Gridlocked care

Twelve months ago, we highlighted the risk of a tsunami of unmet need across all sectors, with increasing numbers of people unable to access care.

We said that funding must be used to enable new ways of working that recognise the inter-connectedness of all health and care services – not just to prop up existing approaches.

In the period since then, the public have shared their growing dissatisfaction with the health and care services that they need to rely on.

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% to 36%. More people (41%) were dissatisfied with the NHS than satisfied.

Satisfaction with every type of service was down:

• GP services from 68% to 38% (the lowest since the survey began in 1983)
• inpatient services from 64% to 41%
• A&E services from 54% to 39%
• NHS dentistry services from 60% to 33% (again, the lowest level since the survey started)

Only 15% of respondents were satisfied with social care services in 2021 and 50% were dissatisfied.

In the 2022 GP Patient Survey (719,137 surveys completed, based on fieldwork from January to April 2022), the proportion of people who reported a good overall experience of their GP practice went down from 83% to 72%. Worryingly, more than a third of people (34%) said they didn’t speak to or see anyone when they couldn’t get an appointment. Fewer patients with a mental health need felt their healthcare professional recognised their needs – down from 86% to 81%. More than a third of patients with a long-term condition said they didn’t have enough support to manage their condition (up from 26% to 35%). And of all conditions, people with a learning disability, people with a mental health condition and autistic people had the lowest results for saying they received enough support (58%, 57% and 50% respectively).

Our Community mental health survey 2021 showed that people consistently reported poor experiences of NHS community mental health services, with few positive results (based on feedback from 17,322 people who used NHS mental health services in England between 1 September 2020 and 30 November 2020). Many said that their mental health had deteriorated as a result of changes made to their care and treatment due to the pandemic. Across many areas of care, experience of using mental health services was at its lowest point since 2014.

Our Adult inpatient survey 2021 (based on feedback from 62,235 people who were in hospital in November 2021) showed a decline of 4 percentage points in the number of people that had ‘a very good experience’ from 40% in 2020 to 36% in 2021.

NHS staff have also aired their deep frustration. In the 2021 NHS Staff survey (based on feedback from over 600,000 people working in the NHS between September and December 2021), the proportion of staff happy with the standard of care provided by their organisation declined from 74% to 68%. Only just over a quarter (27%) said there were enough staff in their organisation for them to do their job properly – down from 38%. In ambulance services, only 1 in 5 staff (20%) said this. For midwives, it was only 6%.

Introduction of integrated care systems

This period of deepening public disaffection with health and care coincides with the start of a fundamental change in the organisational structures that sit behind health and adult social care in England.

New integrated care systems (ICSs) in England formally took up their responsibilities in July 2022. There are 42 area-based ICSs, each covering a population of between 500,000 and 3 million people (figure 1).

Figure 1: Integrated care systems in England

 

Map shared with the permission of NHS England.

 

The aim of ICSs is to deliver joined-up care that better meets the needs of local people. ICSs are partnerships that bring together NHS organisations, local authorities and others to take collective responsibility for planning services, reducing inequalities and improving health across geographical areas.

 

The changes have been described as the biggest legislative overhaul of the NHS in a decade. Overturning a longstanding approach in which the emphasis was on organisational autonomy, competition and the separation of commissioners and providers, ICSs will rely instead on collaboration and a focus on places and local populations as the driving forces for improvement.

 

Importantly, to really understand whether their work will make a difference, ICSs will need to use insights from local people on whether the care in their area is improving and giving them what they need.

 

The urgent care system

 

Packed emergency departments

 

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.

 

This increase has contributed to a domino effect on access to other services, including medical and elective care. People have experienced long delays in waiting to be triaged within emergency departments, as well as then being seen by a medical professional.

 

The proportion of people left waiting for more than 4 hours to be admitted, treated or discharged from A&E continues to grow. National performance estimates show that in 2021/22 over 5 million attendees waited more than 4 hours in A&E, compared with just over 3.5 million in 2019/20.

 

Across 2021/22, the estimated number of people waiting more than 12 hours to be admitted to a ward from A&E (after a decision to admit them) increased massively. The latest data for July 2022 shows this figure was nearly 65 times higher than it was 3 years before: 452 in July 2019 and 29,317 in July 2022 (figure 2).

 

Figure 2: Patients waiting 12 or more hours from decision to admit to admission, England, January 2019 to July 2022

On top of this, NHS hospital providers have told us that people are presenting more acutely unwell, and are therefore more likely to be admitted. This is also reflected in steep increases in category 1 ambulance calls such as cardiac arrest, which are classified as life-threatening.

 

Queuing ambulances

 

The increases in attendances at emergency departments and waits to be admitted have had a huge knock-on effect on ambulance services. Long queues of ambulances waiting outside emergency departments to hand over their patients have become a regular sight.

 

According to the Association of Ambulance Chief Executives (AACE), the volume of patient handovers taking more than 60 minutes has reached an unprecedented high level. In March 2021 there were 7,000 handovers taking over 60 minutes. In March 2022 there were more than 45,000. Our analysis shows that this translates to more than 1 in 10 ambulance handovers taking over an hour in March 2022, when the standard is 15 minutes and no-one should have to wait more than 30 minutes.

 

AACE reported that the longest handover recorded was 23 hours, in March 2022.

 

Ambulances are not the best place to treat someone

 

 

Ambulance handover delays are a consistent risk to the quality and safety of patients’ care. Although the care from ambulance crews during these waits tends to be good, ambulances are not the right locations to care for people once they have arrived at the emergency department. In some providers, paramedics care for patients in the ambulance, including if their condition deteriorates. The training for paramedics and emergency care assistants does not account for providing ongoing care. Providers mitigate this risk as far as possible, supporting ambulance staff to monitor patient’s conditions using clinical tools such as the National Early Warning Scores (NEWS) tool.

 

 

Handover delays create a huge risk for people needing an ambulance

 

Another impact of handover delays is that ambulances cannot respond to emergencies in the community, resulting in delays to ambulance response times to 999 calls. The result is that people with urgent health conditions cannot always access the care they need, when they need it, resulting in serious injury and, in some cases, deaths.

 

We have also received consistent concerns about ambulance response times from care home providers. People in care homes should receive the same level of emergency care support as other people. In one case, a person with a fractured hip was not classed as ‘urgent’ as they were deemed to be in a place of safety. Care home staff were told not to move the person and were only able offer them paracetamol for pain relief. Despite a number of calls to the ambulance service, they lay on the floor for over 8 hours before the ambulance attended and transported them to hospital.

 

In August 2022, Healthwatch commissioned a survey asking a representative sample of 2,036 people about urgent and emergency care services. While just over two-thirds of people who responded (68%) were confident they would receive high-quality care, treatment and support at an emergency department, the proportion who felt they would be seen in a reasonable time in an emergency department or that an ambulance would arrive in a reasonable time was closer to one-third (37% and 38% respectively).

 

The survey also found that people over 55 were generally less confident that they would be seen or treated within a reasonable time, compared with people under 55.

 

Adult social care

 

There are large numbers of patients who are stuck in hospital longer than they need to be, due to a lack of available social care packages.

 

Commenting on NHS performance figures for July 2022, NHS Confederation highlighted that only 4 in 10 patients were able to leave hospital when they were ready to. They said that at that point there were almost 13,000 patients a day who spent more time in hospital than needed.

 

This is due, to a large extent to severe staff shortages in adult social care, resulting in homecare providers handing care packages back to the local authority and a reduction in hours of homecare. Workforce shortages have also contributed to a reduction in care home capacity, with a number of providers choosing to hold empty beds because they don’t have the care workers to staff them.

 

In December 2021, we introduced our adult social care workforce survey. As at 30 June 2022, this survey had been completed over 5,500 times by our inspectors talking to providers. It explores with providers what impact workforce challenges and staffing shortages have had on the services they deliver to people. Of care home providers that reported workforce challenges in the survey (36%), 87% said they were experiencing challenges related to recruitment. Of homecare providers that reported workforce challenges (41%), this figure was 88%. This is reflected in vacancy rates in both care homes and homecare providers, which are more than 10%, and staff turnover rates in care homes in excess of 30%.

 

Importantly, it is not just the adult care sector that recognises the seriousness of the situation it faces. NHS Confederation said in July 2022 that the pressures on health and care services are driven strongly by the severe capacity challenges affecting social care. In its July 2022 survey of healthcare leaders (243 respondents), 99% agreed that there is a social care workforce crisis in their local area.

 

It said that these pressures are affecting the ability of the whole health and care system to deliver care across community and acute settings. Almost three-quarters of healthcare leaders surveyed (73%) said a lack of adequate social care capacity is having a significant or very significant impact on their ability to tackle the elective care backlog. Over 80% said it is driving the demand for urgent care.

 

Our urgent and emergency care reviews

 

In the face of this emerging crisis, and recognising that local care systems need to find ways to cut through this gridlock, we carried out a programme of coordinated inspections of urgent and emergency care (UEC) services in 10 integrated care system areas. This enabled us to review the whole UEC pathway, rather than looking at providers in isolation.

 

For this State of Care report, we reviewed the findings and themes from the first 5 areas:

 

• Cornwall and Isles of Scilly
• Gloucestershire
• Kent and Medway
• Norfolk and Waveney
• North East London.

 

The subsequent inspections were carried out in:

 

• Cambridgeshire and Peterborough
• Leicestershire and Rutland
• Cheshire and Merseyside
• Lancashire and South Cumbria
• West Yorkshire.

 

Overall findings from our reviews

 

It is clear that urgent and emergency care services across England have been – and continue to be – under immense pressure. Our inspections of systems found people facing long waits and overcrowding – putting them at risk of harm and of deterioration in their condition. At every point along this urgent care pathway, the risk to people is increasing.

 

Our reviews have highlighted many issues, often comprising multiple providers and complex pathways, which are not always well understood or communicated by those operating within them.

 

Flow of patients

 

Ambulance delays are a symptom of a systemic problem. Emergency departments have been struggling to get patients admitted to the right hospital wards, because those wards have been struggling to discharge people back into the community.

 

Hospital beds are occupied by people who don’t need to be there and who would get more appropriate care elsewhere. Hospitals have seen a huge increase in the number of patients waiting on a trolley in the emergency department while they wait for a bed.

 

We heard from providers that this is due to lack of capacity in care settings in the community, such as adult social care settings.

 

Ambulance handover delays are generally caused by this poor flow through the acute hospital, and out into the community. Where ambulances cannot hand patients over to emergency departments quickly enough, their staff are having to wait outside and care for patients in the ambulance until they can be handed over.

 

Managing the flow of patients on care pathways is important for people who need care – the services involved must talk to one another. However, all 5 systems we saw had examples where people were unable to leave hospital and go home or move into community care.

 

At 4 of the 5 UEC systems, people who were medically fit to be discharged from hospital could not leave because there was insufficient social care capacity. People could not go home from hospital because there was no homecare support in place, or there was a lack of nursing or residential care beds.

 

Primary and community care challenges

 

In the systems we inspected, the high demands on urgent and emergency care services were exacerbated by people’s inability to access primary care services as a first port of call. People had problems getting GP and dental appointments (including out-of-hours appointments), which was leading to people calling NHS 111 and being told to go to acute urgent services, or attending A&E directly.

 

NHS 111 was experiencing high call volumes, along with staff shortages. This caused delays in giving clinical advice, and high call abandonment rates may have led to people going to A&E instead. The lack of available GP and dental appointments meant that NHS 111 could not always appropriately signpost people to primary care, resulting in directing people to call 999 or to present at A&E.

 

In 3 systems, there was a lack of capacity for people needing community and mental health hospital services. We heard how people were either directed to, or chose to use, urgent and emergency care services when they could not access care another way.

 

Staffing problems

 

Problems with staffing levels, absences, recruitment and retention were found throughout system partners. These were limiting the ability of services to recover from the impact of the pandemic and affecting patient care.

 

All 5 UEC areas highlighted staffing problems, including issues in general practice, mental health care, dental care and adult social care. The causes ranged from stress and exhaustion to uncompetitive pay.

 

We look at workforce in detail later in this report.

 

Complex pathways

 

We found complex urgent care pathways across multiple providers. People’s care pathways within and between services were complicated, and communication between providers was sometimes poor. Some people got inappropriate referrals or had additional triage processes – this was resource-intensive and resulted in delays for actual care.

 

Although services were under great pressure, we have raised concerns that providers, local authorities and NHS trusts sometimes work in isolation – demonstrating a lack of good oversight of risk to patient care and safety. In one area we saw that local authorities, providers and NHS trusts were working separately to try to resolve system issues – this didn’t solve their collective problems, but merely diverted them.

 

Sometimes mistakes were made where services were not working well together, but there was no learning because the providers were not sharing information. Among other problems, we found people’s care pathways were not always well understood by everyone involved, increasing the risk of wrong referrals and additional triage. There were also delays in people’s access to services because of a lack of collaboration and poor communication – different digital operating systems within services was a barrier.

 

Collaboration

 

Across the UEC systems, there was a pressing need for better communication and collaboration to alleviate pressures and reduce risks to patient safety. Although we found some examples of good communication and collaboration, this was generally at particular pressure points and did not take a wider overview of the patient pathway.

 

We found that systems working collaboratively across health and social care were able to manage issues more effectively than those that didn't. In addition, where we saw pathways that were streamlined and easy to understand, people were able to access more appropriate care more quickly.

 

With systems under severe pressure, better communication and collaboration can help. We saw examples of efforts to improve communication between services. In Cornwall, for example, hospital, mental health and community health trusts shared board members and a chief nurse. They also held system-wide discussions to try to address critical issues.

 

 

Putting people first

 

When we completed our reviews, we brought system leaders together in a workshop to discuss the improvements needed across UEC pathways and, importantly, to identify improvements they could implement in their organisations to improve people’s experiences of urgent and emergency care services.

 

The good practice highlighted through this workshop forms the basis for our new PEOPLE FIRST resource, focusing on systems, published in September 2022.

 

Building on our Patient First resource developed in 2020, PEOPLE FIRST provides system leaders with helpful solutions that bridge the artificial divides between primary care, secondary care, community care and social care. It aims to support everyone to design person-centred urgent and emergency care services and to drive innovation across the system.