Week in Public Services: 22nd April 2022

This week: terminating the tutoring contract; backlogs in home adaptations; and is Easter the new winter in the NHS?

General

In continued fallout from the spring statement, Ben Zaranko explains what’s behind the GDP deflator’s low inflation estimate and why it matters in this great thread. This sounds incredibly niche, but due to complexities in accounting for public sector output (which Ben explains far better than I can), the rebound in measured public sector output after the pandemic has resulted in economywide inflation appearing to fall between 2020/21 and 2021/22 and then increase slowly — even though all other measures of inflation are showing fast rises. This has allowed the Treasury to say that the Spending Review cash uplift should be enough to cover any inflationary spending pressures — even though their measure of inflation is super dubious. In short, economywide inflation isn’t accurately capturing inflation in the public sector — meaning that it is spectacularly bad reasoning to infer that the public sector is facing small inflationary cost pressures.

Health and Care

The King’s Fund and Nuffield Trust have published their 2021 survey of public satisfaction with the NHS. The headline is not good: a 17 percentage point decline compared to 2020. With only 36% of people responding that they are very or quite satisfied with the NHS, public satisfaction is it at its lowest level since 1997. It is also the first time since 2002 that those who are very or quite dissatisfied outnumber those who are satisfied. Not good. Digging deeper, the three areas driving dissatisfaction are the time taken to get a GP or hospital appointment, the lack of NHS staff, and the feeling that the government does not adequately fund the service.

The survey was conducted before the Omicron wave — but the current pressures, which have seen record numbers of A&E patients waiting 4 or more hours to be discharged, transferred, or admitted, and record numbers waiting more than 12hours from a decision to admit to admission, shed a light on what’s behind longer waiting times.

The TL;DR is that there simply aren’t enough beds to admit everyone who needs care as the NHS tries to (1) catch up on the elective backlog and patients stay in beds after operations, while facing (2) increasing demands for emergency care, and (3) continuing to treat Covid patients (who occupied roughly 10–15% of beds in April 2022). The Financial Times note that overall bed occupancy is now higher than at any point since mid-2021.

So why is the NHS so short of beds? It’s Easter, after all — these are not the sort of waiting times you would expect to see at this time of year. It’s…complicated. A lot of people lay the blame at lack of social care, arguing it’s not possible to discharge patients from hospital who are ready to go home, because they can’t stay at home on their own. Sometimes this is the case — but not always. We would be able to assess how big a factor this was if we had information on delayed transfers attributable to social care compared to the NHS, but that data collection has been suspended ever since February 2020. Super.

Another possible cause is that longer waits for elective care result in people’s health deteriorating such that they seek emergency care — though it’s hard to prove. An analysis of A&E attendees by the length of time they’ve spent on a waiting list, and for which procedures, would be helpful here…

A third possibility is that internal co-ordination failures within healthcare are resulting in delays e.g. badly-schedueled operations resulting in high bed occupancy at time of peak emergency demand (see almost everything Steve Black has written for the last decade).

I’m not sure which factors, and in what proportion, are contributing to the problem this time. But if I were the government, I’d commission NHS England or Improvement to do a Monitor-style analysis of waiting times, to try to get to the bottom of the problem. Without knowing what is responsible for the substantial declines in performance, history suggests that no-one will take responsibility and little will change.

While we’re discussing under-analysed-but-important-things, Steve Black also blogged on NHS productivity, putting the blame on lack of capital investment. For this government, it is especially bizarre given its desire to massively incentivise private sector capital spending (such as the capital tax allowance ‘super deduction’ in the 2021 budget)

I am inclined to think lack of NHS capital investment is a problem. Investment sounds more important than spending, after all. But one odd thing in the NHS ERIC (Estates Return Information Collection) statistics is that as the cost of fixing the maintenance backlog (bringing buildings assessed as below a certain set of risk criteria up to minimum standards) has risen over the last decade, it doesn’t seem to have resulted in more “Estates and facilities related incidents” or “Clinical service incidents caused by estates and infrastructure failure”. In other words, a bigger backlog hasn’t led to more reported failures — which doesn’t fit the anecdote of surgeries being cancelled due to leaking roofs etc.

I’m totally willing to believe that some failures might not be recorded in ERIC, and that some productivity gains from higher capital spend (reducing clinical staff time spent on administration with better IT, for example) wouldn’t be captured in those metrics. But, anyone with an answer on why a bigger maintenance backlog hasn’t translated into more recorded incidents of infrastructure failure, I’d love to hear it — message me!

In other capital investment news, HSJ reports bad news about the progress of the government’s new hospital building programme. Oh dear.

In workforce news, the 2021 NHS staff survey is now out, showing concerning rises in staff reporting work-related stress, dissatisfaction with pay, and a decrease in the share of staff saying that there are enough staff at their organisation for them to do their job properly. So — time for an NHS workforce plan then? Steady on, says Craig Nikolic, who points out the complexities in this simple-sounding task (demand is pretty tough to measure and a different mix of staff could reduce costs while maintaining or increasing treatment quality — there is a risk that simplifying assumptions in a plan would just bake in existing inefficiencies). Steve also made a similar argument that a workforce model sounds great but it’s hard to account for productivity and staffing changes (so risks assuming the current staffing model is correct and will be so forever more), and focussing on a future workforce model does distract attention from fixing current retention problems. I find these criticisms quite compelling…so would love to hear how Health Foundation/King’s Fund/Nuffield Trust folk would respond to them.

In research news:

  • A useful Health Foundation analysis of what the spring statement means for health and care. The main two points I took away were their rough-n-ready estimate of higher energy prices. For the NHS estate, “a 50% [increase] in the unit cost per Kilowatt hour (kWh) would cause an additional cost of about £0.3bn”. Their analysis of what the government’s elective recovery programme would mean for the number of people waiting for care is also useful. They estimate that it would still leave more people (8.5m) waiting for care in April 2025, compared to the 6m people waiting in December 2021
  • Another interesting Health Foundation blog covers discharge-to-assess (guidance on how to improve the experience of people leaving hospitals), and worries about the implications of removing central ringfenced funding to embed this approach
  • The Commons health committee published a useful short report on the government’s cancer targets, with an Ofsted-style evaluation of progress against the commitments. The overall rating? “Requires improvement”. Sidenote: also a really interesting model for a select committee to have an expert panel evaluate government commitments independently of the committee
  • Billy Palmer spotted a concerning trend in the latest workforce data that more UK and EU nurses left the NHS than joined in 2021, in contrast to nurses from the rest of the world
  • The University of York published a paper on different approaches for modelling healthcare demand (TL;DR — it’s not straightforward)
  • Last but not least, an NHS Confederation and Providers blog looked at the impact of the pandemic on health services for children

Elsewhere, Tom Chivers wrote an excellent analysis of why automated monitoring missed the high number of stillbirths at Shrewsbury hospital and James Illman wrote a good article (£) and short thread about changes to the reporting of 12 hour waits for A&E admissions. The change in methodology — measuring from the point of arrival in A&E rather than from the decision to admit — means that the already bad A&E waiting time numbers are going to get worse. NHS England know this, and their response that they will make the change “in due course” doesn’t inspire confidence.

Children and Young People

The biggest news of the last few weeks has been that the Department for Education have terminated the national tutoring programme contract with Ranstad early. The cash will now go directly to schools instead, although the Department for Education are going to procure for a new supplier to do “quality assurance, recruiting and deploying academic mentors and offering training”. As well as Ranstad’s poor performance, perhaps this is an admission that the original tutoring contract was just too big? My colleagues Stuart and Nick wrote blog arguing that the government is still too focussed on cost over quality, here.

In research news:

  • The latest learning loss data still shows pupils behind where pre-pandemic cohorts were at similar ages, with the effects largest in the most disadvantaged groups.
  • A new Ofsted report draws lessons about education catchup schemes, based on 280 post-pandemic inspections and inspectors’ insights about what is working well and badly. The inspectorate are particularly concerned about the youngest (those in early years’ education) children’s development, and note that some schools are not using the National Tutoring Programme. The reintroduction of face-to-face education in prisons has been slow, too. Ofsted’s review of the National Tutoring Programme will be one to watch
  • A paper by Sam Sims and Asma Benhenda (with accompanying thread from Sam here) looks at recruitment and retention of teachers for subjects where there are normally shortages (maths and physics). They look at the effect of paying early-career teachers in those subjects more. The outcome is — surprise — the more they are paid, the less likely they are to leave teaching. The paper argues that the government can address shortages by targeting maths and physics teachers with preferential pay packages early in their careers.

Over at the Education DataLab, an interesting blog analyses the Department for Education’s change to the GCSE target from a ‘threshold’ measure (% of children achieving Grade 5 or above in English and Maths) to an average attainment measures (“the average grade in GCSE English language and maths will increase to 5 by 2030”). Why change it? The Education DataLab suggests it could be because the Department wants to improve attainment across the whole distribution of pupils, not just set a floor target. The 2019 average score was 4.5. How ambitious is a target of 5? In the words of the DataLab: “DfE is giving itself to 2030 to achieve results in GCSE maths that were slightly higher than in 2021. However, it will be with a cohort (currently in Year 3) that have had two of their early years of schooling disrupted by the pandemic.” So…somewhat?

Last but not least, children’s health is too often the poorly understood cousin of healthcare for adults — but provides another indicator of how stretched the NHS is at the moment: a survey of GPs has revealed that the Child and Adolescent Mental Health Services (CAMHS) cannot provide care to young people with conditions such as eating disorders or psychosis, which the authors attribute partly to higher demand due to worsening mental health during the pandemic.

Law and order

Less news this week, but an interesting Lords Justice and Home Affairs report analysed the use of new technologies in the justice system and concluded that “the Government should establish a single national body to govern the use of new technologies for the application of the law. The new national body should be independent, established on a statutory basis, and have its own budget.”

Richard Hyde from the Social Market Foundation makes a counter-intuitive argument that police numbers are not getting enough attention. I was sceptical — the high-profile nature of the 20,000 additional police officers target made me think the opposite, that police numbers were getting too much attention. But he makes a reasonable case, arguing that England and Wales are ‘under-policed’ (have fewer police officers per person than other wealthy countries) and that this will become a bigger problem as crime becomes increasingly complex. Worth a read.

Finally, a really remarkable letter from a number of different organisations who do not always agree (the Prison Officers Association, the Prison Governors Association, the Prison Reform Trust, the Royal College of General Practitioners, Mind) has demanded that the MoJ and DHSC conduct a review of mental and physical health. Clearly prison conditions massively deteriorated during the pandemic — I’m minded to think a review would be worthwhile. I had not realised there had been a 60% increase in in-cell prison calls to the Samaritans between 2019 and 2021.

Local government

A good piece from Richard Partington cites Institute for Government analysis of the scale of the income hit to councils’ spending power (in the region of £800m to £2bn, depending on whether you use economywide prices or consumer prices or to adjust for inflation) as a result of the government not uprating spending plans in line with inflation at the Spending Review. The interviews with council leaders give a sense of what this will mean for local authorities — and it’s quite concerning.

The social care reforms add costs on top of inflationary pressures too, and Surrey Council are making the case for a pause in the government’s social care reforms to give them the time to collect information on how much the ‘fair cost of care’ reforms will cost, and how much they will change the market for people who currently pay for their own care. I imagine lot of other local authorities with high numbers of people who pay for their own care will be wondering the same thing too.

The Local Government Association have published a cool thing– regional breakdowns of their regular survey of resident satisfaction with local government and the services it delivers! Well worth a delve into it — I was surprised to see that there wasn’t that much difference between regions.

In nerdy news, the Department of Levelling Up, Housing, and Communities review of the revenue outturn statistics has agreed to some positive changes. I for one would massively appreciate someone trying to reconcile the DfE and MHCLG statistics on children’s social care spending!

And finally, a good bit of work from the Bureau of Investigative Journalism which has looked at the disabled facilities grant (DFG) in depth. The DFG is a grant local authorities can pay to people who need to adapt their home to make it safe and accessible if someone in the house has a disability. The limit on grant awards (£30,000 in England), which has not been increased in line with inflation, has resulted in applicants having to crowdfund or local authorities offering additional grants or loans to applicants so they can actually pay for improvements.

The Bureau also fund that the ‘true’ waiting times are much longer than the theoretical 18 months (six months for approval and a year to do the work) because of local authority staff shortages such as occupational therapists, who have to assess and approve new claims: a good example of a backlog not many people are talking about.

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Graham Atkins

Graham Atkins

Senior Researcher @instituteforgov: public services, infrastructure, other things. Too often found running silly distances in sillier weather.