Week in Public Services: 24th April 2023
This week: the (high?) cost of care; Ofsted in trouble again; and the state of health in prisons
General
Welcome back to your favourite public services update! Typical of our unabashed status as self-adulatory representatives of the new elite, we’re going to disagree with Greg Hands, who thinks public services are in “great shape”. Evan Davis pushed back on this in PM, citing some brilliant work as evidence that this isn’t quite true.
Sarah O’Connor has a piece in the FT about immigration to fill workforce gaps (with post-pandemic labour shortages and ageing demographics driving competition for migrant labour in an increasingly wide range of sectors). I was surprised to learn that, with net migration reaching a record high of 500,000 last year, the public is largely in favour of increasing or maintaining levels.
Our recent commentary on the effects of strikes has focused largely on their effect on health outcomes and the need to set pay at a level that supports staff recruitment and retention. This (£) FT piece takes a different angle, looking at the economic impact of strikes through an increasingly affected (and unhealthy) overall workforce. it argues that the pre-Christmas strikes led to lots of diverted (not just destroyed) economic activity, while only a small minority found themselves unable to work during rail strikes. However, strikes in health and education are harder to absorb. Most parents will have to at least cut their hours if school strikes continue, while halted health services will do little to bring those experiencing long term sickness into the workforce (nor prevent new people entering that group). Important context for those still convinced by the line that higher public sector pay is the inflationary wolf in sheep’s clothing.
(Speaking of, that article reminded me of this piece on the potential utility of occupational therapists — to prevent the workforce becoming sicker — working further upstream in the health system, and even employed directly by organisations)
On strikes, Stuart argues that the government’s approach to managing strikes isn’t working and that it should take a less combative approach to dealing with public service unions. The most striking thing about this analysis is just how cheap it would be to settle with the junior doctors compared to other staff groups. Even if the government granted them the full 35% pay increase that they are demanding, it would only cost £1.7bn, which is not a lot of money in the grand scale of the NHS budget. The government’s argument would be, however, that granting doctors a higher offer would lead to teachers, nurses, and others demanding even more — an outcome which would start to get expensive.
Health and care
Resolution Foundation has done some work on how the cost of living crisis affects people in different living in varying quality of housing. Of particular interest for this blog is the effect that poor housing has on health. They find that those living in poor quality housing have worse physical and mental health outcomes than those who do not, even when controlling for demographic factors that often associated with poor quality housing.
The Guardian reports that one in eight Britons paid for private health care in the last year, with one-third of those using private health care for the first time. The article quotes “NHS campaigners” extensively, who claim that this is the start of a “two-tier” health service. I’m a bit more sceptical. For a start, this is one survey presented in a vacuum that I think raises more questions than it answers: what’s the baseline rate of private care use? Is private care more or less affordable than it has been in the past? What proportion of procedures does the private sector account for? I need a bit more evidence before I’m convinced of those campaigners arguments.
The i paper has this write up of some data that the Lib Dems gathered through a series of FOIs. The data shows that more than 43,000 people were declared dead by the time an ambulance arrived last year. While this is obviously a terrible statistic, there seems to be quite a few holes in the data. Every trust had their own definition of what constituted a “death before the ambulance” arrived and suspiciously the Lib Dems only released data for 2020 to 2022, despite FOIing data as far back as 2018.
Steve Black has this piece on some ill-discussed problems in primary care: complex funding, inconsistent behaviour, and the geographical distribution of GPs. I found the third particularly interesting. Steve argues that, irrespective of GP numbers, the question of where they are isn’t given the time of day. Practices vary hugely in their GP-patient ratios, with the worst integrated care board (ICB) having 50% more patients per GP than the best. England has 480 practices with more than 5000 patients per GP, worse than twice the national average. For this reason, average ratios even at the ICB-level can hide huge variations patient access levels. As the below chart shows, this is a problem that has worsened over the last decade, with larger patient lists in surgeries across England. The problem here is twofold: there are both more patients registered with practices, and also fewer practices than in 2013. The result is every higher workloads for the remaining practices.
I missed this a few months ago, but this work from the Health Foundation and Ipsos on public perceptions of health and care has some interesting data. Some things that stood out to me:
· More than half (53%) the public would like to see an increase in taxes to invest in the NHS. This despite the hesitancy in political circles around proposing tax increases to fund public services
· Respondents favoured a tax earmarked specifically for the NHS as a way of increasing spending. This is interesting (a) because it shows the psychological benefit of associating taxes with particular bits of spending, even if hypothecation doesn’t exist and (b) because the government scrapped exactly that type of tax — the Health and Social Care Levy — last year
· One disappointing result from the polling was around the question of where the public thinks the govt should spend additional money in the NHS. By far the most popular response (81% compared to the next lowest at 55%) was on urgent and emergency care (UEC). But this would be almost the last place I would choose to spend extra money. The results of that question seemed to almost perfectly correlate (maybe unsurprisingly) to the areas the media pays the most attention to. Still, it’s a good illustration of the political difficulties in addressing NHS problems; as long as the public cares most about UEC, politicians will continue to pour money and resources into it, despite the limited effect it has on performance.
A sobering piece from Emma-Lou Montgomery outlining the scale of the care challenges society faces (and will increasingly continue to face) in the coming decades. She outlines a worrying level of unpreparedness among over 55s with respect to this predicament (52% of whom haven’t considered how they will pay for it according to survey data). With the number of over 65s set to grow 6m by 2040, and ¾ people needing later-life care, this lack of preparedness is a worrying prospect (irrespective of the financial wellbeing of the respondents). It’s worth noting that charging reforms would have addressed quite a few of these issues — not least the catastrophic care costs — but that the government has scrapped (sorry delayed) them. One other quick thing; the estimate for average cost of care over a lifetime seems…high. The author estimates that on average someone will face costs of £99,500, but then also says that only 1 in 7 people will require care that costs over £100k. That either means that this is a distribution with a very long and expensive tail or that her estimate is an exaggeration.
Children and young people
With Parliamentarians returning to Westminster the PM delivered a speech on the need for better maths education. Déjà vu? Perhaps the Matrix is glitching? Well this time the Sunak went up against the ‘anti-maths mindset’ that is holding the economy back. The crux of the announcement was the launch of a new expert advisor group. Attempts to regain the agenda stalled though as media attention focused on the shortfall in teachers and the high workloads facing the profession (the focus of this inquiry launched by the Education Select Committee).
Ofsted-linked work pressures in teaching continue to dominate educational news with NASUWT starting a campaign to abolish Ofsted as Freddie Whittaker at Schoolsweek reports. This was also a focus of questioning in Parliament to Gillian Keegan who said Ofsted is reviewing its approach to safeguarding in schools — for more details see this from Freddie at Schoolsweek.
This report on falling primary school applications in London leading to school closures caught our eyes this week. As we flagged before in Performance Tracker, the number of primary school children is expected to fall in the next decade (see below). But, interesting to see that taught school finances are challenging the financial viability of some schools in London. Jonathan Burn-Murdoch has a great thread linking this to the decline in people aged 25–39 in the capital due to exorbitant housing costs.
Ofsted has faced further criticism following the conclusions of the safeguarding panel investigating the abuse of children in three Doncaster care homes (see this edition of Week in Public Services for the backstory). The regulator was criticised for a lack of oversight and there are now calls for urgent reform. The panel made 9 recommendations including new statutory guidance, and a new regulatory framework for residential settings including joint inspections Ofsted and CQC.
The horrific murder of 10-month old Finlay Boden hit the news after a court found his parents guilty. Much of the reporting focused on the injuries sustained in the 39 days after social services released him back into his parent’s care. An independent child safeguarding review has been launched but for now the British Association of Social Workers has drawn attention to the potential impact that covid played in denying agencies accessing Finley. As Mark Easton at the BBC comments — three recent inquiries into the murder of children led to the government’s proposals for overhaul of social care, though as we’ve noted previously, these proposals have been criticised for being too small and slow.
In his inaugural presidential speech to the Association of Directors of Children’s Social Care (ADCS), John Pearce highlighted concerns about increasing child poverty, the need for more ambitious SEND reforms and criticism of risks in the government’s proposals for new regional care cooperatives (outlines in the government’s plans to overhaul the children’s social care system). He also emphasised the need for better children’s mental health facilities.
Timely comments given an FOI investigation which found significant variations in children mental health provision with extremely long waits in some local authorities and a high proportion of children turned away. Alan White has a great summary here.
Finally, last month the Lords’ Public Services Committee heard from witnesses about the Children’s social care implementation strategy and family hubs rollout. Witnesses so far have included Anne Longfield and Josh MacAlister, the LGA and ADCS and the Children’s Commissioner — unsurprisingly, raising common themes on the scale, funding and speed of social care reforms.
Law and order
Late on the uptake here, but earlier this month Sean Seldon put out this piece on Sir Mark Rowley, who warned the Met has ‘hundreds of people who shouldn’t be here’, and bemoaned as ‘nonsensical’ the fact that he doesn’t have the power to sack staff. Interesting to read from Phill Matthews that chief constables already have the power to dismiss ‘rogue’ officers… I’m sure I’m missing something here, and I’d be very grateful if anyone could DM me an explanation!
Charles Hymas has this piece outlining changes to the way police record crimes. This includes efforts to prevent double counting, and the requirement that police not record (in some cases) neighbourly rows or offensive correspondence. I’d be surprised if the latter made a huge amount of difference to the charge rate (at most, these types of offences comprise less than 1% of all police recorded crime), but we could expect positive effects in terms of better use of police time (we’ve noted previously how much of this is wasted). Efforts to prevent double counting, I’d imagine, are likely to have a more significant effect on charge rates. I’m reminded of the multiple reports of (at least) double counting that inflate crime stats.
This Guardian piece argues officers in Essex, Suffolk and Staffordshire police forces face higher rates of sexual misconduct claims than Met officers. Despite issues in comparability due to different forces’ recording practices (which the piece acknowledges), it’s useful to start building a picture of the performance of other forces what the everyone’s (including our) Met-centrism in recent years.
New research from the Nuffield Trust and Health Foundation outlines the health problems faced by the older prison population. It shows, but example, that 44% of men in prison aged 50 or over who were admitted to hospital in an emergency showed signs of frailty, a sign of poorer health outcomes (only 8% of the same demographic from the general population show similar signs of frailty). This throws up a number of questions and challenges. Firstly, why is this the case? The inability of prison officers to adequately care for ill people due to staffing problems would seem logical, given that prison officers are not trained for these types of issues — but problems caused by continued lockdowns in prisons also fits the bill). Secondly, how much worse will these demands become, given that the prisoner population is ageing? Thirdly, do prisoners have adequate access to healthcare? (The report would suggest not, with fewer diagnoses of conditions like hypertension than in the general population)
Local government
Aysha Gilmore at Room151 reports on Bradford Council’s decision to use reserves to plug an 8% budget gap. The council will be drawing down £32m equivalent to a quarter of the council’s remaining reserves having already drawn down £100.3m of reserves during 2022/23. The main driver is reportedly children’s social care which experienced a £50.5m variance and other inflationary pressures.
In other local news, Devon County Council has launched a governance review due to ‘serious, material, well evidenced failures’. Martin Ford at Municipal Journal has the story here.
There has been widespread coverage of renumeration analysis from the Taxpayers Alliance showing the number of council staff receiving more than £100k stands at 2,759 of which 721 received more than £150k. For more details see the writeup by William Eichler at LocalGov.co.uk. For any / all seeking to sharpen the pitchforks, its worth taking a quick glance at tables 9 and 10 of this survey from the Local Government Association — councils are still struggling to recruit social care managers, ICT professional, legal professionals, chartered Surveyors, planning officers etc. so worth remember the recruitment and retention situation isn’t quite the gravy train suggested by Tufton Street.
It would be remiss of us to overlook the upcoming elections. For more details of which local authorities have elections go to this guide from the BBC. Curious to see this multi-regression analysis from the team at electoral calculus suggesting the Labour party could gain up to majority control at 15 councils. With the government currently managing expectations by suggesting it may lose up to 1,000 seats all eyes will be on 5th May and whether new voter ID rules will indeed prevent many voters from casting their ballots.
On the subject of local elections… new analysis from the Liberal Democrats are drawing attention to… you guessed it… potholes. Their analysis, covered in the Guardian, shows some councils taking more than a month to repair and in some instances potholes remaining in place for 18 months. But according to some party officials also covered in the Guardian, sewage in streams may be the new electoral issue motivating Lib Dem swing voters in the so called “blue wall”.
