Week in Public Services: 23rd February 2024
This week: fiscal fantasies; GP contract quarrelling; and brutal cuts in Birmingham
General
I had to check my calendar a few times to make sure this one is true, but it seems that we have another fiscal event in less than two weeks. I’m not sure about you, but it feels like we wrapped up the autumn statement about 3.5 days ago. I’m very much with my colleague Olly who recommends the Chancellor call the whole thing off, and give us all break from rabbits out of hats and painful jokes. But if we have to have it, here’s the IfG’s view on what to look out for.
On the topic of fiscal plans, the IFS published a great paper outlining the tough fiscal trade-offs that the next government is going to have to make. They argue that as it stands, neither party is being honest with the electorate about what tax and spending plans mean for the quality of public services, the level of debt, or a host of other areas such as immigration, net zero, and disability benefits. They accuse both parties of “fiscal cakeism”. I completely agree with them on this — the choices after the next election are going to be stark. But the politics are also terrible for either party to be the first to abandon cakeism. Imagine, for instance, that Labour says that the fiscal situation is untenable and will require tax rises. Or that the Conservatives said that they were going to have to make severe cuts to public services. They would basically write their opponent’s attack ads for them. I still think one or both party should have a bit more political courage, but it’s understandable why they don’t.
With that context, it was the extremely frustrating to see the government trailing the possibility of more short-term tax cuts funded by spending cuts. It’s obvious to anyone paying attention that the spending plans from April 2025 onwards are completely made up, with the government pencilling in whatever it wants to make the books balance for its pre-election tax cuts. Speaking of which, I’m still waiting for the tax cuts from the autumn statement to turn the Tory polling numbers around. I’m sure it’ll be any day now, and if it doesn’t happen, then I’m sure just a few more tax cuts at the budget will make all the difference.
More seriously, a system that allows this much gaming is so broken. How can we not know what departments’ budgets are going to be in 13 months’ time? As my colleague Olly Bartrum pointed out, if a general election happens in autumn, departments will have already begun budgeting for spending cuts from April 2025 onwards. That’s not abstract planning, it’ll mean cutting staff and programmes in preparation.
In slightly less ranty news, the IPPR have published an insightful paper on health disparities in the UK. It identifies seven ‘foundations’ needed to close the gap — safe homes, healthy bodies, clean air, good jobs, strong relationships and community, freedom from addiction and a great start to life — and proposes creating ‘Health and Prosperity Improvement Zones’. I like this because it highlights the narrowness with which policy makers currently think about health which can often boil down to: if you’re sick you go to the NHS, if you need care, you might get some if you’re lucky. From our own research and conversations, the frequency with which poor housing comes up as a cause of so many problems — in health, in care, but also in social services, schools, and the criminal justice system — is really astounding.
Health and care
First up, NHS finances. The HSJ reports that of the 33 ICBs that have published their third quarter financial results, 13 are forecasting that they will end the year in deficit. The HSJ estimates that when all 42 ICBs report, the net financial position for the NHS will be a £1.5bn deficit for 2023/24. In case anyone’s forgotten, the NHS already had a £800m injection in autumn last year to help close some of the deficit that emerged from ongoing strikes and other cost pressures.
A couple of evaluations of NHS programmes for the health policy nerds. The first is from Nuffield Trust who have looked into the effectiveness of patient initiated follow up (PIFU). They found mixed results from a review of existing literature. Eight out of 15 reviews found a statistically significant drop in the number of outpatient appointments, while seven showed no impact. There was no impact on clinical outcomes, or quality of life, with a small increase in patient satisfaction. Though they also note the studies are mostly outside the UK, and were often poor quality.
Nuffield then did their own evaluation and found a lot of variation between specialties in the use of PIFU, with the greatest use occurring in trauma & orthopaedics and physio cases. Using PIFU in some specialties led to more outpatient appointments, while reducing them in others. They also note, that it is difficult to assess the impact on other parts of the health and care system, including primary care. This is a very brief overview, though and their report is far more extensive.
Next, an evaluation of the effectiveness of virtual wards. You remember virtual wards, that policy that the government rolled out with much fanfare before hitting its own target of 10,000 open beds(what a nice number, which I’m sure was chosen for extremely good, well-evidenced reasons and not just because it’s large and round) by September last year. The authors found that virtual wards contributed to shorter stays in hospital. But that it cost almost 75% more (£935 vs £536) for someone to stay in a virtual ward bed for 24 hours compared to a hospital bed. How is that possible? Anyway, I’m sure that NHSE welcomed the study, acknowledged shortcomings with the programme, and that they would make adjustments…of course not. This HSJ article says that “NHSE dismissed the findings, claiming the study was “misleading” because of its limited size and time span”. I also enjoyed this mildly snarky point by the HSJ author: “when invited to point to other research papers offering a more comprehensive analysis, [NHSE] failed to do so”. What an excellent, constructive approach to valid criticism from an independent evaluation.
Now for some internal DHSC machinations. The HSJ reports that the Office for Health Improvement and Disparities (OHID) has been “effectively dismantled”, with its functions split across different directorates, and a headcount reduction of 40%-50%. For those not keeping track of the various fates of public bodies and government departments, OHID was established in DHSC in 2021 following the abolition of Public Health England (PHE). This is, to put it mildly, not great from DHSC. Public health and prevention is already a frequently-ignored part of the health and care system. Muffling the department’s internal voice on this issue won’t do much to change that.
Negotiations are under way for the one year GP contract for 2024/25. Needless to say the start has been rocky. The government’s opening offer was a 1.9% uplift on baseline GP funding. That offer was met with a swift rejection by the BMA’s GP committee. Obviously times are tight, the coffers are empty etc etc. But that offer looks ridiculous following a period of marginal increases in the contract and very high inflation. Unfortunately for GPs, the political incentives make it unlikely that the government will substantially increase its offer. With an election around the corner, and tax cuts gleaming in the eye of the chancellor, they won’t want to “waste” fiscal headroom on addressing some of the deep problems in general practice. The unknown for the government is how GPs might react. Industrial action is different in general practice than hospitals, but widespread disruption in an election year would not be a good look.
Interesting work from the University of Cambridge and INSEAD business school (strange that they’re doing work on primary care, but we’ll take whatever we can get at the IfG) which found large benefits from continuity of care in general practice. This is one of those things where everyone who works in and around primary care rolls their eyes and says “of course”. The interesting quirk for this study is that it frames continuity of care in terms of productivity, arguing that there are longer gaps between consultations if patients see the same doctor. I suppose the question is: when will government make continuity of care a priority given the wealth of evidence for it? Part of me wonders if it’s because there’s no easy way to measure it, meaning it is easy to quietly forget about it.
I loved this report from the King’s Fund, which assesses why there has been such consistent failure to shift care out of acute hospitals and into the community, and then recommends how to actually make it happen. I couldn’t agree more with the recommendations to target ICSs on shifting care (rather than just constantly managing acute trust performance), creating flexibility in the GP contract to allow for local prioritising, and investing in a primary and community care estate that would actually make this possible.
The Queen’s Nursing Institute (QNI) released a report looking at the effectiveness of the Additional Role Reimbursement Scheme (ARRS). For those who have lost track of another NHS acronym, this is the additional money that government has given general practice to hire staff such as pharmacists, care coordinators, and social prescribing link workers, with the goal of reducing GP and GP nurse workloads. The QNI’s report does not pull its punches. Claims include:
· ARRS staff were not able to complete work assigned to them due to “lack of knowledge, skill, being out of scope, regulatory issues, or unfamiliarity with primary care”, leading to poor care which GP nurses had to then pick up
· ARRS roles appear to be based on availability of funding rather than any local demand; there was a high supervision burden for GP nurses
· This major change to the workforce was carried out with little to no consultation with the workforce.
There were some benefits. The report found that ARRS staff helped reduce workload when the work was closely assigned to their area of expertise e.g. pharmacists conducting medicine reviews. This is a damning report, but should also be taken with a pinch of salt; the QNI is a charity that aims to improve nursing care and is therefore likely to favour the views of GP nurses, who might feel ill-disposed towards a large change in their working conditions. Nonetheless, really interesting research that addressed a lot of questions I have about the ARRS scheme.
Cast your mind back to the winter of 2022/23. With a crisis emerging in the NHS, the government announced emergency funding to improve discharge from hospitals. The King’s Fund have published a report looking at how effectively that money was spent. The short answer is: not very effectively. The longer answer is much more interesting. The typical issues emerge. It’s very hard to spend money effectively when it is announced on such short time frames. Central government’s requirement for fortnightly and even daily reporting on how money is spent is incredibly burdensome for local areas. But other things were more of a surprise to me. Participants reported that government is focused on the wrong metrics for reporting, being more interested in what the money is buying than outcomes. On cooperation at a local level, interviewees thought they were doing well, while actually planning for different outcomes. Really great report that highlights issues in cooperation across all policy areas, not just social care.
The House of Commons library conducted analysis into the number of NHS clinical service incidents, where services are disrupted for at least 30 minutes because of safety issues. The Guardian reports that between 2018/19 and 2022/23 there were 27,545 such incidents in England, working out at over 100 a week. One hospital in Essex alone had over 40 sewage leaks in this period, hardly ideal for the wellbeing of both staff and patients.
In yet another low water mark of performative cruelty, the government is openly boasting about banning care workers from bringing family members to the UK. You know, those workers who are caring for our loved ones? Those care workers who have essentially stopped the social care sector from collapsing over the last few years? Those care workers who the government encouraged to come and work in the UK less than two years ago? Putting aside the more values-driven argument for a moment, there is no plan to make social care more attractive for British workers.
Children and young people
The House of Commons Education Committee issued a series of recommendations this week on Ofsted’s inspection process and rebuilding trust with schools, following a bruising year for the inspectorate body. The committee has called for the DfE and Ofsted to replace the increasingly controversial single-word judgements (outstanding, good, requires improvement and inadequate) with a new system, although it doesn’t elaborate what this might be. It also calls on Ofsted to issue clear guidelines for training inspectors including how to respond when school leaders show signs of distress during an inspection. Promising early steps for the new chief inspector.
Sir Andrew McFarlane, the most senior judge in family courts in England and Wales told the BBC’s Today programme that the rise in children placed in care is down to austerity. He stated that cuts to local authority spending reduced the options available to social workers, and that the high caseload and backlog in family courts reflected “something wrong with society”. The increase in children in care is an issue we’ve naturally covered in Performance Tracker, but this is something that has continued even as spending on children’s social care has risen again recently and is now above 2010 levels. What has definitely changed though is that local authorities have shifted most of their spending to looking after children in care, squeezing other options further.
Law and order
This excellent article in the Guardian goes behind the scenes with a barrister leading the prosecution at two rape trials in London, and questions why both cases going to court and convictions are lower compared to other offences. When asked about taking on such cases, he made a very good but worrying point that many barristers are reluctant to take them on owing to the complex and time-consuming work which delivers far less pay in return than for commercial law. The result has been that over a fifth of junior barristers and nearly half of KCs left the criminal bar between 2017 and 2022, worsening the backlog of criminal court cases.
We’ve often covered the poor conditions of prisons here, but the picture’s even grimmer for inmates with serious mental health conditions, who are segregated from the rest of the prison population according to a damning report by the Independent Monitoring Board (IMB). There are some shocking revelations: one man who was self-harming was kept isolated for 800 days, while another with complex needs was kept in a care and separation unit for 300 days before being assessed, and another 250 days in addition before being transferred to a psychiatric hospital. The IMB’s description of this as inhumane doesn’t really seem strong enough.
Local government
Some excellent reporting from the Birmingham Mail on what residents in Birmingham can expect from upcoming cuts following their section 114 notice. It seems that the council will look to make savings of approximately £112m from their budget, with large swathes falling on children and family services. This means a complete cut to the early help contract, cuts in youth services and a drop in funding to the Birmingham Children’s Trust. In some ways, this is very understandable. Children’s services are one of the largest budget line for any local authority. But this is also just insanely frustrating. Almost every cut described in that article would be a false economy, providing a short-term saving while storing up problems for the future, meaning Birmingham will be back in the same place in a couple of years’ time. I’m not blaming the officers or councillors for this. They’re in an invidious position. If they don’t make cuts now, commissioners will seize control of the council. If they do, then they know they’re storing up problems for the future. Meanwhile the most vulnerable people in Birmingham suffer.
The above story has now been confirmed by the BBC (yes we’ve been writing this edition for over a month, I know, terrible from me), who also report that the government has granted Birmingham permission to increase council tax by 10% in both 2024/25 and 2025/26 (for a 21% total increase across the two years).
Onto a story that’s flown relatively under the radar in local government finance. There has been a steadily rising number of local authorities requesting “exceptional financial support” from the government. As Jack Shaw points out in this tweet, Cheshire East is the latest, but there were eight more before. The question becomes now if the government grants them the support they’ve asked for. According to the government’s website on the topic, it’s granted support to nine authorities since 2020 (some twice), mostly in the form of capitalisation directions. Cheshire East has warned that if the government does not provide the support, it will have to issue a section 114 notice. As we asked in the previous edition of Week in Public Services when is a section 114 not a section 114? If the government starts to grant large number of authorities support — mostly in the form of capitalisation directions — that are most typically provided once an authority issues a notice, then what’s the point of section 114s at all? This isn’t rhetorical. I’m genuinely interested in views. Is the extent of financial distress in local government so wide as to render s114s redundant? Does it even matter if an LA issues one now? Or will the government do anything to avoid any more in an election year?
In case you missed it, our colleague Philip Nye wrote this excellent comment piece about the rising (and underreported) spate of deficits in local authorities from special educational needs and disabilities (SEND) spending.
Sexual health services provided by local authorities in England are ‘at breaking point’ according to this article, with council telling the BBC that they are unable to keep pace with rising infection rates unless central government delivers both additional funding and a long-term plan to address the increased demand. We’ve previously covered this issue in Performance Tracker, where the lifting of social distancing measures and reopening of STI services contributed to an uptick in the infection rate.
