Week in Public Services: 8th December 2022
This week: Integrated care analysis; lack of prison spaces; and questionable local authority lending
General
Welcome back to another Week in Public Services, one of the last editions before what’s turning out to be a not-so-merry Strikemas — in case you missed it, a smorgasbord of industrial action news was announced over the weekend. Phillip Inman has this useful summary of the main developments, which includes nursing strikes (which we reported on here) and possible action by Russian stooges like hospital support staff (people who prep patients, update records… you know, unimportant things) and ambulance staff.
Nadhim Zahawi says disruptions could be temporarily patched up by getting the army to man the border and drive ambulances. Perhaps a workable short-term solution on the ambulance front (although I should point out that, according to the Chief Executive of the NHS Federation, unions will commit to providing emergency and critical care). Not sure how happy the soldiers will be about having to sit around waiting to hand their patients over to under-resourced and under-staffed hospitals… might discontent reach mutiny levels? You heard it here first.
Health and care
Why not kick off this week’s section by looking at what Labour have to say for a change? Starmer appeared on the Today Show (2:21:22 in) and said that he was “sick of the sticking plaster approach to the NHS”. He followed that up by saying that “the real problem is we don’t have enough staff in the NHS, I want to double the number of medical students being trained every year”. It’s a nice ambition, but I suspect he’ll find more push back from professional bodies than he might imagine.
The King’s Fund published a report about the first months of Integrated Care Systems (ICSs), Integrated Care Boards (ICBs), and Integrated Care Partnerships (ICPs, and yes the list of incredibly similar acronyms is an issue the report points out). There’s a lot going on here, all of it fascinating, if not somewhat wonk-ish. Some things that jumped out:
· The report highlights public health as an important link between ICBs and local authorities, as boards have responsibility for population health while directors of public health sit in local authorities. It will be interesting to see how they manage a service that has suffered from continuously declining grants in comparison to the relatively well funded acute trusts
· Some ICSs choose to have the same chair for the ICB and the ICP, while others opt for different chairs. The debate is an interesting one: the former supposedly demonstrates the ICB’s commitment to the longer term ICP vision, while those who opted for the latter argue that having a separate chair creates more accountability for the ICB. The separation of powers comes from a concern that acute secondary care will continue to attract the vast majority of attention and resources, one that I suspect will prove to be justified
· It is still unclear how ICSs will be inspected and rated, which sounds like a marginal point, but offers a real opportunity for driving improvement. For example, one suggestion in the report is that no ICS should be rated as “outstanding” if any trust is rated “inadequate”.
· The shift to statutory ICSs has been more resource-intensive than expected
· There are concerns among stakeholders that ICBs will just add another, redundant layer of administration and will ultimately become a glorified “talking shop”. One interviewee described NHSE often circumventing ICBs and going straight to trusts with performance issues
Seems to be a lot of thinking about ICSs this week, with CIPFA releasing their report on what’s needed for ICSs to work effectively. Key among their recommendations is a national outcomes framework that is flexible enough to adapt to local priorities and aligning financing across organisations.
This month’s NHSE board meeting included the organisation’s response to the autumn statement. As Sally Gainsbury points out, the key line is that the uplift of £3.3bn per year “should provide sufficient funding for the NHS to fulfil its key priorities” (emphasis my own), without making clear what those priorities are.
Another month, another plan for making progress on the backlog. This month: details of how the government will “turbocharge efforts” to reduce the backlog with the introduction of more community diagnostic centres (CDCs) and the establishment of an “Elective Recovery Taskforce”. The focus of the taskforce will be on how the independent sector could be used to increase NHS capacity. All this sounds very familiar and the Health Foundation published a good piece on this in the summer. On the CDCs, additional capacity is obviously good, especially if that capacity is really in the community, as opposed to in traditional settings. But as this King’s Fund piece points out, only 1 in 5 of existing CDCs have truly been placed in the community, the rest are in hospitals or primary care sites.
The other question I have is how productive CDCs are? This most recent press release says that they hope for the planned 160 CDCs to carry out 9 million tests per year by 2025. That’s 56,250 test per CDC per year. But this doesn’t stack up against reports of current productivity. A bit of back of the envelope maths: this press release from April says that the 73 centres that were open at that time were carrying out 30,000 tests per week — that’s 411 tests per CDC per week, or 21,370 per year. That’s about 2.5x less than government plans. That difference is huge. Given that the NHS carried out 23.3 million tests in 2019/20, that shifts CDCs from contributing an additional ~40% capacity, to an additional 15%. That’s not nothing, but it’s nowhere near the claim.
A lot of discussion about remote consultations in general practice, some if it useful, most of it not. On the not-useful side of the conversation is the incessant call for more face-to-face appointments from the usual suspects (*cough* the Mail and the Telegraph *cough*). On the thoughtful side of the debate are people like Steve Black who point out that the public often prefer remote consultations. And this piece in the BMJ by Rebecca Rosen and Trisha Greenhalgh is a good reminder that the shift in appointment delivery is still a work in progress. They make five recommendations for improving the quality of remote appointments, including greater use of video consultations.
Interesting blog from Richard Smith about why he thinks it’s misleading to talk about rising demand for health care. Instead he posits that a lot of demand is actually “supply-induced” i.e. as we discover new treatments, doctors make more interventions, ostensibly increasing the demand for care. All of this seems to make sense, but it left me with a couple of questions: first, most of the examples come from the US, where it could be argued that the insurance-based system incentivises more activity; are NHS doctors really using already stretched resources to deliver unnecessary care? Second, how do we draw the line between a necessary or unnecessary intervention? It’s very unclear to me.
This thread from Steve Black challenges the view that the NHS’s main problem is a staffing crisis. Steve argues that the NHS’s requirement for ever more staff is not because there is more caring work, but rather staff are spending more time doing “useless work” that is generated by the need to manage patients through a clogged system. Interesting hypothesis but ignores the fact that the NHS under-indexes on nurse and doctor numbers compared to other OECD countries. Either way, this is more nuanced than the current debate.
This thread from Charles Tallack about the delay to adult social care charging reform is a must read, particularly for anyone that claims that delay is justified because the reforms were purely protecting the wealth of the better off (see this tweet in particular). He also tackles the zombie policy idea of an effective insurance market for social care.
A festive (?) piece from Simon Bottery, that posits different reasons for repeated delays to adult social care.
Children and young people
IPPR published a great report, Delivering a childcare guarantee. Sam Freedman summarised the key findings here. Put simply UK childcare is in a mess, with confusing and incoherent financial support. This matters as parents struggle to pay for ever spiralling childcare costs. As the report shows, access to high-quality nurseries has a big impact on the likelihood children secure high quality GCSEs. The report also makes sound comments on the impact this has on the gender pay gap and several other areas. Well worth a read.
Great thread from IfG colleague Philip Nye about concerning teacher training data which shows an increase in the underlying shortfall in trainees. The outcome is that post recruitment targets are being missed in every subject but history, with the physics target missed by a shocking 83%. The government hoped for 33k people to start teacher training… but only 23k did.
Second reading in the House of Lords last week for the private member School (Reform of Pupil Selection) Bill. The bill aims to end selective admissions in all state schools, which would effectively end the status of the remaining grammar schools in the country. Very unlikely it will become law, but interesting nonetheless.
Staying in the Lords, on 8 December the second chamber will be debating the motion “this House takes note of the Independent Review of Children’s Social Care, published on 23 May and the case for integrated care and support across all services.” Look no further than Emily Have’s note in advance of the debate for a summary of the review, the sector and the recent House of Commons debate.
For a detailed account of the Children’s Social Care sector drawing on 6 months of interviews with social workers, see Anoosh Chakelian’s recent article. She gives a human face to the working lives of social workers and the crushing pressures of the cost of living crisis, the greater level of crisis work they now undertake and the difficulties retaining staff.
Anastasia Koutsounia at Community Care has crunched recent Ofsted foster care data showing the lowest number of applications to foster in several years and one in eight fostering households quitting last year. A key driver highlighted is again, the cost of living crisis which is also helping to drive carers to agencies to secure higher fees.
Finally, an interesting discussion in the Conversation on academic research at Oxford University into the impact that outsourcing care homes has on children’s social care quality. Using longitudinal data from 13,000 care homes the authors find for-profit care homes: have a worse Ofsted rating on average; they violate more statutory requirements and receive more recommendations; and local authorities using for-profit care homes get worse ratings. Yet, as the authors highlight almost 80% of children’s homes are run for profit.
Law and order
The police have been asked to make 400 cells available for a prisoners unable to be safely housed in prisons. Prisons minister Damian Hinds chalked this up to two factors: a “long anticipated” rise in the prison population because of increased efforts to tackle crime, and the recent barristers strike, which led to an increase in suspects being held on remand (i.e. post-charge but pre-trial). No doubt the barristers strike may have exacerbated this in the short-term, but as Nick Davies points out, the MoJ should have been more than prepared to absorb this increase — they previously predicted that the country would require capacity for about 2,160 more prisoners than there currently are (hint: that’s higher than 400).
The government released its response to Lord Bellamy’s Independent Review of Criminal Legal Aid last week, which inspired this less than happy response from the Law Society, which accuses its favourite Justice Secretary of imposing a real terms cut to criminal legal aid. The amount of legal aid (which helps people pay for legal advice and representation) received by barristers alone has fallen substantially in recent years (by 41% between 2011/12 to 2021/22, as we reported here). A below inflation pay increase will do little to improve the shortages in barrister numbers.
Finally, a couple of interesting data findings:
The latest MoJ data release on criminal courts shows us that illness among defendants — which contributed in 2021/22 to the highest annual share of ineffective crown court trials since 2010 — has fallen substantially in the last quarter. Another quarterly release next month should put us (fingers crossed) into pre-pandemic territory.
Secondly, the high share of ineffective trials in the most recent quarter is due largely to the failure of defence advocates to attend — the barristers strike would be an obvious reason for this, but I reckon the story is a little more complex. Partly because strikes were known about in advance (so why register them as ‘on-the-day’ disruptions?), and partly because as well as the highest recorded share of advocates failing to attend, we also see the highest recorded number of ineffective trials due to advocates being engaged in other trials. That doesn’t sound like a striking barrister to me. I’d wager other advocates (e.g. like solicitor advocates) were trying to pick up the barristers’ workload, with the understandable strain this would put on their diaries soon to follow. Please dm me with alternative theories here.
Local government
Following our dive into the financial mismanagement of Thurrock and Croydon councils in last week’s edition, Gareth Davies brings us the news that KPMG — the auditors of Spelthorne Council — found that the local authority had “acted unlawfully” by purchasing a number of commercial properties.
It seems the press is catching onto the trend of local authority financial mismanagement as the FT publish this piece. The story sounds almost too ridiculous to be true. After conducting due diligence on one company — The Hut Group (THG) — owned by a man called Matt Moulding, Warrington Council then lent £202m to a different company owned by the same man, which had nothing to do with THG. The story is eerily reminiscent of Thurrock’s lending that we discussed in last week’s Week in Public Services. It raises the question of how many other multi-million pound loans have been made to businesses by local authorities without thorough due diligence.
The news keeps coming on the financial fragility of councils with the new Somerset unitary authority struggling to avoid capitalisation direction following news that they need to find £38m worth of savings in 2023/24. A tough start for a newly formed council.
For an idea of potential measures the government might use in Croydon and other authorities that issue section 114 notices, we can look at Slough Council, which Room 151 reports has sold £115m of assets (two commercial properties) to pay down a portion of their outstanding £760m debt. This is at the direction of central government, following the council’s issuance of a S114 notice in July 2021. Even with that sale, the authority is still required to divest a further £485m worth of assets.
One lesser noted (by this blog at least) element of the autumn statement was the announcement of further rates relief for businesses, worth £13.6bn over the next five years. Room 151 reports that this has caused some consternation among local authorities (arguably rightly so given they don’t have a lot of leeway to lose £13.5bn in the next few years). Authorities are worried about the time left to update software and that they will not receive full compensation for lost revenue. The finance settlement later this month therefore becomes even more important for outlining compensation for authorities.
Some fellow IfGers wrote this summary of local government aspect of Gordon Brown/Labour’s Commission on the Future of the UK report. Proposals include reforms to the funding system between Whitehall and regional authorities, giving local leaders more flexibility to allocate resources in line with local priorities.
