Week in Public Services: 7th February 2023
This week: Delays to the obesity prevention strategy; DHSC’s accounts raise red flags; and the government responds to the MacAlister review
General
Its déjà vu again in this week’s edition, as strikes continue across a range of public services. In the NHS, Monday turned out to be the largest single day of strikes in the service’s history, with nurses and ambulance workers both walking out. Teachers also held their first day of strike action on Tuesday last week, of which more below. We’ve spent a lot of recent editions discussing the implications of the strikes and speculating as to when the government will budge from their clearly untenable position. So for a change I’m going to write about something else in this section. As for strikes, please choose the appropriate line depending on the day’s smoke signals from Downing Street: the government must end its intransigence on strikes/the government’s change in tone is welcome/what is Sunak thinking? These are clearly not the miners’ strikes, he is clearly not Thatcher and the public are firmly on the side of strikers. If you do want more strikes content, Andy Cowper has a great thread on the state of the NHS strikes here.
Instead, here are a few other things outside our normal remit which caught my eye.
Colleagues at the IfG are working on a report about the government’s obesity prevention strategy and asking why it has proved to be such a thorny policy area. As a primer, Sophie Metcalfe wrote a blog arguing that the recent ‘cakegate’ scandal shows us how hard it is to effectively frame the debate about obesity. Effective policy making is also hampered by a limited evidence base — a problem we’ve come across in thinking about preventative services more generally. For example, a recent study from the University of Cambridge found mixed results for the efficacy of the sugar tax in reducing childhood obesity. This has been jumped on by opponents of the wider obesity strategy as a reason to delay implementation. But as Sophie points out in this thread, that would be a mistake, given the multitude of factors that affect obesity. Instead she argues that the government should focus on implementing the 2020 obesity strategy, where there is more consensus about the efficacy of interventions. This is important for other public services. Improving population health is one of the key levers we have for reducing the prevalence of long-term conditions and thus demand for acute NHS services.
The NHS urgent and emergency care plan (more on which below) included a little-reported element that caught my eye: the introduction of 100 new specialist mental health ambulances. The numbers are small for now, but this is a large step forward in a particularly under-resourced service. This story about Bedfordshire police charging the NHS for “unnecessary” mental health call outs shows why this policy has implications beyond the health service. While it is clearly a bit absurd to suggest billing the NHS (will the local NHS trust be able to bill the police for the cost of traffic accidents?), it does highlight the problem of having the police act as first responders to mental health crises.
Outside of our usual public services fare, colleagues at the Institute for Government published our annual Whitehall Monitor last week. Jump in for dozens of great charts on topics such as civil service pay, departmental grade distributions, and diversity of the service. Lead author Rhys Clyne has a thread on some of the highlights here.
Health and care
The NAO issued a qualified opinion about DHSC’s 2021/22 annual accounts, related to the UK Health Security Agency (UKHSA), where the NAO says there was “a lack of adequate governance, oversight and control”. Apparently neither the Advisory Board nor the Audit and Risk Committee met until 6 months after the UKHSA launched, leaving the agency without any effective risk oversight. Some other eyebrow-raising stats: DHSC wrote down £14.9bn worth of PPE and other Covid stock in 2020/21 and 2021/22. Ongoing storage and disposal costs of unusable PPE will be £319m. The first departmental annual report that I would describe as “can’t miss”.
The government published its urgent and emergency care plan this week. The plan had a few new measures — for example 800 new ambulances, more on that in this thread — but broadly expanded on previously announced policy. I would say that I agreed with more of the analysis than previous papers and it was welcome to see more focus on expanding reablement and step-down care. What felt more notable though was what wasn’t mentioned; there was discussion about growing the workforce but no acknowledgement that ending strikes was the priority. There was talk of £1bn of funding for increasing capacity, but no recognition that it isn’t new money. These points are emblematic of the NHS’s problem: to a large extent performance in the service is constrained by political decisions outside its control.
There were also some interesting data announcements in the plan: the NHS will publish data on 12-hour waits in A&E from time of arrival from April this year. This is a massive improvement on current data which is 12-hour waits from decision to admit. The NHS is also “working with social care partners on a better measure of discharge”. An interesting one to watch.
NHS England submitted evidence to the NHS pay review body (PRB) for 2023/24. This is obviously one of the most high profile submissions in memory, given the ongoing industrial dispute, and NHSE didn’t mince its words. One of the standout sections was paragraph 12, which, as Nick Davies points out here, says that if the government awards another unfunded pay rise, the NHS will not be able to deliver on its strategic priorities. Worth reading for yourself to see how starkly it lays out the trade-offs between funding pay rises and increasing activity. I can’t imagine the government will be that happy with the submission.
Interesting thread from Lawrence Dunhill. The new Royal Liverpool Hospital has attracted criticism since opening last year because it is has fewer beds than its predecessor, with more people treated in single rooms than in wards. But it seems that this might be better for patients by, for example, allowing them to sleep through the night, which in turns means they leave sooner than previously, thus reducing length of stay.
The Hewitt review was supposed to publish initial findings on 31 January, but as of writing there has been no update. The timeline did seem ambitious.
The Royal College of Emergency Medicine (RCEM) make headlines again, this time with the claim that people aged 80 and over are waiting the longest in A&E, and almost twice as long as they waited in 2021.
This article in the Times (£) about Somerset ICS is worth a read. The ICS is held up as an example of innovation driving productivity improvements across primary, secondary, and social care. Some of it is genuinely new to me — for example, the GP ‘call centre’, where GPs from a local practice sit in a room together, answering calls from patients and directing them towards the most appropriate care. But some of it just seems like good implementation of existing NHS policy. In this camp fall measures such as improved step-down and reablement care, increasing numbers of non-GP appointments in primary care networks, use of virtual wards, and extended use of total triage. This is not to take away from the successes described in the article; they are impressive and difficult to achieve. The question I have is why Somerset ICS seem better at implementing these policies than other ICSs?
A team of researchers from the Health Foundation and the University of Birmingham have an analysis of GP and secondary care integration, in light of increased chatter on the subject in both major parties. This is a more balanced review than a lot of the press and political commentary, and raises the point that while we can evaluate the effect on the NHS’s ways of working, there is little evidence yet about the effect on patient experiences and outcomes.
Nigel Edwards had a thread looking at how primary care is delivered in Spain. He then had another thread summarising some of the interesting debate that this sparked about continuity of care in the UK. Steve Taylor points out that continuity becomes harder as practices grow, and Ben Allen argues that good front of house staff and strong admin are key to promoting continuity of care. Really interesting discussion.
Nuffield Trust examines what has happened to social care reform in each of the nations of the UK. It is interesting that despite different political contexts, social care systems, and funding arrangements, reform is proving to be difficult across all four nations. Maybe, as the author Camille Oung suggests, there is more of a role for government to play in positively framing social care reform to enable people to live “gloriously ordinary lives”.
Children and young people
The National Education Union strike on Wednesday saw more than half of schools in England with restricted attendance or closed. The BBC’s Hazel Shearing reported that (of their sample) 49% of schools were fully open, 42.8% were open with restrictive attendance and 8.9% were closed. An interesting report from Samantha Booth showed use of Oak Academy on the first strike day was more than double that used at during the Omicron wave (for more on Oak Academy — check out this IfG case study). For a great summary of impact and ongoing dispute between the NEU and the government check out this report by Freddie Whittaker. And for an interesting report on the impact that pay may have on teacher recruitment and retention check out this from Jack Worth.
Fascinating report from Education Datalab. The team have published a journal article analysing Ofsted inspection outcomes across 30k school inspections between September 2011 and August 2019. They provide a granular account of the likelihood of different outcomes based on multiple characteristics from inspection team size, experience of inspector to their gender and type of inspection.
In other Ofsted news — Schools Week reports that Ofsted has suspended its independent scrutiny panels. These panels scrutinise Ofsted complaints handling and included a sector representative. Their suspension has prompted criticism that Ofsted is evading proper scrutiny.
Finally, the government published its long-term strategy for children’s social care — Stable Homes: Built on Love. This matters because the Conservatives promised it in their 2019 manifesto election, it also comes after several highly critical reports on the social care system including: the MacAlister Review, the CMA review of the Children’s care market and the national review into the murders of Arthur Labinjo-Hughes and Star Hobson. But while social care leaders have welcomed parts of the report relating to special education needs, multi-agency working and disparities — there was widespread disappointment that it only provided 20% of the funding called for by MacAlister, and is well short of the £1.6bn annual deficit for children’s social care claimed by the LGA. The upshot that this does not deliver the transformative shift in social care away from an acute response system that has long been promised. For his part, Josh MacAlister (of the review) was supportive of the report but is critical of the speed and scale of the government’s response.
So why such a limited financial response? One explanation could be Treasury spending restraint. Another could be to take the DfE at its word that it wants to develop a clearer evidence base for change through a ‘test and learn’ approach. To that end, the report has launched multiple pilots — including a new early help model for families being trialled across 12 local authorities. Alongside pilots, the government will launch multiple consultations, including one on reforms to the care worker market — proposals include banning agency teams, capping pay rates and creating a national pay scale. These potential changes will occur alongside a new regional care cooperative model (see paras 207–208) a proposal called for by the CMA. Yet many in the sector remain concerned about the current state of staff vacancies and projected demand facing children’s social care over the next decade.
The volume of measures and timetables to report back on are complex and it will require clear leadership to see all proposals delivered. Yet, with some pilots not expected to conclude until after the next election, it will likely fall to yet another new minister to drive these changes through. Given the firm line Labour party line — that change is long overdue — there’s scope for political consensus on change, but any extra delays to reforms will only take us closer to the 100,000 children in care scenario outlined by MacAlister.
Law and order
HM police inspectorate have released the findings of their inspection of the South Yorkshire Police which, in being positive about the forces’ efficiency and capacity to prevent crime and protect vulnerable people, provides a heartening counterpoint to the consistent drip-feed of bad news.
Consistent is the key word, however, with the Guardian reporting on HM inspectorate’s assessment that 1 in 10 officers should never have made it through the vetting process in the course of the police uplift programme. Those with prior convictions and links to criminals are among those alleged to have slipped through the net, according to the inspectorate. It’s a damning indictment of the government’s (largely successful if off-target) attempts to increase the number of officers in recent years.
In his second appearance in as many weeks, Charlie Taylor (HM inspector of prisons) sounded the alarm over the lack of support for offenders held on remand. This is in the context of weak prison staff recruitment and an increase in the prison population that could result in doubled-up cells. Recent events have all too horribly highlighted the dangers to public safety of release without adequate supervision and monitoring. Interestingly, Taylor calls for prison governors to be able to pick their own staff to address the retention crisis. The logic behind this appears to be that governors have more information about exactly what their prison needs and precisely the kind of people who can fill those needs, meaning a lower likelihood of hiring and training the wrong candidates who are inevitably more likely to leave.
This reminds me of this recent evidence submission by the PCS union, which argues that the retention crisis is in part driven by the greater autonomy prison governors have enjoyed in recent years, removing a degree of consistency in prison management has, for example, allowed local management to ignore initiatives to increase staff wellbeing (supposedly because doing so may hinder their ability to meet certain targets). Of course, both things can be true, but it’s notable that both examples point respectively to different approaches to prison management from the MoJ.
In prison news, Russell Webster have released this summary of the latest offender management statistics which reveal, among other things, that the prison population stood at 81,806 in England and Wales in December, 3% higher than the year before. Particularly worrying are the remand figures, which show a 12% increase in the untried remand population compared to the year before. As the IfG has reported, a higher remand population means potentially innocent people waiting longer to have their day in court, even driving them to plead guilty if this poses the prospect of a shorter spell in prison.
Russell Webster also has this summary of two recent reports from the Prisons and Probation Ombudsman on people who die after being released. Notable were the Ombudsman’s recommendations around those dying by suicide on release, which (almost unbelievably given its conspicuousness as a basis for good practice) involve information-sharing between prison and probation services. In one case, a man died by suicide after probation staff were not informed of his status as a suicide-risk.
Local government
Tony Travers claimed in an article about the 2023/24 finance settlement that “ministers and officials are trapped by the rococo complexity of their funding system”. He harked back to a “simpler era” when “a council set a local tax rate, received one or more central grants and possibly added some cash from reserves to set a budget”. That might be a slightly rose-tinted view, but I think he is broadly right that the range of grants used to fund local government is incredibly dense and difficult to understand. An interesting point he makes is that local authorities who resisted raising council tax in the 80s and 90s, in line with Thatcher and Major’s recommendations, have ended up being punished as successive governments cut grant funding since 2010.
You can assess the complexity for yourself, with the House of Commons Library publishing its report on the finance settlement. A lot of interesting analysis in there, but one thing that stood out to me was the consistent way that spending power has outstripped spending review forecasts since 2019/20 (p.15). Made me wonder if this is a longer-term trend.
Speaking of the finance settlement, the government has still not allocated the public health grant to local authorities, despite the new financial year being less than two months away. Councils are warning they will have to cut spending pre-emptively if the government does not let them know budgets very soon.
In another absurd example of the over-centralisation local government funding, DLUHC announced that it has allocated £7m (yes, that is correct) as part of the second round of the Changing Places toilet fund. Obviously the toilets will be welcomed in recipient communities. But it is absurd to allocate micro amounts of funding this way. Why not increase grant funding, allowing local authorities to choose where money is spent while also saving them the hassle and money of bidding for these tiny pots?
DLUHC has appointed CIPFA to undertake targeted reviews of councils’ financial position and wider governance and leadership. Work is reported to develop a complete picture of the context, risk and issues in authorities under review. Perhaps as David Green said to Room151, this may be an example of the government assess how to exercise new intervention powers.
The NAO recently published a report on the timeliness of local auditor reporting finding concerning delays. This matters because timely information helps transparency, accountability and helps local government planning. The knock on impacts have delayed the certification of central government departments and reduced the quality of the whole of government accounts. The Local Government Association responded saying “local audit is in crisis which is a serious concern for councils”.
