Week in public services: 8th November 2023

This week: Launch of Performance Tracker 2023; prisons at capacity; and local authority finances under strain

General

It’d be remiss of me not to open this week’s edition without letting everyone know that we’ve published this year’s version of Performance Tracker. The report is a beast, clocking in at a record 300 pages and 160+ charts across ten chapters. But don’t let that put you off, the Summary is a quick way into the report. For those who can’t face even that (shame!) I’ll provide a very, very short wrap-up here.

Apart from schools, public services are performing worse now than on the eve of the pandemic. Hospitals are one example, with an elective waiting list at 7.8 million in August 2023, 3.2 million more than before the pandemic. Only 56.7% of A&E attendances are admitted or dismissed within 4 hours, well below the 95% target rate (or even the newer, more modest 76% target). One in 10 waited people more than 12 hours from the time of arrival, compared to only 3.1% in 2019/20. The situation for prisons is especially dire: the prison population was only 1,897 places shy of total operational capacity (beyond which prisons cannot guarantee functioning conditions and security). Government itself forecasts that there will 7,800 more prisoners between July 2023 and March 2025, while they only plan on building an additional 2,600 spaces in that time. Someone needs to get the Lord Chancellor a calculator, quickly.

It’s not just pandemic-related disruption which is affecting services. None of the public services in Performance Tracker are doing better than in 2009/10. The overarching reason for this has been short-termism in spending and public services policymaking, where day-to-spending and short-term fixes have been prioritised over the investments which would maintain productivity over a longer period. As shown in the chart below, the decline in capital spending across the key government departments was especially pronounced in the 2010s, and the effects on infrastructure are clear. Not only this, but government policies to hold down public sector real pay while implementing measures to cut staff numbers has led to an exodus of the more experienced workforce across the services, worsening productivity now.

All of this contributes to a ‘doom loop’ in the performance of public services. Unfortunately for anyone hoping for a brighter future, funding levels look insufficient to return performance to pre-pandemic levels in any service by the end of this spending review period.

Despite this, the report’s not all doom and gloom. There are four recommendations which the current (and any future) government should take to improve public service productivity:

· A new multi-year budget for each public service

· A long-term capital programme

· A long term and stable policy agenda

· Improved approach to the public service workforce (pay, workforce planning and conditions)

Of course, none of these will be straightforward and will require renewed and steady commitment to public services from all the main parties (not just Labour, as this Guardian editorial on the report has done). But it’s clear that without addressing these recommendations, public services will continue to be stuck in the ‘doom loop’ that the media have so keenly picked up on, to the benefit of no-one.

Health and Care

I really like this report from the Nuffield Trust looking at the attrition rates of both medical and other health professionals as they progress through training, mostly because this is something that we’ve been wrestling with quantifying. Some of the key findings:

· Around one in five nurses, occupational therapists, physios, and radiographers leave the service within the first two years of qualifying. Strangely, the rate for midwives is half that.

· For doctors, international graduates leave the medical register sooner than British graduates; 13% of British doctors that graduated in 2012 had left the register 9 years later, compared to 67% and 40% of graduates from the EEA and the rest of the world respectively — a stat that does not bode well for the government’s increasing reliance on international staff.

· The proportion of doctors who pause their training after FY2 doubled from 34% in 2011/12 to 70% in 2020/21. Given an attrition rate of 1 in 6 not returning, that potentially represents 12% of medical graduates gone from the workforce.

· Not that momentous, but an interesting counter to anecdotes of British medical graduates bolting for Australian beaches: in 2019, 9% of FY2 doctors reported that they would work abroad, which was lower than the average of the previous eight years and below the peak of 13% in 2012.

· Finally, they estimate that for every two filled GP training posts, there will only be an increase of one fully-qualified, permanent GP.

This is fascinating because much of the NHS long term workforce plan relies on increasing training places. But if the training bucket is so leaky, then the government looks set to waste a substantial proportion of its investment. This is why our recent Retention in public services paper is so important — the government needs to think about how to keep the people it trains, not just pour more money into a broken system.

The government is becoming ‘disproportionately reliant’ on independent (private) providers to help clear the elective backlog according to this article (paywall, see this tweet). Private sector provision of elective activity has gone up by 30% compared with pre-pandemic levels, with Rob Findlay commenting that this was not merely clearing the existing backlog, but the private sector “plugging some of the recurrent shortfall in core NHS capacity”.

A good write-up in the Guardian of the Royal College of Emergency Medicine’s proposal to publish A&E data at a hospital, rather than just trust level. They claim that the current system allows trusts to effectively hide poor performance of individual sites by aggregating data. The HSJ published site level data following some FOIs to illustrate the problem. As ever when we talk about the NHS gaming targets, I have to tap the sign (/link to our report on the use of targets in public services, but that’s less catchy).

The NHS has relied heavily on increased use of Advice and Guidance (A&G) to keep unnecessary referrals off the elective waiting list. This report from Pulse Today indicates that the NHS might be making use of A&G mandatory for some specialties, as part of its outpatient strategy which will be published next month. That makes this article in the HSJ particularly interesting. That shows that the number of processed A&G requests has dropped off a cliff, while the overall number has remained quite steady. That implies that consultants in hospitals are struggling to respond to the volume of requests. That could spell bad news for the yet-to-be-announced outpatient plan, but also for the elective waiting list which was relied on A&G to keep numbers down. An interesting one to watch.

I really liked Julian Hartley’s (chief exec of NHS Providers) defence of NHS equality and diversity (EDI) in the New Statesman. This comes after Steve Barclay told the NHS to stop recruiting for EDI roles. Hartley makes a convincing argument that EDI is not about being politically correct, but about providing better care.

If you’ve been on health twitter recently, you’ll have seen debate raging about physician associates (PAs). The discussion has been reignited by a recent incident where a woman called Emily Chesterton died after a PA missed a pulmonary embolism. Helen Salisbury has written well in the BMJ about the dangers of relying on PAs in general practice and the confusion that patients might have about who they are consulting with. David Oliver also wrote in the BMJ about the increasing vitriol in this debate and gave a balanced view of the role PAs could and should play.

The Labour shadow team lay out their vision for health and care in this piece in the New Statesman. There’s not much in there that’s that revolutionary (maybe a shift to a more preventative approach, but that’s easy to say in opposition). All of it of course will be funded by scrapping non-dom tax status, a policy which is now funding 97.2%* of the next Labour manifesto. *this number is an estimate based on the number of times that the author has seen non-dom tax status used as a means of funding Labour policy.

The government this week agreed to pay outsourced health workers the one-off payments that permanent Agenda for Change staff received earlier this year. This follows a planned legal challenge by Social Enterprise, a body representing 10,000 non-NHS community health workers. The BBC previously reported that anyone who worked for the NHS on outsourced contracts were not eligible for the one-off payment.

Children and Young People

With RAAC rumbling on, the last thing the DfE needed was the revelation that it miscalculated funding for schools to the tune of £370 million, which has now resulted in a government inquiry. A letter of apology by the DfE’s perm sec stated that the error followed a miscalculation of forecast pupil numbers, but with little detail how this arose. Multiple sources have since identified the cause as the DfE overlooking how Cumbria split into two local authorities in 2023 and so only including pre-split pupil numbers in its calculations. However, I’m sceptical that this mistake could lead to such a large misstatement.

Headteachers have since expressed concerns that already-constrained schools would be forced to reduce services to a “barebones boilerplate model” as a result of this reduction in expected funding, with many having to cut teaching assistant roles and infrastructure projects. Reducing schools to a skeleton was a Halloween surprise that no one saw coming.

Law and Order

The big news this/last week is that prisons are full, leading to a series of policy changes announced by Alex Chalk. You can read Gil’s excellent blog on it here. TL;DR — this has been a crisis which the government has seen coming for ages. The fact it’s got to this point is a catastrophic failure of policy making.

Government thinking and policy making on this has been chaotic from start to finish. Take reform of short sentences as an example. As justice secretary, David Gauke developed plans to shorten sentences, but those were then shelved when Johnson came to power. Now, in the face of a crisis in prisons, it’s back on the table; Chalk has proposed reducing the number of short sentences for lesser crimes. This is a positive step, and reflects what should probably be government policy even without a prison crisis. However, it was only 3 months ago that Alex Chalk dismissed this kind of reform, suggesting instead that the way to solve the crisis was to reduce the remand population… translation: ignore an obvious solution, while suggesting in its place a ‘solution’ that depends on more throughput in the courts and hence more demand on prisons anyway. Rob Allen has this great blog, in which he points out that suspending short term sentences maybe isn’t ideal given the state of the probation service (you can read about this here and here).

I also worry about the effect that this train of incompetence has on other aspects of sentencing policy. The Telegraph reports that speculation of a ‘soft justice’ approach will be met with tougher sentences for rapists, for example. I can understand the political incentives at play behind the ‘bang em up/throw away the key’ approach to serious crimes, but it is depressing that sentencing policy is so blatantly beholden to a crisis of the government’s own making? We’ve essentially got a flurry of major sentencing reforms sparked not by a level-headed, rational consideration (why would we want those things influencing policy???), but instead by the government’s grasping reaction to a crisis it saw miles off.

For a bit of a wider look at these themes and penal policy more generally, the Prison Reform Trust has this discussion paper covering sentence inflation (a 250% increase in the number of people locked up for over 10 years since 2008), reconviction rates (42% of adults reoffend within 12 months of leaving prison — 59% for those serving sentences under 12 months), and much more besides. Hardly surprising given it’s a system that (as the report describes it) is “coping rather than flourishing”.

The Economist has this piece on the poor performance of probation services, in which high workloads and a dearth of experienced staff threaten public safety and make reoffending more likely. Part of the problem is attributed to the service’s 2014 privatisation (see the IfG’s assessment of the reversal of this policy here), which created incentives to get rid of more expensive (and senior) staff. I found particularly interesting the fact that, in recent decades, appointments of probation officers and probation policy has become more centralised (officers were once appointed by magistrates, for example) — the effect of this has been courts having less knowledge about and confidence in community sentences (hence less willing to use a tool that has better reoffending outcomes).

Local Government

A tiny smoke signal from Labour on what we might expect on local government finance if they take power at the next election: in an interview on BBC West Midlands Starmer claimed that budgetary pressures over the last decade contributed to Birmingham issuing a section 114 notice and that Labour would move towards longer-term finance settlements. Both good points and echo what we’ve argued in the past. But it’s worth saying that this is just the start of the reform that is needed. Long term settlements are all well and good, but if they’re long-term, very low settlements, then they don’t solve many councils’ issues.

This BBC report clearly illustrates how councils are coming under increasing financial pressure just from providing statutory services. Hastings Borough Council expect to use a quarter of its entire budget, or £5.6 million, to accommodate 500 homeless families this year. The council is spending a further £11 million on purchasing properties to use as temporary accommodation. An underlying cause of this is the lack of affordable housing in the town. Hastings is not alone in struggling to meet its housing obligations from already stretched budgets, Thanet District Council has spent £5 million on 42 homes to accommodate homeless families. As means of comparison, the government allocated Thanet £3.1 million as its share of the Homelessness Prevention Grant — an amount that is evidently far too little to meet demand.

The County Councils Network is warning that one in 10 county councils and unitary authorities risk being unable to balance their budgets. They estimate that the current deficit stands at £600 million for 2023/24, an amount exacerbated by rising demand for statutory services, with children’s services alone account for half of that total.