Week in Public Services: 6th October 2023
This week: slimmed down cancer targets; police no longer answering mental health callouts; and Birmingham council woes
General
It’s been a while since our last Week in Public Services but rest assured, the break is for good reasons; keep an eye out for an update to our annual Performance Tracker coming at the end of the month.
A couple of teasers for those who can’t wait that long:
· In adult social care, the government likes to talk about the additional £7.5bn worth of funding it has allocated over 2023/24 and 2024/25, but our analysis shows that cost and demand pressures mean it is unlikely to be enough to meet the government’s objectives in 2023/24.
· In general practice, high numbers of GP trainees — increasingly being recruited from outside the UK — are not translating into fully-qualified, permanent staff, exacerbating ongoing staffing issues in the service.
· In police, both charge rates and charges are up for the first time in years, potentially
Enough about us, what else has been going on in public services world?
In an effort to re-establish our nerd credentials, let’s start with this working paper from the OBR which evaluates their own forecast accuracy since they were established. A few things that are relevant to public services in this. First, the OBR has consistently underestimated how much the government would need to borrow over their forecast periods. The reasons behind this are interesting. In the first half of the 2010s, the underestimation was driven by optimism about rising tax receipts, which came from a consistent expectation that productivity would return to trend increases following the financial crisis (which put them in the esteemed company of literally every other forecaster). In the second half of the decade, increased public sector borrowing was driven by higher-than-expected spending on public services. That came from the government having to allocate more in the 2015 spending review than expected. I also wondered what effect the topping up of spending between 2015 and 2020 had on those forecasts.
The IFS published a paper examining the amount spent on the NHS, police, local government and public health in areas around the country. They find that more deprived and densely populated areas spend more per capita, but that spending is still not enough to meet the estimated need in those areas. This is definitely one of those reports I’ll be coming back to a lot.
Party conferences are in full swing, so I’m going to take this opportunity to shamelessly plug the IfG’s takes on the going-ons in Manchester. First, will the electorate believe Rishi Sunak’s magical thinking? Then a comment from our Deputy Director and Chief economist: HS2 is a fiasco of change and churn. Finally, six key takeaways from Tory conference, including some thoughts about public services policy announcements (spoiler: there weren’t many of them, and they were quite unconvincing).
Right, on with the content. This week is a bit of a hodge podge of various stories that have interested us and which (crucially) we’ve had time to write up over the summer. Plenty more that were missed.
Health and care
Following the fiasco that was ‘small boats week’, the NHS was subjected to ‘health week’. I suppose from the government’s point of view it would take a hospital collapsing for that week to be worse than the previous one — though that isn’t an impossibility, what with the ongoing RAAC saga.
One very IfG-ish thing that caught our eye is the government’s decision to cut the number of cancer targets from nine to three. The three targets they are keeping are:
· Diagnosis or all-clear within 28 days of referral (target of 75% within standard)
· Starting treatment within two months of an urgent referral (85%)
· Starting treatment one month after a decision to treat (94%)
So how’s the NHS performed recently versus those targets? Not great, particularly on the “starting treatment two months after referral” target, where the NHS last hit its target in December 2015. The other two have similarly been below standard for much of the last few years.
A couple of thoughts. As a rule, fewer targets is better as it allows services to prioritise (more on targets here). The most controversial decision is removing the “two week from referral to appointment with a consultant” target, and I think there are good arguments against it. First, it could be good for a senior member of hospital staff to have ownership of cancer referrals, ensuring they’re held responsible for timely treatment. Second, it’s all well and good referring people straight to a diagnostic test, but is there sufficient capacity to deal with patients who have not been triaged by a consultant? On the other hand, if there is diagnostic capacity, wouldn’t it be beneficial to reduce senior doctors’ workloads? Interested to hear if anyone has opposing opinions.
Next, the government announced that it will roll out 900 new beds this winter, across 30 trusts. That’s a nice shiny announcement, but isn’t really new and is rather just the implementation of the UEC recovery plan from January. But still, it makes nice headlines for a day during health week. This thread from David Maguire provides some more thoughtful analysis of why bunging beds into hospitals to relieve winter pressures is not the best solution.
Speaking of beds, the NHS is making much of its expansion of virtual beds to relieve pressure on physical beds this winter. They aimed to have 10k available virtual beds open by September, and had reached 9.8k by August (the last available dataset). But despite that high number of available beds, only 65% were occupied, compared to a vacancy rate of >90% in the rest of hospitals. What’s going on? Why are they so underutilised? And will they actually have any impact come winter? Lots of open questions on this. Fundamentally though, the concept of a virtual bed just seems nebulous to me. What happens when it’s not filled? Does it stop counting? Could you say you have any number of virtual beds, but just not the staff available to work on them? It’s very unclear how to measure performance of this NHS innovation. A thread on virtual ward data from me here.
The Health Foundation published an evaluation of the Long Term Workforce plan and found that the assumptions around the scaling up of university capacity are stretching. One shocking stat from this is that one in six of all first year university students by 2031/32 will be future NHS clinical professionals, up from one in nine currently, if the NHS is to hit its target.
The BMA’s general practitioners committee (GPC) for England has a new chair, Dr Katie Bramall-Stainer. It’s really worth giving this interview with her in Talking General Practice a listen. She has lots to say about the current state of primary care and her vision for the upcoming GP contract negotiations. Astutely, she says that she will likely try and negotiate a single year contract in 2024/25, followed by a longer-term one from 2025/26 onwards, which would be negotiated with a new government.
Speaking of the GP contract, Pulse reports that GP negotiators will likely pursue further streamlining of quality outcome framework (QOF), investment and impact fund (IIF), and primary care network funding into core general practice funding. Looks like it could be a big fight for the new government.
Children and young people
The big news in schools is the government telling more than 100 schools that they will not be able to reopen for the start of term because at least parts of their buildings have been built with reinforced autoclaved aerated concrete (RAAC), which has the potential to unexpectedly collapse. This is obviously bad news for the children and families affected, especially following years of learning disruption from Covid. But it is also a telling indictment of the government’s approach to capital investment in public services, which has basically been: put it off at all costs, until there is very high probability of random death and injuries for members of the public, at which point the political cost becomes unbearable. More to come in Performance Tracker (though likely in less emotive language).
Speaking of underinvestment in schools, I can’t recommend this article — “One year in a struggling British state school” — by Jennifer Williams in the FT enough. Maybe I like it so much because it anecdotally supports so many of the findings of our research. Namely: the parlous state of the schools estate, the pressure that SEND demand puts on schools’ budgets, the difficulties recruiting teachers for certain subjects, the problem of finding appropriate catch-up tutoring after the pandemic. One thing that came across that I hadn’t expected was the impact of housing policy on school attendance, with insecure accommodation contributing to difficulties studying and poor attendance.
Law and order
In mid-August the Guardian reported that the Met “had won its battle” with healthcare providers to stop officers responding to the majority of mental health call outs, effective from 31 October. The framing has generally been one of the NHS taking police resource away from the front line, but this situation is the mostly the result of deep financial constraints on NHS mental health services. It’s currently unclear what effect this will have on NHS services. On a recent site visit to an A&E, one consultant told us that they felt it was appropriate that the NHS deals with these issues, but warned that it was also really poorly equipped to do so.
Remaining with the Met, September has brought new challenges for Mark Rowley in his quest to reform the Met and restore public confidence. The CPS’s decision to charge a serving armed officer with the murder of Chris Kaba, an unarmed Black man shot dead in 2022, led to 300 colleagues turning in their weapons permits. In the midst of this Sir Mark wrote an open letter to the Home Secretary in which he called for a more stringent prosecution threshold for police officers — a step which might reassure officers, but risks further compromising trust in the service.
Aside from making it clear that anyone can get into and out of prison on the bottom of a truck, Daniel Khalife’s escape from Wandsworth Prison last month also drew attention to conditions in prisons. The Guardian’s Peter Walker attributes many of the service’s issues to austerity, which prevented the addition of new capacity, and allowed existing prisons to fall into disrepair, with a maintenance backlog of more than £1 billion. The result is that a fifth of prisoners experience overcrowding. For example, there are 1,600 men in Wandsworth, a prison which was only built to hold 900. Walker draws a direct link between the high turnover of officers, especially in the decrease in the proportion of experienced officers, with continuing shortfalls in staffing numbers. It is therefore unsurprising that, in the words of Steve Gillan, the head of the Prison Officers’ Association, “shortcuts were taken” when 70 duty officers were responsible for a prison population 22 times larger. All points with which the upcoming Performance Tracker would agree.
A bit old now, but the prisons inspector has this fascinating blog on the prison population crisis. HMIP notes how Operation Safeguard (whereby police cells are used to house prisoners) has involved placing prisoners, many of whom are detoxing or suffering mental health difficulties, with police utterly unable to cope with these needs. And yep, there’s a slight irony here, with police simultaneously trying to do their best to free themselves of mental health demand…a neat case of abysmal demand planning, pulling policy in opposite directions simultaneously! HMIP argues population pressures mean prisoners are often transferred to prisons far from home, damaging their chances of success on release. I was also stunned to learn that if a prisoner is taken to court, there’s a chance that the prison they came from might be full by that evening. As such, some simply refuse to go to court to avoid having to settle into a new jail. Can’t help but wonder whether prisoners in these situations are forced into having interrupted rehabilitation or harsher prison terms… not great news for resettlement in the community post-release.
Alex Chalk was fairly dismissive of the idea of doing away with short sentences in a recent select committee hearing. Pavan Dhaliwal, Chief Exec at Revolving Doors, has a different take. 63% of people serving sentences of 12 months or less commit another crime within a year, while the proportion is much lower for those given community or suspended sentences (while I think it’s worth asking if that’s to do with the type of offender to be given a prison sentence in the first place, I can’t imagine time in jail for, say, repeat shoplifting, will do these offenders and their communities any good). Pavan points out that low-level offenders often miss out on the kind of support that would actually benefit them, damaging their health and communities all at an exorbitant cost to the taxpayer.
Local government
The big news in local government since the last Week in Public Services is definitely Birmingham City Council’s section 114 notice (colloquially known as a bankruptcy). The immediate cause seems to have been the uncovering in June of a £760m liability relating to an equal pay claim from 2012. Yes, we don’t understand either how a liability that large went undiscovered for more than a decade. The upshot is that the government has sent in a number of commissioners who will take over management of the council for five years. In an incredible piece of journalistic hyperbole, the FT labelled Max Caller — the leader of the team of commissioners in Birmingham — a ‘dormant volcano’, which seems like a name that should be reserved for a professional wrestler or supervillain, not a local government expert. Shameless plug of my view on the episode here.
The problems aren’t limited to Birmingham, however. A survey by SIGOMA (a representative body of municipal local authorities) revealed that five of their 47 members were at risk of issuing a section 114 notice in 2023/24, with a further nine saying they may have to issue one next year. On one hand, these surveys should always be taken with a shovelful of salt as the incentives are always for LAs to signal financial distress. But on the other, there does seem to have been an uptick in these reports and there is increased anxiety in conversations that we have with authorities.
What’s most worrying is the change in the reasons for s114s. Everyone’s aware that the likes of Thurrock, Croydon, and Woking have issued s114 notices due to severe financial mismanagement. But the councils now warning of s114s are doing so because they’re stuck between the Scylla and Charybdis of rising costs and statutory duties to deliver services. They managed this over the last 13 years by reducing services to the bare statutory minimum. But that approach has a limit and it seems many authorities have reached it.
Next up: chess boards. Compared to s114 notices, this is small fry, but is — I think at least — depressingly indicative of the government’s approach to local government. For those who missed it, DLUHC created a £250k fund that it will allocate to 85 local authorities to install 100 new chess tables. This is overcentralisation at its worst. Such a small pot of money for such a specific purpose is bizarre — a real policy blunder. At a time when local authorities are struggling to provide basic services, it seems strange for government to be focusing time and resource on such a marginal need.
Back again in the coming weeks once Performance Tracker is out.
