After austerity, comes the reckoning

Jason Lowther

The publication last month of the Institute for Government’s report on the impact of cuts in local services during the decade of austerity has revealed to the public what has been obvious in the sector for years – austerity was hugely unfair and hit the poorest hardest. 

Neighbourhood services under strain is written in IfG’s usual forensic style, and its conclusion is all the more brutal because of it: the most deprived areas received the biggest grant cuts, resulting in bigger reductions in local services such as libraries and recycling.  Central government grants were cut more in deprived areas because of the way cuts to grant funding were distributed ignoring councils’ different degree of dependency on this income source.  Because of the central cuts and pressures such as the increasing demand for social services, councils have been forced to cut preventative and universal services like children’s centres and housing programmes to help vulnerable people to live independently.

The report’s detailed analysis of changes in spending reported to DHCLG concludes that most councils chose to protect similar services.  ‘Relatively protected’ services included environment and regulatory services, homelessness and public transport.  At the other extreme, most councils applied higher than average spending cuts in housing, cultural, and planning services (figure 1 below).  This mirrors earlier analysis by the National Audit Office (which also highlighted the protection of social care services).

Figure 1: Local authorities that disproportionately cut, relatively protected, or increased neighbourhood services spending between 2009/10 and 2019/20, by category

Source: Institute for Government analysis of DLUHC, Local authority revenue expenditure and financing in England: individual local authority data – revenue outturn 2009/10 and 2019/20.

The IfG report hints at the innovative ways different councils responded to these pressures, from contract renegotiation and the use of new technology, to service redesign and rationalisation.  For a more detailed exploration of this, I recommend Alison Gardner’s excellent thesis on how local councils responded to austerity – including strategic asset management, shared services, commercialisation, co-production and demand management.  Whatever methods were used, however, it’s clear that by the second half of the decade of austerity the cuts were no longer into ‘fat’ but into ‘flesh’.

These new findings add to a growing library of research on the effects of the UK government choice to pursue austerity policies, including a BMJ study in October 2021 which suggested that the constraints on health and social care spend during this period of ‘austerity’ have been associated with 57,550 more deaths than would have been expected had the growth in spend followed trends before 2010.  Considering cuts to local government funding specifically, a July 2021 study in The Lancet estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women between 2013 and 2017. Overall reductions in local government funding during this period were associated with an additional 9,600 deaths in people younger than 75 years in England. Well before the pandemic, the UK was seeing a rapid slowdown in life expectancy gains in the 2010s and, although a number of other high income countries also saw such slowdowns, of large populations only the USA experienced a more severe slowdown/reversal and the magnitude of the slowdown in the UK was more severe than other large European populations.

Perhaps the most damning finding of the IfG report is that central government lacks the information to know what the impact of its spending cuts are on local services.  This echoes the assessment of the Nuffield Trust and Health Foundation back in 2014 which warned government was making decisions with ‘no comprehensive way to quantify the impact that social care cuts are having on their health and wellbeing’ and were therefore effectively ‘flying blind’.  Having abolished the Audit Commission in 2010, the government was left with no comparable performance statistics for two-thirds of local services.  Some may believe that this was quite convenient, given what we are now learning about the effects of that government’s spending policies.

NHS is a precious resource but this resource is finite

Cllr Ketan Sheth

As another week passes, Covid-19 infections in London have continued to fall. This is extremely encouraging news. After almost two years, I’m sure everyone is keen to start moving forward with their lives and moving back as close as we can to the life we knew before the pandemic.

But while the case numbers are moving in the right direction, it was actually some other figures published by the NHS in recent days that I would like to focus on in this blog. In December alone, England’s ambulance services answered more than 925,000 calls to 999. That’s 20% more than December 2020 and means a call came in every three seconds. These are truly incredible numbers, and represents the unwavering commitment and hard work of our emergency services.

London Ambulance Service has told me that as bad as the pressure was for them when Covid first appeared in 2020, 2021 was even more challenging. This might come as a surprise to many people. But as the capital began to open up and all remaining restrictions were removed last July, our health services saw a level of demand never seen before during summer months.

In fact, 2021 was London Ambulance Service’s busiest ever year, receiving a record two million 999 calls. That is simply astounding, and I would like to say a huge and heartfelt thank you to all of the staff and volunteers at London Ambulance Service.

The NHS is a precious resource. But this resource is finite, so we must use it wisely so the sickest and most seriously injured people get care quickly in their hour of need. We can all do our bit to help. It’s important people only call 999 in a life-threatening emergency. Otherwise, we should take a moment and just think about the many alternatives which are more appropriate. For example, please do visit NHS111 online or call 111 if you need urgent medical advice and are not sure what to do. Our GP surgeries and pharmacies are also open and able to help. Urgent treatment centres are there for those needing attention for something which is serious but not life-threatening. Finally, at this time of New Year’s resolutions, I’m sure we could all do more to look after ourselves from eating healthily to getting more exercise. Prevention, as they say, is better than a cure.

The past 22 months have undoubtedly been exhausting and stressful for all of us, but for those caring for the health of 9 million Londoners, perhaps even more so. We owe all those on the front line tremendous thanks for all they have done and continue to do as we emerge from the shadow of the pandemic and another extremely busy winter. But actions speak louder than words. Doing your bit in one of these ways is perhaps the best way to show thanks to the dedicated staff and volunteers working for our NHS.

Cllr Ketan Sheth is Chair of the NW London Joint Health Scrutiny Committee

Let’s Tackle Covid

Cllr Ketan Sheth

The ‘mass vaccination event’ at Twickenham Stadium on the Spring Bank Holiday was a proud day for the NHS and local government. The North West London NHS and Hounslow Council, supported by the Rugby Football Union, pulled off this remarkable day with less than a week to plan, following a surge in Covid cases in Hounslow.

The communications around the event included the obvious routes of national, local and social media, but also included targeted door knocking in Hounslow. During the day, as it became clear that there were likely to be some vaccines left over, the local NHS took the wise decision to open up the offer to anyone aged 18 and over and this was quickly picked up and reported by the BBC, Sky and other media outlets. The result was a huge spike in demand towards the end of the day. By the close, over 11,000 people had been vaccinated – a record for a single day at one venue in the UK. Those behind this effort are to be hugely congratulated.

There are three lessons I think we can learn from this remarkable event. First, it may be a myth that young people don’t want to get vaccinated. Most of those turning up when the offer was extended were under 30. Media reports talked of a ‘festival atmosphere’ and those who attended have confirmed to me that there was a real ‘buzz’ among the young people coming forward. A number of young people turned up with older family members, having persuaded them belatedly that they should be vaccinated. While time will tell, this does suggest that there may be more enthusiasm among younger people for getting vaccinated than had been previously suggested.

Second, and perhaps more contentiously, the quicker we open up to all age groups, the easier it will be to coordinate the vaccine effort. Had the whole day been open to anyone aged over 18, it is likely the demand would have been even higher throughout the day. While the initial targeting of older and more vulnerable people made sense, it becomes harder to justify as we move down through the age groups – and harder for the NHS to coordinate and promote vaccination. We might also want to think about vaccinating people at their convenience wherever they live – while the event was targeted at Hounslow residents and others in the NHS ‘North West London’ sector, I know people from Richmond were not turned away.

Finally, what we can learn is that if everyone pulls together and works as one team, remarkable things can be achieved, even in short space of time. This is a lesson that extends beyond Covid-19 and the vaccination programme – and bodes well for ‘integrated care systems’, in which the NHS and local authorities are expected to work in statutory partnerships in the years ahead.

Cllr Ketan Sheth is Chair of Brent Council‘s Community and Wellbeing Scrutiny Committee and Chair of NW London Joint Health Overview & Scrutiny Committee 

Big changes to the NHS

Cllr Ketan Sheth

Big changes come into effect this month in the way our local health services are managed. Eight clinical commissioning groups (CCGs), including Brent, have merged into a single North West London CCG. This CCG  will also be working with every hospital, mental health trust, community trust and local authority in North West London as part of an ‘integrated care system’ (ICS).

People often ask if such changes really matter. My sense is that they really do and that they can be both a risk and an opportunity.

NHS doctors and managers tell me that the benefit to patients is that a single organisation and system can drive a consistent approach to high quality services, using data on population health to target improvements and tackle health inequalities. There are huge inequalities across our patch, with outcomes and life expectancy varying widely between the poorest and more affluent areas. We saw this play out tragically during the Covid pandemic, where the least well off, including many people in Brent, were disproportionately affected.

The role of local authorities in the ICS – which is expected to become a statutory body in April 2022 – is also important, as it means we can better join up health and social care services, building them around the needs of our communities by working as a single system.

We also have to recognise the risks. A bigger system across eight London boroughs – North West London will be the biggest CCG and ICS in the country – could easily become far removed from local needs and concerns in each area. We know public input to both health and local council services improve those services. So ensuring a strong resident voice, at both borough and North West London level, is going to be critically important.

So too is local decision-making. I am pleased that the single CCG will have strong borough-based teams – and particularly, that the intention is to create a local ‘integrated care partnership’ (ICP) between all part of the NHS and the council in each borough. While this may sound like lots of new jargon and bureaucracy, it is important. The balance of power between the ICS and the local ICPs will be important: ICPs should be setting the local agenda with their residents while the ICS steers the overall direction of travel for the system.

On balance, the changes feel like the right thing to do – residents often complain that services don’t work together closely enough. But the success of this latest NHS reform will really depend on all of us. If we can ensure that the local systems work and play their part in driving down health inequalities across the whole area, there should  be huge benefits for North West London. If we lose local voice and influence in a sprawling, centralised bureaucracy, we will have failed.

Cllr Ketan Sheth is Chair of the Community and Wellbeing Scrutiny Committee of Brent Council

NHS that involves and listens to local people is in all our interests

Cllr Ketan Sheth

Readers may be aware that the way in which the local NHS is run is likely to see big changes in the months ahead. Part of the NHS Long Term Plan is for local NHS bodies in each area to work in partnership with local councils as part of an ‘Integrated Care System’ (ICS). In North West London, this will mean a huge partnership across eight boroughs, including Brent – my Local borough. It may also mean a merger of the eight clinical commissioning groups (CCGs) across these areas into a single CCG for North West London (subject to a vote of GPs in each borough).

NHS leaders assure us that this is not a change to services, but to how their staff are organised. They say that any changes that are proposed under the new working arrangements will be subject to the same – or more – consultation and scrutiny. We need to hold them to this promise. The biggest concern for me, as a Brent councillor, is that the voice of Brent residents is not lost in a new system covering a huge geographical area (the North West London ICS and the single CCG would be the biggest in the country).

At a recent Joint Overview and Scrutiny Committee, we had the chance to question managers and GPs about the single CCG merger. There were certainly encouraging words about their future approach to involving local people in shaping health services. They have put in place a new programme, rather grandly called ‘EPIC’ (Engage, Participate, Involve, Collaborate), which they say is a direct response to the challenge of maintaining the voices of local residents in a much bigger system.

Working with local patient groups and Healthwatch organisations, they are co-producing an ‘Involvement Charter’ setting out how the public can get involved and setting standards we can hold them to. They have expressed a commitment to strengthening the current approach and involving more people, reaching deeper into our communities than ever before. They have promised to work with councillors and others to reach the most vulnerable and isolated people, who the NHS does not have a good track record of engaging. And alongside this ‘qualitative’ engagement, they have set up a 4,000-strong Citizens’ Panel, representative of local communities, allowing them to test public opinion through surveys and focus groups on a range of issues.

The programme is ambitious and no one could argue with its stated objectives. But as ever, the proof of the pudding is in the eating. The NHS is facing big challenges right now, not least in getting services up and running again in the wake of Covid-19. Getting public engagement right is going to be more important than ever. If this programme really does see a step change in how the local NHS works with our residents – and most importantly, if it acts on what people tell them – it will have my support. My message to NHS colleagues is simple: the goals you have set out are welcome, but we will need swift and tangible evidence that things are really changing for the better. The National Health Service that involves and listens to local people is in all our interests.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

Social care reform – comprehensive is good, but comprehensible vital

Chris Game

Cllr Ketan Sheth’s recent blog on ‘Local Government and the NHS Integrated Care System’ was, as he explained, timely for him personally – as an elected London borough councillor about to take on a novel scrutiny role in a new ICS.

For us Midlands readers it was timely too, for reasons most easily conveyed by the King’s Fund’s recent highly colourful Map 1 of ICSs so far established – highly colourful, that is, for some parts of England, including Cllr Sheth’s London, but bleak grey for others, like the whole of the Midlands, with merely our at least slightly more localised Sustainability and Transformation Partnerships (STPs).

This blog is not directly about either STPs or ICSs, which have only a late walk-on role. It is, though, about the future of social care and local government’s involvement in, or marginalisation from, that future, and it opens with one of Boris Johnson’s first Prime Ministerial broken pledges, in his very first speech as PM, to “fix the crisis in social care once and for all with a clear plan we have prepared”.

The ‘clear prepared plan’ bit was obvious fiction, and confirmed as such in the Conservatives’ December election manifesto.  60 pages, nearly 1,000 days working on a promised but still undelivered Green Paper, and no sniff of a plan.  One un-costed pre-condition (p.23) – that nobody should have to sell their home to pay for care – and a slightly desperate hope to build cross-party consensus on reform.

But last week, just eight months on, jostling with daily lockdown bulletins and courtesy mainly of The Guardian newspaper, saw a sudden small flurry of tantalising leaks. First came Ministers’ “radical plans for everyone over 40 to contribute towards the cost of social care in later life” – paying more in tax or national insurance, or insuring themselves against “hefty care bills when they are older”.

Broadly resembling the German and Japanese funding systems, it is variously labelled a ‘comprehensive’ and ‘compulsory’ insurance model, both of which, to be effective, it surely has to be.

But an even bigger question, I suggest in the blog’s title, is surely whether it can become a comprehensible and comprehended model, and pretty quickly – because the evidence is that our collective understanding of even the existing system is worryingly low.

With coincidental but near-perfect timing, the New Statesman magazine recently commissioned a poll by Redfield & Wilton Strategies asking a sample of 2,000 GB adults about their awareness of how social care is currently funded and organised. Its findings, for a topic dominating news headlines for several months now, were concerning.

Fewer than one in eight felt they were “significantly aware”, under half even “moderately aware”, and nearly a quarter “not aware at all”. They were then asked which of (1) the NHS, (2) private operators, and (3) my local council, they thought were currently providing community care in their locality.  Being a GB-wide sample, there are no precisely right or wrong answers, and ‘providing’ makes it almost a trick question – which personally I’d have opposed phrasing in this way. Still, there are better and worse guesses.

“My local council”, chosen by 55%, is a decent pick – if, by providing, you mean paying for.  But not, for decades now, if you mean actual care home beds.  As Covid has tragically demonstrated, funding is nowadays effectively separated from extremely fragmented provision, with only some 3% of beds directly provided by councils and at least 80% in over 11,000 homes by for-profit private companies, local organisations and charities.

As for payment – roughly £600 per week here in the West Midlands – just over one-third of residents have their fees met by their local authority; one in eight pay top-up fees, but the biggest fraction must find the full fees themselves.  Which, given our apparently limited understanding of the present-day system, must frequently come as a serious shock.

Exactly half the poll respondents ticked the “private operators” option. However, virtually as many (48%) nominated the NHS, which, note the authors, is nowadays “a very small player” indeed in providing social care.  It’s not totally wrong, but close – and that, in the proverbial nutshell, is Ministers’ social care problem.

The public generally have low understanding of how even the present care home system works, of how literally dis-integrated it has become, with home care provision twice as fragmented and considerably more expensive. But they love, clap for, and think they know ‘their’ NHS.

It was even more starkly highlighted in the crunch question: “Which of three options for the future of social care comes closest to your own view?”  Exactly half the respondents selected the ‘NHS model’ that many had just demonstrated they seriously misperceived: “Social care should be free at the point of use, regardless of whether individuals contributed taxation into the system during their working lives”.

Just over one-third preferred the ‘pension’ or ‘compulsory insurance’ model referenced in the Guardian story – or, rather, first story.  For, the following day, it reported Government plans to in effect merge health and social care services, taking the latter away from local councils altogether and handing them and their £22.5 billion annual funding over to the NHS.

The Department of Health and Social Care issued a routine denial, but the PM’s long awaited ‘plan’ appears, currently, to be that care services would be commissioned by, and funded through, the new NHS regional Integrated Care Systems (ICSs) gradually unrolling across England – although not, as yet, the Midlands, where we’re still in the Sustainability and Transformation Partnership phase.

I conclude with what seems a bit of a personal dilemma. Having worked for over half my life for an ‘Institute of Local Government Studies’, I instinctively deprecate both the fact and implications of elected and accountable local authorities losing a major function for so long integral to their existence.

On the other hand, if that’s what most people reckon they want, and the Government fundamentally misunderstands, distrusts, and already wants to diminish and/or abolish local councils ….   The question is: would the public be prepared to pay the cost of NHS-style “social care, free at the point of use”, largely unaddressed in the New Statesman questionnaire?  But that’s for another blog.

 

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Chris Game is an INLOGOV Associate, and Visiting Professor at Kwansei Gakuin University, Osaka, Japan.  He is joint-author (with Professor David Wilson) of the successive editions of Local Government in the United Kingdom, and a regular columnist for The Birmingham Post.