Elderly and vulnerable people are having difficulty accessing high-quality care as local authorities slash funding and raise the eligibility criteria and social care and care home operator fees increasing, the strain is now palpable.
Today’s CQC annual report State of Care confirms to many organisations involved in care that entire care sector including the NHS is teetering on the edge of an abyss.
Most health and adult social care services in England are providing people with safe, high quality and compassionate care – but with pressures rising on demand, access and cost, the quality regulator is raising concerns about how long this can last.
In its annual assessment of the quality of health and adult social care in England, the Care Quality Commission (CQC) has found that despite challenging circumstances, as at 31 July 2016:
· 71% of the adult social care (ASC) services that CQC had inspected were rated ‘good’ and 1% were ‘outstanding’;
· 83% of the GP practices inspected were ‘good’ and 4% were ‘outstanding’; and
· 51% of the core services provided by NHS acute hospital trusts were ‘good’ and 5% were ‘outstanding’.
However, some people still received very poor care; 2% of adult social care services, 3% of GP practices and 5% of hospital core services were rated ‘inadequate’.
Around three-quarters (76%) of NHS services, care homes, general practices and other services that had been rated as ‘inadequate’ by CQC were able to improve their ratings following re-inspection. 23% went from ‘inadequate’ to ‘good’ and 53% went from ‘inadequate’ to ‘requires improvement’.
While this shows that regulation can support providers to offer people better care, CQC’s analysis also reveals that some services are failing to improve despite being given clear information on where improvement is needed.
47% of providers that were re-inspected following a rating of ‘requires improvement’ were not able to improve their rating. Most worryingly, in 8% of cases, the quality of care had deteriorated so much that the rating was downgraded to ‘inadequate’.
CQC has raised concerns that the sustainability of the adult social care market is approaching a tipping point. This view is based on the evidence of inspections, information received through CQC’s market oversight function, and a variety of external data.
· Although three quarters of ASC services that were initially rated ‘inadequate’ improved following re-inspection, nearly a quarter of re-inspected services were not able to improve their ratings. Half of services rated as ‘requires improvement’ that were re-inspected (904 out of 1,850) had no change to their rating. In 153 cases we found that the care had become inadequate.
· CQC data shows that a five-year period of steady increase in the number of nursing home beds – going from 205,000 beds in 2009 to 224,000 beds in March 2015 – has now stalled, with numbers remaining static since that time.
· Already CQC has seen examples of providers starting to hand back contracts as being undeliverable; local authorities warn of more to come. This is due to pressures on fees that funders of care are able or willing to pay, and cost pressures that include the impact of the national living wage (introduced in April 2016).
· In 2015, Age UK estimated that more than a million older people in England were living with unmet social care needs (such as not receiving assistance with bathing and dressing); a rise from 800,000 in 2010.
· The number of older people receiving local authority-funded social care fell 26% from more than 1.1 million in 2009 to around 850,000 in 2013/14. Also, 81% of local authorities have reduced their real-term spending on social care for older people over the last five years.
The fragility of the adult social care market is now beginning to impact both on the people who rely on these services and on the performance of NHS care. The combination of a growing and ageing population, more people with long-term conditions, and a challenging economic climate means greater demand on services and more problems for people in accessing care.
This is translating to increased A&E attendances, emergency admissions and delays to people leaving hospital, which in turn is affecting the ability of a growing number of trusts to meet their performance and financial targets.
Despite the well-documented financial challenges that the NHS faces, CQC found much good and outstanding care – particularly in children’s and young people’s services and critical care. CQC has awarded ‘outstanding’ ratings to five acute NHS trusts and two mental health NHS trusts. Also, five NHS trusts have exited special measures since April 2015.
However, CQC has also found too much acute care that has been ‘inadequate’ – particularly urgent and emergency services and medical services. It will be increasingly difficult for NHS trusts to make improvements to these services unless they are able to work more closely with adequately funded adult social care and primary care providers.
David Behan, chief executive of the Care Quality Commission, said: “The good news is that, despite challenging circumstances, most people are still getting high quality care and there are encouraging levels of improvement taking place. This is something to celebrate. However, there continues to be wide variation in quality, some providers are struggling to improve and there is emerging evidence of deterioration in quality.
“We are becoming concerned about the fragility of the adult social care market, with evidence suggesting that it might be approaching a ‘tipping point’. The combination of a growing, ageing population, more people with long-term conditions and a challenging financial climate means increased need but reduced access. The result is that some people are not getting the help they need – which in turn creates problems in other parts of the health and care system, such as overstretched A&E departments or delays in people leaving hospital.
“While there are no easy answers or quick fixes, what distinguishes many of the good and outstanding services is the way they work with others – hospitals working with GPs; GPs working with social care and all providers working with people who use services. Unless the health and social care system finds a better way to work together, I have no doubt that next year there will be more people whose needs aren’t meet, less improvement and more deterioration.”
Peter Wyman, Chair of the Care Quality Commission, said: “We know that tough financial conditions are having an impact on providers. But the focus on the financial problems of the NHS has to some extent masked other issues – reduced access to adult social care and vacancies in primary medical services have led to increased demand in secondary care, which is often not in the best interests of people while generally being considerably more costly.
“Our evidence suggests that finance and quality are not necessarily opposing demands; many providers are continuing to deliver good quality care within the resources available by beginning to transform the way they work through collaboration with other services and sectors. Leaders now need to think outside traditional organisational boundaries – no amount of money will be able to support the system if this doesn’t happen.
“We will continue to highlight good and outstanding care, support improvement and take action to protect people where necessary. And we’ll use the uniquely detailed information we hold on quality to help those that lead, work in and use health and care services to make the right decisions. All of us all want the same thing – good, safe care that’s sustainable into the future”
The annual State of Care report, out today provides the most comprehensive view yet of CQC’s inspection findings from its new regulatory approach, which it rolled out two years ago. This involves expert-led inspections, which in most cases then lead to ratings of ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’ to help people make informed choices about their care.
The report finds that the quality of care received in NHS mental health trusts is broadly similar to that in acute trusts, but with an even higher level of variability within providers as well as between them – community services are more likely to be rated ‘good’ and ‘outstanding’ than inpatient services, such as wards for working age adults and psychiatric intensive care units. In particular, CQC has concerns about the safety of acute mental health services. Problems with physical environments frequently contributed to ratings of ‘requires improvement’ or ‘inadequate’ for inpatient services.
The quality of care provided by primary medical services (PMS) remains high. Despite a context of increased demand, coupled with a shortage of GPs and increasing vacancy levels, 83% of the GP practices CQC has rated so far are ‘good’ and 4% are ‘outstanding’.
The challenge for PMS, as for the rest of the system, is to consider what responses to increasingly difficult conditions will maintain quality, now and in the future. There has been more evidence of collaboration in primary care, while general practices have formed new models of care, including joining together in federations, involving people who use their services in their conversations from an early stage.
Responding to this, Jeremy Hughes, Chief Executive of Alzheimer’s Society, said: “This is the second warning in less than a month that social care is in dire straits. The CQC highlights a system unable to sustain itself, consequently failing many of the people with dementia it serves. Each successive report echoes what we hear from people with dementia and their families – from the devoted husband who must choose between having a hot meal and paying his wife’s care home top-up fees, to the 94-year old grandmother in hospital with infections due to poor personal care.
“With the NHS rising to the top of voters’ priorities, the knock-on effect from an underfunded social care system is clear. The NHS and social care go hand-in-hand – we cannot fix one if the other remains broken. Social care urgently needs a solid financial grounding before this entire house of cards falls.”
Professor Martin Green OBE, Chief Executive of Care England said:
‘I am proud to say that CQC’s State of Care report shows that, at a time of unprecedented financial constraints and rising need for care, 71% of the adult social care services inspected were rated ‘good’. This is a testament to the enormous amounts of hard work in the sector, leadership in care homes and services across the country, and the sector’s efforts to improve and learn. 1% of adult social care services were rated ‘outstanding’: Care England’s Outstanding Society brings together outstanding services in a forum to share best practice and spread this across the whole sector, helping good services to strive to provide even better care.’
‘Despite the excellent work of social care workers and managers, underfunding is damaging the sector. The current funding settlement entirely disregards demographic change, the pressure on the market, and the impact on people receiving care. As CQC highlights, more and more people are living with unmet needs for care, and more providers are pulling out of unaffordable caring activities like nursing. CQC’s emphasis on providers turning down contracts reflects the impossible market for care: Care England members are still being asked to care for adults with complex needs for as little as £2.25 per hour. This undoubtedly affects the NHS, where delayed discharge figures will not improve while social care remains starved.
The fragility of the market cannot be overstated: as this week’s media coverage has also shown, providers are being put in a perilous position by a lack of political will to meet the funding needs of social care. The CQC is a trusted voice, and is right to use its role to highlight sector difficulties: now the government must take heed and action to reverse a trend of gradual but definite erosion of this sector, a lifeline for many vulnerable people.’
Caroline Abrahams, Charity Director for Age UK, said:
“When any regulator says that it is worried that a service may be reaching a tipping point in terms of quality and sustainability – and when the trend is constantly downhill – it is clearly time for very serious concern.
“Everything we hear from older people and their families and from our local Age UKs reinforces the CQC’s view: because of lack of money and the drip drip closure of care providers it is becoming ever harder to find good, affordable care – in your own home or in a care home.
“The inherent vulnerability of older people who need social care makes it one of our most important public services and while the Government has tried to prop up the system through measures like the Better Care Fund and the social care precept it is obvious that these do not go far enough. Next month’s Autumn Statement is an opportunity for the Government to give social care the priority it deserves in terms of public spending and this report shows how important it is that the Government acts. Otherwise ‘a tipping point’ threatens to become something infinitely worse, placing many older people at risk of harm.”
Margaret Willcox, Vice-President of the Association of Directors of Adult Social Services, said:
“Our budget survey earlier this year found that more than 4 in 5 adult social services directors reported providers facing challenges to deliver high quality care, which is already being reflected in CQC ratings, with nearly a quarter of services assessed as “requiring improvement”. Additionally, more than three quarters of councils experienced some kind of social care provider failure last year, with care homes closing and home care providers handing back contracts despite 82 per cent of councils increasing fees to providers. As the full impact of the introduction of the welcome National Living Wage is felt and demand continues to rise as the population ages and people develop increasingly complex needs, we will only see more services put at risk.
“We have been arguing for some time now that adult social care needs to be given adequate recognition and resourcing. Services are being cut and the outlook for future care is bleak. We are at a tipping point where social care is in jeopardy and unless the Government addresses the underfunding of the sector, there will be worrying consequences for the care market, the NHS and, most importantly, for older and disabled people, their families and carers.
“In our submission ahead of the Autumn Statement we have called on the Government to be a power for good and support older and disabled people and their carers by addressing the current shortfall in funding, as well as the longer term financial issues. We are also asking them to work with us to improve recruitment and retention in social care to make sure that we have the right people available, in the right places, to give people the care and support they need.”
Mike Padgham of Independent Care Group (York and North Yorkshire) said: “We have been arguing for years that social care across the country is in crisis. Generations of under-funding, exacerbated by the economic downturn have left the care of our oldest and most vulnerable citizens in tatters.
“Millions of pounds have been cut from social care by cash-strapped local authorities in recent years and it is inevitable that standards are going to fall and providers leave the sector.
”These statistics from the inspection body make grim reading, but unless we can bring reform to social care, the situation is going to get worse.”
Figures reported in the media suggest that more than half of health and social care providers rated “inadequate” or “in need of improvement” at a CQC inspection either stayed the same or got worse when they were inspected again.
“Everyone takes a share of the blame for what is going wrong – Government, local authorities, providers and the public and we have to work together to resolve it,” Mr Padgham added.
“We have to get round the table and look at how we provide better care for people. If that means merging NHS and social care and if that means we have to look at raising more through taxes or National Insurance, then so be it – people are suffering and this cannot be allowed to go on.”
Earlier this year the Independent Care Group warned that the impact of the National Living Wage had contributed to grave fears about the future amongst its membership. Asked about the future, two per cent of those surveyed by the ICG feared they would close within a year, five per cent within two years and 10 per cent within three years.
Head of Voluntary Organisations Disability Group Professor Rhidian Hughes said:
“Great social care enables people to live the life they choose. But providers cannot deliver high quality care at any cost. Unless we balance disabled people’s needs with sufficient funding we jeopardise day-to-day support and quality of life for 11.9m people in this country. It is imperative that Government uses the Autumn Statement to put things right for social care.”