Week in Public Services: 31st January 2023
This week: excess deaths debate; refugee safeguarding failures; and reforming the Met
General
Strikes continue to be the only show in town, with the beginning of February shaping up to be the worst stretch of the crisis so far. Teachers have jumped on the industrial action band wagon, meaning that Nick Gibb is the latest minister given the chance to trot out the Conservative party’s lines. Thus, he recognises the “pressures that teachers are under” but also doesn’t want to award an “inflation-busting pay settlement”. Stop me if you’ve heard this before. If you’re wondering why teachers are striking, this chart comparing change in teachers’ pay since 2010 with other OECD countries should provide at least part of the answer.
Compounding the ongoing crisis in the NHS, junior doctors in the HCSA (that’s the Hospital Consultants and Specialists Association, for anyone playing union acronym bingo) voted 97.5% in favour of striking. The result isn’t too devastating for the NHS, as the HCSA only represents 531 junior doctors. More worrying is what the overwhelming result means for the likely outcome of the BMA’s ballot which is due at the end of February. The BMA represents 45,000 junior doctors, meaning a walkout by that union would really pile pressure on an overstretched system.
BUT there might be some light at the end of this particular tunnel. Bloomberg (£, but Alex Wickham has a thread summarising here) has the scoop that Sunak might be close to a deal with rail workers and firefighters, and hope that there will be a “domino effect” with more deals following. A couple of things to note. First, the Treasury expects any pay deals to come from existing budgets. Pretty standard Treasury line. What’s more interesting will be the fiscal contortions departments go through to meet that requirement. Wickham thinks many will claim “efficiency savings” (read: cuts to other parts of budgets) or will push spending into the future. Neither option bodes well for public service performance. Second, Wickham thinks that any pay deal now will anger some Tory MPs who will wonder why the government couldn’t have avoided months of chaos and negative headlines. On this I agree with Tory MPs — it’s been clear for months that public opinion has been on the side of strikers, and the government’s lack of a plan has hardly inspired anyone to think they’d be able to skilfully navigate those treacherous political waters.
Back in wonk-world (a terrifying thought), debate rages on about public service reform, particularly in health. For some reason, primary care has become the focus of those discussions, with Sajid Javid the latest figure to wade into the debate. He came out in favour of a policy Sunak proposed a while ago: charging for GP appointments. While Labour’s proposed reforms generated interesting back and forth, Javid’s suggestion has been met with unanimous condemnation from health wonks. Luckily Nuffield Trust have published another of their excellent myth-busting series dealing with just this question. Charles Tallack from the Health Foundation clears up another argument that Javid makes: that NHS spending can’t continuously increase as a share of GDP.
Health and care
Going against every sinew of my British upbringing, I’m starting with some self-promotion. I published a report last week answering three questions about the NHS crisis: (1) Is the government right about the cause of the crisis? (2) How is government responding and will it be effective? (3) Is Sunak’s pledge about the NHS really as unambiguous as he claims? Thread here for anyone who doesn’t have enough time to read the whole report. As a teaser, the thread concludes with an unlikely connection between the report and Rod Stewart. If that doesn’t entice you, nothing will.
Back to normal programming. Fullfact examined the Royal College of Emergency Medicine’s (RCEM) claim that delays in A&Es are causing 300–500 excess deaths per week. Unsurprisingly they find it difficult to verify, because (as we said a couple of editions ago), the methodology is not the clearest. Despite this, Fullfact acknowledge that the actual total could be higher or lower than RCEM’s estimate.
That brings us nicely on to Adrian Boyle’s (president of the RCEM) appearance in front of the health and social care select committee last week. He started off by defending that excess deaths claim, before heading into a more wide ranging discussion. Most interesting was Boyle’s rejection of the use of “modular units” outside A&Es as a solution to delayed handovers. Instead, he called for expanded use of continuous flow to get patients into hospitals. He also highlighted the high resignation rate of senior nurses as a serious loss to the service. Finally, he expressed scepticism about the efficacy of virtual wards; interesting, given NHSE’s reliance on them for capacity expansion.
Other witnesses included Chris Hopson from NHSE. Hopson started off by attempting to cast doubt on the RCEM’s modelling of excess deaths, though as Steve Black points out here, it seems the only evidence that would satisfy Hopson would be an RCT. Much of the rest of Hopson’s appearance was standard NHSE fare, stressing the benefits of the falls service, respiratory hubs, and system control centres. Pretty much what you get in every NHSE press release.
Steve Brine also announced that Steve Barclay will appear in front of the committee at 4pm today.
On the topic of emergency medicine, an article in the Guardian claims 57,000 people experienced “potential harm” in December due to ambulance handover delays. I’d never come across this metric before so fell down a bit of a rabbit hole. The stat comes from the Association of Ambulance Chief Executives’ monthly report on national ambulance data. They seem to arrive at the 57k number (p.36 here) by applying a proportion found in a clinical review of patients in 2021, to the total number of delays in a month. Interesting datapoint, though I’m still unclear what constitutes “potential” or “severe” harm and also wonder if the effect of worsening handover delays is linear?
A poll by a company called Hologic found that the UK ranked 30th in the world for women’s healthcare. Astoundingly, Saudi Arabia scored ahead of us. Areas that lowered the UK’s score included mental health and access to preventative care (e.g. cancer and diabetes screening). In line with other areas of health in the country, performance has worsened in the last year.
In more depressing female health news (£), the UKHSA thinks that lower rates of vaccination against the HPV virus among teenage girls during the pandemic has set back the UK’s attempt to eradicate cervical cancer.
A few editions ago we pointed out a measure being rolled out by NHSE that would see people taken off the elective waiting list if they decline two elective appointments. It looks like this is now being used by trusts, with James Illman reporting that 135 people have been taken off the waiting list and put onto active monitoring. While not a lot of people, there is the potential for more extensive trimming.
Nuffield Trust have a report out about the progress of integration. They identify five key risks to the success of integration. These are:
1. Existing cultures and behaviours in organisations
2. Organisational complexity involved with integration
3. Resource constraints — be that revenue, capital, or capacity
4. Difficulties in evaluating integration
5. “Integration fatigue” among staff
The fourth of these interests me the most. What does good integration look like? How would we measure it? And, as the paper later asks, how can we draw causal links between changing outcomes — for which ICSs are ostensibly responsible — and integration? None of that is really clear.
Nye Cominetti at Resolution Foundation has a really insightful report out on the adult social care workforce. A few things leapt out at me. First, it’s striking how much satisfaction care workers (rightly) take from their work, especially when compared with other sectors. Second, and something I hadn’t considered, high vacancy rates mean high job security for those that stay in the sector. At the same time pay is still remarkably low, which does seem strange to me; you’d think scarce workers (as shown by strong job security) would have high bargaining power with employers? But maybe the explanation is in another of Nye’s points: union membership is exceptionally low, at 20%. Finally, Nye distinguishes pay between different types of carers, and points out that domiciliary care workers are often paid below the national living wage, due to time spent travelling between clients. The report recommends a sector-specific minimum wage, set at £2 above the national living wage.
Children and young people
Two childcare-related horror stories broke last week. The Guardian published this story showing 222 unaccompanied asylum-seeking children had disappeared from hotels run by the Home Office. These hotels are used while the Home Office assesses the applications of asylum-seeking children. By the weekend another whistleblower alleged that child migrants had been racially abused, threatened with violence, and illegally detained by hotel staff.
Shockingly, the sector flagged these risks well in advance. First, when the DfE passed legislation which exempted the Home Office from Children Act duties, despite — as Kathy Evans notes here — people warning about safeguarding risks. Second, HM Inspector of Immigration wrote a critical report on using hotels for asylum seeking children. Finally, an ADCS safeguarding pressures report which noted the “high risk of trafficking and children going missing”. That language closely mirrors the Home Office’s own 2017 safeguarding strategy which stated “Unaccompanied children can be highly vulnerable and can be particularly at risk of going missing due to trafficking and exploitation”.
The response by the government has failed to reassure. On Wednesday the PM sidestepped a direct question, instead emphasising that local authorities have a duty of care to children. This was promptly debunked by Kathy Evans, who clarified that children in the care of the Home Office are outside the duties of the Children Act. The government will continue to face scrutiny on this from the Children’s Commissioner, as it struggles to determine who has “corporate responsibility” for the children. Meanwhile, multi-agency teams continue to look for the missing children.
In further awful news, the BBC outlined systematic and sustained abuse at a Doncaster children’s home which had received a “good” Ofsted rating. This was despite Ofsted receiving 40 reports about incidents in the home. The only response so far comes from the Education minister Gillian Keegan who say the government aims to strengthen Ofsted investigatory powers for private homes.
Last week the Chief Executive of Solihull council resigned following a critical Ofsted report which concluded the council’s services are inadequate, with serious and widespread failings. As Birmingham Live reports, this is one of several Ofsted reports that have followed since the tragic murder of Arthur Labinjo-Hughes. Incidentally, this also follows closely after the Chief Executive of Bradford Council’s decision to step down — a council which had its Children’s Services taken away following the murder of Star Hobson.
Other children’s services have been in the news recently:
· Sefton is still at risk of losing children’s services and the DfE has now appointed a second commissioner to direct improvements in children’s services
· Hereford last month published a plan explaining how it intends to improve its services following ‘widespread and serious failures’
· The DfE is also ‘extremely concerned’ by service provision in Devon
The House of Lords Library has a concise summary of the Commission on Young Lives.
As noted in last week’s edition — the NEU have planned strikes and both NASUWT and NAHT are investigating re-balloting members after postal issues. This week started with news that last-minute meetings between the government and the NEU failed and strikes are going ahead.
Schoolsweek has a great report on the teacher student loan reimbursements pilot. Summarising findings from CFE research, he shows it only has a “subtle” effect on career choices and little benefit for teachers facing work-life balance concerns.
Finally, following Sunak’s proposal that students should study maths to 18, Dave Thomson of FFT Datalab crunched the number on post-16 maths. He finds that it is those who score between 4 and 6 at GCSE that are most likely to give up the subject, and therefore where the highest growth can be achieved. There is one thing that I thought was slightly odd about the analysis though: the number of people who continue studying maths after 16 includes those doing GCSE resits. While this is technically correct, it feels somehow against the spirit of Sunak’s proposal?
Law and order
There are, unsurprisingly, a lot of stories this week about police reform in light of last week’s revelations. Both Jonathan Freedland and Danny Shaw wrote pieces advocating an organisational shake-up of the Met along the lines of the Royal Ulster Constabulary (RUC). While superficially the analogy has a lot going for it — a lack of public trust in the service, both in need of reform — the context of paramilitary engagement and sectarian violence probably makes it a slightly inappropriate model on which to base a root and branch reform of the Met.
Imy Harper at Tortoise has a useful write-up of the story, replete with judgements and quotes from big names in policing.
Suella Braverman had this piece on the story in the Telegraph. She claims she wants to empower chief constables to get rid of anyone unfit to wear the uniform, wants forces to urgently check their staff against the police intelligence database, and has promised to review the officer dismissals process.
Mark Rowley, the Met Commissioner, has published his ‘Turnaround Plan’ for sorting out his scandal-stricken force. Police Professional has this useful summary. Priorities include, a greater focus on identifying abuse, corruption and misconduct in the Met, and a stronger emphasis on neighbourhood policing across London. For context: PCSO numbers declined from 4,645 to 1,170 from 2010 to 2022. The proposed 1,600 PCSO uplift would almost double the current level, but would still leave the number of PCSOs 40% below the 2010 level.
Final thing on this — remember when we said things would get worse in the Met before they got better? It seems like Rowley agrees, with the BBC reporting on a session the Commissioner had with the London Assembly in which he revealed 2 or 3 Met officers would face court per week in the coming months.
Elsewhere, the ONS released its latest crime figures, which shows domestic burglary declining pretty consistently since the mid-90s to one of its lowest levels on record.
An interesting piece of analysis from TaxWatch suggests that despite tax fraud costing 9x more than benefits fraud in 2018/19, there have been 23x more prosecutions for the latter than the former since 2012. A matter of complexity? Perhaps, although that isn’t reflected in staff numbers — the DWP employs 3.5x more staff in compliance than HMRC.
Charlie Taylor (the Prisons Inspector) has this on the limited access to education and training in prisons (not due to lack of facilities, but because some are locked up for 22hrs per day). Why? This could be a response to the explosion of drug-fuelled violence between 2015 and 2019. Measures to reduce this coincided with the pandemic, leading to a belief among officers that the way to make prisons safe is to keep prisoners in cells. Add to the mix a large proportion of inexperienced and, overall, too few staff, and it’s easy to see why prisoners don’t have adequate rehabilitative opportunities.
This story on officers being hired without face-to-face interviews caused a bit of a stir, something which we noted back in November. Gavin Hales has this thread suggesting that vetting capacity might have been slimmed down since 2010 given the fall in officer numbers (so fewer recruits to vet) and cuts to funding. Add in social distancing, and it’s easy to see how the face-to-face angle of recruiting (which is important for vetting) could be pushed aside.
Finally, the BBC has this story about the murder of Zara Aleena by a man who probation staff wrongfully assessed as “medium risk”. The Chief Inspector of probation, Justin Russell, candidly admitted that the public might not be safe due to a chronic shortage of probation officers across England.
Local government
The biggest story in local government last week was the allocation of the second round of the Levelling Up fund. I’m not going to get into speculation about what drove decisions, but some of the successful bids are just ludicrous. This successful application from Rutland and Melton had me scratching my head trying to work out what they actually wanted to do with their £23m. Looking past the ins and outs of who got what, the clearest lesson is that bidding for competitive pots of money is a terrible way of allocating funding. Think of all that wasted time put into unsuccessful bids. And then consider that this is only one of many funds that councils have to bid for.
As this FT article points out (while referencing IfG work, second bit of self-promotion in one edition, this is becoming a dangerous pattern), the funding is also a scale of magnitude smaller than the level of cuts the government imposed on the sector in the 2010s. The one thing that can be said for this money is that it is incredibly well branded, grabbing headlines in ways that a quietly announced increase in grant funding would not.
Not that surprising, given the parlous state of public sector staffing, but a survey by the LGA shows that nine in ten councils are experiencing staffing shortages. There’s almost no part of local government that isn’t finding it difficult to recruit and retain staff, with children’s and adult social care, public health, planning, environmental health, and administrative staff all highlighted as areas of concern.
LGC reports (£) that SOLACE has called for a “fundamental” rethink to local government funding. The headline is that the sector would like to see a 5-year funding settlement, but with my cross-public services’ hat on, the more interesting suggestion is for “shared funding pots” between local government, health, police and “others”. Splits in funding streams between different services can cause problems, with different organisations attempting to shift responsibility to others. But the logistics of this will be a thorny problem to solve.
It wouldn’t be a Week in Public Services if we didn’t discuss Thurrock. So finally, DLUHC announced that it is scaling up its involvement with the financially-stricken council, apparently getting to the point where it is a near “full takeover”. I’m sure there’ll be more on that story in the next edition.
