Week in Public Services: 3rd May 2024
This week: spending review timings; rethinking GP access; and local election watch
General
You can’t move these days without someone speculating when the general election’s going to be. But you hear less guesswork about when the timing of the next spending review. Arguably the latter is more important for public services in the short-term, as departmental budgets run out at the end of March next year, leaving everyone guessing what budgets they’re going to have. IfG colleagues have written a short report explaining the implications of that cliff-edge. They argue that the next government should carry out a quick, single-year spending round for 2025/26, and then run a comprehensive spending review the following year, to cover the rest of the parliament.
This really matters to public services. As we’ve said for months, spending plans from April 2025 onwards are a fantasy and will leave key services really struggling if the next government sticks to them. Running an accelerated round will mean difficult decisions having to be made very quickly. But as my colleagues point out, that doesn’t necessarily preclude spending increases on political priorities.
One particularly interesting point (for a local government finance nerd like me) is the timing of the local government finance settlement. Normally the government releases the provisional settlement in December, following the setting of the spending envelope at the most recent fiscal event. The provisional settlement is then followed by a couple of months of wrangling over details (and occasionally some more substantial changes, as happened this year), with the final settlement coming in February. That timing is already terrible; setting local authority budgets a couple of weeks before the start of the financial year doesn’t scream “sound financial planning”. But that already-short timetable could be compressed further in the event of a November or December election. The report speculates that the provisional round could even be moved to before the general election. But in that case, it’s hard to imagine that a government about to fight an election it is likely to lose will be planning local government spending with much of an eye to the future. An interviewee in the report called the timing “extremely challenging”. I think that’s likely a polite understatement.
Speaking of local government, there were some elections this week. Of course, Westminster has approached these completely sanely, with absolutely zero speculation about what it means for the timing or outcome of the general election. Shockingly to some, these elections are quite important in their own right. For everything you need to know, colleagues in the devolution team have been working flat out, with two events this week and an explainer on the six most interesting things to look out for. Follow the team’s twitter accounts for more information this weekend.
The government thinks we give too much money to sick people, particularly those with mental health conditions. As arguments go it’s definitely one of the ‘bolder’ (adding a “sarcasm” label here, for anyone who missed the tone) positions to take. Instead, Sunak and his ministers have been encouraging people to seek talking therapies and then return to work as soon as possible. Which — as Isabel Hardman argues in this piece — would be all well and good if there was some spare care capacity to go round.
Another proposal is for “independent assessors” to issue sick notes instead of GPs. Look, I’m all for reducing GP workload. But I do wonder who these “independent assessors” are going to be? Other doctors? In which case the government is just shifting work from one part of the NHS to another. If not doctors, are they non-medical people in call centres following decision trees, like for remote triage? If so, that feels rife with potential problems such as a limited ability to deal flexibly with nuanced and complicated cases. If the answer to that is that GPs will ultimately decide, then we’re back to square one.
Health and social care
Regular readers may be getting tired of discussions about trust deficits in this blog, but I think it’s one of the biggest — and arguably most poorly reported — stories in the NHS this year. Steve Black has an excellent article (£) in the HSJ in which he argues that trusts have expanded their workforce too quickly, not realising that the funding uplifts from 2019 onwards would be front-weighted. The result is overspending this year, and the need to cut back on staff.
This article from the Health Foundation is useful on the benefits of technology in the NHS. Researchers spoke to frontline staff and asked them both what technologies save them most time now and which have most potential to save time over the next 5 years. Tellingly, the tech that saves time now is not the more highly-publicised, patient-facing stuff, but rather things like video conferencing and instant messaging with colleagues (Microsoft Teams is highlighted as an excellent piece of software). For the future tech, clinicians feel that electronic health records (EHRs), clinical documentation (speech-to-text software) and image recognition software will help the most. The last two of those use some form of “AI”, countering my extreme scepticism on the topic.
Alastair McLellan at the HSJ (£) argues that the 4-hour wait target in A&E is not fit for purpose. He makes some interesting points. He says it creates strange incentives for trusts to treat the least sick first (though it would be good to see some evidence for this, as this has rarely been my personal experience) and that it encourages people into hospital when it might be more appropriate for them to be seen in primary or community care (though lack of capacity there also makes that difficult). Strangely though, he also argues that having a target of 95% and then missing it “throws considerable shade on even very significant advances in performance”…which is fine, except that the NHS had a target of 76% last year (which it missed) and 78% this year.
Every now and again you read something that really changes your perspective. This long read from the Health Foundation and the Healthcare Improvement Studies (THIS) Institute is one of those times. They argue that many — and I’d include myself in this group — think too narrowly about access to general practice, often in terms of the supply of GPs. They propose that there are further barriers to access which relate to a patients ‘candidacy’. In other words, does an individual identify themselves as needing care, are they able to navigate the system, how able they are to use their ‘voice’ when they reach care, and finally how do GPs adjudicate their need.
There were a couple of specific things I found fascinating from this work. The first was their argument that someone’s perception of the availability of services also mediates their candidacy. That perception can be because of actual supply constraints, or because of reported supply issues in the press. It made me wonder if the same phenomenon could explain the relative flatlining in demand for A&E since the pandemic. Second, they point out that rapidly changing the way that patients can book or manage appointments might worsen access, as people feel uncertain about how to make an appointment. Which hardly bodes well for the massive changes in online triage, increased remote appointments and other changes in general practice in recent years.
The NHS long term workforce plan requires a massive expansion of nursing training places. Despite that, Nuffield Trust shows that there was a drop in both nursing applications and the number of applicants accepted onto nursing degrees in 2023/24. There were 20,790 accepted applicants in that year, down from a high of ~25,500 in both 2020/21 and 2021/22. Obviously, there was a pandemic era bump in applications, and the 2023/24 level is still slightly higher (5.2%) than in 2019/20. But that number will need to increase substantially if any government is going to meet the workforce plan commitments.
Nuffield Trust have published a briefing for the next government on the adult social care sector. One thing that stood out to me was their recommendation that the next government “should not seek to define a national package of care for all and instead consider notional budgets to be used flexibly to suit an individual’s needs and preferences”. To me, this felt like a warning shot about Labour’s (so far) vaguely defined ‘National Care Service’. If so, I share their wariness. I also agree with their recommendation for ICSs to focus more attention on social care. Though this is a difficult outcome to mandate for.
The King’s Fund and Skills for Care have written up a series of workshops that they held on expectations of the social care workforce. Maybe this is just because we’re getting close to publishing our report on prevention, but I was interested to read this snippet: “Prevention is often cited as a goal of social care services, though there is relatively little on the precise role of social care in preventative approaches”. This fits with what we’ve found elsewhere; there’s a lot of ambition on prevention, but very little idea of how to get there or what exactly it means.
Children and young people
This article in Tes magazine covers the findings of a Unison survey on teaching assistants (TAs). It finds that schools are increasingly calling on TAs to cover for teachers at short notice due to staff shortages. 85% of respondents said that they covered lessons for at least an hour a week, while two in five TAs reported covering for over five hours weekly — almost an entire school day. It makes for an interesting juxtaposition with a survey released just a couple of days before, where a majority of teachers reported cutting teaching assistant roles due to budget constraints.
The Association of Directors of Children’s Services (ADCS) published their annual survey which shows that 62 DCSs in 49 upper/single tier local authorities (out of 153) changed roles in 2023/24. That’s the second highest level on record, behind only 2017/18.
Law and order
We wrote about Imprisonment for Public Protection (IPP) sentences in the last edition of this blog. This week, David Blunkett — the home secretary who implemented IPPs — said that the policy was the “biggest regret I have in terms of the outcome of all the many things that I was involved in in the eight years I was in government”.
Fraud is the UK’s most common crime (shameless plug for an event we held on the topic in March). So this is an interesting summary of the evidence on the psychological and social impact of the crime. These include: negative impacts on physical and mental health; harm to relationships; and changing behaviour. Those behavioural factors include reluctance to use the phone or to answer genuinely important calls.
Following the awful incident in Hainault this week, there were some calls for police officers to be routinely armed. Matt Ashby has a good thread posing questions for those who support that policy. For me, the crucial question he raises is this: would routinely arming the police result in more lives saved, or more lives lost? This could be through things such as officer suicides or from people being mistakenly shot by the police. I understand the urge to give officers more options and greater protection, but the spectre of the US policing system looms over this and that unnerves me.
Local government
Good primer on the local government elections this week from Richard Partington at the Guardian. As he points out, spending commitments on areas such defence, childcare and the NHS will likely leave local authorities out in the cold when it comes to spending settlements. That will likely be partly offset by more council tax rises, but will still leave budgets lagging demand in most councils. He’s not convinced by Labour’s plans either, arguing that “without much extra financial firepower they risk being inadequate for the scale of the challenge”. As an impartial observer, I couldn’t possibly comment.
The Municipal Journal reports that Gove is thinking about launching a police investigation into Birmingham council for financial mismanagement. This was reported the day before the local elections, so should probably be taken with a pinch of salt. But if he does, it would be the first time since the government created that power in 1999, as Jack Shaw points out here. Gove doesn’t seem to have been that bothered by purdah in advance of the elections. He also tweeted a link to some very dodgy Times analysis (my thread on why it was so bad here) which claims that Labour councils are the worst run in the country.
Donna Hall tweeted pictures of the letter that Simon Hoare — the minister for local government — sent to local authorities about productivity in local government. It’s a mixture of patronising pronouncements (how do you approach identifying and reducing waste in your organisation?) and pathetic culture war nonsense (how much time and money do you spend on staff equality, diversity and inclusion (EDI) training networks and other programmes?). The idea that local authorities have spent 14 years of austerity just twiddling their thumbs, ignoring potential savings in the face of enormous cost and budgetary pressures is ludicrous.
