• Public opinion does not appear to be the main obstacle to interventionist public health policies:
  • More people were in favour of than opposed to the vast majority of policies polled.
  • Advertising restrictions and policies to benefit children are particularly popular.
• Taxes, especially new taxes, tend to be relatively unpopular – but public health taxes are seen more favourably than other forms of tax.
• Expert interviews suggest resistance from the media, industry and party colleagues is a bigger barrier than voter opposition.
• That means politicians seeking to take action on public health need to be prepared for a long-term project requiring political capital and stamina.
• There are at least two strategic approaches they might take:
  • Building ‘scoreboard momentum’: carefully picking battles, proposing measures that are likely to pass and consolidating.
  • ‘Two steps forward, one step back’: recognising almost anything proposed will meet resistance, take a maximalist approach fighting on multiple fronts, expecting to lose on some.

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• In general, more ‘interventionist’ policies (such as bans, taxes and regulations) tend to be more effective – though the story is nuanced.
• Individual-level interventions (eg incentive payments, treatment) are more amenable to experimentation, and so have stronger evidence behind them.
• However, the evidence that we have on measures that affect whole populations suggests they have bigger effects, and are cheaper (and so more cost-effective).
• The evidence – particularly from tobacco control – suggests that a range of policies, implemented together, should reinforce one another and make each policy more effective.
• Yet the most impactful measures may be those that appear most politically difficult because they involve raising prices or restricting availability.

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• A combination of circumstances – Brexit, COVID-19, austerity, and two reorganisations thrown in – created an existential threat to the NHS.
• Public satisfaction with the NHS and social care is at an all-time low, 29% and 14% respectively.
• The long-awaited Workforce Plan faces formidable challenges: currently there are 112,000 staff vacancies and is on a trajectory for this to grow to 360,000 by 2037.
• To survive another 75 years, and beyond, policymakers must radically reform the NHS to meet changed expectations and demographics, and reckon with the damage done over the past decade or so that has landed the NHS in its current mess.

RECOMMENDATIONS

• Radical change required to save the NHS includes: devolution of expanded community services; concentrating specialist services on fewer sites; more standalone surgical hubs and more diagnostic capacity in the community, and a robust plans for improving population health and prevention of ill health, with a new independent Office of Public Health.
• There are three big changes needed at the centre for the pursuit of the radical reform agenda:
  • Reforming DHSC: A more businesslike approach is required. If the business’s delivery systems need changing – as they do – then DHSC top management should be capable of understanding how to do that
  • Quangos and efficiency reviews: The DHSC needs to have a more organised and transparent programme directed at improving efficiency and productivity
  • Workforce planning and delivery: Treasury and DHSC negotiating a new longer-term system for NHS and social care remuneration with six key features.

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• support improvements among the tail of under-performers, especially among acute care providers
• increase significantly the proportion of healthcare providers rated “outstanding” in CQC inspections.

Central to tackling both these problems is improving leadership and management in healthcare providers. Mounting evidence shows these factors make an important difference to healthcare delivery. Our survey findings suggest that, while two-thirds (65%) believe leadership across the NHS is effective, there is a significant minority that do not (27%), indicating room for improvement.

Performance benchmarks linked to an organisation’s overall ambitions are an example of management best practice. Yet the results from the survey found that 19% of managers did not have performance targets relevant to their role in place. Even among those who did, less than two-thirds (62%) had targets that aligned with the goals of the healthcare organisation they worked in.

Even when leaders and managers already employ best practice approaches, their impact is maximised when the environment is conducive. 62% of leaders and managers surveyed said that they faced obstacles that hindered their ability to do their job as effectively as they might otherwise be able to. Obstacles cited by respondents included human resource challenges, organisational problems and internal red tape.

In order to help improve leadership and management and, in turn, boost the quality of healthcare delivery across the entire country, we propose a number of reforms, including:

• expanding the degree of oversight of and support for leaders and managers by the CQC
• offering more training in leadership and management skills to those working in healthcare
• pushing for the take-up of best practice measures in underperforming hospitals, to help improve workplace culture.

The government should:

• broaden the CQC’s “well-led” category for inspections so that it includes a detailed review of the management practices, training and leadership pipelines of the organisations it inspects
• establish a set of benchmarks for judging good leadership and management that the CQC can use in its assessment of whether or not an organisation is “well‑led”
• mandate in‑work leadership and management training requirements across the NHS. including primary care, for managers and leaders
• mandate NHS England to establish a compulsory national excellence framework for the minimum in‑work leadership and management training requirements
• pilot workplace democracy in the NHS in under‑performing trusts.

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• UK public sector performance has been poor for more than two decades, with overall public sector productivity (one metric) growing just 4% in that time.
• Across the UK and the world, highly-trained public sector leaders and managers are helping deliver better public service performance, offering examples of the gains the UK could benefit from if there was a strong focus on management quality.
• Good leadership includes articulating a mission that others buy into, inspiring colleagues and leading by example. Effective management practices include setting clear performance goals, underpinned by effective performance management, effective hiring practices and the retention of good staff.
  • In healthcare, individual leadership appears to be less important than the quality of the wider senior management team and the nature of the priorities they set. Having clinicians and specialist managers in senior roles seems to be especially valuable.
  • In education, the headteacher or principal is vital. In addition, recruitment, retention, target setting and performance management are also important.
  • In local public administration, the adoption of methods such as performance management can improve outcomes. However, management measures must be implemented with sensitivity to local conditions, in order to deliver results.

This briefing is the first of several outputs, that will be focused upon the topic of how leadership and management in the public sector can help improve service delivery. The next three will look at healthcare, education and local government, in turn.

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• The rule of law is recognised as vitally important by the vast majority of British citizens: 83% agreed that the rule of law is “essential” for a free and democratic society, while 74% agreed that it is “essential“ for a successful economy.
• Many also see that it is central to the UK’s international standing, with 67% saying that they do care that the UK is seen by others as adhering to the rule of law.
• However, only 16% view the rule of law as an important emblem of British identity.
• Nevertheless, there is scope for the rule of law to play a more central role in bolstering Britishness because it is a point of “cultural overlap” between the peoples of the UK and it has been a key driver of the “mutual economic advantage” that the people of the UK have enjoyed over centuries. Additionally, there are growing risks to the UK’s international reputation if people in other countries become more aware of the erosion of the rule of law in the UK through the persistent problems in the civil and criminal courts.
• Improving the situation will require the people to see and experience more practical benefits from the law than they do currently, e.g. the courts more effectively delivering security for communities from crime and easy access to channels for effective and fair resolution of legal disputes.

Recommendations

• Develop a UK-wide understanding of the rule of law that all of the nations of the UK can coalesce around. The key tenets of this mutual accord over the rule of law should be: access, clarity, equality, fidelity and security.
• Reinvigorate citizenship teaching in all British schools – lessons should impart a clear understanding of the rule of law, its long history in this country and the legal traditions of the three legal systems of the UK.
• Reduce the “civil justice gap” in England and Wales by improving access to the civil courts for individuals, families and businesses through making them world leading by 2030.
• Transform the efficacy and efficiency of the criminal courts in England and Wales, such that they become world-leading by 2030.

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• The National Health Service (NHS) is in serious decline – struggling to recover from the devastating impact of the pandemic and Brexit.
• The issues are deep-seated and more extensive than the pandemic’s treatment backlog. The future sustainability of a tax-funded comprehensive NHS is now open to doubt.
• Throughout its history, the NHS has focused on treating ill-health, even as the disease profile of the UK has vastly changed.
• Rising demand will mean the NHS is unable to provide services to all, ushering in a two-tier health system that no longer provides free universal care.
• Politicians must be much braver in making major changes to the way the country structures and delivers health and care services.

RECOMMENDATIONS

1. Reform public health and prevention – by creating an independent public body, the Office of Public Health, which will make decisions on policy and resource distribution
2. Expand community health services and social care – rather than expanding hospitals, much more of the NHS capital should be allocated to community health facilities, including GPs
3. Consolidating specialist health services – create a new system for determining the consolidation of specialist health services on fewer sites
4. Creating elective surgery and diagnostic hubs – NHS England should be directed to establish either surgical hubs or standalone surgical centres to undertake elective surgery
5. Reforming workforce planning and delivery – DHSC should be given new powers and a long-term budget to meet future NHS labour demands

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• There is a civil and criminal justice problem in England and Wales: Many people, especially those with relatively low value “civil legal problems” are unable to access justice.
• Also, the criminal courts have been failing to deliver justice effectively for many years, contributing to higher crime and undermining the rule of law.
• The state of affairs is reflected in international rankings, as England and Wales are below a number of other common law countries.
• The civil and criminal courts need a more ambitious transformation in their organisation and functioning than the current modernisation programme is delivering – which is likely to fall short of its original aims and leave the civil and criminal courts lagging behind other countries.
• The goal should be to build world-leading civil and criminal court systems in England and Wales by 2030. The reforms need to:
  • Be future-facing and based upon a robust body of evidence.
  • Built upon proven approaches, through the application of key lessons learnt from successful examples of court system transformations and models of dispute resolution that have demonstrated themselves to be effective.
  • Have a central role for the right technologies, which can help deliver the transformations in the structures, management and processes of the two court systems that are needed.

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• Civil justice issues are highly common: around two-thirds of people have experienced them in the last four years.
• Most are addressed without formal action or legal support, and many are not even recognised as legal in nature.
• The consequences can be severe: 53% of people experience stress, 33% financial loss, and in extreme cases, people may lose their jobs or turn to drugs or alcohol.
• Recent changes to legal aid have substantially limited affordable help – the number of publicly-supported cases are a fifth of what they were a decade ago.
• On the other hand, government efforts to move civil procedures online and make them more convenient and efficient have borne some fruit, though concerns remain over the digitally excluded.

RECOMMENDATIONS

Policymakers should:

• Reverse cuts to civil legal aid, which some estimates suggest would save the government money by limiting expensive downstream problems.
• Prioritise early, joined-up interventions, providing resources and incentives for legal and other services to collaborate. An example would be co-locating legal advice clinics with hospitals or GP surgeries.
• Collect better and more timely data, for example through a biannual Civil Justice Survey for England and Wales.

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