Summary

The health and social care system is gridlocked

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.

Today, our health and care system is in gridlock and this is clearly having a huge negative impact on people’s experiences of care.

People in need of urgent care are at increased risk of harm due to long delays in ambulance response times, waiting in ambulances outside hospitals and long waiting times for triage in emergency departments.

Large numbers of people are stuck in hospital longer than they need to be, due to a lack of available social care . And people’s inability to access primary care services is exacerbating the high pressure on urgent and emergency care services.

At the heart of these problems are staff shortages and struggles to recruit and retain staff right across health and care.

One major survey shows the proportion of people satisfied with the NHS overall dropping from 53% to 36%. More people (41%) were dissatisfied with the NHS than satisfied. Another survey shows that the proportion of people who reported a good overall experience of their GP practice went down from 83% to 72%.

People are struggling to access care

The repercussions of the COVID-19 pandemic continue to be felt by individuals, families and care staff – people are still being affected by problems ranging from frustrations in accessing regular appointments to delays that stop people getting the life-saving treatment they need when they need it.

Many people are still waiting for the health and social care support and treatment they need, and many are waiting too long.

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. Over 1 in 5 people (22%) said they were currently on a waiting list for healthcare services like diagnostic tests, mental health services, consultant appointments, an operation or a therapeutic service such as physiotherapy.

More than a third (37%) on a health waiting list did not feel well supported by health and care services . Two in 5 (41%) said their ability to carry out day-to-day activities had got worse while they were waiting.

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.

In our community mental health survey 2021, only 2 in 5 respondents felt they had ‘definitely’ seen NHS mental health services enough for their needs in the last 12 months. This was the lowest score across the period from 2014 to 2021.

People are also struggling to access GP practices and NHS dental care. Worryingly, the GP Patient Survey showed that over a third of people didn’t see or speak to anyone when they couldn’t get an appointment at their GP practice, and more than 1 in 10 went to A&E. 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. At the same time, care home profit margins are at their lowest level since our Market Oversight scheme began in 2015.

Inequalities pervade and persist

Inequality continues across large parts of 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.

Health and social care providers need to do more to make their services accessible, especially to people with different communication needs.

Our survey of more than 4,000 older people who had used health and social care services in the last 6 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. We 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.

Furthermore, 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.

Wider inequalities issues include our finding that 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.

Specific concerns

In 2021/22 we continued to focus on higher risk providers and where people were most at risk of receiving poor care.

Overall, when people have been able to actually access the care they need, we have been able to reassure people that the quality of care at the point of delivery is mostly good. Health and social care staff across the country are working relentlessly to ensure people are kept safe . At 31 July 2022:

• 83% of adult social care services were rated as good or outstanding.
• 96% of GP practices were rated as good or outstanding.
• 75% of NHS acute core services were rated as good or outstanding.
• 77% of all mental health core services (NHS and independent) were rated as good or outstanding.

But we have deep concerns about some types of care. The quality of maternity care is not good enough. Action to ensure all women have access to safe, effective and truly personalised maternity care has not been sufficiently prioritised to reduce risk and help prevent tragedies from occurring. Furthermore, women from ethnic minority groups continue to be at higher risk of dying in pregnancy and childbirth than White women, and more likely to be re-admitted to hospital after giving birth.

Also, the care for people with a learning disability and autistic people is still not good enough. Despite multiple reviews and reports, people continue to face huge inequalities when accessing and receiving health and social care. Our 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.

Mental health services are struggling to meet the needs of children and young people. This increases the risk of their symptoms worsening and people reaching crisis point – and then being cared for in unsuitable environments.

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.

Depleted workforce

Across all 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. Despite their efforts, in many cases providers are losing this battle, as staff are drawn to industries with higher pay and less stressful conditions.

Sickness, vacancy and turnover rates are having a deep impact. Continuing understaffing in the NHS poses a serious risk to staff and patient safety, both for routine and emergency care; and shortages in social care are even worse than they are in the NHS. Retention of staff is just as big a challenge as recruitment, one that in many cases is crucial to maintaining relationships between staff and patients. These relationships can be lost if there is a high turnover of staff or increased use of agency or bank staff.

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. We have seen nurses moving to jobs with better pay and conditions in the NHS, and care homes that have had to stop providing nursing care.

In our workforce pressures survey, 36% of care home providers and 41% of homecare providers said that workforce challenges have had a negative impact on the service they deliver. Of the providers who reported workforce pressures having a negative impact, 87% of care home providers and 88% of homecare providers told us they were experiencing recruitment challenges. Over a quarter of care homes that reported workforce pressures told us they were actively not admitting any new residents.

Only 43% 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.

Challenges and opportunities in local systems

This year, integrated care systems (ICSs) were formally established and the role of integrated care boards set out in legislation. This will bring with it a new role for CQC to review and assess each ICS, starting next year.

We have for several years been looking at the challenges for systems, particularly around inclusivity and planning in health and care services for residents.

From our own work looking at care within the emerging and newly formed systems, and from listening to people’s experiences of care, we can point to some areas of focus for local systems as well as some tangible collaborations that are already making a difference in people’s lives. Local partnerships are starting to make a positive difference – they must be focused on outcomes for people.

Understanding the health and care needs of local people is paramount for integrated care systems, and each one faces a different challenge in meeting those needs. Good leadership will be vital for local systems as they become established during challenging times for all services. All services working in a local health and social care system should be included in planning for healthier communities.

To maintain and develop the required workforce, as well as to plan for the future, providers and systems need to be clear about demands in the longer term, including the required workforce skillsets. A strong understanding of local community needs is required to ensure the right services, including preventative health measures and plans for improving health outcomes, are delivered.