This is the 2021/22 edition of State of Care
Key points
- Health and social care providers need to do more to make their services accessible, especially to people with different communication needs.
- Our survey of people aged 65 and over who had recently used health or social care services found that older people 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, although they did use them more frequently.
- Our survey also found that disabled people were less likely than non-disabled people to describe the care and support they received for their health and wellbeing over the previous 6 months as good.
- Ethnic minority-led GP practices are more likely to care for populations with higher levels of socio-economic deprivation and poorer health – this increases the challenges they have around recruitment and funding.
- The recording and use of demographic data by services generally needs to improve, to make sure data is complete, accurate, widely shared and used to bring about improvement.
Inequality continues to pervade and persist across health and social care. It is vital that everyone, inclusively, has good quality care, and equal access, experience and outcomes from health and social care services. It is also important that we focus on the quality of care for groups of people who face barriers in getting the care they need, and those most likely to have a poorer experience or outcomes. Not getting the care and treatment people need, in a way that meets their individual needs, is a breach of the Equality Act 2010 and puts people at risk of poorer health outcomes.
Deprivation
We commissioned a survey of more than 4,000 people aged 65 and over who had used health or social care services in the previous 6 months. The findings have painted a distinct picture of inequality.
In particular, we have seen how deprivation can affect people’s health and access to health and care services.
Among those who had used services in the previous 6 months, people living in the most deprived areas were more likely to report that they had a long-term condition, disability or illness (70%), compared with the average for all survey respondents of 65%. Despite this, they tended to have used fewer health services over the last 6 months (58% had used 3 or more health services over the last 6 months, compared with 67% for those living in the least deprived areas).
Use of dentists was significantly lower for people living in the most deprived areas (43% compared with 65% of those living in the least deprived areas). This is supported by evidence from Healthwatch. In its 2020/21 annual report, ‘Championing what matters to you’, Healthwatch reported that people from lower income households were less likely to have visited an NHS dentist during the pandemic, more likely to have avoided treatment due to the cost, and less likely that they would see a dentist in the future.
The British Dental Association reported a growing backlog for child tooth extractions, as the number of treatments in NHS hospitals more than halved during the pandemic. It also reported that children from the poorest areas are 3 times more likely to have extractions than those from the most affluent communities.
Oral health is closely linked to a person’s wider health, so poor access to dentistry is only likely to exacerbate other health inequalities.
From this evidence, we can infer that people from the most deprived areas are less likely to access preventative care, or receive care at an early stage when their condition may not be as serious. This was an issue we raised in our 2020/21 Mental Health Act annual report, which highlighted that people living in the most economically deprived areas face disadvantages in accessing mental health care and support when they need it. NHS Digital statistics for 2020/21, published in October 2021, showed that the most economically deprived areas had rates of detention more than three and a half times higher than the rate of detention in the least deprived areas.
Through our survey of more than 4,000 people aged 65 and over, we have also seen how some groups of people consistently report poorer experiences of care and support than others.
Overall, people aged 65 and over who have used health and social care services in the last 6 months were positive towards the care and support they have received for their health and wellbeing, with more than three-quarters (78%) describing their care and support as good, including around half saying it has been very good.
However, experiences were less positive in more deprived areas, with 76% in the most deprived areas saying their care and support has been good, compared with 80% in the least deprived areas.
In the 2022 GP Patient Survey, there was a clear association between levels of deprivation and people’s experience of GP practices. Sixty-eight per cent of people in the most deprived areas rated their experience as good, compared with 76% of people in the least deprived areas.
Analysis by the Health Foundation in January 2022 also showed how GP services in more deprived areas of England perform less well on average on key quality measures. It highlights how, compared with more affluent areas, people in the most deprived areas face a 12-year gap in healthy life expectancy and are more likely to experience multiple health conditions – creating a greater need for GP services in deprived areas. The analysis referenced previous research (from 2020) showing that GP practices in poorer areas received about 7% less money per patient than less-deprived parts of the country, once the increased workload and health needs of patients in poorer areas were factored in.
Findings from our monitoring and assessment of ambulance services suggest that people living in the most deprived areas may be more severely impacted by ambulance delays. Anecdotal evidence from our monitoring and assessment of ambulance services suggests that, traditionally, the ambulance service has fulfilled an informal role in helping people from deprived communities to navigate the health system (for example, GPs and urgent treatment centres) and therefore access the care they need, when they need it.
In June 2022, a report from the British Medical Association highlighted the need for change. It warned that, without wholescale reform of the social care system, people living in poorer areas of the country will see their health and wellbeing worsen in the coming years.
Disability
In our survey of more than 4,000 people aged 65 and over, disabled people were less likely than non-disabled people to describe the care and support received for their health and wellbeing over the last 6 months as good (75% compared with 80%).
There appears to be a cumulative effect for some groups of people. For example, it was less common among disabled people living in the most deprived areas to rate the care and support received as very or fairly good than among disabled people living in affluent areas (72% compared with 79%).
Our survey also highlights the impact of the pandemic on people’s use of activities that contribute to their health and wellbeing, such as exercise groups, clubs or religious institutions. Across all respondents, a fifth (20%) were participating less often than before the pandemic. However, this figure was higher for disabled people (26%, compared with 16% of non-disabled people).
We asked why these people were accessing groups or activity less often. Being too unwell to engage in activities was much more frequently mentioned by disabled people (32%, compared with 8% of non-disabled people).
In the 2022 GP Patient Survey, disabled people were less likely to describe their experience of their GP practice as good: 68% did so compared with 72% of all respondents to the survey.
Ethnicity
The COVID-19 pandemic has continued to have a disproportionate impact on people from some ethnic minority ethnic backgrounds. In August 2022, the Health Foundation reported that, in the Omicron variant wave, Bangladeshi and Pakistani men and women had mortality rates between 2 and 3 times higher than White British men and women. Mortality rates for Black Caribbean men and for women of Mixed ethnicity were also higher than for White British men and women respectively.
A recent review into Ethnic Inequalities in Healthcare by the NHS Race and Health Observatory, published in February 2022, highlighted ongoing ethnic inequalities across a number of areas of focus including mental health care, maternal and neonatal health care, and the NHS workforce. (We also discuss inequalities for women from ethnic minority groups in relation to maternity care in section 4 of this report.)
In our provider collaboration review on the mental health care of children and young people during the COVID-19 pandemic, we found a lack of long-term and cohesive strategic planning focusing on young people from ethnic minority groups.
NHS Digital data for the number of people detained under the Mental Health Act (MHA) in 2020/21 showed that rates of detention for people from the Black or Black British group were over 4 times those of people from the White group. The rates of use for community treatment orders for people from the Black or Black British group were over 10 times the rate for people from the White group. We will discuss this in detail in our report on the monitoring of the MHA to be published later in 2022.
Our survey of more than 4,000 people aged 65 and over who had used health or social care services recently shows that older people from ethnic minority backgrounds tend to use services less frequently (68% said they use them about once every 2 to 3 months or once in the last 6 months, compared with 58% of people from White British backgrounds).
In 2021/22, we carried out a programme of research to look at the impact and experiences of regulation on ethnic minority-led GP practices. Notably, we found that ethnic minority-led practices are more likely to serve populations with higher levels of socio-economic deprivation and poorer health. This can affect the ability of a GP practice to achieve some national targets, and increase challenges around recruitment and funding.
Ethnic minority-led practices were more likely to report they were single-handed – meaning they are operated by just one GP without other partners to offer support. This can present challenges around resourcing and capacity. GPs from ethnic minority backgrounds who participated in our research also cited a lack of leadership support from external bodies.
We commented how, as the first port of call and foundation of most people’s health care, a huge expectation is placed on every practice team. However, we found that ethnic minority-led GP practices are often not operating on a level playing field in terms of where they work, and the support available to them.
Healthwatch reported in May 2021 that people from ethnic minority groups said they were less likely to be registered with an NHS dentist and more likely to struggle to access one when they needed to.
Accessible health and social care
Getting care in the first place, and then experiencing the care itself isn’t as easy for some people as others. In 2021/22, we carried out a review of the experiences of people with a learning disability and autistic people when in hospital. A full report of our review will be published in the autumn. Emerging findings suggest that some people don’t get the reasonable adjustments that they regularly need, for example access to interpreters for different languages.
A February 2022 report from Healthwatch found that many NHS services are not supporting equal access to care for Deaf and Deafblind people. In particular, it noted that people had to rely on family and friends when they were not given communication support. This made them feel less independent and forced them to share sensitive health information with family members rather than a healthcare professional.
We have also heard about a lack of reasonable adjustments for Deaf people when accessing primary care and emergency services.
Harriet’s experiences of care
Harriet and her sister Jemima told us about the challenges that Harriet faces as a Deaf person trying to access health and care services. They also described Harriet's experiences as a Deaf mum to her hearing daughter, Jessie, who is 8 years old.
Harriet has faced ongoing problems with booking interpreters for GP appointments. She described having to wait weeks for an appointment with an interpreter, even in an emergency. As a result, most of the time Harriet doesn’t have access to an interpreter and relies on communicating with her GP in writing in English. She described how this increases the risk of misinterpretation. Harriet described how British Sign Language (BSL) is a visual language so sometimes she can’t read written letters as she doesn’t know what some words mean.
While Harriet was able to get face-to-face appointments during the pandemic, she still faced issues in booking an interpreter. This situation was made worse because of the use of face masks. Harriet described how not having easy access to an interpreter affects many of her Deaf friends, as it puts them off from going to the GP at all.
Without access to interpreters, Harriet and Jemima told us that healthcare professionals often assume that Jemima will be able to interpret for them. However, Jemima told us, “I’m not a professional, qualified BSL interpreter. What if they give her the wrong tablet and it’s my fault?”.
She also worries about what will happen if she is not there to help.
Lack of access to interpreters has been a particular challenge for Harriet when accessing services for her daughter Jessie. In one instance, Jemima told us that Jessie had fallen unconscious and she had to call for an ambulance. When the ambulance arrived, the paramedics told Jemima that they did not have access to a BSL interpreter. As a result, the paramedics spoke to Jemima, not Harriet as Jessie’s mum. Not only was this extremely upsetting for Harriet, but could be a confidentiality issue.
Interview with a member of the public
Providing accessible information and ways to communicate are legal requirements for health and care providers. In July 2022, Healthwatch published the findings from its Accessible Information Survey. This survey looked at 605 people’s experiences of receiving accessible healthcare communication. Healthwatch found that 28% of respondents said they had been refused help when asking for support to understand information about their health care.
Respondents also reported that the quality of communication from NHS and social care services had worsened over the last 2 years. Two-thirds (67%) felt that the way health and care services communicate with them had got worse or slightly worse over the course of the pandemic. Over a third (38%) said not having accessible information affected their mental health and wellbeing.
People need to be able to use health and care services in different ways that suit their own needs. In our survey of more than 4,000 people aged 65 and over who had used health or social care services recently, we asked about specific aspects of access to health and care services. Around two-thirds of respondents (65%) told us they were satisfied with being able to access services when they need them, with a quarter (24%) dissatisfied. People felt the same way about being able to access services in a way that suits them, with 66% satisfied and 23% dissatisfied.
However, this was not everyone’s experience. Satisfaction with being able to access services when needed was lower among disabled people (61% satisfied compared with 68% for non-disabled people). Similarly, 60% of disabled people were satisfied with being able to access services in a way that suits them, compared with 70% of non-disabled people, and the same with the process of making appointments (48% compared with 58%).
As with other issues, positive experiences were less common among people living in deprived areas. Those living in the most deprived areas were less likely to be satisfied with being able to access services when they need them (61%, compared with 69% in the least deprived areas), and being able to access services in a way that suits them (63% compared with 68%).
Satisfaction was generally lower than average among Asian and Asian British people (noting the small base size of 40 who took part in our survey):
- 45% of these respondents were satisfied with their ability to access services when they need them.
- 47% were satisfied with their ability to access services in a way that suits them.
- 36% were satisfied with the process of making appointments.
These figures compared with 65%, 66% and 55% among White British people respectively.
The importance of data
We know that robust and reliable information is a fundamental tool in identifying, tackling and improving health inequality. Through our provider collaboration review on children and young people’s mental health, we found a number of local health and care systems were using data proactively to identify and support children and young people with mental health needs who may face inequalities. In one area, we heard how system leaders then used this information to target their communication to areas where children and young people were potentially being missed.
Another area we visited as part of our review told us how their analysis of data had shown that large proportions of children and young people from ethnic minority groups were missing appointments or not attending school during the pandemic. In response, they worked with community safety partnerships, schools and youth hostels to share information, targeting areas of high diversity and deprivation.
However, many of our publications over the last year have highlighted that, in many cases, the current recording of demographic data, for example on ethnicity and disability, is still not good enough.
For example, in our September 2021 report ‘Safety, equity and engagement in maternity services’, we highlighted the importance of collecting and reviewing data and called for services and systems to use the ethnicity data they collect to review safety outcomes for women from ethnic minority groups.
In January 2022, our Insight publication shone a light on substantial concerns about the quality of data in many mental health datasets. This makes it more difficult for organisations to analyse and use data to address potential inequalities and check that services are meeting the needs of individual people.
Most recently, early findings from our review on the experiences of people with a learning disability and autistic people in hospital have raised concerns around recording and flagging people’s communication needs on electronic records. Not having access to information or sharing it with all staff can have a significant impact on people. Better recording of people's communication needs would also help to improve a provider’s compliance with the Accessible Information Standard, especially when people are moving between services.
This is supported by the NHS Race and Observatory report Ethnic Inequalities in Healthcare, which recommended that work is needed to ensure recording of ethnicity is complete and accurate. It also highlighted the need to develop systems for routine data collection, particularly experiences of racism and discrimination.
Similarly, in April 2022, findings from NHS Providers’ race and health equality survey showed that nearly half of the trust leaders who responded (254 people in total) were concerned about the lack of access to data about health inequalities within trusts (49%) and across the health system (48%).
The report highlighted that, despite these challenges, tackling inequalities is high on the list of providers’ priorities. It described “high board-level commitment and strategic emphasis on tackling health inequalities”, and a commitment to making action on health inequalities core business.
But it is not just about addressing inequality at the point of delivery. Leaders on the new integrated care boards (ICBs) have a key role in ensuring they take a systematic approach to addressing inequalities across the areas they manage.
As outlined in our strategy, we’ll be continuing to check that the care provided in a local system is improving outcomes for people and reducing inequalities in their care. This includes looking at how services are working together within an integrated system, as well as how systems are performing as a whole.
