On 22 June 2021, the House of Lords is due to debate the following motion:
Baroness Armstrong of Hilltop (Labour) to move that this House takes note of the Report from the Public Services Committee, A critical juncture for public services: lessons from Covid-19, (Session 2019–21, HL Paper 167).
The committee’s report and the subsequent Government response are wide-ranging. This briefing examines some of the key thematic areas and recommendations made, though does not provide commentary on every issue examined in the report.
House of Lords Public Service Committee’s report
Established to consider the operation and future of public services including health and education, the House of Lords Public Services Committee began work in February 2020. As the committee has recognised, following the outbreak of Covid-19 and the subsequent first national lockdown in March 2020, “it became clear that the pandemic would have an enormous impact on the delivery of public services in the years to come”. As a result, the committee set up an inquiry to “examine what the experience of the coronavirus outbreak can tell us about the future role, priorities and shape of public services”.
The committee’s report was published on 13 November 2020, shortly after the UK entered its second national lockdown. Contending that the pandemic marked a critical juncture for UK public services, the committee’s report found five key “weaknesses” in public service provision which it argued made the response to the pandemic more challenging. These weaknesses were:
- insufficient support for prevention and early intervention services;
- over-centralised delivery of public services, poor communication from the centre, and a tendency for service providers to work in silos rather than integrate service provision;
- a lack of integration especially between services working with vulnerable children and between health care and adult social care;
- an inability and unwillingness to share data between services; and
- inequality of access to public services and a lack of user voice.
The committee argued that, unless these weaknesses were tackled, “significant opportunities” for innovations in public service delivery developed during the pandemic would be lost. To ‘lock-in’ these innovations, the committee recommended that the Government should prioritise:
- Recognising the vital role of preventative services in reducing the deep and ongoing inequalities that have been exacerbated by Covid-19.
- Radically improving the way government communicates and cooperates with local-level service providers to deliver effective public services. This should include analysing where services are best delivered from the centre and where local level service providers are better placed, and where visible accountability sits. Indeed, the committee recommended that the Government should acknowledge that local providers are equal partners in the delivery of services.
- Recognising and supporting charities, community groups, volunteers, and the private sector as key public service providers.
- A different, more flexible approach to the sharing of data.
- The integration of services to meet the diverse needs of individuals and the communities in which they live, by public service providers working together at the local level, supported by joined-up working across government departments at the national level.
- Giving local services and frontline workers the resources and autonomy to innovate and improve the delivery of public services, and improving mechanisms to ensure the accountability of local services.
- Using advances in digital technology to increase access to public services, particularly for hard-to-reach groups, while ensuring that online services never replace face-to-face service.
- Involving users in the design and delivery of public services.
Further detail on the committee’s findings is provided below.
Prevention and early intervention
Asking why the pandemic appeared to have an unequal impact on different groups, the committee argued that a lack of investment in public health services prior to the Covid-19 pandemic resulted in high levels of ill-health and chronic diseases, including obesity and diabetes. In turn, this placed additional pressures on the NHS once the pandemic began. Further, the committee argued this lack of investment was particularly acute in poorer areas and areas with high black and ethnic minority (BAME) populations. The committee cited evidence highlighting the disproportionate impact of Covid-19 on BAME communities, including:
- almost a third of all patients critically ill with Covid-19 in hospitals were from BAME backgrounds, despite making up just 13 percent of the UK population; and
- people of Bangladeshi background in England were twice as likely as white British people to die if they contracted Covid-19.
The committee recommended that the Government take an approach to public health that focused on preventing health inequalities over the long term. It did welcome the Government’s 2019 manifesto commitment to extend healthy life expectancy by five years by 2035, but also called for the publication of a strategy “as soon as possible” setting out how preventative measures will be implemented.
Similarly, the committee called for early intervention in other policy areas. In the area of education, for example, it noted evidence received from the Children’s Commissioner’s Office (CCO) which showed how exclusion from school can severely negatively impact later life chances. Similarly, the committee was worried about the impact of school closures early in the pandemic, particularly on vulnerable and disadvantaged pupils, arguing that:
Missing school can affect vulnerable children more than others. Research suggests that children from disadvantaged backgrounds fall behind their peers during the regular six-week summer break.
Consequently, the committee called on the Government to:
[S]et out how it will support early intervention in education services to close the attainment gap, reduce exclusions and ensure that disadvantaged children’s education will not suffer adverse long-term effects from the first lockdown. The Government should [also] consult with Ofsted and the Children’s Commissioner on how to hold schools to account and measure progress made in supporting disadvantaged children to catch up.
In the area of homelessness, the committee also heard evidence supporting a preventative approach. It heard from the Revolving Doors Agency, a charity working with people who come into contact with the criminal justice system, how “too often the criminal justice system [is] a service of last resort that ends up trying to support people with a range of mental and physical health issues, [including] homelessness”. As a result, the committee recommended that:
The Home Office and Ministry of Justice draw up joint guidance on how the police, the prison system and National Probation Service should work with homelessness, mental health and addiction services to support people whose complex needs may have deteriorated during the pandemic. It should also outline the level of resource that the police and justice system should invest in preventative services.
Over-centralised delivery of public services
The committee also argued that the Government Covid-19 response suffered from over-centralisation of public services, stating that:
We heard that frontline public service providers were often required to interpret and implement the Government’s public announcements on Covid-19 without prior consultation. There was no coordinated communications strategy across Government; local authorities often received divergent messages from different Government departments.
In evidence provided by the Deputy Chief Executive of the Local Government Association, one local authority described trying to construct a Covid response as “like trying to construct a piece of Ikea furniture with a piece missing and the instructions being posted daily in bits and pieces”. Others cited a lack of central government understanding of the role of local public health authorities, and a lack of communication between central and local authorities. The committee heard further evidence that:
- national attempts at recruiting volunteers were not aligned with locally coordinated responses;
- national public health executive agencies did not use local public health resources (such as regional directors) effectively; and
- high levels of experience and knowledge within local authority contact-tracing teams remaining unused in the design of NHS Test and Trace.
The committee argued this led to a fragmented public health response, where regional directors of public health were having to coordinate different elements of the Government’s strategy, including provision of PPE and testing, without sufficient communication from central Government. The committee cited evidence from the Local Government Association, who said that local flexibilities allowed quick delivery of PPE, testing and food deliveries where “sometimes the initial national arrangements did not seem to be working”.
The committee argued that these experiences showed that certain key public service functions are best delivered locally. As a result, the committee recommended that:
To increase the resilience of public services in any future health crises, the Government must give more decision-making responsibility to its partners at the local level.
To do this, the committee argued that the Government must rethink how it funds and supports services at a local level and “radically improve the way that [it] communicates and cooperates with local-level service providers”.
Lack of integration between services
The committee noted that people often use, or are protected by, multiple public services and that they can be disadvantaged if these services are not complimentary or sufficiently integrated.
As an example, the committee pointed to children classified as vulnerable. The risk posed to these children, from factors ranging from having a parent with a severe mental health problem, to living in a household where domestic abuse is occurring, often increased during lockdown. This was partly due to schools being closed, with other factors such as a reduction in home visits from social workers also significant. The committee warned that these factors increased the risk of vulnerable children becoming “invisible” or falling “through the cracks” when responsible agencies had different priorities or considered the child’s needs the concern of a different agency.
As a result, the committee recommended that the Government should urgently develop a cross-agency strategy that would support vulnerable children in, or at risk of, crisis. As part of this strategy, schools should be allocated professionals from Child and Adolescent Mental Health Services (CAMHS), police liaison officers and youth workers who can collaborate to address vulnerable children’s needs.
In turn, this echoed the committee’s wider recommendation that there should be greater collaboration between public service providers working together at the local level, supported by joined up working across Government departments.
Sharing data between services
Similarly, the committee argued that data sharing between national and local services during the pandemic was “inadequate”.
For example, the committee cited evidence from the Deputy Chief Executive Officer at the New Local Government Network, who said that in the early stages of the pandemic local authorities did not receive data or information from central Government about shielded groups. Similarly, evidence from Dr Jeanelle Louise de Gruchy, Director of Public Health for Tameside in Greater Manchester contended that skills and knowledge of tracing programmes held locally were not being fed into the national scheme early in the pandemic, leading to local authorities lacking important test and trace data.
The committee found similar examples elsewhere, and observed a number of barriers to a general lack of data sharing which included:
- a lack of integration deriving from cultural reluctance and risk aversion to sharing personal data;
- systemic barriers such as data protection regulations; and
- silos existing between different agencies.
Suggesting that these barriers had impaired the pandemic response, the committee recommended that the Government and national public services review their systems for sharing data with local services. Further, it called on ministers to work with the Information Commissioner to address structural, legal, and cultural impediments to data-sharing.
User voice within public services
A number of witnesses to the committee’s inquiry also stressed the importance of involving those with experience using services in service design. For example, the National Council for Voluntary Organisations (NCVO) told the committee that:
Organisations with deep roots in a community or led by people with lived experience often pioneer approaches that build strength and capacity, reaching those who are disengaged from ‘mainstream’ services.
As an example of this input in practice, the committee cited evidence from Rosie Lewis, Deputy Director of the Angelou Centre, a community organisation supporting black and minority ethnic women in the north east of England. Lewis told the committee that involving BAME people in the design of services would have made services more responsive to minority communities’ needs in the years before the pandemic, and helped to identify the “health inequalities that led to BAME people being disproportionately vulnerable to Covid-19”.
Consequently, the committee argued for the inclusion of “co-production” principles within service design. This would see providers work with service users as equal partners and is based on the principle that those who are affected by a service are best placed to help design it.
The committee recommended that the Government should set out how it will encourage co-production in the commissioning of public services, and “how it will measure the levels of involvement in service design by groups of service users such as disabled people and those from BAME backgrounds”.
Locking-in innovation developed during the pandemic
While the committee argued that existing weaknesses within public services negatively impacted the response to Covid-19, it also described examples of innovation by the Government, local services, and frontline workers that “overcame structural hurdles”.
Examples given by the committee included:
- the ‘Everyone In’ scheme launched in March 2020, which requested that all local authorities provide accommodation for rough sleepers in their area, often in hotels or hostels;
- Integrated Care Systems bringing together local NHS organisations, councils, and other local stakeholders to manage resources and improve the health of local population; and
- an increase in civic action in many communities across the UK, including new mutual aid groups coordinating volunteers who “formed a bridge between service providers and hard-to-reach individuals”.
The committee argued that these examples represented a ‘place-based’ approach to public services, where the Government enabled collaboration among local services, on a statutory and non-statutory basis, in order “to meet an area’s unique needs”.
The committee argued that taking a place-based approach in more public service provision would allow:
- the integration of services to meet the unique needs of communities in their area;
- the use of local knowledge and insight about local needs to improve the delivery of services; and
- the activation of the skills and capacity of the local voluntary sector and community groups on a local level.
Consequently, the committee recommended that the Government set out in forthcoming white papers on English devolution and social care how it will ensure that local areas have the means and autonomy to develop a placed-based approach to delivering public services.
The Government did not provide oral evidence to the inquiry, and the committee stated that an offer to send written evidence was received too late. The Government published its response to the committee’s report on 25 February 2021. Like the committee’s report, the response was wide-ranging and included the areas highlighted below.
Health inequalities and preventative measures
The Government accepted the committee’s argument that the pandemic “exposed areas in the economy and the inequalities in our society that mean[t] the most vulnerable people have been hit the hardest”. In response, in addition to measures designed to reduce the impact of inequalities during the pandemic, ministers stated that as part of the NHS Long Term Plan, certain funding will be dependent on service areas setting “specific measurable goals and mechanisms by which they will contribute to narrowing health inequalities over the next five and ten years”.
Further, on 7 August 2020 the NHS published further guidance for health trusts on how to tackle wider health inequalities, building on the broader strategy set out in the NHS Long Term Plan. These included:
- developing digitally enabled care pathways in ways which increase inclusion;
- accelerating preventative programmes which engage those at greatest risk of poor health outcomes, including more accessible flu vaccinations, better targeting of long-term condition prevention and management programmes, such as obesity reduction programmes; and
- strengthening leadership and accountability, with a named executive board member responsible for tackling inequalities in place in September in every NHS organisation.
The Government response added:
We are determined to level up health life expectancy across our country. We are committed to ensuring people can enjoy at least five extra years of healthy, independent life by 2035 and reducing the gaps between rich and poor. We must integrate good health into housing, transport, education, welfare, and the economy because we all know preventing ill health—mental and physical—is about more than just healthcare. The best way to improve life expectancy is to prevent health problems from arising in the first place.
In response to the committee’s recommendations on homelessness, the Government said:
£46 million from the Shared Outcomes Fund would be used for a new programme—Changing Futures: changing systems to support adults experiencing multiple disadvantage. [The] Ministry of Justice and Home Office are key partners in this cross-government work, led by Ministry of Housing, Communities and Local Government’s (MHCLG) which will test innovative approaches and improve outcomes for people experiencing multiple disadvantage including a combination of homelessness, offending, substance misuse, domestic abuse and poor mental health.
On vulnerable children, the Government also outlined steps it took to protect them during the pandemic. These measures included:
- keeping primary, secondary, alternative provision, special schools and further education open to vulnerable children and young people throughout lockdown;
- setting up Social Work Together, which brought 8,000 more social workers back into essential roles in response to the Covid-19 pandemic;
- investing in programmes at a local level, including £4.6 billion of funding to support councils through the Covid crisis; £9.5 million to fund research by What Works for Children’s Social Care to develop interventions to improve outcomes for children who need or have needed a social worker; £7.6 million through the Vulnerable Children National Charities Strategic Relief Fund to support national charities operating in England and Wales; and £1.6 million to expand and promote the NSPCC’s helpline.
National Institute for Health Protection
The Government response also highlighted the work that is ongoing to create a new National Institute for Health Protection (NIHP). The NIHP will bring together the health protection and resilience functions of Public Health England, the Joint Biosecurity Centre, and NHS Test and Trace.
The NIHP will deal with “domestic and global threats to health”, including infection control, emergency response and preparedness, and global health security. However, it is unclear whether it will also take a preventative role around long-term diseases, including those that disproportionately affect the UK’s poorest communities.
The Government response stated that:
Work has begun to support the formal and full establishment of the National Institute for Health Protection (NIHP). The accountability arrangements of the new body, including how the Department of Health and Social Care will hold NIHP to account, will be set out in the Framework Agreement which will be published when the organisation is formally established in Spring 2021.
We are considering the best future arrangements for the wide range of Public Health England’s non-health protection functions that are vital to support health improvement, prevention and delivery of health services and we will be setting out further details of our approach in due course.
In answer to a written parliamentary question on whether obesity policy will transfer to the NIHP in May 2021, Parliamentary Under-Secretary at the Department of Health and Social Care, Jo Churchill, added:
The department has had discussions with a wide range of stakeholders on our overall public health reform programme [and] published Transforming the public health system: reforming the public health system for the challenges of our times, inviting views on supporting effective implementation of our reform programme. The responses are currently being analysed.
Local decision making
In response to the committee’s recommendations on integration and local decision making, the Government argued that:
There has been heightened engagement between central and local government, and between national and local services, throughout the response to the crisis. MHCLG has engaged with the local tier as a way of testing, communicating, and monitoring public service interventions in response to Covid-19, and as a way of ensuring local partners have a voice in the design of interventions led by other government departments.
In response to the committee’s recommendations around data sharing, the Government said it recognised there is “untapped potential” in the way it shares data with local authorities. It said that a key objective of its National Data Strategy is transforming how government uses data to drive efficiency and improve public services. It acknowledged that there are “long-term and systemic barriers” to be addressed, including a “lack of consistency in the standards and systems used across the government”, which makes it hard to share data efficiently.
Local authorities and mutual aid groups
While welcoming the volunteering and civil action seen through mutual aid groups, the Government also stated that such groups were more prevalent in “areas with high social capital, which often correlated with areas of affluence”. In contrast, the Government said that poorer areas tended to “lack the prerequisites that help connect communities together, especially as they often receive less funding and investment”.
As a result, the Government said that it will continue to work with the sector, including through the Voluntary and Community Sector Emergencies Partnership, to prepare for future emergencies. Ministers argued that this would enable central government “to complement, and not detract from, the important local efforts responding to this crisis”.
A place-based approach
In response the committee’s recommendations on taking on a ‘place-based’ approach, the Government said that a white paper on English devolution and local recovery will be bought forward “in due course”. Ministers said this will include a new £5 million “shared outcomes fund” that will “test a new place-based model of policy design and delivery which [would] drive greater cross-Whitehall coordination”.
- Nick Davies, Graham Atkins and Sukhvinder Sodhi, Using targets to improve public services, Institute for Government, 16 June 2021
- Anna Charles and Leo Ewbank, ‘The road to renewal: five priorities for health and care’, The King’s Fund, 8 April 2021
- Mariana Mazzucato and Rainer Kattel, ‘Covid-19 and public-sector capacity’, Oxford Review of Economic Policy, 2020, vol 36, s1
Image by John Cameron from Unsplash.