Latest news with #InstituteforGovernment
The Guardian
27-04-2025
- Health
- The Guardian
The Guardian view on GPs: the importance of being face to face
That members of the public value access to in-person GP appointments sounds like a statement of the obvious. But the findings of an Institute for Government report about general practice in England have more complex implications too. One striking finding is that waits for appointments seem to matter less than is often assumed. Successive governments have pushed for same-day consultations. If this was done to please the public, the research suggests they should not have bothered. Surprisingly, it found no statistically significant relationship between patient satisfaction and length of wait. For many people, there is no substitute for a face-to-face conversation with the family doctor who they may have known for years. A higher number of online and telephone consultations is correlated with lower satisfaction. The shift away from in-person consultations, which accelerated during the pandemic and has not reversed, has coincided with falling confidence in general practice – though the reduction on spending on primary care, relative to hospitals, must also be factored in. Appointments with other staff do not boost patient satisfaction to anything like the same degree. Once again, this finding raises a question over recent policy, which has been to substantially increase the 'direct patient care' workforce, including pharmacists, in England's 6,200 GP surgeries. The most popular appointments of all are those in smaller practices with higher numbers of GP partners. People's preferences are not, in themselves, a mandate for change. This study found that practices with higher satisfaction scores also meet more targets. But measuring outcomes in primary care is complicated and previous research has raised doubts about some of the care offered by the smallest practices. That said, the report highlights the importance of personal contact in healthcare, as in other public services. Under the new public management ethos that emerged in the 1980s, strenuous efforts are made to make health, education and social security systems work like businesses. Increasing efficiency and productivity are the goal. Human interactions are tightly managed with the aim of suppressing demand. Objectors to this approach have long argued that the emphasis on outputs is overly narrow, creates perverse incentives, and devalues much that is important. As Ambulance, the BBC's Bafta-winning documentary series, shows week after week, what many people need more than anything else in their interaction with public services is a feeling of connection. As the paramedic Nimah Shyr-Nai said in last week's episode, 'everyone's got a story in the end'. A recognition that care quality is to do with relationships lay behind Labour's promise to 'bring back the family doctor'. But this is easier said than done. Given ongoing difficulties in recruiting enough GPs, ministers need to ensure that other primary care staff are equipped to meet people's needs – while also training more doctors. Policymakers must reject efficiency as the sole measure of success and rebuild public services around human connection. It should not be seen as utopian, or nostalgic, to advocate for public services that value relationships. These do not all need to be in person. Automation can streamline services and help different people, and age-groups, meet their needs in various ways. But John Donne's famous assertion that 'no man is an island' still holds. We are all connected, each 'a part of the main'. That matters in public services, too.
The Guardian
22-04-2025
- Health
- The Guardian
Patient satisfaction with GP services in England has collapsed, research finds
Patients' satisfaction with GP services has collapsed in recent years as family doctors have switched to providing far fewer face-to-face appointments, new research has revealed. The proportion of patients seeing a GP in person has plummeted from more than four-fifths (80.7%) in 2019 to just under two-thirds (66.2%) last year. Telephone appointments have almost doubled over the same period from 13.4% to 25.4%. Those undertaken by video or online, including some in which patients fill in an online form but have no direct interaction with a GP, have risen almost eightfold from 0.6% to 4.6%. The Institute for Government (IFG) thinktank also found patients valued face-to-face appointments so highly that they regarded them as more important than their GP surgery offering more appointments overall by maximising the number provided remotely. They are more satisfied with practices that offer more in-person sessions, and less satisfied with those relying more on telephone and remote consultations, even though those free GPs up to see more patients. The dramatic shift in how family doctors interact with patients has coincided with a huge fall in public satisfaction with GP services. 'Patient satisfaction is higher in practices that deliver more of their appointments face to face,' according to an IFG report tracking the performance of England's 6,200 GP surgeries since 2019. Surgeries that offer the most remote appointments have experienced the biggest falls in satisfaction, the IFG analysis shows. Practices where in-person appointments remain common are also better at managing diseases such as asthma and diabetes, managing smoking and obesity, and providing check-ups to spot illness early, such as health screening and blood pressure checks, the thinktank found. Remote ways of providing care to patients that became commonplace as Covid-19 hit in 2020, which were widely thought at the time to be temporary, have become established ways of doing so at many GP surgeries, even though patients prefer traditional face-to-face appointments. Surveys have found that patients' satisfaction with GP services has fallen dramatically over recent years. Only 31% of people in Britain are satisfied with GP services, and just 23% with GP waiting times, the recent British Social Attitudes survey found. Silver Voices, a not-for-profit campaign group for over-60s, said GP care should not be reduced to 'intermittent telephone conversations' and that the lack of face-to-face appointments undermined Wes Streeting's repeated pledge to 'bring back the family doctor'. Dennis Reed, the group's director, said: 'Older patients are particularly affected by more remote consultations as we are more likely to be living with multiple conditions which require personal examination, rather than the need to just treat immediate symptoms. 'Many older patients are also uncomfortable about discussing intimate issues remotely, and the risks of misdiagnosis therefore increases.' Ministers should legislate to give patients a legal right to an in-person appointment, he said. GP leaders responded to the IFG's conclusions by stressing that surgeries were so overstretched that remote appointments were needed to help them keep up with the growing demand for care. Prof Kamila Hawthorne, the chair of the Royal College of GPs, said: 'We recognise that many patients want to see their GP face to face and the majority of GP appointments are carried out face to face – 64% in February. However, we also know that many patients appreciate the convenience of remote appointments, which can be delivered safely and securely with virtual technologies or over the phone. 'The unfortunate reality is that general practice today is totally overstretched. Patient need for GP care and services continues to outstrip resources following years of neglect and underfunding by successive governments. 'GPs and our teams are now delivering more appointments than ever before – 367m last year, more than a million per day – but with just a handful of more qualified GPs than in 2019.' Stuart Hoddinott, a senior researcher at the IFG and co-author of the Nuffield Foundation-funded report, said the relentless demand for care and shortage of GPs meant patients should not expect in-person appointments to return to pre-Covid levels. He said: 'The pandemic-era shift to providing many more appointments remotely can explain some – though not all – of the collapse in patient satisfaction. 'Although patients, especially those over 65, seem to prefer face-to-face appointments overall, the need to deliver ever more appointments to cope with demand in the system makes a return to pre-pandemic levels of face-to-face appointments unlikely.' The report, which was based on analysis of a range of official data about GP services, also found that: There are too few full-time GPs for the health secretary to fulfil his promise to 'bring back the family doctor', and that is unlikely to change in the years ahead. The government's policy of pushing GPs to offer more appointments may not be 'wise' because GPs will respond by providing more remotely – which patients dislike. GP appointment times will need to be extended from 10 to 15 minutes if Streeting is to deliver his pledge to shift the NHS from a treatment to much more of an illness prevention service. If GPs shift to being more preventive in their work, that might reduce the number of appointments they can offer, because patients will need more time to discuss their health. The Department of Health and Social Care insisted that patients who wanted an in-person consultation should get one. A spokesperson said: 'GP services are buckling after years of neglect but through our plan for change, we are working with GPs to fix the front door of the NHS and bring back the family doctor. By cutting red tape and investing more in our NHS, we have recruited more than 1,500 GPs to deliver more appointments. 'This government is also clear that patients should have access to health and care when they need it and people who prefer a face-to-face appointment should have one.'
The Independent
12-04-2025
- Business
- The Independent
Is Labour's ‘reform' to the state just a cover for austerity 2.0?
The announcement that 2,100 of the Cabinet Office's 6,500 jobs will be axed is cited by ministers as evidence that they are serious about reforms to 'rewire the state'. At first glance, it looks like a bold act by Pat McFadden, the Cabinet Office minister and one of the government's most powerful figures. It is an intended signal to cabinet colleagues to follow suit – to deliver the 15 per cent cut in civil-service running costs Rachel Reeves has demanded, as part of her government-wide spending review. Labour politicians who once criticised their Conservative predecessors for attacking a self-serving Whitehall 'blob' now tell me: 'We know what they meant.' They, too, are convinced a 'flabby' civil service (in Keir Starmer's words) is not match fit to deliver the change the government wants. To frustrated ministers who pull levers and complain that nothing happens, Whitehall's 'Rolls-Royce machine' at times feels more like a clapped-out, misfiring rust bucket. A total of 50,000 civil service jobs are likely to disappear – many more than the 10,000 figure given by the chancellor. True, the size of the civil service has grown by 34 per cent to 513,000 staff since the pandemic. But as one senior Whitehall figure put it: 'Ministers never talk about the extra functions given to us by their demands and their legislation.' Starmer and his ministers do talk a good game about 'reform'. There is a strong case for it at the Cabinet Office. It is supposed to be a strong strategic centre that helps 10 Downing Street deliver the government's priorities and bangs departmental heads together. But it has ballooned into an unwieldy operation after becoming a dumping ground for the bits and pieces no Whitehall department wants; many of its functions would sit better in departments. Indeed, 900 of its 2,100 job cuts will be achieved by transferring staff to other parts of Whitehall. As ever, headlines with big numbers look different on closer inspection. The Cabinet Office had already announced a headcount reduction of 400-500, and that it would move functions such as digital and project management elsewhere, so a large part of the 2,100 is 'not news', according to the hawk-eyed Institute for Government think tank. Across the government waterfront, there is growing evidence its 'reforms' are motivated primarily by the urgent need to save money. Starmer and Reeves do not want a very tight spending review to look like the austerity 2.0 they promised to avoid. Ministers are happy to flag up popular cuts: axing civil servants and switching overseas aid money to defence will probably play well in The Dog and Duck. Some more controversial cuts are dressed up as change. Ministers would rather talk about their £1bn package of back-to-work measures rather than their £5bn of cuts to sickness and disability benefits. The package gives them some cover to label the shake-up as 'reform' – and to imply (wrongly) that everyone on these benefits is capable of work. But the small print of last month's spring statement reveals that only £200m will be spent on the back-to-work drive when the benefit cuts bite in the 2026-27 financial year, and its budget will not reach the £1bn a year until 2029-30. The £500m of last-minute savings on universal credit on the eve of the spring statement surely revealed the real agenda on welfare – to enable Reeves to meet her fiscal rules. Civil service unions claim the 'reforms' will harm the very frontline services ministers argue will benefit from funds accrued by 'efficiency savings', making it harder to achieve Starmer's 'plan for change'. The unions would say that, wouldn't they? But they have a point. Lucille Thirlby, assistant general secretary of the FDA union representing senior civil servants, said there was a 'difference between reforming and cutting', adding that 'the success of any reforms will depend on whether the scale of cuts undermine the reform'. For example, the abolition of NHS England will be accompanied by unfunded job cuts in health trusts and integrated care boards; it could mean a total bill of £1bn for redundancy costs which diverts resources from the front line. A promised cull of the more than 300 quangos, including NHS England, is part of the reform agenda. As on civil service jobs, ministers play a self-fulfilling numbers game; they will have to deliver scalps. It would be better to focus on the savings rather than headline-grabbers on cutting jobs or axing bodies. The low-hanging fruit in the 'quangocracy' has already been picked. Senior Whitehall figures suspect the real aim is to save money and say history tells us that hurried mergers or closures rarely work. Balancing the nation's books will not be easy and some pain will be inevitable. But there is a limit to what salami-slicing 'efficiency savings' can achieve after years of austerity. A more honest approach would be for ministers to decide the state should withdraw from some functions. That would be much more politically sensitive, but more effective in achieving the savings they want. Genuine 'reform' done strategically would be better than yet another round of rushed penny-pinching.
The Guardian
09-04-2025
- Business
- The Guardian
UK needs annual migration plan to end incoherent policies, says thinktank
Ministers should introduce an annual migration plan to put an end to decades of 'incoherent, disconnected and unpredictable' policies around work visas, according to a Whitehall thinktank. The Institute for Government (IfG) said that successive governments have put forward 'reactive, kneejerk policies' formulated when politicians have been questioned by broadcasters over net migration figures. According to a report released on Thursday, a migration plan could be launched by the prime minister and home secretary. Similar to a spending review, it could be published as a public government document, debated in parliament, and be subjected to select committee scrutiny. The suggestion comes as the government prepares to release an immigration white paper, while facing competing demands for lower overall migration and more visas from businesses, the NHS, universities and social care. Reports earlier this week claimed that the white paper was delayed following rows between the Home Office and education ministers over proposed student numbers. The Home Office has tended to focus on limiting migration. For other departments – including the Treasury, the Department of Health and Social Care, the Department for Environment, Food and Rural Affairs and the Department for Business and Trade – migration is an economic lever with which to secure workforces and promote exports. Sachin Savur, IfG researcher and author of the report, said: 'For too long, governments have failed to set out what aims they have for migration policy and a realistic route to achieve them. 'They have been tempted to make kneejerk changes in response to net migration and labour market statistics. 'Adopting an annual migration plan would allow ministers to get on the front foot and set out a genuinely cross-government agenda for immigration that takes into account the government's wider priorities, evidence and interests.' Net migration – the measure for the difference between the number of people arriving and leaving the country – hit a record high of 906,000 in June 2023, in a period covering the premierships of Boris Johnson and Rishi Sunak. The figures prompted dismay and allegations that the Tories had failed to 'take back control' of the UK's borders following Brexit. According to the report, an annual plan would give the government's immigration policy credibility by: Allowing for a more honest assessment about the pros and cons of migration. Ending the antagonistic relationship between the Home Office and other departments. Creating a more coordinated approach that weighs up interests and evidence across government to produce a collectively agreed strategy. Ensuring a predictable approach to developing policy which gives certainty to employers, universities and trade associations. An arbitrary annual cap on net migration would be impractical, but more specific targets, set by route, could be more realistic if an annual plan was implemented, the IfG said. The Home Office has been approached for a comment.
The Independent
06-04-2025
- Business
- The Independent
What are the chancellor's fiscal rules and could they be set to change again?
Just days after the chancellor's spring statement balancing act saw her squeak back into line with her fiscal rules, Donald Trump took a bazooka to the global economic order on which the constraints are based. Rachel Reeves had boosted economic growth here, cut spending there, and forecasts from the Office for Budget Responsibility (OBR) placed her back on course to comply with her self-imposed targets. But the official spending watchdog had already warned that a trade war sparked by the US president would knock her back off track, and discussions are already underway about how Reeves can make the sums work in time for a full-fat Budget this autumn. What are the fiscal rules? The chancellor's fiscal rules dictate that she cannot borrow to fund day-to-day spending, and that debt must be falling as a share of national income by the end of a five-year forecast period. They are in place to instil confidence in the markets that ministers are firmly in control of the public finances – and that Britain will be able to comfortably pay its debts. Can the chancellor change or scrap them? The fiscal rules were introduced in 1997 and applied for more than a decade in their first iteration. They have been changed nine times since then – most recently by Reeves herself in October last year, when she moved her focus to maintaining a current budget balance between -0.5 per cent and +0.5 per cent of GDP rather than following Jeremy Hunt 's previous rule, which specified that borrowing must be kept below 3 per cent of GDP. The chancellor also distinguished between borrowing for investment and borrowing for day-to-day spending, a move that was welcomed at the time by economists and the Institute for Government. So tweaks can be made to allow the chancellor varying degrees of wriggle room. The ultimate barrier is the extent to which Reeves can change the rules while maintaining the confidence of the markets. But no chancellor will scrap the fiscal rules altogether. Not only would doing so spook investors, it would prove politically toxic for whichever party chose to do it. Why hasn't Reeves made further changes? The chancellor was urged before her spring statement last month to tweak the fiscal rules rather than attempt to balance the books on the backs of benefit claimants. But Reeves chose the latter. Not only is the Treasury worried about the political optics of being seen to shift the goalposts: it is concerned about the way any changes would be received by the financial markets. No change would prove as toxic as Liz Truss and Kwasi Kwarteng 's approach to the public finances, which saw the former PM and her chancellor produce a mini-Budget with no accompanying forecasts from the OBR. But Institute for Fiscal Studies director Paul Johnson has warned that the rules 'are about as loose as is reasonable', and said: 'We've seen how jittery the markets are.' But is a tweak on the way? There has been a decisive shift in the government's language on the economy since Trump's tariff war began. Keir Starmer had previously talked about the world entering a 'new era' for defence and security; he now talks about being in a new era for trade and the economy. The prime minister could be laying the groundwork for a major change, similar to that seen in Germany, against the backdrop of what he has called a new economic order. Whatever the PM is planning, his change of tone suggests that a big change in approach is on the way.
