The State of Care report: what you need to know

System in gridlock

NHS England data shows that in 2021/22, around 24.4 million people attended A&E: an increase of nearly 7 million on 2020/21 when the NHS was so fundamentally affected by the first waves of the pandemic.

Urgent and emergency care services are under huge pressure, with delays in ambulance response; people experiencing long waits in ambulances outside hospitals; and in emergency departments awaiting triage and to receive packages of care so they can leave hospital. These things are incredibly concerning as they are leading to increased risk of patient harm.

The CQC has characterised the current situation as a ‘system in gridlock.’ It rightly acknowledges that at the heart of these problems are staff shortages and struggles to recruit across health and care system. Lack of capacity in primary care and social care in particular are exacerbating the high pressure on urgent and emergency care services.

Another major impact of these challenges associated with patient flow is a reduction in public satisfaction with NHS care. Results from the latest British Social Attitudes survey, published in March 2022, showed the proportion of people satisfied with the NHS overall dropping from 53 per cent to 36 per cent. More people (41 per cent) were dissatisfied than satisfied.

People are struggling to access care

There is variation across the country in waiting times for elective care and cancer treatment. People living in the worst performing areas were more than twice as likely to wait more than 18 weeks for treatment as people in the best performing areas.

There is a shortage of both dentists and dental nurses in the NHS. Data gathered by the British Dental Association and the BBC found that across England, nine out of ten (91 per cent) NHS dental practices were not accepting new adult patients (4,933 of 5,416). This was highest in the East Midlands (97 per cent), South West, North West, and Yorkshire and the Humber (98 per cent respectively).

A CQC-commissioned survey of people aged 65 and over who had recently used health or social care services, found that more than a third (37 per cent) who said they were on a waiting list for healthcare services like diagnostic tests, mental health services, consultant appointments, an operation or a therapeutic service did not feel well supported. Two in five (41 per cent) said their ability to carry out day-to-day activities had got worse while they were waiting.

In the CQC’s community mental health survey 2021, only 2 in 5 respondents reported feeling they had ‘definitely’ seen NHS mental health services often enough for their needs in the last 12 months - the lowest score across the period from 2014 to 2021.

Access to primary care is also a widespread issue and is impacting on flow in the acute sector. The GP Patient Survey showed that more than one in ten people who couldn’t get an appointment at their GP practice, went to A&E. There is much regional variation in people’s ability to access primary care services. There has also been a significant reduction in the availability of NHS dental care, particularly for children and young people.

Around half a million people may be waiting either for an adult social care assessment, for care or a direct payment to begin, or for a review of their care. In the first three months of 2022, 2.2 million hours of homecare could not be delivered because of insufficient workforce capacity, leading to unmet and under-met needs.

Despite these challenges, healthcare staff are innovating quickly to deliver care more flexibly in order to overcome backlogs and cope with demand. For example, Newcastle upon Tyne Hospitals NHS Foundation Trust now runs its day treatment cancer service seven days a week, which delivers 400 additional appointments a month, supporting patients to receive treatment more quickly and with greater flexibility. The hospital also has a new ambulatory care unit (ACU) that supports haematology and oncology patients regionally. ACUs assess, diagnose and treat patients, enabling them to go home the same day and allowing patients to receive treatment in in their homes, with fewer delays.

Inequality continues

Inequality continues across large parts of health and social care. The CQC’s survey of more than 4,000 older people who had used health and social care services in the last six months found that those living in the most deprived areas were more likely to report that they had a long-term condition, disability or illness, compared with those living in less deprived areas. They also tended to use fewer health services than average, although they did use them more frequently. People with a disability were less likely to describe the care and support they received for their health and wellbeing over the previous six months as good. Disabled people, those with a long-term health condition and people living in more deprived areas were less satisfied with being able to access services when they need them and in a way that suits them. Use of dentists was significantly lower for people living in the most deprived areas (43 per cent compared with 65 per cent of those living in the least deprived areas).

These findings highlight that health and social care providers need to do more to make their services accessible, especially to people with different communication needs, and the recording and use of demographic data by services generally needs to improve.

Maternity

The report highlights maternity care as an area of specific concern. Despite a wide range of programme and policy initiatives in recent years to improve the quality and safety of maternity care in England, the pace of progress has been too slow and the quality of maternity care is simply not good enough.

Of particular concern, women from ethnic minority groups continue to experience additional risks compared with white women that, without the right interventions, can lead to poor outcomes.

The CQC’s engagements with staff delivering maternity services found that staffing shortages and pressures, a drive to meet targets, and insufficient funding are all factors that are directly affecting their wellbeing and their ability to implement safety improvement programmes and ensure high-quality care. From summer 2022, the CQC will focus its operational resource on gathering data on the quality and safety of maternity services nationally and will focus its inspection programme on supporting improvements both locally and nationally. This works aims to accelerate safety improvements, facilitate wider learning across services and influence action from national partner organisations where it is needed to alleviate the current challenges that staff face.

Mental health

Another area highlighted as a concern is the provision of mental health services. People with a learning disability and autistic people, despite multiple reviews and reports into these services, continue to face huge inequalities when accessing and receiving health and social care. The CQC’s review of the care in hospital for people with a learning disability and autistic people will highlight how they are not being given the quality of care they have a right to expect. Services for people with a learning disability, autistic people and people with mental health conditions are more at risk of being closed cultures, ie a culture in a health or care service that increases the risk of harm, and the possibility of breaches of human rights. Over the last year the CQC has taken more enforcement action against adult social care providers of services for people with a learning disability and autistic people, including cancelling providers’ registrations, imposing conditions and restricting admissions.

Mental health services are also struggling to meet the needs of children and young people, increasing the risk of their symptoms worsening and reaching crisis point. This can lead to the unacceptable situation of them being cared for in unsuitable environments. The CQC’s provider collaboration review on the mental healthcare of children and young people during the COVID-19 pandemic found that while there were positive examples of systems working collaboratively together to ensure continued access to mental health support, there were some concerns around silo working.

Ongoing problems with the Deprivation of Liberty Safeguards process mean that some people are at risk of being unlawfully deprived of their liberty without the appropriate legal framework to protect them or their human rights.

Workforce

Across the breadth of health and social care services, providers are struggling desperately to recruit and retain staff with the right skills and in the right numbers to meet the increasing needs of people in their care. This poses a serious risk to the safety and wellbeing of people who use services.

NHS vacancy statistics published by NHS Digital show that, while reported vacancy rates fell during the pandemic, they have risen over the past 12 months, with the overall vacancy rate for England now above pre-pandemic levels. While data indicates that the NHS is on course to hit the government’s headline target of an additional 50,000 full-time equivalent (FTE) nurses in the NHS by March 2024, analysis by the King’s Fund highlighted that the supply of nurses into the NHS is not keeping pace with demand, and supply challenges are worse in some regions. A particularly concerning trend among nurses is that although recruitment has improved - largely due to recruitment of nurses from abroad - leaver rates are high, meaning that highly experienced nurses are being lost. Employment growth has also been concentrated in the hospital sector.

The sustainability of the primary care workforce is also a major concern. According to NHS Digital data, there has been a fall in the ratio of fully qualified GPs per 100,000 patients from 49.8 in June 2017 to 44.6 in June 2022 [ ¹ ]. The CQC’s snap poll of providers in August 2022 revealed that 90 per cent of primary care providers agreed or completely agreed that they are currently struggling to recruit staff.

Unsurprisingly, staffing shortages are reflected in the responses in the latest NHS Staff Survey, which found that only 43 per cent of NHS staff said they could meet all the conflicting demands on their time at work. Ambulance staff continue to report high levels of stress.

The NHS Confederation’s survey in July showed that more than 9 in 10 NHS leaders have warned of a social care workforce crisis in their area, which they expect to get worse this winter.

Care homes have found it very difficult to attract and retain registered nurses. Some nurses are moving to jobs with better pay and conditions in the NHS, and care homes that have had to stop providing nursing care.

Of the providers who reported workforce pressures having a negative impact, 87 per cent of care home providers and 88 per cent of homecare providers told the CQC they were experiencing recruitment challenges. Over a quarter of care homes that reported workforce pressures are actively not admitting any new residents.

Integrated care systems

Following the introduction of the Health and Care Act 2022, the CQC has a new role in reviewing and assessing integrated care systems (ICSs). This will start in April 2023. While CQC’s focus remains the quality and safety of services, and the experience of people when they get care, it will also be looking at the leadership in ICSs and assessing how well services are integrated. From early visits to ICSs – systems in their infancies, or before they assumed their formal ICS existence – it found varying degrees of success in the way services were collaborating to improve people’s experience of care.

From the CQC’s work looking at care within the emerging and newly established ICSs and listening to people’s experiences of care, it has gleaned some areas of focus for ICSs, including understanding local population needs to improve planning and address inequalities, leadership in establishing collaborative local relationships, and ensuring all local services are included in planning how to keep people well.

In August 2022, NHS England (NHSE) published guidance about the winter ahead, also detailing six metrics for accountability in the performance of ICSs.

There are some great examples of ICSs enabling collaborative working to improve patient care. For example, in Cornwall technology is being used to help people take control of the services they use. They are working towards a ‘patient portal’, following the 2021 launch of their ‘patient hub,’ which helps residents keep track of all their hospital outpatient appointment information in a streamlined and accessible way. Across the Herefordshire and Worcestershire ICS, there is a system-wide approach to bank and agency staff. This has helped by setting a pay cap, which means providers are not outbidding one another for new recruits.

However, certain barriers to ICS progress could threaten the success of ICSs in achieving against their four key purposes. The CQC cites the ICS Network’s report The State of Integrated Care Systems, which found a significant risk was posed by ICSs not being given the requisite time and space to deliver the radical changes to health and care services that the pandemic has demonstrated are needed. This research also highlighted national workforce shortages, the involvement of primary care leaders in level planning and strategy, and the need for further support to deliver on the ambition of systems contributing to local social and economic development, as significant barriers to progress.

Analysis

We are pleased to see the CQC acknowledging that health and care staff are doing their utmost for their patients and highlighting that there is a lot of good care across the country. However, they are working under increasingly intolerable conditions, which are leading to record vacancies, standards slipping nationally, and patients not always receiving the care they need.

The report’s findings are an indictment of years of underfunding and political neglect of the health and social care system. While the average number of patients per GP practice has increased by 2,057 since 2015, during the same period the number of fully qualified FTE GPs has fallen by 1,857 despite the government’s manifesto promise of 5,000 extra GPs. NHS leaders are unable to renovate and repurpose NHS buildings and estates due to the £10 million maintenance backlog, despite the government’s manifesto promise to build 40 new hospitals. Nine in ten registered NHS dentists are not taking new adult patients. There are 132,000 vacancies in the NHS and 165,000 in social care, with 500,000 people waiting for social care assessments, despite the government’s promise to fix social care.

We are encouraged by an emphasis on mental health in the report, particularly services for children and young people and those with learning disabilities and autism. In February 2022, the NHS Confederation raised concerns that, without more action to respond to this growing demand, a generation of children and young people will face longer waits for their treatment and their mental health will deteriorate.

Leaders in primary care are doing everything they can to keep up with the scale of demand, but health inequalities and the general practice funding formula do not help. Primary care has manged this demand through triage and making good use of digital tools. However, a national narrative that face-to-face is best, and unrealistic demands from the government to see a GP of your choice face to face in two weeks, leads to low satisfaction and creates a myth that GPs are not available. Primary care leaders need sustainable funding to recruit enough staff to meet demand.

Staff shortages mean some organisations are not able to provide good care. Fixing this requires doubling down on existing policies. This includes a continued drive to achieve the target of 50,000 nurses target; further investment for more training places beyond 2025, including expansion of nurse apprenticeship route; and publication of a fully costed workforce plan for NHS with clear estimates of what the NHS needs and funding commitments.

As the results from an NHS Confederation survey in July 2022 show, health leaders remain very worried about the situation across social care. Only two fifths of patients in hospital are able to leave when they are ready to do so, including due to problems accessing social care. However, the government still has not set out how and when its £500 million winter investment will be released to the system. This is resulting in too many patients being left in hospital beds unnecessarily, leading to waits in emergency departments worsening, more ambulances queuing up outside hospitals, elective procedures being cancelled, and primary care getting more overwhelmed by people’s health deteriorating in the community, including those with complex needs.

The CQC rightly points out that ICSs have the potential to drive forward improvements alongside providers. However, their work is being stymied by the government’s refusal to acknowledge the scale of the workforce and funding challenges and to provide adequate support.

The CQC and other regulators need to support healthcare leaders across the system by regulating in a way that supports organisations to make difficult decisions on behalf of patients and take on additional risk in way that is non-standard this winter, in the interests of delivering patient care with the workforce they have.