Week in Public Services: 5th May 2023
This week: a spate of preventative health reports; NHS Staff Council votes for pay deal; and clarity on funding for teachers’ pay
General
The IfG has been getting a first hand flavour of the police uplift programme this week. As I write, IfG towers — located as it is on the Mall, the epicentre of coronation convulsions — is surrounded by a posse of serious-looking police officers. Initial concerns that they had read Matthew and Gil’s blog post and wanted words with the authors have proved unfounded. Though if there’s no new edition of Week in Public Services next week, it might be worth checking in.
A great review of the ‘What works’ movement by the LSE. They argue that despite the establishment of many What Works Centres over the last decade, their impact on policy making has been a disappointing, for a number of reasons. At the less interesting end of the spectrum is the lack of funding for those centres. More interestingly, the piece argues that the nature of social sciences compared to the hard sciences — more ambiguous results that lack applicability to other cases and the difficulty of carrying out proper RCTs — means that true ‘evidence’ is hard to come by. Further, there are difficulties in convincing politicians more focused on short-term pressures and public opinion to actually follow the evidence — a problem that anyone following debates in health staffing will be familiar with. The piece is a bit depressing for those — like the IfG — that believe in using evidence in policy making. But it’s also a useful reminder that there is a limit to the extent to which we can bring evidence to bear and that politics still matters when it comes to driving change in Westminster.
Demos dive into the buzzy debate around preventative public services with this report. They argue that we should first decide on what public goods we value — for example: healthy lives, empowered communities etc — and work backwards from there to design services. There’s a lot to like in the paper: increasing co-operation across currently-siloed services and further devolution of services. But it feels like there is a tension in their core concept of relational public services — which recommends more community engagement in public service design — and their prescription to increase the range of preventative services.
What I mean by this is that polling often shows that people want more investment in acute and demand-led services. For example, when polled on where in the NHS the government should spend additional money, the leading area by far (81% compared to the next closest at 55%, p.63) is in urgent and emergency care. Obviously preventative services wasn’t an option in that poll, but if it had been I would wager that it wouldn’t have done well. This is not to say that I don’t think that if you explained to people what was meant by preventative services, they wouldn’t support it. But as it stands, there is a large gap between discussions about preventative services in policy circles and understanding/demand among the public. Part of this could be due to the language we use — e.g. prevention (of what?), social capital, and relational public services — which obscures how these services will tangibly help people. Until we get better at communicating this stuff, the public will continue to demand more A&E doctors and police officers.
Starmer claims he will be bolder than Blair on public service reform. The pronouncement was light on detail and heavy on buzzwords. Hence we were told a Labour government would focus on devolution and prevention and that we can expect more announcements in the coming weeks. We’ve been hearing that for a while; let’s see the detail! Give the wonks what they want!
Health and care
The NHS Staff Council voted on Tuesday to accept the government’s pay deal for Agenda for Change (AfC) staff. This follows a week in which unions representing those staff gradually reported ballot outcomes. The end result saw Unison, GMB, the Royal College of Midwives and a range of smaller unions voting in favour of the deal. On the other side, Unite, the RCN and some others rejected the offer. Lawrence Dunhill was a key source of information on this, tracking the result of each vote as it came in. As a side note, the staff council voting process is extremely obscure. It’s done on an electoral college system, weighted by the size of the union. But then also not weighted purely by the size of the union. Unison, for example, has a larger voting weight than the size of its membership. The closeness of this vote was likely not what the designers of the voting system had in mind.
So what happens now? The government will impose the pay deal on all AfC staff, regardless of whether or not their union accepted the deal. But the RCN and Unite are not giving up the fight. Even before other unions had reported, the RCN announced another round of strikes for 1 and 2 May. The government quickly pointed out that the RCN didn’t have a mandate for a strike on 2 May, and went to court to prove it. A bit embarrassing for the RCN. Undeterred, the union is now balloting members for a renewed mandate, though on a national basis as opposed to the trust-by-trust approach last year. This is risky for the RCN. If the national ballot is rejected, then that will be the end of strike action for a while. And it’s not clear that the ballot will pass. Members only rejected the pay deal by a margin of 54% to 46% on a 61% turnout. Staff weary of combative strike action and with a pay bump coming in their June pay packets may not be that keen on returning to the picket line.
One interesting thing I hadn’t considered is that much of the one-off payment for AfC staff will cover the income they lost while on strike. It’s hard not to ask the same question as this paramedic on Twitter: what was the point?
And in case the government gets too complacent, the junior doctors’ dispute is still ongoing, though things have been very quiet from both sides.
IPPR published a report on the relationship between health and prosperity. They find that ill health reduced GDP by about 2% in 2021. Moreover, ill-health is distributed unequally across geography, class, gender and ethnicity. The authors are damning of governments’ attempts to ameliorate the problem: “The more pertinent challenge is the level of willingness and commitment to sustained progress among UK policymakers”. A little like a proposal from Demos’ report discussed above, they recommend carving out investment for improving health outcomes and the creation of a body modelled on the Climate Change Committee that will hold the government to account on these issues.
ANOTHER report arguing for a reorientation of health care away from acute to preventative services, this time from Reform. This one differs from the others by offering a range of successful case studies in other countries.
This Times article (£) on the shutdown of the NHS’s Covid app is a unexpectedly poignant paean to scientific innovation during Covid. Tom Whipple praises the immensity of what he terms “Britain’s Covid-industrial complex”. And he’s right; the scale of the state’s response — an average of 300,000 Covid tests per day, the Covid dashboard that was viewed 76.6m times, genomic testing, the ONS’s Covid survey and much more — is staggering and has now been more or less dismantled. But that doesn’t mean the Covid response hasn’t left a legacy. In particular, mass sequencing of viruses and the advances of mRNA vaccines has been “taken [to] places we wouldn’t have been in 20 years”. Good to know there was some good that came out of the pandemic.
An article (£) in the FT on the topic of something about which I don’t know very much: clinical trials in the NHS. In contrast to usual criticism of the NHS — that it is far too centralised — this piece argues that the need to contract with individual ICSs slows down clinical trials. It also claims that sceptical clinicians are slow to adopt new technologies. Some of this seems odd to me. This sentence for example: “One of the criticisms that GPs levelled against inclisiran [a new drug] was that they were being expected to prescribe it without full information on safety and outcomes”. I hate to seem like an opponent of innovation, but I’m completely with the GPs on this; they shouldn’t be prescribing treatments without full information about safety and outcomes!
An interesting thread from Simon Bottery about the King’s Fund ICS conference. Particularly worrying is the view from ICS chairs that unless adult social care can demonstrate how it supports ICSs’ urgent priorities — elective backlog, urgent and emergency care etc — and their four statutory duties, it will struggle to be heard. Not great news for a system that is supposed to place health and social care on an equal footing.
We discussed the government’s knee-capping of adult social care reform a few weeks ago. Dave West highlights this interesting snippet from Helen Whateley’s appearance in front of the Health and Social Care committee. Whateley says that the government cut money from reforms to funnel it towards “frontline care”. This is one of those occasions where you’re amazed that she’s said the quiet bit out loud. So not only is she admitting that they’re diverting money away from a much needed investment in workforce training and progression but also that carers are not paid enough to deliver the quality of care that the government wants. As a quick aside, I wondered what the impact of spending an additional £250m on carers’ wages would be. Some quick maths: 1.23m people provide direct care, so let’s use those as a proxy for “frontline care”. An additional £250m gives each carer just over £200. Bear in mind, that £250m is not a recurring amount, so the £200 is a one-off payment — less than a 1% salary uplift — for just one year. It’s not nothing, but it’s hardly going to turn the tide on poor recruitment and retention in the service.
Children and young people
The NHS staff council may have accepted the government’s pay deal, but there are still substantial ongoing strikes in schools, the most recent of which took place on 27 April and 2 May. The BBC reports that “more than schools than ever were unable to open fully” on those days. I was curious about the trend in school closures, so I found the source for that claim and sources for previous national strike days. Despite there being an uptick in disrupted schools on 2 May, fewer schools were closed or restricting access than on the first national strike day on 1 February (see below chart). It wasn’t even the day with the greatest proportion of outright closures, which was on the 15 and 16 March. So I’m not sure what the BBC claim relates to.
One of the reported reasons that teachers voted to reject the government’s pay offer was because many resented the fact that it was largely unfunded, and would therefore require cuts to other parts of the schools budget. The IFS brings some clarity to the debate with this piece. First they point out that the one-off £1,000 payment to teachers was fully-funded in the form of a £530m grant from government. The consolidated pay increase of 4.5% is a bit more complicated, though the IFS estimate that in reality, only about £150m — or 0.25% of school budgets — is unfunded. One final point: school costs are now forecast to be lower next year than previously estimated, due to lower energy costs, by enough to cover much of that increase. As the IFS argues, this back and forth about the level of funding for the pay offer distracts from the more pertinent point, which is that real terms teachers’ salaries are still far below 2010 levels, something this pay deal does little to improve.
TES (£) reports on April’s teacher training data and the recruitment targets for 2023–24. The news is good for primary teacher recruitment, which TES estimates will come close to its target. The story is less good for secondary schools, where recruitment will only meet half of its 2023–24 target, with under-recruitment in all but three subjects (history, classics, and PE). One thing that jumped out at me was the cumulative effect of poor recruitment in previous years. In other words, when a target is missed for a subject, the government increases the recruitment target for the following year, making it more likely that target will be missed as well. Hard to see how to break that cycle.
The Economist has this (£) piece on the scale and causes of persistent absence among schools children. More than 1/5 pupils have been persistently absent in England this academic year, twice the pre-covid rate. Adding to the ‘traditional’ drivers of persistent absence has been the pandemic, the pernicious mental health-effects of which have increasingly affected come kids’ ability a) to go to school, and b) to learn when they’re there. I found it particularly interesting to read about the effects of covid-era home schooling, which has both become less inconvenient for some parents who increasingly work from home while challenging kids’ assumptions about the inevitability of school in the first place.
The Children’s Commissioner has written a blog expressing her concern about the Illegal Migration Bill’s impact on refugee children. It seems like she has some high profile support in parliament, with Theresa May speaking on the same topic in the Commons. For those who need reminding, Community Care explains that asylum-seeking children will be detained as adults, unless they submit to having their age assessed “using scientific methods”. One of the most sinister uses of “scientific methods” I’ve heard in a while.
Law and order
Danny Shaw has this piece on the difficulties in sacking poor officers: being a police officer is seen as a job for life, so a high value is placed on camaraderie (useful for officer safety on the streets, sure, but less so when it contributes to insular cultures that tolerate poor performance/behaviour); union resistance to proposals to implement performance-based redundancy; and tackling misconduct cases in isolation meaning repeat failures are missed.
It’s interesting to note that many of the current criticisms over police misconduct (including the oft-cited fact that independent misconduct panels are less likely to dismiss officers) are aimed at processes that were themselves designed to satiate concerns over the police having too much say over the marks assigned to their own homework, as it were. For those wishing to hand the powers straight back to chiefs — giving them the ‘final word’ in the words of the new chief of West Mids — it’s fair to ask exactly what would prevent a similar backsliding in the near future — reforms based on the well-intentioned promises of chief constables at a time of plummeting public trust strike me as quite fragile.
The BMJ has this editorial outlining the importance of prisons in the WHO’s pandemic treaty negotiations, in light of the fact that the covid-19 death rate among prisoners in England and Wales in the first year of the pandemic was more than 3x the rate among those of the same age/sex in the general population.
Crisis then, crisis now? It seems that way, with Justice minister Damian Hinds recently appearing before the justice committee as part of its inquiry into the prison operational workforce. The Morning Star has a brief summary of the main issues covered, which included the fall of prison staff by 600 over the 12 months to last November and the failures of the MoJ to keep people safe given the rising number of deaths among inmates. We’ve previously highlighted similar problems here, including the shocking rise of self-harm incidents in female prisons since the start of the pandemic.
Local government
With Thurrock going to the polls in the local elections this week, Gareth Davies has written a piece explaining how the authority has ended up in such a terrible financial position.
Speaking of the local elections, colleagues at the IfG have written an explainer detailing key battlegrounds and what to watch. Peter Hourston has a summary thread here.
Some more interesting polling by the New Statesman. This time they ask councillors which services they have cut since 2019, after the purported end of austerity. More than 61% report cutting culture and leisure services, 54% transport and road maintenance, and 43% social care. All bad stuff. A couple of observations: yes government is now increasing funding for LAs, but increases since 2018 are from a very low base. In that time, councils often served as the first line of pandemic response, necessitating higher spending. They were compensated for that spending, but with large variation between authorities as to the sufficiency of that compensation. They have also been hit hard by the cost of living crisis, with contractors demanding higher fees for services and increased demand for services from residents. The “end of austerity” therefore doesn’t mean the end of local authority financial insecurity.
Jack Shaw tweets that the Office for Local Government (or the awkwardly acronym-ed OfLog) will report the first metrics on its dashboard of LA performance in “late spring”. At first brush, this is a weird list; adult social care, LA reserves, adult education (for MCAs), and waste. Social care I understand, but why waste disposal and not cultural services? Or public health? Or road maintenance? Second, these are all — with the exception of reserves which requires a bit of manipulation — available in a number of government published, though disparately located, datasets. Third, OfLog is supposed to be reporting on outcome metrics, while these are all outputs. That isn’t necessarily a bad thing, but it does make you wonder what value OfLog is offering. All round, very odd.
South Cambridgeshire council described their pilot of 4-day work week as “overwhelmingly positive”. They will now roll the pilot on for another 12 months. Importantly, analysis by the Bennett Institute shows that the council’s performance in that time was “within normal levels compared to the average over time”. There is a benefit to taxpayers here: the scheme is expected to improve recruitment and retention in the council, meaning that there will be less of a reliance on expensive agency staff, saving the council £1m in total. Interesting.
