NHS England’s bundle of proposed alternatives to the 4- and 12-hour A&E wait targets. This is good news. There is definitely an argument for reassessing some of the NHS’s extensive range of targets, but the 4-hour target has been one of the most effective targets since it was introduced, both in terms of improving performance in emergency departments, but also subsequently in improving mortality outcomes for patients.
On the topic of four-hour A&E waits, Martin Rosenbaum released some FOI’d data about average wait time in A&E by trust. Steve Black had an accompanying thread pointing out some interesting insights. Relevant to the above announcement that the new A&E metrics are being abandoned, Steve shows that those trusts which were piloting the targets didn’t perform markedly better on wait times compared to other trusts, though that also doesn’t take into account any improvements within those trusts since adopting the new targets. Overall, a really great set of data and one that the NHS should publish themselves.
The Health Foundation has this piece on ambulance waiting times, which have been increasing across all incident categories since the start of the pandemic. Contributing factors include: higher proportions of calls for the most serious (e.g. life-threatening) incidents; workforce sickness, which contributed to a 4%-point capacity reduction between March 2019-March 2022 (a fifth of sickness absences are attributed to mental health); higher handover times from the ambulance to the hospital, which means the ambulance has to wait longer before getting back on the road. Interestingly, recommendations include investment in mental health services to reduce ambulance demand from those unable to access care elsewhere.
In general practice, this is the first week that the NHS released practice level data on GP appointments. The idea here is to (a) name and shame ‘low-performing’ practices and (b) improve ‘patient choice’. But as Jake Beech points out in this thread, we should be careful leaping to conclusions from this data for a few reasons. First, data collected from practice IT systems (as this dataset does) is patchy, leaving an incomplete picture of appointments at a practice level. Second, appointments take up a lot of GP time, but by no means all of it (PRUComm estimates that it’s approx. 60%). This dataset risks penalising GPs forced to spend less time on appointments due to, for example, having to write more referral letters.
The government is asking GPs to “prescribe” people heating this winter. I don’t really know where to start with this one. On a personal note, it feels like a truly dire indictment of this country that people have to prove a medical need before they can access what should be a basic right. With my public services hat on, this is an immense waste of already-stretched GPs’ resources at a time when it has arguably never been harder to get a GP appointment. From the perspective of patients, this means more competition to see a GP, while those who need heating will struggle as much as everyone else. Helen’s thread sums up my feelings more eloquently than I can.
If anyone thinks it’s a good idea to add heat prescribing to a GP’s list of duties, this piece by the Guardian should disabuse you of the notion. Obviously just anecdotal, but the article answered a question that has been gnawing at me for a while: a GP in the piece claims that she spends 20% of her time dealing with patients who are on the elective waiting list, giving an indication of how widespread the effects of the long elective waiting list are. The article also highlights the poor incentives for becoming a GP partner, including the risk that you will end up liable for “an asset you are not allowed to sell” — with that framing, I would run a mile from being a GP partner.
The GP contract is up for renewal in 2024 and this episode of Talking General Practice delves into what issues are on the table for the renegotiation (9 minutes onwards). In particular, it looks like funding for Primary Care Networks (PCNs) is going to be a flashpoint. A BMA ballot from earlier in the year shows that more than half of GP practices are willing to pull out of PCNs altogether if PCN funding is not moved into core GP funding. If the contract can’t be agreed, things start to get really hairy. Doctors will reportedly consider a number of options, including limiting work hours strictly to BMA safe working guidance (which would mean 15 minute appointments, rather than the typical 10), rejecting work “dumped on them” by secondary care, refusing to use Advice and Guidance, and halting travel vaccinations. Will be an interesting story to watch.
Children and young people
Following the news last week that hundreds of schools had lost their “outstanding” Ofsted ranking, FFT Datalab come through with some (predictably) excellent analysis of the secondary schools in that group.
Its been busy time in Parliament for Children and young people related stories. On 28 November at education questions — the children’s minister Claire Coutinho confirmed that the government will respond to the SEND review in early 2023. As Schools Week recently reported — this was originally planned to be released by the end of the calendar year. For a summary of other topics raised in Education questions see Freddie Whitaker’s summary here.
Rachel Maskell MP launched a backbench debate in the House of Commons to discuss the Independent Review of Children’s Social Care — aka the MacAlister Review — calling on the government to accept the findings in full. For any wanting to get up to speed on the topic — I highly recommend the House of Commons Library debate pack, available here. Despite warm support from members across the House, including Claire Coutinho, no formal commitment was secured to uphold all the findings in full. Yet, as pointed out in our autumn statement report, the £2bn recommended by MacAlister didn’t feature in the Chancellor’s statement.
Children’s Social Care was also on the agenda for the Public Accounts Committee (PAC), which published a report on the DfE’s Innovation Programme. PAC concludes that the DfE lacked the data it needed to understand the innovation programme and was critical of the general inflexibility of the system.
Reporting from Mithran Samuel at Community Care showed that Sefton council remains at risk of having its Children’s Social Care services removed. DfE has now appointed a second commissioner to oversee improvements despite the council making early progress.
Finally, see this remarkable interview with Steve Crocker, the President of the Association of Directors of Children’s Services (ADCS) in Community Care. In it, Crocker outlines discussions held with the DfE on proposals to restrict the use of agency staff in children’s social care. Watch this space to see whether it features in the government formal response to the MacAlister Review.
Law and order
A star-studded cast recently gave evidence to the Home Affairs Committee as part of their policing priorities inquiry. Dr Rick Muir’s contributions are (as always) particularly enlightening. Among other things, he provided a concise summary of the main challenges facing policing, including: the problem of fraud and cyber-crime, notable for being the largest crime types while commanding only 1% of the police workforce’s attention.
On that, the NAO has published this report on the government’s efforts to tackle fraud. It’s a sobering reminder of the sheer scale of the largest crime type in England and Wales (comprising 41% of all crime against individuals in the year to June 2022) and, scarier still, the holes not only in the response to fraud, but even in the Home Office’s understanding of the issue. Helpfully, its most recent estimate of the cost of fraud to individuals alone (i.e. not businesses) is based on 2015/16 data.
Back to Dr Muir, who also highlighted the police’s increasing responsibility over issues related to mental health, missing persons, and homeless people. Add this to the increasing volumes of reports of violence against women and girls, and the capacity, capability and organisational shortfalls of the police become very stark. As if we needed more reminders about the joined-up-ness of public services.
I found this (month old) article hidden under a mountain of tabs. It reports on the progress of Operation Bluestone, itself part of Operation Soteria, an attempt to increase dismal rape prosecution rates (in this year’s Performance Tracker we also noted that the charge rate for sexual offences fell from 11% to 3% between 2014/15 and 2021/22). Bluestone, which involves an increased focus of officers’ time on questioning suspects, checking suspects against databases, and supporting victims, has tripled the charge rate for rapes in Avon and Somerset over the last 18 months (although 90% of cases still don’t reach court). Notably, much of the resourcing for the operation has been fed by the police uplift programme.
The article is also a useful reminder that, when thinking about crime outcomes, the criminal justice system is… well… a system: increasing prosecutions for these crimes depends to a large extent on resourcing in the Crown Prosecution Service, which must also be a focus of the government as it seeks to improve rape prosecutions. By my reckoning, CPS staff numbers are down by about 1,750 compared to 2010/11, while police recorded rape has skyrocketed in the same period. Gavin Hales has produced this graphic the number of charges, charge rate, and the proportions of different case outcomes.
The University of Bristol published two reports on prisons this week. One on prison funding during austerity and the other on prisoner access to healthcare. They find that funding cuts since 2010 limited prisoner access to healthcare, either directly — as healthcare providers reduced the scope of services — or indirectly as falling numbers of prison staff meant that prisoners could not be escorted to appointments. This latter point seems like it had a larger effect: 75% of missed appointments were attributed to staff shortages. It would be interesting to know, therefore, what the impact of increasing prison officer numbers in recent years has been on access to healthcare.
Local government
The Local Government Chronicle reports that the local government finance settlement is not expected to be announced until the week commencing the 19th of December. That’ll be a nice Christmas treat for local authority finance teams and wonks across the country.
Croydon Council issued its third section 114 notice in two years, saying that it will not be able to balance its budget in 2023/24. Digging into its medium term financial strategy, the primary cause seems to be the amount of interest the council is paying to service its high debt levels (the authority borrowed £545m between 2017/18 and 2019/20, directly before the first of its S114 notices). That debt was predominantly made up of short- and medium-term facilities which they are now refinancing, but at substantially higher rates than before the pandemic, meaning that the council is now paying an additional £10m per year in interest. The result is that they expect repayments to reach £60m a year — or 20% of their net budget — before they even begin to pay for any services. It’s worth reading the report to get a full picture of the extent of this mess.
In case you’re wondering what a section 114 notice is, this House of Commons Library explainer answers exactly that question and outlines likely outcomes for local authorities that issue one.
And it looks like Thurrock Council aren’t going to be far behind Croydon. This excellent piece from the Bureau of Investigative Journalism outlines how a number of poor investments by councillors have left the authority with a budgetary hole of almost £500m. Given their core spending power in a year is roughly £130m, this is a substantial deficit. A large proportion of the investments that the council made were in one company — Toucan Energy Holdings 1 (TEH1) — that has now gone into administration. From those investments alone, Thurrock is due to lose £188m. The other element adding pressure to the council’s finances will be familiar to councillors in Croydon: rising interest rate payments on refinanced loans. The article says that the council is refinancing loans which they’d borrowed at below 1% with loans where the rate is somewhere between 4%-5%.
There are a few things to expand on here. First, the increase in local authorities making speculative investments in the last few years is not an unexplainable phenomenon. Rather, much of it is driven by local authorities’ search for stable forms of income as grant funding has been cut by central government. Second, given the increasing prevalence of this type of activity, the government should urgently look at how many other authorities’ finances are unsustainable in a suddenly high interest rate environment. Third, government should be concerned about systemic risk here. There has been a rising trend over
Back in Westminster, this is a helpful thread from Jack Shaw summarising Gove’s appearance in front of the Levelling Up, Housing and Communities committee last week.
One thing Jack didn’t pick up on is this report from Room 151 that Gove is interested in reforming council tax, with DLUHC minister Lee Rowley supposedly “looking into it”. If this happens, it would be great news — council tax valuations are still based on the value of your property in 1991 — but the government has form with announcing local government funding reform, before endlessly delaying it, see: the Fair Funding Review. David Philips has a good thread on the implications.
Here’s another thread from Jack Shaw analysing the autumn statement’s implications for local govt. He lays bare the contingencies feeding into the generous-sounding £9 billion increase in local authority funding between 2023 and 2025, including: the fact that this increase depends on authorities increasing council tax by the maximum 5%; and the unclear status of the New Homes Bonus.
Interesting thread from Martin George summarising some of the snap polls of attendees at the LGC Summit last week. Obviously this is very unscientific and likely not representative, but some of the results are…odd. For example, to the question “How has the autumn statement changed the financial outlook for your council over the next 12 months?” only 31% responded “A bit better”, with 43% responding “A bit” or “A lot” worse. This feels wrong. Adult social care charging reforms have been delayed into the next parliament, and the government made new grant funding available for the service. This obviously won’t solve all their problems, and many authorities will still feel financial pressure this winter, but I struggle to see how the autumn statement made authorities worse off? If anyone has a dissenting opinion, DM me.
