Week in Public Services: 9th March 2023
This week: budget prep; GP contract wrangling; and HMCTS reform
General
The New Economics Foundation published their assessment of the autumn statement. They call the spending projections “austerity by stealth” due to funding cuts beyond the end of this spending review period and what they think of as unrealistically low inflation forecasts which will erode spending envelopes in real terms. The question I have is how believable post-election spending projections actually are? In addition, experience suggests government tops-up ungenerous spending settlements, see: SR2015.
The IFS have their budget briefing out on the upcoming fiscal event. They confirm the overall picture of better short term finances discussed last week. Crucially for public services, they predict there may be another below inflation pay offer in 2023/24 as unadjusted budgets mean pay review bodies are constrained by the “affordability” of pay rises. That means industrial action is likely to grind on even if agreements are reached over 2022/23 settlements. They note the £13–14bn “reserve” pot for 2023/24 and 2024/25, designed to meet unexpected spending requirements. While a one-off, this could be used to increase pay in this financial year, though would require higher spending in perpetuity, likely meaning that the Treasury will want to avoid using it.
The IFS expects pressures in the “protected” public services — health, defence, and schools — will mean more pressure for local government, criminal justice, and further education. These are services that have experienced severe cuts since 2010, making you wonder what will happen to performance with another few years of falling budgets.
Martin Wolf reports on two papers highlighting the multi-faceted landscape levelling-up policies face. London’s post-2008 productivity growth is comparable to the rest of the UK thanks to slowdowns in financial service sectors among others. Add a healthy dose of high housing costs to deter immigration/productive sectors, we’re left with equally stubborn growth rates in the south-east and the rest of the country, albeit starting from very different places. The obvious bind for policymakers is the need to help out London to accrue the resources needed to tackle regional inequality — a hard sell!
Health and care
The Public Accounts Committee released a report on the first year of the elective backlog recovery plan. It’s damning about NHS England’s performance and argues that assumptions in the recovery plan were overly ambitious, particularly on plans for activity to reach 129% of pre-pandemic performance. A couple of other things:
· The report is very sceptical about the effectiveness of advice & guidance (A&G), surgical hubs, and community diagnostic centres (CDCs), and calls for NHSE to outline the “extent to which these initiatives have so far generated additional activity, rather than simply displacing activity elsewhere in the NHS”. This is an excellent question and is something — particularly in relation to A&G — that we raised in Performance Tracker.
· NHSE admitted its assumptions about low Covid levels throughout 2022 were “completely wrong”, with higher bed occupancy and staff absences than forecast
“Intensive” strike talks are back! This time Steve Barclay is offering “intensive” talks to ambulance unions about the 2022/23 pay package. But a catch: unions have to call off their strikes this week, which they’ve agreed to. As we speculated last week, it seems that the junior doctors’ strike spooked the government, with this more conciliatory tone towards nurses and ambulance workers an attempt to end those disputes before the junior doctors’ walk out next week. The other factor seemingly driving government’s decision is “concern in Downing Street that industrial disputes are making it impossible to deliver Rishi Sunak’s promise of bringing down NHS waiting lists”. If the government is only just realising this, it’s worse than we thought.
On strikes, preparations for the junior doctors’ strike have been ramping up. Lawrence Dunhill reports that Imperial College trust is asking non-clinical staff to volunteer as “ward helpers”. The BBC reports consultants are “demanding” that the NHS pay them £158/hour during day shifts and £262/hour for night shifts, compared to a typical hourly wage of £42–57/hour. There’s a tone of outrage in the article that I really struggle with. The story details that the BMA specifically said that it should be used by consultants who are asked to work outside their specialty, i.e. in quite a stressful environment. Second, even the night shift rate is still a fraction of what professionals at the top of other fields earn, and consultants are both more highly trained and more valuable than most professions.
Henry Anderson from the HSJ reports that Integrated Care Boards (ICBs) have been told to cut staffing costs by 30% by 2025/26. This is baffling: the government is crippling its own landmark NHS reform less than a year after putting it on a statutory footing. Many ICBs aren’t even properly staffed yet, let alone having fat that they can trim. Steve Black is not impressed with the poor reasoning from NHSE’s Chris Hopson at the Nuffield Trust summit.
On the topic of baffling integrated care takes, this from Claudia Webbe missed the mark on the purposes of ICSs, and heads into conspiratorial territory about a plot to replicate American-style healthcare. This from Olivia Butterworth is a much more accurate (and succinct) summary of ICSs’ purpose.
This Times report (£) provides a preview of the upcoming Dispatches documentary about A&E performance. It is — to say the least — horrific, and makes the documentary required watching.
The FT brings us this story that inflation will hit the NHS capital budget, leaving a £2bn hole by 2027/28. For context, total capital spend is budgeted to be £10.4bn in 2024/25, so this represents a significant hit. Of course the government leapt on this as a reason why it will not be able to hit its target of 40 new hospitals by 2030. But that ignores the fact that it was already woefully behind schedule.
Nuffield Trust held their annual summit on health policy. There were lots of great events, but if you only read one thing it’s worth reading Nigel Edward’s reflections on 40 years in health policy. One of the things that struck me most from that was his recommendation that we need to more critically evaluate solutions that we come up with, being particularly wary of groupthink, and then also make those solutions more understandable for a wider audience. That final point also requires excellent communicators of policy — something he feels has been lacking. His interview about potential solutions to the service’s problems is also worth a read.
The Health Foundation published an explainer on why delayed discharges are increasing. One key thing it highlights — and as I’ve argued before — less than 40% of delayed discharge is caused by adult social care, with the rest due to problems inside the NHS.
Steve Black has some analysis of staffing levels in A&E. He shows that there seems to be an inverse relationship between number of staff in A&E and performance. I was surprised there was a relationship at all, but it does seem to support the hypothesis that poor A&E performance is driven by factors outside A&Es themselves.
Following the GP Committee’s (GPC) rejection of the new GP contract offer from NHS England in February, NHS England has imposed the new contract on GPs. It’s fair to say this has generated waves of anger among GPs and representative bodies, with Dr Kieran Sharrock, acting chair of the GPC, warning that “ramping up GP workload […] without the support needed, will lead to more GPs leaving the profession”. But what’s actually in the contract?
· The policy generating the most outrage is the requirement that practices will now have to offer patients an “assessment of need” on the day they call (not an appointment), and will not be able to request that a patient call back at another time. This is designed to solve access issues with the service. But that also represents an increase in workload for practices.
· A reduction in the burden of Impact Investment Fund (IIF) and the Quality Outcome Framework (QOF) targets on GPs. The former will fall from 36 to 5 and the latter from 74 to 55.
· An expansion of the Additional Role Reimbursement Scheme (ARRS), to include Advanced Clinical Practitioners and to expand the cap on Advanced Practitioners and remove the cap on Mental Health Practitioners
So there is some good amongst the bad, and Dr Ben Allen has a balanced thread assessing these changes. The concern I have is that the requirement to provide an “assessment of need” substantially increases practice workloads and therefore worsens GP retention at a time when the service cannot afford to have more clinicians leave.
The King’s Fund published their always excellent Social Care 360. A few things I learned:
· It reminded me that a lot of the announcements from the December 2021 white paper “People at the heart of care” — including £500m worth of funding for workforce development and £25m to ‘kickstart’ changes in support for family carers — have yet to materialise
· The CQC said that care home profits in March 2022 were lower than at any point since 2015 and homecare profits were also down. Two facts that don’t bode well for market stability
The government published an evaluation of the Workforce Recruitment and Retention Fund (WRRF), which provided £462.5m to local authorities to improve (unsurprisingly) adult social care recruitment and retention during the pandemic. So, did it work? On recruitment, seemingly not: “WRRFs did not have a positive or negative impact on overall recruitment during the funded period”. Retention is slightly better, with the report estimating that there were 33,000 more staff compared to baseline, “driven by increased retention”. Though by the time the funding ran out (March 2022), there were 50,000 fewer people in the ASC workforce than the year before. So mixed at best. And yet more evidence that funding the service with emergency pots of money is really ineffective.
Children and young people
The government published its plan for children and young people with special educational needs and disabilities (SEND). Schoolsweek has this summary of the 16 main changes including new national standards, accountability mechanisms on compliance, digital trails of EHCPs, proposals to roll out of 33 new free schools, and a new ‘adjusted’ intervention approach in failing areas. Coming shortly after the launch of children’s social care reforms the government has promised a close alignment between both new strategies reports Mithran Samuel at Community Care.
Sector voices are sceptical of the package — according to the BBC, the LGA think the measures won’t go far enough in addressing the cost and demand issues in the system. Similarly, Sam Freedman critiqued the gap between resourcing and the proposal’s ambitions. Many plans won’t be rolled out till 2026, leading Children’s Commissioner Rachel de Souza to warn of the risks of several more years of children entering a “vicious cycle of poor outcomes”. Full response here.
A bit late, but concerning data from Education datalab on the illness-absence rates from schools pre-Christmas. Given the volume of seasonal illness including strep A this was expected, but exceeds the rate seen during the Delta and Omicron wages seen in 2021/22 in primary and secondary schools. In further troubling attendance news Poppy Wood at iNews investigates the story behind the 23.4% of children in England that are persistently absent from school.
In financial news, John Roberts reports on the School and College Panel report showing 9 in 10 schools have cut spending due to soaring costs — among 73% of respondents cuts have been largely targeted learning resources and among 63% of respondents cut building/maintenance spend. The survey was carried out in November and predated spending announcements, but given recent discussions on building quality, it’s troubling reading. For more on the structural issues at five schools that triggered the DfE to upgrade its risk assessment on building safety see this by Tom Belger.
We were interested by a Schoolsweek report that the DfE will be trialling a new £10k overseas relocation premium for languages and physics teachers. Aimed at bringing 400 people i.e. £4m total cost. But as Schoolsweek point out England is struggling to fill its shortfall in EU recruits since Brexit. Analysis from Labour suggests significant regional variation in recruitment with schools in the north of England and the Midlands struggling the most.
Finally, two reports out on the impacts of unaffordable childcare. The first, reported on here, shows Britain falling to 14th in the international league table for women in work due to the lack of affordable childcare in the UK which is adding to the gender pay gap. Net childcare costs are approximately a third of the average UK family wage, while in Germany its around 1%. The second from the Centre for Progressive Policy suggesting the UK loses economic output of between £27–38bn due to unsuitable childcare; for more on this 1% hit to GDP head over to Sky News here.
Law and order
This story reporting that 1 in 100 officers faced a criminal charge last year found itself on several front pages. It comes from data showing 1,387 claims were received by the Police Federation for legal support from its members in 2022, 590% higher than in 2012. Tl;dr, this is a bad article. Don’t worry, I’m not going to go down the dubious ‘allegations shouldn’t be taken seriously until it’s proven’ route, but it’s important to remember that legitimate policing is always going to involve heavy-handed tactics that people take issue with. Bluelight’s Brendan O’Brien made the point (7:26am) that complaints are often made about the use of reasonable force, many of which never end up as charges. Unsubtly placed next to stories about David Carrick and Wayne Couzens and a factless portrayal of the Police Federation as an aider and abetter of racism and misogyny, it’s trying to spin a story out of data that, for all we know, might not support the thesis at all. It would be useful if the journos linked the data they used. (Until then, we wouldn’t dare speculate that the 1 in 100 figure comes from 1387*100, which roughly equals the number of officers in England & Wales. That would just be silly.)
Sir Stephen House (former acting Met Commissioner) stepped back from his role on a police productivity review after allegedly referring to rape accusations as ‘regretful sex’. The IOPC investigation might take a while, so watch this space for updates. The exact comments are unlikely to be the subject, so things to look out for will be findings on the conduct of sexual crime investigations under Sir Stephen, and reports about his attitude to sexual crimes during his career. That might be an ambitious wish-list, but it’s good to see the Met was proactive in referring the comments.
Joshua Rozenberg has this summary of a recent study on jury conviction rates for rape and sexual assault cases. In found that jury conviction rates from 2007 to 2021 have consistently (barring 2014) sat between 50 and 60% until 2017, when they rose and hit 75% in 2021. It’s an interesting set of findings, but it feel slightly erroneous to look at them and claim glad tidings for victims who otherwise might think their case won’t get anywhere. That’s because this is very high-level data that tells you nothing about e.g. police performance (a key determinant in sensitive cases) leading up to jury trials, and even less about whether victims will get their case charged in the first place.
Gavin Hales put together a great set of visualisations trying to explain the post-2017 uptick in conviction rates. New to me was the impact of R vs Allan, a case of alleged rape that was dropped after the late disclosure of digital evidence casting serious doubt on the allegations. This essentially raised the bar for which cases the police ended up charging. Given the poor digital forensics capabilities in police forces we’ve previously reported on, this may be as much down to inadequate police capacity as much as ‘weeding out weak cases’.
The Telegraph reports on a scheme to reduce the extraordinary number of hours police officers spend on mental health call-outs. The ‘Right Care, Right Person’ scheme helps officers and healthcare agencies understand when officers should and should not respond (or should quickly hand responsibility over to health authorities) regarding mental health emergencies. College of Policing guidance on how to adopt the scheme is expected later this month. Still in its infancy, it does seem at the very least to be an acknowledgement that the police can’t be relied on as a service of last resort, and that effective policing requires investment in other public services (that being said, the reported £150 million promised for mental health services doesn’t sound like an awful lot!).
The NAO put this out on the progress of HMCTS’ reform programme, designed to modernise the justice system through new technology and working practices, providing new forms of engagement, and reducing complexity. The programme’s importance has taken on added importance given backlogs in the courts system, which we cover here. While more services have been made available online and the common platform (we’ve written about this here) has been partly implemented, it’s hard to avoid the word ‘shambles’ when reading the report. The scope and complexity of the project have consistently been greater than HMCTS’ estimates, while multiple aspects have been delayed without timetable extensions. In terms of justice delivery performance, this has left them having to manage substantial changes to their working practices while having to deal with backlogs, and the rollout of the common platform itself (done with only a partial evaluation of a trial run) has been plagued by technical issues that have adversely affected justice outcomes.
Local government
Room151 points out that local authority investment fell by £4bn in the last quarter of 2022 — down to £58bn from £62bn at the end of September 2022. The largest driver of that decline is a fall in deposits held in banks. Room151 speculates that it was a combination of a higher pay deal for 2022/23 (which required backdating pay), higher cost of borrowing, and rising capital costs that drove investments down. It’ll be interesting to see if this means that LAs are now running down some of their reserves, nullifying DLUHC’s concerns about rising levels.
The Croydon/Slough/Thurrock drama rolls on. Room151 reports that the government is considering providing financial support worth almost £900m to the struggling local authorities. We talked about it last week, but I do wonder how other more financially responsible councils will see this decision.
Some more authorities to potentially join the ranks of section 114-issuers: Southampton City council and Woking Borough council.
Finally on Thurrock, Gareth Davies reports that the Best Value Inspection into the council is due on Thursday the 9th, with the review apparently more damning of elected members than many on the council had hoped.
CIPFA updated their library dataset. The headline: per-person spending fell 17% between 2020/21 and 2021/22. This is curious, because local authority spending on libraries increased slightly (0.6% in real terms) in 2021/22, according to the revenue outturns. The population increases, but not by enough to account for a 17% fall in per person spending. Maybe this includes other, non-local authority spending on the service, in which case there must have been an enormous fall. The article also makes a lot of the fact that in-person visits increased 68% in 2021/22 compared to 2020/21, though my immediate response would be that you would expect them to, given social distancing in 2020/21. It’d be more interesting to compare to 2019/20.
Chris Giles has this write up detailing London’s weak productivity growth, which has been lower than that of the rest of the UK since 2008. The source report argues property policies lie at the heart of this, with rents rising despite productivity stagnation, pulling money away from investments and deters otherwise productive migrants (I’ll refrain from using the B-word). Chris argues simpler planning regulations, liberal immigration restrictions for high-skilled workers and more devolved powers in London to improve its competitiveness. Tom Forth is sceptical. He points out that the “peak” of London productivity used for the start of the comparison was 2007, i.e. when London’s productivity was artificially inflated due to the financial/property bubble which caused the financial crisis.
