CQC warns of growing ‘care injustice’, with access to good care increasingly dependent on how well local systems work together
This year's State of Care shows that most people are still getting good care – when they can access it.
The Care Quality Commission's (CQC) annual assessment of the quality of health and social care in England shows that overall, quality has been largely maintained, and in some cases improved, from last year. This is despite continuing challenges around demand and funding, coupled with significant workforce pressures as all sectors struggle to recruit and retain staff. The efforts of staff, leaders and carers to ensure that people continue to receive good, safe care despite these challenges must be recognised and applauded.
However, it is clear that people's experience of care varies depending on where they live; and that these experiences are often determined by how well different parts of local systems work together. Some people can easily access good care, while others cannot access the services they need, experience 'disjointed' care, or only have access to providers with poor services.
CQC's reviews of local health and care systems found that ineffective collaboration between local health and care services can result in people not being able to access the care and support services in the community that would avoid unnecessary admissions to hospital, which in turn leads to increased demand for acute services.
The most visible impact of this is the pressure on emergency departments as demand continues to rise, with July 2018 seeing the highest number of attendances on record. Emergency departments are the core hospital service most likely to be rated requires improvement (41%) or inadequate (7%). A struggling local hospital can be symptomatic of a struggling local health care system. This indicates that – although good and outstanding primary care is more evenly distributed – there are parts of the country where people are less likely to get good care.
And there is a less immediately visible impact when health and care services do not work well together – on people, like those who use mental health services, who may already have more difficulty accessing support or to have to travel unreasonable distances to get it. For example, inappropriate out of area mental health placements – with some people being placed hundreds of miles from their homes – vary considerably by region. And CQC's review of children and young people's mental health services found that some children and young people were 'at crisis point' before they got the specialist care and support they needed, with average waiting times varying significantly according to local processes, systems and targets.
Posing a threat to effective collaboration between health and social care is the continued fragility of the adult social care market, with providers closing or ceasing to trade and contracts being handed back to local authorities. Unmet need continues to rise, with Age UK estimating that 1.4 million older people do not have access to the care and support they need. In two years, the number of older people living with an unmet care need has risen by almost 20%, to nearly one in seven older people. While the government made a welcome NHS funding announcement in June 2018, the impact of this, and last week's short term crisis funding for adult social care, risks being undermined by the lack of a long-term funding solution for social care.
Ian Trenholm, Chief Executive of the Care Quality Commission, said:
"This year's State of Care highlights both the resilience and the potential vulnerability of a health and care system where most people receive good care, but where access to this care increasingly depends on where in the country you live and how well your local health system works together. This is not so much a 'postcode lottery' as an 'integration lottery'.
"We've seen some examples of providers working together to give people joined-up care based on their individual needs. But until this happens everywhere, individual providers will increasingly struggle to cope with demand – with quality suffering as a result.
"There need to be incentives that bring local health and care leaders together, rather than drive them apart. That might mean changes to funding that allow health and social care services to pool resources; for example, to invest in technology that improves quality of care. Like the digital monitoring devices for patients' clinical observations that have saved thousands of nursing hours, the e-prescribing in oncology that's helping people directly, and the electronic immediate discharge summaries that have improved patient safety.
"The challenge for Parliament, national and local leaders and providers is to change the way services are funded, the way they work together and how and where people are cared for and supported. The alternative is a future in which care injustice will increase and where some people will be failed by the services that are meant to support them, with their health and quality of life suffering as result."
Peter Wyman, Chair of the Care Quality Commission said:
"The fact that quality has been broadly maintained in the face of enormous challenges on demand, funding and workforce is a huge testament to staff and leaders.
"But we cannot ignore the fact that not everyone is getting good care. Safety remains a real concern: although there have been some small improvements 40% of NHS acute hospitals' core services and 37% of NHS mental health trusts' core services were rated as requires improvement on safety. All providers are facing similar challenges – in acute hospitals, the pressure on emergency departments is especially visible – but while many are responding in a way that maintains quality of care, some are not.
"Our other big concern is the fragility of the adult social care market. Two years ago, we warned that social care was 'approaching a tipping point' – as unmet need continues to rise, this tipping point has already been reached for some people who are not getting the good quality care they need. It is increasingly clear without a long-term funding settlement for adult social care, the additional funding for the NHS will be spent treating people with complex conditions for whom care in the community would have been more effective both in terms of their health and wellbeing and use of public money."
This year's State of Care draws on quantitative analysis of inspection ratings of almost 30,000 services and providers, in addition to other monitoring information including staff and public surveys, and performance. It also draws on qualitative analysis of interviews with people who use services, Experts by Experience and CQC inspection staff.