Week in Public Services: 22nd April 2024
This week: NHS trusts balancing budgets; ‘looked after’ children being housed in illegal, unregulated homes; and emergency central government funding for local authorities
General
Liz Truss has been everywhere this week. Apparently, her failure is the fault of the ‘deep state’ (whatever that is). First, her lack of self-awareness or reflection is staggering. Next time I feel even the tiniest bit inadequate, I’m going to chant “Liz Truss” under my breath, a mantra to ward off imposter syndrome. My colleague, Alex Thomas, wrote an excellent piece dismantling her simplistic worldview. His central point — that making large, sweeping change is complicated and difficult — is a good lesson for those politicians who hope to reform public services in the coming years.
If you read the right-wing press, you’ll no doubt be incensed by the level of tax in this country. A recent Telegraph headline screams: “Whitehall spending spree makes higher taxes inevitable”. Those pesky, wasteful bureaucrats. The same publication thinks that people will inevitably flee the country for low-tax havens. But while it may be true that the tax burden is at a record high, work from the IFS shows that we’re below average on both the level of taxation and spending. In monetary terms, the IFS calculates that the UK would have to raise an additional £79bn of tax revenue to reach the average of the G7, or £43bn to reach the OECD average.
The report also argues that we’re much closer to other countries’ average on spending than we are on tax. As the IFS puts it “our appetite to become a more average spender has not been fully matched by a willingness to become a more average taxer”. The result is higher-than-average debt. I think this is key; neither party wants to be seen as a tax-raiser, but they also don’t want to be honest about the implications for public services.
One much-touted solution to this dilemma is increasing public service productivity. Check out our new explainer on public service productivity for discussion of what this means in practice and details of some of the government’s commitments on productivity.
Health and social care
Ahhh the annual race for NHS trusts to balance their budgets, it feels like it comes earlier every year. It may only be April, but trusts across England are already trying to close NHSE’s £4.5bn gap in its 2024/25 budget. Lawrence Dunhill at the HSJ gives a glimpse (£) into what kind of cuts hospitals are considering. According to internal papers, Northern Care Alliance are aiming to cut their ‘corporate services’ by 14%. That might sound nice and sanitised, but includes areas such as patient safety and legal services, learning and development, e-rostering and safe staffing, and assessment and accreditation. Oh good. The patient safety team is being cut. Just what I want to hear if I’m about to go in for a procedure. More seriously, these are not useless roles. One of the key barriers to improving productivity is a lack of management. Cutting that capacity further is short-sighted.
One for NHS data nerds: NHS England released new elective data last week. The headline was that the waiting list is more or less flat, with a fall coming because of the reclassification of about 40,000 community pathways. More interestingly, NHSE released the waiting list minimum data set (WLMDS, I’m so excited for a new acronym), which is a weekly release which will eventually replace the RTT monthly release, though will be comparable. The HSJ has a good article explaining the thinking and process behind the move.
Some excellent flip-flopping by NHSE over the weekend. It first of all decided to shut its mental health and addiction services new staff (though would continue supporting staff already in the service), with the reason seeming to be budgetary constraints. This caused such a stink among representative bodies and prominent Twitter medics that they then reversed their decision (for a year at least). What a pointless, goodwill-destroying kerfuffle.
You might remember that NHSE tried to incentivise (maybe bribe?) trusts to hit its target for 76% of people waiting less than 4 hours in A&E by March 2024. So did NHSE’s very generous offer work? In short, no.
There was some improvement: headline performance for all A&Es rose from 70.9% in February to 74.2% in March. That is also higher than any March since the worst of the pandemic. But as Steve Black points out here, there was a big difference between types of A&E, with trusts that have type-3 A&Es (i.e. GP-led and offering appointments that can often be booked through 111 or by GP referral) performing much better. Out of the 184 trusts for which there is data, every single type-3 A&E hit the March target while only *9* type-1 A&Es did. What does that mean? Well, it was much easier for trusts that see a greater proportion of attendees in type-3 A&Es to hit their targets, and it was likely easier for those trusts to improve performance as it much less reliant on flow throughout the rest of hospital — a crucial bottleneck for performance in type-1 A&Es. All in all, a pretty grubby, ill-thought-through policy from NHSE which didn’t even achieve what they wanted it to achieve, despite aiming to hit a very unambitious target.
The RCEM have claimed that long waits in A&E are causing 300–500 excess deaths per week. At the beginning of the month, they estimated that long A&E waits contributed to approximately 14,000 excess deaths in 2023. I always felt that the methodology had some quite large assumptions in it but Full Fact have now joined the debate and broadly support the RCEM’s analysis. More worrying (though depressingly unsurprising) is NHSE’s obstinate unwillingness to acknowledge the issue. Steve Black has a good thread documenting NHSE’s repeated denials.
The Health Foundation published estimates of how health inequalities will change between 2019 and 2040. They forecast that existing health inequalities — for example, there is a gap of 10 years of illness-free life expectancy between the most and least deprived decile — will continue. They also forecast that the prevalence of chronic conditions will increase more quickly in the most deprived parts of the country and, because those conditions are generally managed in primary care, will require more investment in general practice.
Children and young people
The Observer reports that local authorities placed more than 700 children in ‘unregulated care homes’ in 2022/23 (scare quotes because calling an Airbnb a ‘care home’ is a bit of a stretch). There seems to be a couple of things going on here. The first is something we’ve known for a while: that a lack of space in care homes means that councils place children in increasingly inappropriate care settings. The second is Ofsted’s inability to do anything about these placements, even when they know it’s happening. Ofsted didn’t prosecute a single provider in 2022/23 despite launching 845 investigations. Ofsted argues that the government has dragged its feet on providing previously-promised powers (accidental alliteration alert, and again). As with concerns about school inspections, however, this seems to be another example of expecting a standard of service from Ofsted which it is not resourced to provide.
A new report by the Education Policy Institute takes a deeper look at projections by the Department for Education of a fall in pupil numbers in England by 2030, and what the implications are for funding. There’s a projected annual decline 1% in pupil numbers between 2022/3 and 2028/9 nationally, but there’s substantial variation within local authorities. For example, primary pupil numbers will fall in Lambeth by nearly a quarter, while they’ll increase in Central Bedfordshire by 12.5% in the same period. With school funding closely tied to pupil numbers, the EPI forecasts that total funding for state schools will decline by £1.1 billion by 2028/9.
Another EPI report compares different school groups, with a particular look into multi academy trusts. It finds that teacher turnover rates are similar at primary level between local authority schools and academies. Secondary teacher turnover however is higher for multi-academy trusts (MATs) than local authority-maintained schools. For large MATs, those with at least ten schools, turnover reaches nearly one in five teachers, while absence and suspension rates are also higher than for other mainstream schools. The EPI stresses however that there’s no optimal type of school: multi-academy trusts tend to have better financial health, being much more likely to have positive in-year balances.
The child of the north APPG published a report this week. The paper obviously focuses on children in the north, but their points can be applied more broadly. In particular, they tackle an issue we’ve been wrestling with in our upcoming report on prevention: how much of the increase in children entering care can be attributed to cuts to preventative services and how much to an increase in poverty? There are proponents on both side of the argument, though this report comes down somewhere in between — and therefore likely nearer the truth.
Law and order
No major policy announcements in the crime and justice sphere this week, but plenty of interesting reading to share. We’re back on familiar territory with news on prison capacity: more than 3,000 prison places have been lost since 2010 due to disrepair, as prisons minister Edward Argar revealed in a letter to the Justice Select Committee. For those keeping track, that’s more than 3.5% of our current useable capacity. If you missed it last week, have a look at our comment piece on the crisis in prisons and the sentencing bill. Spoiler alert: it’s not good.
HM Inspectorate of Probation has produced an A-Z of key research messages, pulling together messages and concepts from across their research programme (much expanded in recent years). I must confess to a raised eyebrow at the entry for ‘X’… standing for ‘X and Y relationships’, highlighting the importance of not conflating correlation and causation. Hmm.
Still on inspectorate research, HMI Prisons has published a thematic review on Improving Behaviour in Prisons. In increasingly overcrowded prisons with rising rates of violence and self-harm, this offers some welcome suggestions from prisons doing better on safety, leadership and culture. Key factors highlighted are a strong belief among senior leaders that people are capable of change, and a positive culture that invests in both prisoners and staff. Interestingly, they found the incentive scheme was less closely linked with positive behaviour than prison culture.
Finally, a fascinating long read from The Guardian looking at how modern slavery laws have been used to prosecute drug dealers. Really interesting piece that pulls out some of the complexities of identifying victims and offenders when it comes to drug offences and criminal exploitation. The Times has also just launched a year-long Crime and Justice Commission — look forward to hearing more about this in future weeks!
Local government
This is a great piece of research (£) from the Local Government Chronicle. They find that 74 local authorities are receiving some form of financial support from central government. That comes either in the form of statutory interventions (sometimes following a section 114 notice), exceptional financial support (which we wrote about here), or from the DfE’s safety valve programme. Yet another brick crumbles from the government’s flimsy claim that financial difficulties in local government are purely the result of financial mismanagement. Despite the fact that one in five councils are now receiving some form of emergency support, the government still does not have a credible plan to reform the system.
A BBC article claims that local authorities have a gap of £300m between their current budget and the amount required to properly support young homeless people. For some context, local authorities spent £1.2bn on homelessness services in 2022/23, so this is a significant chunk of their budget. Of course, this funding isn’t going to materialise out of nowhere. Instead, local authorities will be forced to do what they always do when budgetary constraints butt up against statutory duties: ration services. Inevitably, rationing those services will just shift pressure elsewhere in the public sector, meaning the government will still eventually pick up the tab.
