CQC Warns of Care Inequalities and Two Tier Heath System
The CQC has published its annual assessment of the state of health and social care in England.
The State of the Care report highlights inequalities in care, issues in accessing good, timely care, and serious concerns about mental health services, particularly for children and young people.
It draws on inspection activity, findings from CQC’s national NHS patient survey programme and statutory reports, bespoke research into people’s experiences, insight from key stakeholders and evidence collected by the regulator throughout the year about the quality and safety of services in all areas of health and care.
The report highlights that the need for social care continues to increase, including needs when people are discharged from hospital. However, the report says, supply has not always kept pace, meaning more people are not getting the support they need.
The Autumn Survey Report 2023 from the Association of Directors of Adult Social Services (ADASS) highlighted that the number of people waiting for an assessment of their needs, including needs relating to care, support, carers, occupational therapy or Deprivation of Liberty Safeguards, was just under a quarter of a million as at 31 August 2023.
Encouragingly, in its subsequent 2024 Spring Survey report, ADASS noted that the number of people waiting for an assessment of their needs had reduced to just over 227,000, a reduction of 8.9%. This reflected a general improvement in all waiting times in 2023/24, with a total reduction of 11% in the number of people waiting for assessment, care or direct payments to begin or a review of their care between the end of August 2023 and the end of March 2024 (from over 470,500 to just over 418,000).
However, where people’s care is funded by local authorities, the availability of services is increasingly struggling to keep up with the overall level of demand. The latest available data from NHS England shows that in 2022/23, for the first time, local authorities received over 2 million requests for adult social care support from new clients (people who are not currently receiving long-term support). Our analysis shows that since 2017/18, the number of new requests for support has increased by 9%. However, the number of these requests granted with long-term care or short-term care to maximise independence has not kept up, as it increased by only 4% (figure 3). Meanwhile, the number of new requests that received no service increased by 27%.
The increase in the number of new requests for local authority adult social care support in 2022/23 was not matched by the number of requests granted with long-term care or short-term care to maximise people’s independence. The number of new requests that did not result in a service being provided has increased by 27% since 2017/18.
- In April 2024, waits for care home beds and home-based care accounted for 45% of delays in discharging people who had been in an acute hospital for 14 days or more, with nearly 4,000 people delayed on an average day. Although some of these delays will have involved waits for health rather than social care services, social care is likely to have been a significant factor in these delays.
- For much of 2023/24, the North East and Yorkshire region had the highest proportion of delayed acute hospital discharges due to waiting for home-based care, and the North East region had the fewest homecare services per 100,000 population of older people.
- Meanwhile, London had proportionally the most delayed discharges from acute hospital due to waiting for a bed in a care home, and the fewest residential care home beds per 100,000 population of older people.
- At 5.4%, staff vacancies in care homes at the end of 2023/24 were at their lowest rate for the last 3 years.
- Increases in international recruitment showed signs of levelling off over 2023/24, and there has been a steep fall in the number of overseas workers applying for health and care worker visas – representing an 81% decrease in the period April to July 2024 compared with the same period in 2023.
- In 2023/24, we made 106 referrals to partner agencies regarding concerns about modern slavery and labour exploitation – nearly 3 times as many as last year.
Inequalities Persist
More broadly, timely access to good care continues to be a struggle for many, and inequalities in care persist. And issues getting access to services are often exacerbated by deprivation; in 2023/24, attendance rates for urgent and emergency care for people living in the most deprived areas of England were nearly double those for people in the least deprived areas. Analysis conducted for CQC showed that for people attending for mental health reasons, the difference was over three times higher for those in the most deprived areas..
Mental Health Concerns
Mental health services are also a cause for serious concern. Lack of resources, ageing estates and poorly designed facilities are affecting the safety of inpatient wards. CQC’s special review of the care provided by Nottinghamshire Healthcare NHS Foundation Trust also identified wider concerns around community mental health services, leading to recommendations to improve oversight and treatment of people with serious mental health issues.
CQC has particular concerns about children and young people’s mental health services, where demand continues to rise. In 2023, 1 in 5 children and young people between the ages of 8 and 25 were estimated to have a mental health disorder. While the mental health workforce has grown, problems with staffing and skill mix remain. Across the country, services are facing challenges in recruiting staff including nurses, psychologists, occupational therapists, and consultant psychiatrists – all of which are having an impact on capacity, and therefore on the availability and regularity of appointments.
Further research commissioned by CQC into attendances at urgent and emergency care settings by people with a mental health issue found that those aged 18 to 21 consistently have the highest rates of presentation for mental health issues at both emergency departments and urgent care centres. Not getting the right help at the right time can lead to people’s symptoms to deteriorate and they can then end up in crisis and/or inappropriate environments, such as urgent and emergency care.
Two Tier Health System
Last year’s State of Care warned about movement to a two-tier healthcare system – where those who can afford to pay for treatment do so and those who can’t face longer waits and reduced access. This remains a concern, starkly illustrated in dental care. CQC conducted a dental access survey of 1,000 people earlier this year, which found that people relied more on private care where NHS activity is lowest, and that access issues had a clear impact on children and young people.
Parents said they felt pressured to go private and found it difficult to get appointments, even in emergencies, and that children were left in pain while waiting for an emergency appointment. It is notable that the tooth extraction rate related to decay is nearly 3 and a half times higher for children and young people in the most deprived communities, compared with the most affluent.
The report also highlights concerns about care for autistic people and people with a learning disability – both the quality of care and access to it. The waiting time to begin assessment for a possible autism diagnosis is far too long, with average waiting times even longer for children and young people – 356 days in April 2024 compared with 238 days for adults. An autism diagnosis can be vital to getting the right help and support and can make a critical difference for children who are struggling at school.
Ian Dilks, Chair of CQC, said:
“This year’s State of Care describes issues with access to and quality of care and the impact on people who use health and care services – with particular focus on the many children and young people who are not getting the care they need when they need it.”
“While some children are receiving timely, appropriate care, we know that there are more who don’t, with potential long-term repercussions for their mental and physical health. Action now – targeted funding for early intervention, better understanding of local need and improved management of demand, and genuine two-way communication with children and families – will help to ensure a healthier population tomorrow.”
“The health and wellbeing of a nation’s children has been described as the best predictor of its future prosperity; failing to ensure good, safe care for our children today also risks failing their future.”
Adult Social Care “Precarious”
James Bullion, Interim Chief Executive of CQC, said:
“We have consistently highlighted the fragility of the adult social care sector – and the situation remains precarious.”
“The number of new requests for local authority adult social care support that resulted in no service being provided has increased by over quarter over the last 5 years. And in April this year, waits for care home beds and home-based care accounted for almost half of delays in discharging patients who’d been in hospital for more than 14 days. Nearly 4,000 people are delayed on an average day – that’s 50 double-decker buses full.”
“While vacancies in adult social care have dropped slightly, the average staff vacancy rate in social care is still nearly three times higher than in the national workforce – and care workers, despite the crucial job they do, remain among the lowest paid members of society.”
“Some providers are struggling to provide good, safe care – but there are also many outstanding adult social care providers who put the people they care for at the centre of their decision making, as the case studies included in this report demonstrate.”