Week in Public Services: 1st March 2023
This week: Performance Tracker update; new children’s social care workforce data; and a debt write-off for Croydon
General
Ignore everything about strikes, food shortages, or protocols, the week’s really big news is that we released a spring update to Performance Tracker. It’s hefty, so a few headlines: the government’s strikes strategy has exacerbated staffing problems and damaged public services; winter pressures combined with long-standing problems in social care, primary care and hospitals led to the worst NHS crisis in a generation; the government may not meet its target of 20,000 additional police officers while high-profile scandals have further damaged trust in policing; some prisons have insufficient capacity to offer pre-pandemic rehabilitative standards; teacher training numbers are at crisis levels.
The IfG wasn’t the only organisation with a big reveal this week. Starmer descended on Manchester to set out Labour’s national missions. Despite promising ‘measurability’ on them, few measures were given. Nevertheless, a group of us at the IfG gave our view on what we thought of the announcement. On health, Labour will struggle to fund their desired preventive health plans well-received, given it usually pays off over decades, not single election cycles. On education, all we have are laudable ambitions, promises to invest in childcare and…that’s about it. On crime, Labour’s promise to increase convictions don’t sound positive without corresponding plans to tackle the huge court backlogs and at-capacity prisons.
With all this going on, it’s easy to forget that we’re only a couple of weeks away from a budget. Luckily, Resolution Foundation has a primer looking at the effect of lower-than-expected gas retail prices on the Energy Price Guarantee (EPG) and inflation. They find that the government is going to realise “significant savings compared to the expected cost of £12.8bn at the time of the autumn statement”. These savings contribute to the news that the government “surprisingly” needs to borrow £30bn less than expected this fiscal year, due to a mixture of higher-than-forecast tax receipts, those energy savings, and a mistake in OBR forecasting.
My immediate thought was whether those savings could be redirected towards struggling public services, and it looks like this is a possibility. The RCN called off their next round of strikes as the government agreed to “intensive” negotiations over pay (as a side note, I love the fact that these are now intensive. It implies discussions were relaxed before). This willingness to negotiate has been linked to the fiscal windfall, with the government now reportedly considering a higher pay settlement for 2023/24. I also wonder if junior doctors voting to strike last week made the government realise that they would have to resolve a dispute with at least one out of ambulance workers, nurses, or junior doctors, for fear of having to staff the NHS solely with soldiers and consultants.
Centre for Progressive Policy (CPP) have a report out arguing that the under-provision of public services is contributing to worsening health outcomes, which in turn contributes to lower productivity. They argue for a shift to a more preventative approach — investing in community, mental health and social care services — combined with more radical devolution which would, for example, give mayoral combined authorities more control over health policy. There’s a lot in here that I agree with, but also arguments that we’ve heard before and that the government has ignored. Maybe framing problem in terms of lost productivity will encourage decisionmakers in the Treasury that it is actually worth investing in population health.
Health and care
Another article (£) in one of the country’s largest broadsheets arguing for the supposedly-taboo topic of NHS funding reform (I wish there was a way to eyeroll via text). I’m not going to give a lot of time to this, as I’ve written about funding reform before, but I’d like to address one frustrating point. The author says: “This disparity [in performance between the UK and Australia] isn’t down to money. According to OECD figures, Australia allocates about 9% of GDP to health care, while in the UK it is more like 10%.” This got alarm bells ringing. First, I couldn’t find the Australian number that he’s talking about. According to this dataset, the UK did spend just under 10% (9.9%) of GDP on health in 2019 (using that year as it excludes pandemic distortions). But Australia last spent 9% of GDP on health in 2013, and it was actually 10.2% in 2019. But using % of GDP is bad for comparability, it’s better to use health spending per head. Looking at that metric, Australia spent 4,919 USD in 2019, while the UK spent…$4,500, or 9.3% less than Australia.
In addition, Dr Louella Vaughn points out that while Australian health performance was better than the UK’s before the pandemic, that isn’t true now. It’s almost like performance isn’t well correlated with type of funding model. What’s frustrating (aside from the wild inaccuracies), and as Dr Selvaseelan Selvarajah says, is that this endless debate about funding distracts from an actually useful discussion NHS reform.
As predicted a few editions ago, junior doctors represented by the BMA have voted to go on strike, with the first 72-hour strike taking place on 13 March. As with the HCSA ballot last month, the majority was overwhelming, with 98% voting in favour of strike action. The BMA also represents far more junior doctors than the HCSA — 48,000 compared to 531. As with the 2016 junior doctors strikes, consultants are expected to pick up some of the work, but there’s only so much they can do. The question now, as James Illman wonders, is how disruptive this strike will be. Almost certainly, this will reduce activity, making it that much harder for the government to hit their next elective target at the end of April.
A tangible example of the effect of the record estates maintenance backlog in hospitals: the BBC reports that sewage leaks are causing patients and staff to fall ill and preventing care from being delivered in a number of trusts.
Excellent and thorough explainer of community health services from Nuffield Trust. One thing that surprised me is that community staff make up 20% of NHS employees. It’s such a large part of the service and yet is overlooked by many (hands up, that also includes the IfG). One reason we’ve struggled to get to grips with it is a lack of data. Nuffield Trust have done a good job of aggregating what’s available, but there remain large holes in our understanding about the service.
One area I know there is data though is on the community care nursing workforce, which made me curious about how the relative hospital and community nursing workforces have changed. The number of hospital nurses grew 31.6% to October 2022, while the number of community nurses fell 7.2%. It’s hard to square that trend with the government’s purported focus on shifting care into the community.
Healthwatch England published this piece of research about what they call the “referrals black hole”. They found that over a fifth (21%) of people referred by GPs in the previous year had returned to their GP with the same problem, with much of that driven by communication or administrative failures between different parts of the NHS. Quick bit of maths: ~ 8% of GP appointments end in a referral. If 20% of those then come back unnecessarily, that means GPs are repeating 1.6% of their appointments for no reason. With 157.9m GP appointments in 2022, that would mean 2.5m wasted appointments. Not great for a service already under immense pressure.
The NHS workforce plan will reportedly “double” the number of medical school places. All sounds good and definitely a step that is needed. The problem comes later in the article when it is revealed that HMT will provide no extra money for those places.
This research finds that the introduction of a competitive hiring process for CEOs in Chilean hospitals reduced hospital mortality by 8%, primarily because older CEOs who had been doctors before were replaced by younger CEOs with management training. What’s interesting about this, is that I’d previously assumed that it was better to have managers with clinical experience. This seems not to support that.
This from Matthew Taylor (chief exec of NHS Confederation) was interesting. Matthew argues for investment in social care as a means of preventing acute admissions. This isn’t necessarily new, but it is heartening to read senior NHS leaders acknowledging the benefits of investing in social care. There were also fascinating examples of trusts intervening more heavily in the social care sector in their area. Liverpool Hospital Trust, for example, has employed a bank of care staff on NHS terms and conditions to fill local staffing gaps.
It also led me to this (quite old) meta-analysis of social care provision on healthcare utilisation. The authors found a strong relationship between nursing and residential care (but not homecare) provision and improved delayed discharge, length of stay in hospital, and readmission.
Nuffield Trust have the next in their series comparing adult social care across the UK. This one finds that workforce regulators in Scotland and Northern Ireland have driven better terms and conditions for social care staff, likely improving retention. Though they do also acknowledge that the evidence for if this is still tentative and needs further work.
Children and young people
No sooner did we publish the Performance Tracker Spring update, then the government released new, and to be honest quite grim, data on the children’s social care workforce. The headline figures support many of the anecdotal insights on the children’s social care workforce discussed in recent editions of this blog:
· 31,600 FTE children and family workers in post — down 2.7% on 2021, the first fall in the series but still higher than the 2019 workforce. No real change among senior practitioners and managers, but there has been an 5.2% drop in case holders between 2021 and 2022
· The turnover rate now stands at 17% up from 15% a year earlier
· Vacancies are up 21% from 2021, the highest on record
· This appears to be driving larger workloads for staff: 16.6 cases per FTE in 2022, up from 16.3 in 2021 but still lower than the 16.9 in 2019
· It is also pushing local authorities to use more expensive agency workers — 13% more than in 2021, the largest increase in the data series.
· Finally, the FTE sickness absence rate throughout the year is 3.5% — again the highest on record
These all make for troubling reading alongside a report from in CommunityCare showing that council social workers have been offered a ‘full and final’ £1,925 pay rise for 2023/24. While matching the 2022/23 rise and approximates to a 3.9%-6.4% rise for social workers, its well below the 10% inflation facing staff and the 12.7% requested by unions. This both increases the likelihood of strike action (as seen in many other public services) and further incentivises staff to leave for better paid and lower-stress jobs.
Both workforce challenges and pay no doubt will feature heavily in the recruitment and retention challenges research being undertaken by Social Work England. For more details see this report.
In other workforce news — the DfE published its submission to the School Teacher Review Body — the government claims an “affordable” 3% which will keep salaries “competitive” reports the team at Schoolsweek. As Freddie Whittaker reports no extra funding is coming down the line which could lead the DfE to force “efficiencies” on schools. That’s all well and good, but with rising teacher leaving rates this appears to jar with the argument that public sector earnings will keep pace with the private sector.
As we noted in earlier WiPS — the DfE’s Annual Report showed school block collapse had become one of the six major risks facing the department. This week the NAHT, NEU, NASUWT, Unison, Unite, GMB and Community unions issued a joint letter to the Education Secretary calling for urgent action. Troublingly, Schoolsweek report that the DfE responded to an FOI request from Unison saying it didn’t hold data on the number of building at risk or the schools affected. Freddie Whittaker’s school’s week article also outlines the union campaign to better identify where “reinforced autoclaved aerated concrete (RAAC)” — a commonly used yet crumbly form of concrete used in flat-roofed school buildings — is located across the country.
Further concerning news on the specialist schools sector from the BBC: half of state-funded schools with special needs and disabilities are oversubscribed.
The Mayor of London’s plans to continue free schools drew attention this week. Estimated at £130m and anticipated to help 270k children in the capital it will be rolled out in the 2023–24 academic year. So that’s the headline, but is there such as thing as a free lunch? The excellent team at Schoolsweek have crunched the numbers based on NEU estimates — the funding appears to leave a 77p per meal shortfall which if extrapolated could be a £39m shortfall over the year. Schoolsweek also highlights concerns from campaigners that the funding overlooks teenagers and could affect pupil premium funding.
Law and order
In this thread, Jon Yates argues that the 74% fall in violent crime in Southend in summer 2020 is attributable to ‘hot spot’ policing (focusing resources on a high-crime area). I haven’t seen the violent crime data referred to, but given crimes like theft, robbery, violence, criminal damage have declined over the last decade — during which time police numbers have fallen and risen dramatically (which could correspond to a decline and rise in police presence?) — I’d be hesitant to treat hot-spotting as the kind of panacea it’s presented as. Or rather, given these trends, I’m not sure hot-spotting is the best use of police resources. The fall in volume crimes like burglary is, for example, attributable to improvements in security technology. To the best of my knowledge, these trends haven’t plateaued, and until they do it seems more useful to put more officers on e.g. fraud investigations (criminally small proportions of which are investigated).
While doing some reading about this, I came across a particularly neat set of visualisations from Gavin Hales on the relationship between Stop & Search, possession of blades, and levels of injuries from knife crime. Well worth a read.
Transform Justice has a new podcast discussing why the police don’t resolve more crimes. It contains some useful summaries of the main pressures distracting the police from crime work, e.g. mental health supervision and growing amounts of missing persons work. It’s very hard to know exactly how much time these activities take, though. There is activity data but it’s collected locally, meaning national pictures are hard to paint.
The Police Superintendents’ Association joined the chorus of condemnation of the pay review process last week was who sent this submission to the Police Renumeration Review Body. The PSA has a useful write-up here, which emphasises the decline in morale/motivation of senior officers and the lack of procedural justice in the review process. It argues that there’s little point celebrating the recent uplift in officer numbers if pay (considered insufficient by most officers) isn’t enough to keep people in the service or deter new recruits. The fact that police aren’t allowed to strike might, conversely, prove more damaging to public safety than otherwise in this context.
According to Matt Ashby, current Home Office proposals for 2023 will increase pay by 3.5%. While the increase will affect different roles to differing extents, it means a constable just out of training will be paid roughly a quarter less than in 2010.
I missed this piece from Dominic Casciani earlier in the month. It’s a really fantastic history of the crown court backlog, currently at 60,000 cases. A brief summary: 2019, the backlog starts to grow after government caps the number of days judges could sit (to save money and because of falling crime predictions); opening ‘nightingale courts’ to create extra space during the pandemic haven’t helped as much as expected, given the lack of available judges and lawyers. Solutions have involved: persuading more senior lawyers to sit as part-time judges, bringing back recently retired judges, allowing district judges from magistrate courts to deal with serious crimes.
This begs the question of whether the reported continuation of the nightingale courts will have much effect on the backlog: extra space is all well and good, but how long can you plug workforce gaps with unsuitable legal practitioners or by extending magistrates’ sentencing powers without damaging the quality of justice you’re delivering?
Local government
Last week the government allowed Croydon to increase council tax by 15% in 2023/24 to raise an additional £22m and hopefully stabilise the council’s finance. This week Room151 reports that the authority has asked the government to write off £540m worth of debt, to help close a £60m gap in its 2023/24 budget that would otherwise be “impossible” to resolve without extensive service cuts. I’m still undecided what I think is the right course of action here. On one hand, if the government writes off the debt of any local authority that mismanages its finances, then it creates an immense amount of moral hazard which could incentivise greater risk taking by other authorities. On the other, the cost has to fall somewhere and if the choice is between the government and residents — in the form of higher council tax and service cuts — I’m inclined to think the government should protect people who would otherwise be punished for reckless financial management.
Last week we talked about the Treasury taking over capital spending decisions in DLUHC. This week the supplementary estimates (p.245) — basically an update to departmental spending for the current financial year — shows that the department has had £2.5bn of capital spending taken away. Would be interesting to know if that money had been earmarked for spending and if so on what.
Good article from the BBC about the extent of bus cuts in Stoke-on-Trent. The story there is stark — a 50% reduction in bus miles since 2013/14 — but as our report from last year showed, it is hardly alone. The one thing that struck me, and linking back to the CPP report at the top of this edition, the savings made from cutting these routes are surely outweighed by the productivity losses. One woman interviewed in this article says it takes her an hour and a half to travel 8 miles — a distance that would take 20 minutes by car.
