Week in Public Services: 22nd December 2023
This week: the public services naughty or nice list; Streeting’s Singapore fling; and PISA results
General
The wreath is on the door of IfG towers. There’s been a steady stream of mince pies in the office. And we’ve had our now-traditional argument over an answer in the Christmas quiz (this year’s controversial question: What is the oldest legislative body in the world? Don’t say we don’t know how to have a good time). All of that got me wondering who or what would be on the public services naughty or nice list for 2023.
Naughty list
AI: ChatGPT is more than a year old at this point but it feels like it’s been around forever. Ministers love banging on about it, and it now seems obligatory that any public event features someone asking a question about how AI can save [insert public service here]. All I want for Christmas is to never have to hear about AI until it has solved every problem in every public service.
Maths: Admittedly never a strong suit for many politicians, but the MoJ has been thoroughly bamboozled by some basic arithmetic this year. A couple of numbers for you…planned prison places in March 2025: 91,448…the MoJ’s own forecast for prison population for March 2025: 94,400. That means there will be -2,952 available places in prisons in 15 months’ time. I had to run this analysis a couple of times, just to be sure, but my conclusion is that a negative number means there will be too few prison places.
Builders in the 1950s-1990s: It must have felt like a right wheeze at the time; “this concrete is so light and cheap. It’ll need to be replaced in 30 years’ time, but that’s future Britain’s problem”. Well, we’re now future Britain and it seems that using reinforced mint aero (aka RAAC) to build schools, hospitals and courts is a Bad Idea, especially when you have a government that is seemingly allergic to capital investment. I would say the government deserves some coal in its stocking, but I’m worried it may try and build a school out of it.
Objective reality: We have repeatedly called the government’s spending plans beyond 2024/25 a fantasy. And the problem with fantasies is they don’t last long in the real world. That is already happening with the government’s spending plans for public services, which are crumbling faster than a primary school in a stiff breeze. The government could have remedied that at the autumn statement, but it chose tax cuts instead. I’m not a betting man, but if I were, I would put a few quid on the reality of declining performance and higher-than-forecast inflation forcing the government to abandon those plans at some point soon.
Nice list
The rest of the world: It turns out that paying staff in public services terribly and forcing them to work in awful conditions makes them quit. But it also turns out that we need people to work in hospitals, GP surgeries, and the care sector. Who knew. Luckily, there is a source of staff willing to do that work, they just happen to live outside the UK and the EU. Cue immigrants getting the job done across health and care services. That, of course, infuriated the government, and it has now declared open war on those pesky *checks notes* international care workers and their families.
And…that’s all I’ve got for the nice list. Let’s be honest, it’s much more fun writing the naughty list.
Onto some (slightly) more serious content.
An organisation called the New Britain Project has come up with a “Broken Britain Index”. As you can imagine from the name, their analysis doesn’t paint a particularly rosy picture (quick aside: what happens if public service performance turns around? Will it still be the Broken Britain Index? Or will it suddenly become the Brilliant Britain Index? Or the Beautiful Britain Index? Answers on a postcard and sent anywhere but to me). The index takes an interesting approach by combining different service indicators and then ranking different areas of the country. To get a bit geeky for a second, there are some holes in the methodology: proportion of GP appointments delivered the same day is not a good metric of GP quality, and using a single month’s ambulance response times is also a bit dubious because of high levels of monthly variance.
But overall it’s interesting approach. The north east is the area that caught my eye the most: it ranks worst for the ‘forgotten generation’ metrics (broadly: education and mental health outcomes for children) and the ‘crumbling communities’ metrics (crime and neighbourhood services), but best in the country for health metrics. I wouldn’t have guessed that.
Health and care
Wes Streeting’s merry tour of other countries’ health systems continues, this time with a visit to Singapore (£). My overwhelming feeling reading this was weariness. The Streeting schtick — as the only person willing to tell the NHS some painful home truths — is just quite boring. I’d imagine that (with maybe the exception of NHS England) there is no one in the country, including NHS staff themselves, who think that everything is rosy in the service. Streeting repeating this ad nauseam, while patting himself on the back for his remarkable insight is not going to fix a single problem. In fact, I would argue that it risks alienating the NHS staff who he needs to actually implement his ‘radical’ reform of the service, though what that reform will include remains a mystery.
First, for those that haven’t worked this out yet: Singapore is nothing like the UK. It is a small city-state with a population half that of greater London. Its GDP per capita is 80% higher than the UK. Its health system is more like a large, very wealthy, urban ICS than it is like the NHS.
With that out of the way, onto some of the substance of the article. A lot of what Streeting wants to replicate in the NHS — iPads in hospitals, apps that allow patients to manage their care, better electronic patient records — will require substantial capital investment, which is not something Labour has indicated they are willing to do. He also wants to increase the number of GPs, which is great, but hardly revolutionary (the Tories failed miserably at their own goal of increasing GP numbers by 6,000). How he intends to do that is much more important and there’s no real plan that I’ve seen. He wants to free GPs from the “red tape” of 55 targets (he means the QOF and the IIF). Intuitively, that seems good. The only problem is it’s not clear that GPs dislike some of these targets; those present at last month’s LMC conference voted not to abolish the QOF.
One really great thing was that Streeting said that Labour “will not embark on a reorganisation of the NHS”. That’s a genuine relief. It would be such a bad decision. I still worry though that when he’s in government, with no new money coming, the temptation to pull the reorganisation lever will be very strong.
I’ll let Matthew Taylor (chief exec of NHS Confed) have the last word on Streeting and this article. Matthew makes some actually good recommendations for what Streeting should focus on that doesn’t involve alienating the entire workforce.
It seems that it isn’t just Wes Streeting who is having second thoughts about the QOF and IIF. The government has launched a public consultation on the future of both funding streams, asking how effective respondents think the QOF and IIF are at improving patient access, continuity of care, and patient choice, among other things. The consultation closes in early March, and it’ll be interesting to see the result.
I found this example of productivity improvements in hospitals from Rachel Sylvester at the Times interesting (apologies, paywall again). Surgeons in St Guy’s and St Thomas’ increased their throughput by running two operating theatres side-by-side and prepping the next patient on the list as they operate on the current one. This reduces the downtime between operations and means they cleared their lists much quicker. Knowing very little about how operating theatres work, I wonder why this isn’t replicated in other trusts? Some of the debate on Twitter was interesting. One push back seemed to be that when you factor in the large amount of staff and other resources, it’s not that much more efficient. Others argued that the Times’ reporting was overly generous on the throughput.
The NHS awarded the contract for its federated data platform (FDP) to Palantir at the end of November. Nick Carding’s explainer from the HSJ is a good overview of what the FDP involves. In his column, Steve Black argues that it isn’t privacy concerns that the government should be worried about, but rather whether it is possible to consolidate a highly fractured data environment across trusts and — if that does prove possible — how useful the resulting platform will actually be. Concerningly, only four out of the 19 pilot trusts actually reported benefits from using the FDP. Muir Gray disagrees with Steve and argues that the FDP will bring much needed granularity of spending data. For example, it’s currently impossible to know how much different trusts spend on chronic obstructive pulmonary disease (COPD), and how outcomes differ in those trusts. The FDP could help solve some of those issues.
I’m much more concerned about the pattern that’s emerging when the government procures services from Palantir. The FDP builds on the NHS’s data store, a service which — you guessed it — Palantir built for the NHS in 2020 for the initial cost of £1. That was framed as an act of pandemic-era largesse. But now means that it is very difficult for the NHS to move away from using Palantir as a supplier. That means the company has been pretty much guaranteed to win the FDP contract since it was first announced. Palantir has form for this. It offered the government a “free period” to set up the IT system for the Homes for Ukraine programme in February 2022. DLUHC then signed a £4.5m contract with Palantir in September 2022 without any competitive process. The government’s chief commercial officer, Gareth Rhys Williams, has called Palantir out on this. But it looks like his intervention came too late to influence the FDP process. The point of all this is that this is an intensely anti-competitive way to procure massive government contracts. It locks in suppliers and likely leads to poor value for money for the government, as companies are free to charge much higher fees than they otherwise might have done.
The government hit its target to recruit 50,000 more nurses in this parliament (I hope the next election will be fought on better manifesto pledges than this, but somehow doubt it). The HSJ reported that 93% of those recruits came from outside the UK. This is an…interesting outcome, given the government’s aggressive rhetoric around foreign health and care workers recently. The government better hope its training pipeline massively improves or else the Long Term Workforce Plan is going to require a lot more international staff.
The Lancet published a study into mortality rates of the most common cancers in England from 2002 to 2019, and the results are striking. There’s good news in that overall both men and women are less likely to die of cancer before turning 80, but there’s a stark regional divide in the extent of the decline, with higher mortality recorded in northern cities — notably Manchester and Newcastle — than in London. Two of the study’s authors, Theo Rashid and Amanda Cross, told the Guardian that public health programmes and access to screening and other early diagnostic services were key to redressing the mortality inequality.
This was a tough read. The Guardian reports that there has been a large increase in the CQC making referrals about modern slavery: they made four in 2021/22, 37 in 2022/23, and are on track to make 50 in 2023/24. The authors and interviewees attribute that rise directly to the increase in international workers in the sector and their reliance on visas which make it very difficult to leave a job. The timings certainly back up that hypothesis; the increase in referrals started in the first financial year after the government put care workers on the shortage occupation list.
The government published its impact assessment for its recent changes to visa rules for care workers. It interestingly does not forecast fewer care workers coming to the UK because they can no longer bring their ‘dependents’. The report says that the high number of applications indicates that demand for visas will be “resilient” despite the change. The assessment does, however, forecast an impact from the requirement that all companies that sponsor these visas now have to be CQC-registered. They predict that it will reduce the number of visas issued by 22%, which Simon Bottery puts at 20,000 care workers in England.
Children and young people
The outgoing chief inspector of Ofsted, Amanda Spielman, penned a covering letter for the regulator’s annual report which is worth a read. Maybe it’s because her time at Ofsted is quickly winding down, but Spielman comes out fighting for the regulator. She argues that Ofsted’s role is not well understood; it is a regulatory body in the same mould as those in other services and is therefore not supposed to be creating policy or providing support services to schools. In addition, it is a tiny organisation that has experienced substantial funding cuts in recent years, in common with other services. Those funding pressures lead to shorter, sharper inspections that leave little room for more constructive and ongoing support that schools seem to want.
PISA scores are out! The headlines are that most places in the world declined during the pandemic, but England declined less than other countries, meaning it moved up the rankings for maths (17th in 2018 to 11th in 2022) but stayed more or less the same for reading and science (13th). Scotland, on the other hand, continues a trend of decline compared to other UK countries that dates back to 2012.
John Jerrim from FFT Datalab has a really interesting piece of analysis on PISA scores. He looks at why Wales’ reading score was so much lower than in Scotland and England. He finds that schools that took the PISA reading test in Welsh (rather than English) did significantly worse than other schools, despite being from more affluent parts of the country, and therefore normally better performing. Worth saying that the choice of language is completely up to schools, so
Back in October the Local Government Association surveyed local authorities on the cost of placements in children’s social care and the results are now in. Spending on looked after children is forecast to hit £5.4 billion in 2023/24, exceeding planned budgets by £680 million. That follows a roughly similar overspend in 2022/23. Local authorities identified the main drivers of those overspends as: lack of choice of providers, complex mental health needs of children, and challenging behaviours of those in care.
Law and order
Police forces in England and Wales have pushed back hard recently on responding to mental health call outs. So this BBC report that Police Scotland have taken a different approach is interesting. Police Scotland are instead triaging calls more stringently and then trying to encourage the correct agency to respond to the call.
Turning to prisons, HM Inspectorate of Prison’s inspection of HMP Lowdham Grange, privately operated by Sodexo, was so scathing that the MoJ announced that it would take over management for an unspecified interim period. The unannounced inspection back in August detailed 13 key concerns about the running of the Category B prison in Nottinghamshire, including serious safety issues surrounding violence and drugs, high levels of self-harm and staffing shortages undermining support for prisoners. It’s now apparent four months on that Sodexo has failed to improve and the Prisons Minister, Edward Argar, stated that a new governor would be appointed and additional staff brought in.
The situations for prisons is grim, regardless of whether they’re private or public: the BBC reports that HMP Hewell — dubbed by the former chief inspector as the worst prison they had visited — has insufficient staffing levels which means that improvements have “largely stalled”. Meanwhile, serious overcrowding in HMP Dartmoor means that site is “arguably…not fit for purpose”.
Local government
I thought this article (£) from Sarah Norman (chief exec of Barnsley council) was great. Sarah calls for a more nuanced understanding of local authority financial risk that goes beyond “section 114 notices are bad”. In particular, I agreed with her argument that local authority debt to income ratios were often a bad metric of local authority risk, and that’s what more important is how councils spend the money raised from that debt. Obviously bogus solar farm companies (*cough*Thurrock*cough*) are bad, but regenerating the high street — as Barnsley’s done — is a good investment.
Speaking of section 114 notices (and when are we ever not these days), the government published the local government finance settlement this week. There was some vague hope that the government might use that to shore up authority finances, but that was not to be. The settlement made no new money available, despite much higher rates of inflation eroding the valuer of council budgets over the last year. That will leave core spending power in 2024/25 more than 12% lower than in 2010/11 and at roughly 2012/13 levels. As I argue in this blog post, that likely means more s114s are on the horizon.
Section 114 notices always sound quite abstract and technical, but they have severe real-world ramifications. What are those ramifications you ask? Nottingham and Birmingham have both published proposals for closing their deficits. Birmingham’s cuts are more extensive than Nottingham’s, which makes sense given the scale of the challenge in Birmingham. They’re looking to cut £57m (13.3%) from the children’s social care budget, as well as halving the amount they spend on council management services. On that latter point, I’m sure central government will applaud the cutting of back office staff. But Gove has been on the record as saying “poor leadership, weak governance, woeful mismanagement of employee relations and ineffective service delivery have harmed [Birmingham]”. None of those problems will improve if Birmingham takes a hatchet to key functions such as HR, legal, and finance. The council is also petitioning the government to be allowed to raise council tax by 10% in 2024/25–5 percentage points higher than the government’s current limit for social care authorities next year.
In Nottingham, the council is considering a range of options including: shutting down care homes, closing an adventure playground and activity centre, “reviewing” library services, and cutting the bus network to the minimum service level. In both cases, the cost of these cuts will fall most heavily on the worst off residents. It’s easy to forget that behind the technocratic-sounding section 114 notices are real people being denied services they depend on.
To understand the measures that some local authorities are taking to avoid issuing a section 114 notice, it’s worth reading Abigail Marlow’s article about one of the smaller services offered by local authorities which is now at risk: grit bins. Kirklees Council, which declared that it would do “everything” to avoid issuing a section 114 notice, plans to save £160,000 a year by only filling its 1,450 grit bins once a year before winter and not refilling them except after “very exceptional weather”.
The conveyor belt of disaster continues apace in local government: Bradford council is warning that without a capitalisation direction — i.e. permission to sell assets to cover their deficit — they will have to issue a section 114 notice before the end of 2023/24. Capitalisation directions are becoming increasingly common, but it’s not a particularly good long-term strategy — you can only sell assets once and most costs are ongoing.
On that cheery note, the IfG public services team is signing off for 2023! Thanks for reading this year. Have a great Christmas and watch out for a new Week in Public Services sometime soon.
