UK General Election 2019: Public services - what’s the plan?

• After nine years of austerity and growing demands on public services, all parties are promising an injection of much-needed extra funding. But promises of more cash on their own are not enough to address the growing workforce problems facing the public services, or longer-term challenges in health, education and crime.

• Beyond the commitment to spend more money, the Conservatives appear to lack any meaningful plan for reform. Neither their manifesto nor other pronouncements suggest any focus on performance, delivery or even whether front-line services can absorb the additional money and maintain efficiency (let alone improve it).

• Labour’s plan does more than simply promise to out-spend the Conservatives. If enacted, it would represent a significant departure from the status quo, by shifting power from the users of public services to the producers. Evidence suggests that in many cases, this would harm the people most in need of these services. Their plans for compulsory licensing to secure generic versions of patented drugs could see life-saving medicines not sold in the UK.

• The manifestos lack any animating vision on delivery or how they would seek to join up services around people’s lives, integrating health and social care, raising the quality of teaching, and intervening early to prevent crime.

• In health, that means joining up services from home to hospital, bringing together physical, mental and social care to create a whole person approach to wellbeing and health. In education, it means strengthening and streamlining the oversight of schools and upskilling teachers to deliver a more rounded curriculum, with a greater focus on in-depth learning. On crime, it means matching a commitment to recruit more officers with a greater role for the Home Office in driving up police standards. And across public services, it means developing a credible workforce plan to improve retention rates, reduce workloads and improve service provision. 

It is widely accepted that following nine years of austerity, and an upsurge in demand, public services face a funding shortage and are under severe pressure.

Since 2010 funding for the NHS has grown by 1.3% per year after inflation, well below the post-war average funding growth of 3.6% per year. As a result A&E waiting times under four hours stood at 74.5% in England in October, their worst on record; waiting list numbers are up by almost 2 million since 2010; and cancer treatment targets have slipped well below targets with only 77% of cancer patients starting treatment within 62 days.

Other services have been under even greater pressure. Spending per school pupil is down by 8% in real terms since 2010. Police numbers have been cut by around 20,000 over the past decade, and conviction rates per police officer have also fallen sharply, with only 9 per cent of offences being charged. More people in need of social care are now reliant on informal care from family and friends rather than state provision: 2.6 per cent fewer adults now receive publicly funded care than they did in 2015 – despite a 10 per cent rise in the numbers requesting support from local authorities. A knock-on effect of the funding problems is that the NHS, schools and the police are struggling to retain their workforces, while services like adult social care, prisons and probation are on the point of collapse.

The parties are responding to that pressure: all manifestos are promising an injection of additional funding. These pledges of additional funding, however, have not always come with sufficient clarity over (i) how much of the commitments are new funding for individual public services, (ii) the timeframes for the additional spending, or (iii) how it will be paid for. This lack of clarity on spending compounds concerns about how those services will be reformed.

Promises of a cash injection to the public services are welcome and long overdue. However, on the question of how those services will be reformed to ensure that they money is well spent, there are some key differences.

CONSERVATIVES

Beyond the commitment to spend more money, the Conservatives appear to lack any meaningful plan for reform of the public services. Five years ago the NHS’s five-year forward plan signalled, in light of a rapidly ageing population, a need to integrate health and social care and, ultimately, shift resources from hospitals into the community^[_]Yet the Conservatives’ 2019 manifesto is silent on how they plan to reduce the pressure on hospitals or address workforce issues, let alone long-term reform and funding for social care. There is no focus on performance, delivery or even whether front-line services can absorb the additional money and maintain efficiency. On education, the Conservatives have said little about how the additional £14 billion pledged to schools will be used, beyond a nod to the standard ideological tropes, such as expanding grammar schools. These are, at best, a distraction from the major challenges facing schools, and at worst, will damage social mobility.

On policing, the Conservative position is incoherent: effectively amounting to paying to re-hire the people who had been sacked in the years of spending cuts. This is an inefficient and expensive way to use finite public resources. The problem is compounded by the lack of focus and direction in policing policy from the Home Office, leading to reactive and unstrategic use of resources: Metropolitan Police Commissioner Cressida Dick recently noted that “There’s not much central push”. Policing leaders have already pointed out that it will be challenging to spend so much money wisely in such a short time, even with a plan, but this approach virtually guarantees resources will be wasted

LABOUR

In contrast, Labour does have a plan (beyond simply out-spending the Conservatives): but it is one that involves transferring power from the users of public services to the producers. On health, for example, Labour propose banning all outsourcing of services and making the NHS the ‘preferred provider’, which would in practice, be likely to lead to higher costs, lower quality and poorer outcomes for patients. This policy would mean bringing most of the £9bn in outsourced healthcare in house, with significant associated reorganisational costs, at a time when the NHS is unlikely to be well placed to cope with major structural change. Their proposals for compulsory licensing to secure generic versions of expensive drugs for a publicly-owned drugs company would significantly reduce incentives for pharma companies to sell new drugs in the UK market. There is an acknowledgement that health and care ‘must become more joined-up’, but little detail as to how this will be achieved. Similarly, Labour’s plans for investing in social care and capping contributions to care costs acknowledge the scale of the problem, but there is a lack of detail on how the cap would workor how its new National Care Service would work with the NHS.

On education, aside from a pledge to keep class sizes below 30, the big reforms involve a watering down of current accountability arrangements and less transparency for parents: scrapping testing for primary school pupils in favour of a teacher-led ‘continuous assessment’ approach, and abolishing the independent inspectorate (Ofsted) replacing it with a system of Local Authority-led ‘health checks’ – both long-standing demands of the teaching unions.

These proposals are rooted in a belief that we should trust professionals to always make decisions in the best interest of public service users, and that poor performers and failing providers will somehow be self-correcting. This is not supported by international evidence, which suggests public services with robust accountability regimes and greater transparency generally perform better. In particular, studies have shown that scrapping standardised testing in favour of relying only on teachers’ assessments would unfairly disadvantage poorer pupils^[_] and SEN students, while reinforcing gender, racial and class steroetypes.^[_] Leaving aside the politics (surveys of parents suggest the vast majority value the work Ofsted do) these reforms are wrong in principle: weakening accountability and transparency would lead to a deterioration in services that disproportionately hurts those in most need.

On crime and policing, Labour’s policy largely mirrors the Conservatives, with a pledge to increase the number of police officers by ‘2,000 more than the Tories’. However, there is little indication that the party would be prepared to back an increase in enforcement activity. Indeed, if anything, the manifesto suggests a watering down, rather than expansion of stop and search, which begs the question: what would the additional officers be used to achieve? None of these reform proposals suggest that the extra money will substantially improve outcomes for service users.

LIBERAL DEMOCRATS

On health, the Liberal Democrats have the most comprehensive diagnosis of the problems and plans to fund social care, address workforce issues, and improve wider public health. When it comes to funding, they plan to raise income tax by 1p in the pound to raise £7bn to address short-term priorities on social-care, public health and mental health. And on health and social care integration, there are plans to ‘move towards single place-based budgets for health and social care’ – as has occurred in Greater Manchester, encourage greater collaboration between Clinical Commissioning Groups and local authorities on commissioning. Over the medium-term, they plan to establish a cross-party commission to set out a long-term funding settlement for the NHS and social care, and plan to introduce a Health and Social Care tax to fund it. 

On education, the Lib Dem offer is much less convincing. The party has struck a similar pose to Labour in that they appear to be in favour of shifting power away from users to producers. However, in addition to abolishing Ofsted and SATs, they would go even further with a pledge to scrap league tables, which have been in place since 1992. The impact of these measures can be assessed by looking at countries that have instigated similar reforms. For example, in 2001, the Welsh government abolished league tables. The impact was to lower school performance in Wales relative to England, and the effect was concentrated in the lower 75% of schools, with the poorest and lowest average ability schools falling behind the most^[_]

On crime, the Lib Dems have pledged £1 billion to ‘restore community policing’ with two new police officers for every ward in the country and a £500 million fund to tackle knife crime – with the money to be used to increase spending on youth services. However, while community policing is indeed critical, but it needs to be targeted. A blanket approach that places officers in every neighbourhood regardless of crime levels diverts resources from the high-crime areas that need them most. Moreover, there is little evidence that increasing spending on youth services would have a material impact on levels of crime.

THE BIG CHALLENGES BEING MISSED

Health: bringing together physical, mental and social care to create a whole person approach to wellbeing and health, and avoid the inefficiencies that currently occur at the boundaries between different systems.

Social care: Despite each acknowledging the scale of the problem, none of the parties provide sufficient detail on a sustainable, long-term solution to providing social care.

Education: a plan for upskilling teachers to deliver on the new Ofsted framework, which is pushing schools towards a more rounded curriculum, with more in-depth learning; and a coherent approach to strengthening schools’ oversight within an increasingly fragmented landscape, whether via multiple academy chains or local authorities.

Crime: a clear plan that seeks to address the links between the drugs market and the related problems of knife-crime, anti-social behaviour, and acquisitive crime. This should be combined with a much greater focus on early intervention, which has been a casualty of the cuts.

After a decade of cuts, it is welcome that the political parties are committed to putting much needed resources back into public services that are struggling to sustain performance levels in the face of rising demand. But on its own, more money won't be enough to break the cycle of crisis or to address the longer-term, underlying issues facing the public services.

There is little in the main parties’ proposals to give confidence that citizens will see a significant improvement for the extra money they will be asked to put in, meanwhile some of the most pressing big challenges have been dumped in the ‘too difficult’ box.