Week in Public Services: 26th April 2024
This week: more cuts for unprotected services; NHS waiting list ambitions; and dodgy maths for new PCSOs
General
Did you hear? The government’s pouring money into the military. Sunak announced that the UK will be spending 2.5% of GDP on defence by 2030. It wouldn’t be a government announcement without some dodgy maths, and this one was a doozy. Sunak claimed that that commitment would entail and additional £75bn worth of spending, with the money coming from cuts to the civil service headcount. But as Ben Zaranko points out, that claim of £75bn only makes sense if the government was planning on holding defence spending flat in cash terms between now and then, thus breaking previous commitments. Then there’s the claim that this can be funded from civil service efficiencies. My colleague Alex Thomas argues here (and more extensively in this report) that while the government could find efficiencies in the civil service, it is unlikely to release piles of cash.
This may seem like a long detour into an interesting, but ultimately irrelevant topic for a blog that focuses on public services. But here’s the rub. As ever when the government announces new spending, that money has to come from somewhere. And Sunak and Hunt don’t seem too keen on raising taxes or borrowing, meaning that once again public service cuts will do the heavy lifting of election-year giveaways. Admittedly, spending plans for 2025/26 onwards are a complete fantasy, but we have to take the government at their word sometimes. So as our chief economist Gemma Tetlow argues in this piece, meeting Sunak’s commitments on defence spending, the NHS, and childcare, while still only increasing overall RDEL spending by 1.1% in real terms per year, implies annual cuts of 2.6% in real terms (down from -2.3% before the announcement) for unprotected services. You know, all those services like prisons, the courts, and local government that are all doing so so well at the moment.
The What Works Centre for wellbeing is closing. For their final report, they’ve pulled together a review of all the determinants of and the interventions that can improve life satisfaction. Relevant for the state of public services is that education, physical health, and culture are strongly associated with life satisfaction. I’m sure it’s fine, then, that it’s much harder to access care and that local authority spending on cultural services has been hollowed out. Surprisingly (to me at least) there is little evidence that community belonging and cohesion improves life satisfaction.
Health and social care
We’ve written about the NHS’s £4.5bn deficit in the last few editions. This week, Staffordshire and Stoke-on-Trent Integrated Care Board claimed that closing its deficit of £130m will require a 10% cut in their workforce, bringing teams “below safe staffing levels”. I understand the point, but if this ICS is like the rest of the NHS, it will have had an increase in staffing numbers of roughly 20% since 2019, without a commensurate rise in activity. Which raises the question of why they can only manage roughly they need those extra staff to deliver the same level of activity. As Steve Black argues in this thread, some of the cause of the system-wide deficit is likely poorly planned spending increases — particularly on staff — since 2019.
NHSE are reportedly (£) drawing up plans to halve the elective waiting list by 2029. That target may sound a bit arbitrary, but it is supposedly the level that the NHS thinks the overall list needs to reach to hit their target of 92% of people treated within 18 weeks of a referral. This proposal raises a big question: after more than a decade of a growing waiting list, is this actually possible? NHSE leadership seems to think so, though — and this made me laugh — it is dependent on “targeted extra capacity, technology, resolution of strikes and on which other targets are set, especially around emergency waiting times”. So basically NHS leaders think it’s possible if: they can magically create capacity where it’s needed; the government massively increases capital budgets for new tech; the government rapidly and permanently resolves the worst bout of NHS industrial action in history; and the NHS essentially sacrifices UEC performance for a few years. All stuff that seems super easy and very likely to happen. (This was some great exclusive reporting form James Illman at the HSJ by the way).
Interesting blog from Luca Tiratelli at the King’s Fund discussing the way that the role of Director of Public Health (DPH) has changed since the introduction of ICSs. From interviews, he finds that while the pandemic made public health more prominent, DPHs now struggle to have their voices heard in ICSs that are still predominantly focused on acute care and balancing the books. Luca does, however, argue that the role of DPHs differs from local authority to local authority, with some continuing to have a more prominent role since the end of the pandemic.
On the topic of ICSs and health inequalities, NHS Confed has a report out looking at how ICSs are addressing health inequalities. They find that ICSs are still struggling to address health inequalities in their area. Funding that is supposedly ringfenced is often used for others purposes (for example addressing acute and elective pressures) and there is still a lack of capacity in ICSs for addressing health inequalities (something that won’t have been helped by the government cutting ICS management budgets by 30% in 2023/24). On the positive side, there seems to be a real willingness to devolve responsibilities, with funding pushed out to primary care and neighbourhood teams. Some ICSs are also taking an experimental approach, using funding to pilot schemes and then gathering evidence about their effectiveness.
If you’ve been listening to Rishi Sunak, then you’ll know that we’re a country full of lazy shirkers who like to fake sicknotes to get out of work. Luckily, Tony Wilson, Director of the Institute for Employment Studies, has a corrective thread. He points out that the number of sick notes issued in the UK is pretty much flat compared to pre-pandemic trends, and that the UK issues remarkably few sick notes compared to OECD countries. There is, however, an issue with a rising number of people off work as long-term sick. But as Tony argues, this is due to a slow flow of people out of the economically inactive classification, not a rise in people joining it. It’s always a shame when Sunak’s lazy rhetoric collides with someone who actually knows what they’re talking about.
Chris Hopson — the Chief Strategy Officer for NHSE, and erstwhile critic of the organisation — has been back on Twitter with another thread, this time extolling the wonders of primary care. As has happened with almost all of Chris’ recent threads, this was instantly piled on. This thread in response from GP partner Phil Williams argues that the expansion of MDTs has harmed primary care by distracting GPs from actually being GPs. Henry Jefferson also points out that it’s a bit rich for NHSE to be extolling the importance of general practice while once again imposing an unpopular contract on the service. I for one can’t wait to see what Chris tweets next.
The Health Foundation are starting a programme of work to create a “Bill of health”, which aims to support government to improve health and reduce health inequalities. Anita Charlesworth is leading the work and has written a blog laying out the challenges of delivering a preventative approach.
The focus of discussion around the 2024/25 GP contract has (rightly) been on levels of funding. But the government made other changes too, as highlighted by this article from Ben Gowland at Ockham Health. The first is that clinical directors in PCNs are being asked to determine which practices are eligible for additional funding under the “Modern General Practice Access” requirements. That puts a lot of pressure of those directors to make decisions early and release funding. The government’s funding for cloud telephony in practices seems to have come with some strings attached. Namely, practices are now required to report a range of performance metrics on things like time taken to answer calls, number of missed calls etc. This could mean interventions from an ICS or NHSE for areas or practices that perform poorly.
Children and young people
Sutton Trust’s annual teacher survey into school funding paints a gloomy picture. Two-thirds of all teachers report cutting back on teaching assistants due to budget pressures including 74% of primary school heads. At secondary level, financial constraints caused 27% of teachers to reduce subject choices for GCSE and A-Levels. More worryingly, 47% of surveyed headteachers admit to using the pupil premium (intended to provide extra funding to disadvantaged pupils) to plug gaps in the school budget instead.
The DfE has launched (£) an “advisory group” to look into unacceptable profiteering in children’s homes. You can’t complain too much about the government doing something that is clearly needed, but it’s been two years since the CMA published its report which found that providers are making profits that are “materially higher” than would be expected if the “marker were working well”. Baby steps, I suppose.
Back in January, the education select committee recommended that the Department for Education replace single-word Ofsted inspection judgements. The DfE has now replied that it has no plans to scrap them, describing them as having “significant benefits” by offering a summary of school performance for parents. Unsurprisingly, school leaders are dismayed at this announcement that a major part of what some consider a “fundamentally flawed” inspection system will remain in place for the foreseeable future.
Education Datalab have updated their school absence analysis with data from the spring term. They find that while there was a drop in absences during the Christmas term compared to 2022–23, the rates in the spring term 2023–24 was broadly the same in primary and slightly higher in secondary. Of course, absences are still much higher than they were before the pandemic, and don’t seem to be coming down.
Further analysis of school absence figures by Community Care reveals that the absence rate for children known to social care is 10.1%, nearly five times higher than for the general pupil population. The rate is even higher for children on child protection plans, where one in four miss over half of school time at secondary level.
Law and order
Yvette Cooper has reiterated Labour’s pledge to boost neighbourhood police officers and PCSOs by 13,000 in an op-ed in The Times. PCSO numbers have fallen substantially in recent years, more than halving since 2009/10. Numbers dropped over 15% from 2019/20 to 2022/23, with many PCSOs recruited into the police uplift programme. As we argued in our last edition of Performance Tracker, this hasn’t translated into greater police visibility and often means employing more expensive warranted officers in place of PCSOs. Further recruitment into the police on top of the 20,000 uplift could prove challenging, should Labour find themselves in government — particularly given the renewed focus on vetting and officer standards.
Cooper claims this will be funded by centralising police equipment procurement. This is currently handled by individual forces, with sometimes dramatic price variation. But Labour is noticeably light on the detail of how the numbers stack up. The Times cites Police Foundation research which estimates that procurement reform could save up to £40 million a year. By contrast, the 20,000 police uplift programme was estimated to cost £3.6 billion over three years. PCSOs are cheaper than warranted officers, but I’ll need to see a more detailed breakdown before I’m convinced.
Yet more polling showing low levels of trust and confidence in police forces across the country, particularly London. This poll finds that 26% of respondents believe the police would arrest and prosecute someone if they were burgled, while an optimistic 7% say the same about a pickpocket. A separate poll found that 41% of people said they trusted the police, dropping to just 36% in London. London was also the only region where women were less likely to trust the police than men.
A potential breakthrough on IPP sentences. A quick reminder: Imprisonment for Public Protection (IPP) sentences is that heinous New Labour policy which meant people could be held in prison indefinitely if they were deemed a threat to the public. While IPPs were abolished in 2012, this was not applied retrospectively, meaning thousands of people are still serving IPP sentences today.
This week, the government announced amendments to the Victims and Prisoners Bill which would make it easier to dismiss an IPP recall or release a recalled IPP prisoner. This should help many serving IPP sentences, but will not improve things for the 1,200 IPP prisoners who have never been released. It’s also unclear when (or if) the bill is likely to come to Parliament. Relevant reading: this week’s Guardian long read highlights the devastating impact of IPP sentences on people’s lives and mental health — sometimes with the most serious consequences.
We’ve known for a while that austerity led to the closure of police stations across the country. This paper from the IFS shows the impacts of those closures on crime prevention and citizens’ welfare. The author, Elisa Facchetti, examined the closure of 115 out of 160 police stations in London between 2008 and 2018. She found that closures caused: lower police deterrence and, consequently, an increase in violence in the nearby area due to lower response times; decreased police effectiveness due to difficulties collecting evidence and investigating crime; a decline in citizen cooperation; and (most worryingly of all, of course) a fall in local house prices. Fascinating paper.
Local government
Back in February, the government rejected Somerset council’s request to raise council tax by 10%. In response, Somerset has started a round of redundancies, with the goal of saving £30m in 2024/25 (just over 5% of their spending power for the year).
New polling in Politics Home shows that only 32% of *Tory* councillors think that their local authority has sufficient funding to provide adult social care, with 24% thinking they don’t. I’d love to see the polling for the other parties. Probably more surprising to me was that only 10% of Tory councillors think that there is insufficient funding for libraries. Which either means they’re not paying attention or they have a very different idea to most of the country about what constitutes an adequate library service is.
