Week in Public Services: 23rd August 2022
This week: health backlogs; the NHS winter plan; and conflicts over adult social care reform
Ready… set… ACTION.
Welcome back everyone. After several months in the wanting and wilted wasteland of a world without WiPS, I can happily report both that IfG style guides now mandate alliterative introductions, and that our Week in Public Services has returned!
For anyone new to WiPS, it’s a (not quite) weekly summary of the main developments in the public services we cover here at the IfG, complete with brief explanations, award-worthy wit, and the occasional piece of cutting analysis.
A lot has happened since we last posted. So much so that [drum roll please] we’re giving you not one but two WiPS. Yes lucky reader you read that right, two WiPS! Today we’re reducing the backlog of health, social care and local government news… and, teases that we are, you’ll just have to wait until our next post for the juicy updates on education, crime and justice!
Health and Care
Backlogs:
We’ll get started with the good news that the number of people waiting more than two years for routine procedures has shrunk from 22,500 in January 2022 to less than 200. This represents good progress towards the government’s backlog targets (the first of which is to eliminate >2-year waits by July 2022). Thumbs-up for the first of the government’s backlog reduction targets.
However, it’s not all sunlit uplands from here. First, the Guardian reports that these figures exclude more than 2,500 complex or deferred cases. Furthermore, as the IfG will report in this year’s Performance Tracker in collaboration with CIPFA, the next two targets (eliminating the 18-month waitlist by April 2023 and the 52-week waiters by March 2025) will be far trickier.
Second, the further back you stand, the more this victory adopts a slightly nugatory gloss — the backlog of people waiting for care has just hit 6.7 million. That’s a growth of 1 million since last August.
Performance and innovations:
A huge thanks to the amazing Nick Davies (is it obvious that he’s my boss?) for alerting me to this article by Dr Iain Smith and Elaine Bayliss in BMJ Open Quality, showing that improved administrative organization can reduce backlogs and the burden on frontline staff.
Dr Pritesh Mistry has this brilliant piece on technology in healthcare. It’s a reference-rich must-read exploring digital healthcare, covering a variety of digital tools, their ease of use, and the representativeness of the data underlying technological innovation (among other things).
This recent Health Committee report gives a comprehensive summary of the NHS’ performance with respect to cancer diagnosis and treatment (including some fairly dismal international comparisons). See the government’s response here.
Nigel Edwards has this piece on the geographical, training, payment, and bureaucratic contributions to the dentistry crisis, after a commendably fastidious BBC investigation found that a third of NHS dental practices are not taking on adults (and 8 in 10 are not taking on children).
The NHS has released its winter plan, aiming for thousands more beds and call handlers, among other ambitions. We’ll keep an eye on this, but at the time of writing there are no details regarding how the NHS will staff the new beds (which will, per the plan, increase by more than 7% of the current total of general and acute beds) or telephones.
On this point, note the Health Foundation’s recent finding that the NHS’s FTE staff shortage is currently around a whopping 103,000. Nor are there any details on how many of these beds will be real as opposed to virtual (side note: for more on virtual wards and health outcomes see this report).
We do know that the NHS plans to create some of the new bed capacity by improving patient flow through hospitals. If the NHS has a credible plan to achieve this, we need to ask when it was developed, and — if it’s been sitting in the pipeline for a while — why they are only now putting it into action. Given the size of the current backlog, efficiencies are too valuable to wait around for seasonal use.
Future of healthcare:
This Health Foundation piece is a fantastic insight into the changing share of elective NHS treatments carried out by the independent sector (IS). The share of admitted treatments started by the IS in England has grown since the pandemic (the share was 15.8% in the 10 months to March 2022, compared to 12.8% across the 10 months prior to the pandemic). This, however, is at least partly a function of the reduced number of treatments started by the NHS, which is entering into new arrangements with the IS to help tackle the backlog.
In other news, integrated care systems (see this Kings Fund explainer) were put on a statutory footing as of 1 July, the hope being that formalised partnerships of health providers responsible for large geographical areas will allow the health service to remove some of the barriers to effective long term care.
This HF piece provides some excellent analysis of the uneven levels of deprivation ICSs will contend with (figure 2). Such variations raise several concerns over the standards by which these partnerships are judged, and should inform the distribution of government support.
By allowing for better community treatment, service integration may reduce avoidable hospital admissions, which obviously has knock-on effects regarding backlogs.
That being said, given the number of patient records ICSs have to integrate, it might be a good while before progress shows itself. Thanks to Pritesh Mistry for pointing this out.
I’d be remiss not to mention the Tory leadership election. According to this useful table from PublicFirst (thanks to Jordan Urban for bringing this to my attention), there isn’t much we can say about Truss’ plans, other than that she is “completely committed to [the government’s promised spending increase], to the hospitals, to the doctors.”
Sunak, the floor’s yours. His promise to increase the number of Community Diagnostic Centres (recommended back in 2020 to separate elective and acute services) to 200 by March 2024 involves a far higher rate of growth than the 100 planned by the NHS by 2025 in their elective care backlog plan.
Yet, with spiralling costs, whether these promises are affordable is another matter — see here on how an unfunded staff pay increase could stretch the NHS budget.
This article from John Burn-Murdoch looks at how NHS waits are driving growth in crowdfunding for private healthcare, and finds that the share of the poorest households facing ‘catastrophic healthcare costs’ doubled between 2008 and 2019 (similar findings were reported in this IPPR report from March — p.12–3). Going forward, this is a great example of the use of GoFundMe data to understand the impact of backlogs on healthcare practices.
Social care reform:
In early July, the government announced it was delaying the implementation of section 18(3) of the Care Act for those already in care. On 1 August, the (Conservative) Chairman of the LGA Community Wellbeing Board (Councillor David Fothergill) wrote to the health secretary on the government’s social care reforms saying: “The serious and precarious nature of our existing adult social care system, and the very real consequences of current pressures on people who draw on care and support, is unquestionable.”
So, what’s the problem? Central government spending is reported to fall short of covering local authorities’ financial requirements, while councils estimate that the cost of the care reforms is far higher than they can afford (see this brilliant thread from Stuart Hoddinott for all the detail). As a result, many councils want to delay implementation. For example, they want to delay the implementation of section 18(3) of the Care Act for those not already in care. As the letter makes clear, underfunded reforms will cause cuts in other services (and let’s not forget that, as of 2019/20, adult and children’s social care took up 2/3 of local authority-controlled spending).
Lisa Morgan produced this article outlining why the proposed social care caps aren’t as generous as they seem. A TL;DR paraphrase: The adult social care spending cap will be £86,000. This doesn’t include accommodation, which is expected to be capped at a figure >£12,000.
Workforce:
This H&SC Select Committee workforce report starts with the line: “The National Health Service and the social care sector are facing the greatest workforce crisis in their history.” With 200,000 vacant posts in the NHS and social care, it’s a dismal picture. The committee’s recommendations on boosting GP numbers — offering leave to remain to international GP trainees, visa extensions, reducing barriers on family settlement in the UK — almost exclusively deal with international recruitment (see p.59), and are particularly noteworthy in light of the government’s poor progress against its GP staffing commitments.
Similarly, this thread from Billy Palmer (also of the Nuffield Trust) gives a great overview of the demographics of NHS staff.
Wrapping up health:
We’ll end health with the news that the Royal College of Nursing will open ballots on industrial action to its +465,000 members from 15 September. If successful, it will be the first strike in the RCN’s history. (Other unions are also balloting members — see here for news from the BMA and Unite).
As strikes continue and loom, this insight paper from Dr Gemma Tetlow makes the case that public sector pay should reflect public sector retention pressures.
And finally, see this thread on the potential pay cost pressures the NHS may have to absorb thanks to the mismatch between budgeted funding and the public sector pay increase.
Local government
The LGA has released this survey of councils’ confidence in their ability to deliver social care reforms. Tellingly, 62% of adult social care leads reported being ‘not very or not at all confident in their council’s ability to deliver the programme to the government’s timetable’, while a staggering 98% were ‘not very or not at all confident that the government funding earmarked for the adult social care reforms is sufficient to deliver them.’
This report from the DLUHC committee makes several recommended changes to social care funding. These include reducing local authorities’ reliance on council tax and requiring the government to provide multi-year funding settlements (p.74–6).
I’ve come across this useful resource that compiles case studies on council-level outcomes across a range of health issues.
Also see the most recent LGA resident satisfaction survey.
This report on the 120,000 children living in temporary accommodation in the UK is a stark reminder of the scale of the homelessness problems that local authorities will have to tackle over the coming months and years. With spending on homeless services increasing by over 450% in some authorities between 2009 and 2020 (see p. 19), this may continue to add significant budgetary pressures on councils coping with recent declines in income-generating services, increased wage and energy costs, and higher costs from providers often linked to weak bargaining positions (e.g. the CMA recently found councils’ weak bargaining power contributed to excess profits among independent child social care providers).
Coming up in local government:
Christmas has come early for local government nerds after the government outlined some of the data-related responsibilities to be covered by the new Office for Local Government. For example, it’ll cover recycling, adult social care, climate change, and education. The Office may also throw some light on the roughly 70% of neighbourhood services for which performance data is not currently collected!
To wrap up this weeks’ week in public services — since the last edition of week in public services, we published our ‘Neighbourhood Services Under Strain’ report, exploring how local authorities in England have adapted their delivery of services in light of spending changes since 2009/10. Given the cuts to services like libraries outlined in the report, it’s interesting to see the changes in how authorities adapt their use to support educational and development outcomes.
But with increasing inflationary pressures, local authority budgets and services face a tough year ahead. Comfort might be sought from the recent announcement that 2-year funding settlements would be provided to councils. With any luck, these plans may assuage the irritation many councils feel at not being able to make multi-year plans for improvements to public services. That being said, the Asphalt Alliance reports 65% of councils require 5-year funding strategies to ensure resilient road networks (see p.10 here). It could also signal a shift away from the 3-year funding plans for road maintenance announced in the spending review.
Only 2 months after the 2-year settlement was announced, in August the Local Government Association called for extra funding to help reduce the impact this has on services. And as Paul Johnson of the IFS recently commented — while the scale of cuts won’t be as great as the 2010s, they are starting from a tougher position. To offset these inflationary pressures the IFS estimates a £1.2bn uplift would be needed.
For more on the inflationary pressures biting council budgets — keep eyes peeled for November for the IfG/CIPFA Performance Tracker 2022! Until then, you’ll just have to look forward to the next bumper Week in Public Services!
