The precarious state of the state: Public services

Most services are performing worse than at the start of the 2019 parliament and substantially worse than in 2010. Whoever forms the next government will have to grapple with the distinct challenges facing each public service, as well as their often shared and systemic causes. 

Current spending plans would mean only limited improvement in most services, and further decline in the criminal justice system

Spending plans from April 2025 onwards for public services are very tight. Sticking to these – given existing commitments to fund the NHS workforce plan, increase defence spending, maintain overseas aid and expand free childcare – implies other areas of spending being cut by 2.6% a year in real-terms between 2024/25 and 2028/29. With the NHS assumed to receive additional funding, demand for schools set to fall, and local authorities able to raise funds through council tax and business rates, the biggest impact of these cuts would be on the criminal justice system. 

Implementing these spending plans would mean only limited improvement for most services, and a further decline in the criminal justice system. This means they are likely to prove politically impossible to deliver, with whoever forms the next government forced to provide emergency funding, as has been done serially in recent years, in an attempt to maintain service levels.

This parliament has seen some of the worst hospital performance in NHS history 

As clearly disruptive as it was, the Covid pandemic largely exacerbated existing declines that started from 2010. Hospital waiting time targets have not been met for elective care, A&E, cancer treatment, or diagnostic tests since at least early 2016. 

Other performance indicators paint an equally dismal picture across elective and emergency care: 

• The elective waiting list has fallen from the record high of 7.8m in September 2023, but remains almost 3m million higher than on the eve of the pandemic.
• The NHS missed its target for both 4-hour A&E waits and ambulance response times in 2023/24, despite relaxing the target for both. ⁵⁸ NHS England, ‘2023/24 priorities and operational planning guidance’, ENGLAND.NHS.UK, 27 January 2023, retrieved 6 June 2024, p. 7, www.england.nhs.uk/wp-content/uploads/2022/12/PRN00021-23-24-priorities-and-operational-planning-guidance-v1.1.pdf
• More than 1.5m people waited more than 12 hours in major A&Es in 2023/24 compared to 500,000 in the 12 months to February 2020.

That poor performance comes despite substantial staffing increases in recent years. There were around 20% more doctors and nurses working in hospitals in March 2024 than in December 2019. Hospital staffing increases have been far greater than in other parts of the health and care system, which has driven large increases in spending on the service.  

As well as staff numbers increasing, spending has also risen though performance in hospitals has flatlined since the pandemic. This is down to a combination of decisions from successive governments. Substantial cuts to capital spending in the 2010s has resulted in the highest maintenance backlog on record, IT systems that do not communicate across the service, and insufficient equipment for staff to carry out their work. The government has also underinvested in the management, administration, and analytical capacity that is needed to make the most of the additional doctors and nurses that have been hired.

This parliament has also seen widespread industrial action, with various staff groups walking out as inflation further eroded the value of their pay. This too followed successive governments’ decisions – namely to freeze and then hold down staff pay in the 2010s for most staff groups. While the government has resolved most of the industrial disputes (with the exception of junior doctors), there is still widespread dissatisfaction with pay. ⁶⁰ NHS, NHS Staff Survey 2023: National results briefing, March 2024, p.23 www.nhsstaffsurveys.com/results/national-results/

GPs are delivering more appointments than ever, but patient satisfaction is declining 

General practice has absorbed much of the post-pandemic pressure on the NHS. GPs are delivering more appointments than ever, even as the number of fully-qualified GPs has declined. The service’s ability to deal with that pressure has been admirable, particularly as core elements of general practice funding has not kept pace with inflation. ⁶² Hoddinott S and Davies N, Performance Tracker 2023: General practice, Institute for Government, October 2023, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/general-practice#the-2023/24-gp-contract-does-not-increase-funding-in-line-wit…-  But there is a risk that GPs – who were already reporting burnout before the pandemic – will be even more overburdened, worsening the ongoing retention crisis in the service.

Rising numbers of GP trainees are also not translating into commensurate numbers of fully-qualified GPs. There were 1,626 fewer of the latter in the service in April 2024 than in September 2015, a drop of 5.7%. There is an even greater problem in the GP partner workforce, which the service relies on for many aspects of delivery. The service lost more than 5,500 GP partners between September 2015 and April 2024, a decline of more than a quarter (25.7%). 

Over the same period, the number of patients registered at GP surgeries increased by 11.3%. There are now 2,348 patients for every fully-qualified GP, up from 1,990 in September 2015. This is not spread evenly across the country; the ratio of patients to GPs is much higher in more deprived parts of the country. ⁶⁴ Hoddinott S and Davies N, Performance Tracker 2023: General practice, Institute for Government, October 2023, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/general-practice#patient-to-gp-ratios-are-increasing-and-are-worse-in-more-dep…  This mismatch in the demand for general practice and the supply of GPs is evident in declining patient satisfaction with the service.

While the number of fully-qualified GPs have declined, the number of staff in the wider primary care service workforce (for example, pharmacists, care coordinators and social prescribers) has grown by 39,000 since 2019, and is now roughly 1.4 times the size of the entire fully-qualified GP workforce.

The twin pressures of rising demand and budget cuts have forced local authorities to cut prevention and universal services

Between 2009/10 and 2019/20, governments cut grant funding to councils by approximately 40% in real terms. ⁶⁷ Atkins G and Hoddinott S, Local government funding in England, Institute for Government, 10 March 2020, retrieved 6 June 2024, www.instituteforgovernment.org.uk/explainer/local-government-funding-england  While this has partially been offset by rising council tax and recent (minor) increases in grant funding, local authority spending power ⁶⁸ A measure of the total funding available for local authorities to spend. It is a combination of central government grant funding, council tax, business rates and a few smaller income sources.  is still approximately 10% lower in 2024/25 than it was at the beginning of last decade.

At the same time, local authorities have faced ever rising demand from overall population growth, more people aged over 65 and rising level of poverty. Strikingly, in 2022/23, there were 730,000 more children living in poverty than in 2010/11. ⁷³ Hoddinott S, Davies N and Kim D, A preventative approach to public services, Institute for Government, May 2024, p. 17, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services

Caught between the twin pressures of budget cuts and rising demand, almost all local authorities have been forced to make difficult decisions to balance their books. This has often entailed cutting spending on more preventative or universal services. For example, local authorities cut spending on youth services and children’s centres by more than three-quarters (77.9%) in real terms between 2009/10 and 2022/23. ⁷⁴ Hoddinott S, Davies N and Kim D, A preventative approach to public services, Institute for Government, May 2024, p. 15, www.instituteforgovernment.org.uk/publication/preventative-approach-public-services

Even with those cuts, local authorities are struggling to keep their heads above water. Councils have issued a spate of section 114 notices since 2018 (in effect declaring bankruptcy), with eight local authorities issuing 12 notices in that time, compared to two in the 30 years before 2018. ⁷⁵ Hoddinott S, Local government section 114 (bankruptcy) notices, Institute for Government, 9 October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/explainer/local-authority-section-114-notices  For fear of more councils following suit, central government has provided additional financial support for a further 19 local authorities in 2024/25. ⁷⁶ Department for Levelling Up, Housing and Communities, ‘Exceptional financial support for local authorities for 2024-25’, GOV.UK, retrieved 6 June 2024, www.gov.uk/guidance/exceptional-financial-support-for-local-authorities-for-2024-25

The problems in adult social care have not been fixed

Boris Johnson’s first speech as prime minister included a pledge to “fix the crisis in social care once and for all”. ⁸⁰ Johnson B, ‘Boris Johnson's first speech as Prime Minister’, speech at 10 Downing Street, 24 July 2019, www.gov.uk/government/speeches/boris-johnsons-first-speech-as-prime-minister-24-july-2019  This has not happened, and the current ill-designed system creaks onwards. The inadequacy of this system is evident in its inability to meet rising need. The number of people receiving long-term care has fallen since 2022/23, even as the number of requests for support ⁸¹ The first step that someone takes to access local authority-provided care.  to local authorities has increased. 

There are several potential explanations for this, however the overriding reason is that central government funding has not kept pace with rising demand and inflation, meaning that local authorities have been forced to rationed care. That has led to rising amounts of unmet need and pressure on friends and family to provide ever more unpaid care.  ⁸² Hoddinott S and Davies N, Performance Tracker 2023: Adult social care, Institute for Government, October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/adult-social-care#a-decline-in-people-receiving-long-term-support-is-unlikely-…
 

The adult social care sector has also gone through a major workforce crisis since the 2019 election, with record vacancy rates of 10.6% in 2021/22. ⁸⁷ Davies N, Hoddinott S, Fright M and others, Performance Tracker 2022, Institute for Government, October 2022, p.79, www.instituteforgovernment.org.uk/publication/report/performance-tracker-2022-0  In response, the government made it easier for those who want to work in health and care to come to the UK in February 2022. ⁸⁸ Department for Health and Social Care and Home Office, 'Biggest visa boost for social care as Health and Care Visa scheme expanded’, press release, 24 December 2021, retrieved 6 June 2024, www.gov.uk/government/news/biggest-visa-boost-for-social-care-as-health-and-care-visa-scheme-expanded  That decision was remarkably effective and led to an increase in the workforce in 2022/23, driven entirely by recruitment from outside the UK and EU. 

However the government then decided to tighten eligibility when it came under pressure to bring down net migration in December 2023, ⁸⁹ Home Office, ‘Home Secretary unveils plan to cut net migration ‘, GOV.UK, 4 December 2023, retrieved 6 June 2024, www.gov.uk/government/news/home-secretary-unveils-plan-to-cut-net-migration  leading to a drop of 76% in applicants for health and care visas in the first four months of 2024 compared to the same time in 2023. ⁹⁰ Home Office, ‘Monthly monitoring of entry clearance visa applications ‘, GOV.UK, updated 22 May 2024, retrieved 6 June 2024, www.gov.uk/government/statistics/monthly-entry-clearance-visa-applications/monthly-monitoring-of-entry-clearance-visa-applications  Given the sector’s recent reliance on international recruitment, this poses a substantial risk to the sector’s ability to meet demand.

Meeting increased demand in children’s social care has come at the expense of spending on early help services

Local authorities have shouldered rising demand for children’s social care. Lockdown restrictions in 2020 temporarily decreased referrals, but the lifting of these measures from 2021, especially the reopening of schools, ensured a rapid rebound to pre-pandemic levels. While the number of child protection plans decreased very slightly in 2022/23, the number of children in care has risen steadily since 2009/10.

This has driven increasing cost pressures for local authorities, exacerbated by greater use of expensive private providers of residential care. There was a real terms increase of 66.2% for spending on residential care between 2015/16 and 2021/22. In response, councils have substantially reduced spending on early intervention services. ⁹⁴ Fright M and Davies N, Performance Tracker 2023: Children’s social care, Institute for Government, October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/childrens-social-care

The increased demand for children’s social care comes at the same time as local authorities grapple with an ongoing recruitment challenge. There were 7,900 vacancies in 2022/23, the highest figure on record, while workforce turnover rates were at their highest since 2013. Consequently, local authorities have continued to rely on record numbers of agency workers to fill the shortfall in the full-time workforce.  ⁹⁵ Department for Education, ‘Children’s social work workforce, reporting year 2023’, retrieved 6 June 2024, explore-education-statistics.service.gov.uk/find-statistics/children-s-social-work-workforce ⁹⁶ Fright M and Davies N, Performance Tracker 2023: Children’s social care, Institute for Government, October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/childrens-social-care#the-number-of-social-workers-fell-in-the-past-year-and-l…

School performance has improved since 2010, however the pandemic has caused considerable disruption to learning

School performance in England had been improving from 2010 – one of the few services to do so, and true both in absolute terms and relative to international comparators. ⁹⁸ Sizmur J, Ager R, Bradshaw J and others, Achievement of 15-year-olds in England: PISA 2018 results Executive Summary, Department for Education, December 2019, p.3, assets.publishing.service.gov.uk/media/5f20292e8fa8f57ac3af2d11/PISA_2018_England_Exec_summary.pdf  However, the pandemic caused considerable disruption to learning, which primary and secondary schools are still attempting to make up for.

At key stage 2, some 59% of pupils met the expected standard in reading, writing and maths in 2023, compared to 65% in 2019 – far short of the current government’s target for 90% of pupils to reach the expected standard by 2030. ¹⁰⁴ HM Government, Levelling Up the United Kingdom, CP 604, The Stationery Office, February 2022, p.xviii, assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1052706/Levelling_Up_WP_HRES.pdf  The picture is less clear at key stage 4: the proportion of pupils achieving a grade 4 or above in GCSE English and maths is largely static from 2019 to 2023, however results in 2023 benefited from some grading protections after the disruption of the pandemic to ensure they were not below 2019 levels. ¹⁰⁵ Alternative evidence found little statistically significant change in English and maths attainment nationally between 2017 and 2023. For further details see assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1180184/NRT_Results_Digest_2023.pdf

At both primary and secondary level, however, the attainment gap between disadvantaged pupils and their non-disadvantaged peers has widened to levels not seen in more than 10 years. Besides this, schools are struggling with a teacher recruitment crisis ¹⁰⁶ Nye P and Davies N, Performance Tacker 2023: Schools, Institute for Government, October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/schools#there-are-record-numbers-of-teachers-but-the-government-is-missing-ini…  and in many cases operating out of sub-standard buildings ¹⁰⁷ Nye P and Davies N, ‘School concrete crisis shows the danger of short-term capital budget thinking’, Institute for Government, 5 September 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/comment/school-concrete-crisis  caused by more than a decade of low capital spending.

Meanwhile, two thirds of local authorities have deficits on the part of their budgets reserved for schools spending, largely due to the cost of meeting their statutory duties to those with special educational needs and disabilities. Across these local authorities, the cumulative deficit totalled £1.6bn as of March 2023. ¹⁰⁸ Nye P, ‘SEND spending needs reform to stop local authorities going bust ‘, Institute for Government, 26 January 2024, retrieved 6 June 2024, www.instituteforgovernment.org.uk/comment/send-spending-reform-local-authorities

Despite record numbers of police officers and a rise in recorded offences, charges are down 

The government’s 2019 pledge to recruit 20,000 new officers was successfully delivered, meaning there were 149,566 officers by the end of 2022/23 (headcount). This is around 3% above the previous peak in 2008/09 in full-time equivalent (FTE) terms; however, population growth means we still have fewer FTE officers per capita than in 2008/09.  

While the number of police officers have increased, the number of police community support officers (PCSOs) has more than halved since 2008/09. Warranted officers are more expensive than PCSOs or staff, which leads to poor value for money if these officers fill roles that could be performed by others.

The increase in officer numbers contributed to a small increase in the total number of charges in 2022/23, the first uptick in a decade. But the number of charges remains substantially down on previous years and nearly 40% below 2009/10 levels, despite a rising number of recorded offences since around 2014. While this was principally due to declining officer numbers from 2010 to 2014, after this the number of charges per officer also began to fall sharply. 

Falling charges reflects worsening productivity in the police, and is not driven by growth in non-charge positive outcomes, such as out-of-court disposals and other diversionary activity, both of which have fallen as a proportion of outcomes in recent years. Instead, there has been a sharp growth in offences with evidential difficulties, particularly where the victim does not support further police action. This category made up 27% of all outcomes recorded in 2022/23, and is likely due to increasing court backlogs and declining trust and confidence in the police.

Since 2019, there has also been a productivity hit from the new officers joining the police as part of the uplift programme. New officers take time to become skilled in the role, and training them in large numbers places a burden on more experienced officers’ time.

The Crown Court backlog is now the worst on record

There is a large and growing backlog in both the Crown and magistrates’ courts. The pandemic was a significant driver of this, and particularly affected the ability of courts to deal with jury trials and the most complex cases. But again, the pandemic is only part of the picture. 

Magistrates’ courts initially made good progress working their way through the pandemic-related backlog, reducing it substantially from an all-time high of over 420,000 in mid-2020. However, in 2023 the backlog began to grow again, rising 10% from March to December. The sharp rise towards the end of the year suggests this may be driven by the ongoing capacity crisis in prisons, which has caused some hearings to be delayed.

The situation is even worse in the Crown Court, where the backlog now stands at 67,573, over three quarters (78%) higher than on the eve of the pandemic and the highest on record. Taking account of the greater complexity of cases in the backlog, we calculate this to be the equivalent of 95,045 cases. The backlog has continued to grow since pandemic restrictions were lifted in 2021 and strike action by criminal barristers was resolved in 2022.

The root cause of this growing backlog is declining efficiency in the courts. A lack of legal staff, poor-quality infrastructure and less time spent actually in hearings have all contributed to this. ‘Ineffective trials’, where a trial is scheduled and then rearranged on the day, have risen dramatically and made up more than a quarter of all Crown Court trials in 2023, up from 15% in 2014. 

Prisons are at crisis point

Prisons will pose an immediate challenge for whoever forms the next government. With the prison population at its highest level ever and extremely limited places available, the current government has resorted to various emergency measures to ease the crisis. These have included releasing prisoners up to 10 weeks early, delaying magistrates’ court hearings and using police custody suites as overflow capacity, as well as doubling-up inmates in single-occupancy cells. Operating margins have also been decreased, from 2,000 available spaces before the pandemic to just 1,350 now. This makes it harder for prisons to house prisoners in appropriate facilities and to respond to any major incidents of disorder.

According to government projections, the prison population is expected to reach 99,300 by the end of next year. By 2028, it is estimated it will be 105,000. This is driven by the police uplift programme, longer custodial sentences and the continuing sharp rise in the remand and recall populations (largely reflecting challenges elsewhere in the justice system). The current government’s prison building programme is expected to deliver a further 4,000 prison places by December 2025 – only a third of the additional capacity required.

Public service performance has been damaged by a lack of capital investment

The UK has invested less than other wealthy nations on capital over several decades. There have, for example, only been two years since 1970 when the UK has spent more than the OECD average of health capital. ¹¹¹ Hoddinott S and Davies N, Performance Tracker 2023: Hospitals, Institute for Government, October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/hospitals#underinvestment-in-capital  But even relative to this low base, the 2010s saw deep cuts to the capital budgets of the departments responsible for critical public services. The deepest cuts were in the Ministry of Justice, where spending averaged less than half of what it had in 2007/08. 

Due to historic underinvestment in capital, public services are often short of critical equipment like CT scanners or forced to rely on outdated technology. Maintenance backlogs across schools, hospitals, prisons, criminal courts and the road network have also grown substantially and now total £37bn. ¹¹² Davies N, Hoddinott S, Fright M and others, Performance Tracker 2023: Cross-service analysis, Institute for Government, October 2023, retrieved 6 June 2024, www.instituteforgovernment.org.uk/publication/performance-tracker-2023/cross-service-analysis#historic-underinvestment-in-capital-has-hit-public-serv…-  All of this makes it harder for staff to do their jobs, reducing the productivity and performance of public services.