Week in Public Services: 9th Feb 2022

This week: the NHS elective recovery plan; predictable private school exam result gaming; and new schools research

General

There are, erm, some stability problems in the government at the minute — maybe you’ve heard? Expect domestic policy to take a backseat for a while (‘operation red meat’ notwithstanding) — but have no fear, there’s still plenty of new public services analysis to get your teeth into!

Health and Care

How’s the health and care bill coming along? As it passes through the Lords, it’s well worth reading former NHS England chief Simon Stevens’ reflections in the Lords debates. His point about NHS workforce planning is pretty damning: “what, to everybody else, is blindingly obvious has instead been confronted with wilful blindness”.

The big news this week is the NHS England elective recovery plan, which was published on Tuesday 8th and set out how the NHS would reduce elective waiting backlog (even if it was more guidance than plan).

The NHS England plan was published late, with The Times reporting that the Treasury, the Department for Health and Social Care, and NHS England were all arguing about what ‘reasonable targets’ would be, with ministers having supposedly pushed for “very tough targets”. This all feels a bit groundhog day: as if the only lesson from the New Labour era was that setting the targets and terrorising staff led to improvement (spoiler: it’s not).

If all good management took was demanding targets, then the NHS would be performing a whole lot better. Last December provides a classic example. NHS England identified that delayed discharges — where patients who were medically fit to leave were still in hospital beds— were reducing bed availability, and issued an edict to hospital trusts asking them to “to work together with local authorities, and partners across your local system including hospices and care homes to release the maximum number of beds (and a minimum of at least half of current delayed discharges).” Sounds sensible, right? A reasonable enough ask of NHS Trusts. But did it make difference?

The percentage of patients eligible for discharge being discharged hit 60% in the week ending 23rd of January, up from 55% in the week ending 5th of December. Why have delayed discharges got worse? The staffing crisis in community and social care — in part driven by Omicron but also due to longer term staffing issues — has worked its way into hospitals. The really basic point, though, is that there was almost no theory of change, analysis of the problem, and limited suggestion of what Trusts could have been doing differently*, to reduce delayed discharges. See also: the guidance that all ambulance Trusts should “immediately stop” ambulance handover demands.

I have some sympathy with ministers wanting targets — the levers for achieving change in public services are not direct. Setting targets is one way of making your priorities clear. But, alone, it’s not really effective. And more concerningly — this doesn’t seem to solely be a problem of ministers. As Steve Black argues, a worrying number of NHS ‘plans’ (as many from NHS England as the Department for Health and Social Care) are more like “wish-fulfilment fantasies” than plans based on clear analyses. Craig Nikolic is also a good read on NHS management. For a more sensible take, my colleague Nick has a good read on why ‘targets alone’ won’t be enough to solve the backlog.

The elective recovery plan itself doesn’t commit to hard targets — partly because the number of people who will ‘return’ to seek care after staying away during the pandemic is uncertain, and partly because future waves of the virus and infection control procedures are unknown — but it does promise “an update in the summer” when there is more information on both. Keep an eye out for that.

Overall most of the key measures in the plan have already been announced — such as separate sites for elective care from urgent and emergency care (learning from the pandemic separation of ‘hot’ and ‘cold’ sites) and the expansion of ‘community diagnostic centres’ (diagnostic centres located outside of hospitals). That’s not to say they are bad measures (I actually think they’re pretty sensible), but it’s more of a list than a strategy.

The odd omission in the document, though, is the ‘8-million-people-sized-elephant’ in the room: lots of patients who stayed away during the pandemic haven’t returned yet. What, if anything, is the NHS’ strategy to ensure people who need care come forward? There is a line that “it is vitally important that anybody who has health needs, including cancer symptoms, comes forward, and we continue to urge people who need help to seek it”. But that is what the government and NHS England have been saying for months — what will be different now?

Maybe more people will return now that the worst of the Omicron wave appears to be over and there are fewer concerns about ‘overwhelming the NHS’. An NHS England survey in August 2021 found that 60% of people were still concerned about “burdening the NHS”, and almost half say they “would delay seeking medical advice compared to before the pandemic” — maybe those numbers are lower now. But if I were the health secretary, I’d be as worried about people not coming forward as I was about hospitals’ ability to undertake activity.

In other news, NHS England had its regular board meeting and HSJ journalists summarised the salient points — some of the reforms NHS England is calling for, such as more single bed rooms, would cost more. Building resilience could be very expensive — although in many areas there is scope to utilise the UKs existing strengths, such as its diagnostics infrastructure, as Axel outlines here.

The government has been ‘kite-flying’ a lot of new policies recently — from ‘hospital academies’ a few weeks ago, to GP ‘nationalisation’ last week. Now that the noise has died down, this thread from Nigel Edwards is excellent on why the evidence behind that idea is somewhat weak — to put it charitably.

And some may have noticed that the Levelling Up white paper also contained some health targets, including increasing healthy life expectancy by five years, while reducing the gap between the richest and poorest. It’s a worthy target! But it is achievable? Probably not, concludes Jo Bibby.

Back in the non-policy world, some ‘care hotels’ which local authorities and NHS Trusts set up as a temporary measures to accommodate people discharged from hospital have been expanded. Although official NHS guidance says they should only be used for a few days, some of them have had residents staying for months. The cost of having a resilient system with slack are high, but the damage to people’s quality of life is large too.

In new research news:

  • The Health Foundation have analysed whether the ‘inverse care law’ (areas in greater need of support generally have lower levels of resources) stacks up, and whether past attempts to address inequity in access to general practice have worked. They find that GP practices in more deprived areas of England are still relatively underfunded, under-doctored, and perform less well on a range of quality indicators compared with practices in wealthier areas — despite lots of initiatives to change this. Becks Fisher’s twitter thread is a great summary
  • They’ve also analysed how to better use data in the NHS, arguing that the NHS needs to improve its underlying data and technology infrastructure, and ‘develop its analytical workforce’
  • Aaaand they’ve got new polling out, showing that people are generally pessimistic about the state of the NHS and — interestingly — that people are no longer likely to say that their local NHS services are performing well. Only 9% of people in England think that the government has the “right policies” for the NHS (though we do not know what they think the “right policies” are)
  • A good article by Peter Sivey analyses the longer-run causes of the NHS’s struggles this winter — “the NHS’s stagnant workforce and demand for healthcare outstripping resources” (documented in detail, of course, in Performance Tracker)
  • NHS Confederation have a nice longread about NHS management, following on from new research about NHS management a few weeks ago. The key point I took away from it is that the number of staff who are not clinically-trained is not a good proxy for the number of managers — and newspaper writers (ahem) ought to check more rigorously!
  • Nuffield Trust have analysed whether the shift to remote primary care will increase inequalities, and what could be done about it (better use of data and carefully designing access with service users)
  • Finally, the IFS and Health Foundation have published a joint analysis of the government’s social care reforms, comparing the effects of the extended means test and cap with, and without, the amendment to exclude state-funded spending on care from the cap.

Their analysis shows that the people who lose if state-funded spending on care is excluded out are people with moderate assets who end up needing a lot of care — because it will take them longer to reach the cap, or they will never meet it. The researchers also conclude that “the unpredictability of future care need [means] this would reduce the benefits of the cap in terms of helping people plan and have peace of mind around future care costs” — one of the key rationales behind the policy...

There is an also important point — that I hadn’t clocked — that working-age adults with modest income and significant care costs could be affected, because they would be required to use any income they have above the minimum income guarantee (£91.40 per week for someone aged between 25 and pension credit age) to pay for their care until they hit the cap. Excluded public money from the cap means that their income could be limited to this income level for longer.

Children and Young People

Lots of news this week. The tutoring programme row rolls on, and Sam Freedman has written a good TES blog (£) on shortcomings — not least the apparent inflexibility of the procurement rules, and the Department for Educations’ refusal to consider a provider other than Ranstad because of concerns about legal challenge. The reporting around this seems to be that almost all policy advisors and ministers didn’t want to award Ranstad the contract out of concerns they wouldn’t administer the scheme well — which have been borne out — but felt they had to due to procurement rules. Expect the eventual NAO report to be damning…

The levelling up white paper contained one pretty high profile education target — getting 90% of 11 year-olds meeting expectations in reading, writing, and maths by 2030 (up from 65% at present — this is really ambitious). A great ambition — even if there is a lot less detail on how to achieve it. This Guardian piece on what headteachers think is needed to ‘level up’, and the Education Policy Institute’s reaction are both worth reading to understand the context.

Elsewhere, the Education DataLab have been crunching numbers to see how many schools would be affected if ‘underperforming’ schools were moved into multi-academy trusts — a proposal which could be in the upcoming schools white paper. The crunch is that this is only likely to affect a small number of schools because only 155 schools in Education Investment Areas which have had successive poor inspections grades are not already part of a MAT.

They’ve also looked at whether the government’s latest initiative to improve school attendance will work, and conclude it doesn’t stack up because it’s based on the assumption there are some well-performing and some poorly-performing schools. In reality, pupils with low absence rates are not clustered in a small number of schools. So the government’s plan to “improve consistency of support” between schools is unlikely to make a big difference.

For good measure they’ve also looked at the characteristics of pupils who are severely absent (missed more than 50% of in-school time) and pupils not on school rolls. A greater proportion of pupils with special educational needs were absent in the 2021 autumn terms — perhaps linked to reduced access to services

And in a blast from the (predictable) past, The Times reports that private schools “gamed the system” to ensure that their pupils achieved the highest A-level grades. Sam Freedman is right to suggest that state school teachers faced a “prisoners’ dilemma” here — if you’re the only school not inflating grades then you’re only hurting your own pupils…a tricky situation to put teachers in.

Karen Wespieser has a really interesting thread about the parallels between school admissions (focused on overall merits of decision) and school exclusions reviews (focused on legality of exclusion), which make for a pretty clear case that school exclusions should be more like admissions.

In the children’s social care world, I missed this earlier in the year — but in January, the government scrapped a national social work assessment and accreditation scheme introduced in 2018 — partly because of the cost and difficulty of running in-person exams. The Ministry of Justice also allocated additional funding to Cafcass, the Children and Family Court Advisory and Support Service, to help reduce the backlog of family law cases and reduce the amount of time it takes to process public law cases.

Law and order

Russell Webster has summarised the annual youth justice statistics. The clear lowlight is the continued racial disparity amongst those in the criminal justice system.

One controversial question that’s arisen from the pandemic is whether restrictive prison regimes sustainably reduce violence. The Prisons Inspectorate conclude that “the data and our reports show is that […] violence is likely to reduce where there are enough experienced officers in post and strong leadership […]complemented by a robust strategy for preventing drugs coming into prisons and meaningful opportunities for prisoners to work, learn and socialise in a way that helps them to prepare for a successful life on release”.

Last but not least, a fascinating blog explores whether long-term prison sentences work — and the difference between analysing ‘deterrence effects’ (where there is not much evidence) vs. ‘incapacitation effects’ (where there is a bit more). A blog from the same author last year on the Crown Prosecution Service is well worth reading too.

Local government

IFS head honcho Paul Johnson gave an interview to Room151 about local government funding, which is possibly the simplest overview of changes in local government finance over the last ten years that I’ve read. Recommended.

CIPFA released new analysis of local authorities’ financial resilience using financial data from 2020/21. They find a rapid growth in reserves (as the IFS did too) — but argue that this year’s data represents a ‘transitional period’, and that local authorities largely built up reserves because of funding injections from central government decisions which came late in the year.

* For what it’s worth, the edict did give examples such as “could include using personal health budgets, which has been successfully piloted in Cornwall and Lancashire; or use of hotel beds” — but I don’t think this is particularly useful

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Graham Atkins

Graham Atkins

Senior Researcher @instituteforgov: public services, infrastructure, other things. Too often found running silly distances in sillier weather.