Week in Public Services 23rd June 2021
This week: how to use targets; the most expensive breakfast in history; and Schrodinger’s social care reform
Using targets to improve public services is, unsurprisingly, controversial. Targets can focus staff’s attention on the measurable, rather than the important. Targets can create enormous amounts of paperwork owing to the big audit, measurement, and monitoring trails they necessitate. And sometimes they just encourage staff to manipulate data.
On the flipside, there’s good evidence that they can also be helpful. From the 4-hour A&E waiting time target (which resulted in a 14% reduction in the proportion of people dying within 30 days of attending A&E) to the 5 A*-C GCSE metric (whose removal as part of removing school league tables in Wales led to pupils in Welsh schools not improving as quickly as those in England)
So when do targets work? Good news — our latest report answers just that. If you’re a civil servant/spad/wonk/minister (delete as appropriate) thinking about introducing a target, ask yourself the following questions first:
- Is it possible to design a target that is closely aligned with the desired outcome?
- Are public expectations of a service different from those of front-line staff?
- Do those subject to a target have control over whether it is met?
- Is the service performing poorly?
(And give the full report a read, obviously)!
For another perspective, check out this interesting report on ‘human learning systems’ — often portrayed as an alternative management mode to targets — with lots of interesting case studies on using this as a way of doing public management differently.
Health and care
Lots of new stuff this week — a good place to start is this extremely comprehensive Andy Cowper roundup of health news, which includes good analysis of how feasible it would be to train more NHS staff domestically. One for Dido Harding to put on her reading list (and this one about how much influence the head of NHS England really has over NHS staff training).
What can the government learn from “the most expensive breakfast in history”? (That’s Blair’s commitment to increase NHS funding on David Frost’s breakfast television show, and the following Wanless review). Nick Timmins explores this in a report for the Health Foundation, and makes (in my view) three really important points for the post-covid recovery situation:
- The backlog in health operations now, in 2021, is likely to include many urgent cases (cancer and cardiac), whereas the large backlog in the 2000s was primarily elective procedures for non-life-threatening problems such as hip and cataract surgeries
- Bringing elective waiting times down to 18 weeks took 4 years from health secretary John Reid’s announcement in 2004 — put simply it took a lot of staff to increase the number of operations — that is likely to be a constraint again
- The New Labour government implemented a lot of structural reforms at the same time as trying to reduce waiting times and “there was quite simply not the bandwidth, either nationally or locally — where the management reorganisations consumed much time and effort — to achieve all of that successfully”. A similar situation applies to the current government and the NHS bill which is about to go through Parliament
There are also lots of fascinating quotes from former senior civil servants in the Treasury and the health department about the internal politics of funding arguments. A slower rate of growth in spending might have meant NHS budgets were better spent in the 2000s but department were unlikely to accept that. As a former Department of Health official puts it: “if you are a spending department and it is jam today or jam tomorrow… well jam tomorrow never arrives. I want this frontloaded so I have got it in my pocket”.
In other health research and analysis:
- FullFact wrote an extremely clear explainer on the government’s proposals for greater NHS data sharing
- The Nuffield Trust have updated their staffing tracker! Excellent! Looks (broadly) like the government are still on track to hit the nursing manifesto commitment, but they are running slightly behind when it comes to GPs and mental health professionals
- Interesting NHSX blog on whether and how digital technology could be used to reduce elective waiting times
- Analysis of how Brexit affected the NHS from Nuffield’s Mark Dayan
- New NHS Providers survey of what NHS Trusts are worried about — staff burnout, leaving rates, and a possible covid surge during the winter months
- Interesting analysis of the slow growth in booked A&E appointments by Jenny Davies — the percentage of A&E attendances that are booked increased from 1.2% in August 2020 to only 4.2% in May 2021
- Useful analysis of what can be done to help recover cancer services, and what pandemic innovations — such as the coordination of specialist oncology workforce in cancer ‘hubs’- should be kept
- Excellent blog about pressures in general practice, what the data (and doesn’t tell us) about workload, and why the longer-term picture for workforce isn’t great from Greg Fell. See also this contextual article from the Manchester Evening News’ Jen Williams. Both make the interesting point that the payment system (hospitals are paid by activity while GPs are paid by the size of the population they serve — with some adjustment for needs) partly determines the data collected. So we know more about activity in hospitals — because hospitals are paid for the activity they undertake — but less about activity in general practice, where they are not. Some GPs have set out what they see as potential solutions, here. David Oliver wrote a good blog about GP workload here, too
- NHS Providers make the case for a permanent uplift in discharge-to-assess funding
- Kings Fund argues that chronic excessive workload is the key cause of burnout in the NHS
- Richard Murray on what a ‘comprehensive NHS recovery’ would look like
In social care, the big news was the widely-trailed social care reform meeting between Johnson, Sunak, and Hancock that was supposed to happen, then did not happen. For those that missed it, I am referring to the slightly mad farce that led senior journalists to spend time investigating minister’s diaries to see if there was ever a meeting planned, and whether it had postponed or cancelled. Schrodinger’s social care meeting, if you like. This account by Jessica Elgot and Heather Stewart seems like a more well-informed account, however. In any case, less time was devoted to the actual substance of said reforms. I was annoyed about that — so I wrote a blog about it.
TL;DR — a cap on care costs only solves one problem in social care. It does not tackle any of the problems exposed by the pandemic — low funding of publicly-funded care, lack of resilience in care homes and homecare, low care worker pay. (And yes, I know that a cap would expand access to care and insure people against catastrophic costs, which would be obviously beneficial — the government could do both, as anyone who has listened to Andrew Dilnot over the last two years will have heard!)
Elsewhere, a useful Public Accounts Committee report on the adult social care market. They show that the initial drop in care home occupancy seems to have been maintained (it was still only 80% in February 2021), and that — in more positive news — the government’s additional funding for coronavirus did appear to stop widespread care home closures. The Care Quality Commission told the committee that there were only 361 voluntary closures in 2020, down from 482 in 2019. The committee conclude that “the Department urgently needs to provide confidence by announcing what support will be available to help providers move beyond COVID-19” — which seems fair to me.
A useful ADASS survey of local authority directors on how many referrals they are receiving, and how many day services they are now able to run again as pandemic restrictions ease. Most surprising finding for me was that “48% of Directors who responded indicated that there have been increases in the numbers of people presenting with need as a result of not being admitted to hospital since November 2020.” The elective waiting list has big consequences outside of the NHS, too…
Last but not least, the Care and Support Alliance charity have calculated that local authorities in England have turned down 2 million requests for care since Boris Johnson stood at Downing Street and promised to “fix social care once and for all”. Not sure how they calculated the number, but it’s certainly a striking way to represent growing demand for social care outpacing local authorities’ ability to provide it!
Children and Young People
The big story this week is the education select committee’s report on school performance of and outcomes for white British children eligible for free school meals, which made headlines when some newspapers wrote up the report as arguing that language like “white privilege” might have contributed to “neglect” of white working class pupils…
Beyond the headlines though, that is not really the bulk of the report, which essentially shows that white British children eligible for free school meals perform worse than most minority ethnic groups eligible for free school meals on some educational outcomes and discusses the complex reasons why that might be.
The controversy is the section of the report which discusses white privilege and implies (though does not state) that a focus on white privilege in schools and policymaking is the root cause of the disparity in performance. For what it’s worth, the report actually says “our inquiry has shown that poor White pupils are far from “privileged” in education”. Not much of a conclusion.
But as an implicit diagnosis of the problem, ‘the gap is due to excessive focus on ‘white privilege’, is downright bizarre. As Chris Cook and Sam Freedman have pointed out, there have been a lot of Department for Education policies aimed at trying to improve attainment for white British children eligible for free school meals. Do not fall for the artificial non-debate. This Kenan Malik thread is also good.
In other news, Luke Sibieta has compared education catch-up packages in England, Scotland, Wales and Northern Ireland. He finds that Wales has the biggest spending package, though reckons all the devolved nations will end up spending more than England once the devolved administrations find out about their funding for 2022/23.
Education DataLab analyse the overlap between pupils who receive social care, have special educational needs, and/or attend alternative provision. Combining the Children-in-Need survey with the national pupil database, they find that “by the end of 2019, 130,000 young people [born in 2002/03] (21%) had been referred to social services.” A higher proportion — 39% by the end of 2019 — had been classified as having special educational needs by the end of 2019. Only 4% of pupils have ever attended alternative provision schools, but “the majority of [these] pupils who experience alternative provision are identified as having special educational needs and are referred to social services for a child in need assessment during their school career.” Interesting analysis of the available data.
Law and order
Good news for a change! Court judgements will now be hosted publicly by the National Archives