This year’s State of Care shows that most people are still getting good care – when they can access it.
The Care Quality Commission’s (CQC) annual assessment of the quality of health and social care in England shows that overall, quality has been largely maintained, and in some cases improved, from last year. This is despite continuing challenges around demand and funding, coupled with significant workforce pressures as all sectors struggle to recruit and retain staff. The efforts of staff, leaders and carers to ensure that people continue to receive good, safe care despite these challenges must be recognised and applauded.
However, it is clear that people’s experience of care varies depending on where they live; and that these experiences are often determined by how well different parts of local systems work together. Some people can easily access good care, while others cannot access the services they need, experience ‘disjointed’ care, or only have access to providers with poor services.
CQC’s reviews of local health and care systems found that ineffective collaboration between local health and care services can result in people not being able to access the care and support services in the community that would avoid unnecessary admissions to hospital, which in turn leads to increased demand for acute services.
The most visible impact of this is the pressure on emergency departments as demand continues to rise, with July 2018 seeing the highest number of attendances on record. Emergency departments are the core hospital service most likely to be rated requires improvement (41%) or inadequate (7%). A struggling local hospital can be symptomatic of a struggling local health care system. This indicates that – although good and outstanding primary care is more evenly distributed – there are parts of the country where people are less likely to get good care.
And there is a less immediately visible impact when health and care services do not work well together – on people, like those who use mental health services, who may already have more difficulty accessing support or to have to travel unreasonable distances to get it. For example, inappropriate out of area mental health placements – with some people being placed hundreds of miles from their homes – vary considerably by region. And CQC’s review of children and young people’s mental health services found that some children and young people were ‘at crisis point’ before they got the specialist care and support they needed, with average waiting times varying significantly according to local processes, systems and targets.
Posing a threat to effective collaboration between health and social care is the continued fragility of the adult social care market, with providers closing or ceasing to trade and contracts being handed back to local authorities. Unmet need continues to rise, with Age UK estimating that 1.4 million older people do not have access to the care and support they need. In two years, the number of older people living with an unmet care need has risen by almost 20%, to nearly one in seven older people. While the government made a welcome NHS funding announcement in June 2018, the impact of this, and last week’s short term crisis funding for adult social care, risks being undermined by the lack of a long-term funding solution for social care.
Ian Trenholm, Chief Executive of the Care Quality Commission, said:
“This year’s State of Care highlights both the resilience and the potential vulnerability of a health and care system where most people receive good care, but where access to this care increasingly depends on where in the country you live and how well your local health system works together. This is not so much a ‘postcode lottery’ as an ‘integration lottery’.
“We’ve seen some examples of providers working together to give people joined-up care based on their individual needs. But until this happens everywhere, individual providers will increasingly struggle to cope with demand – with quality suffering as a result.
“There need to be incentives that bring local health and care leaders together, rather than drive them apart. That might mean changes to funding that allow health and social care services to pool resources; for example, to invest in technology that improves quality of care. Like the digital monitoring devices for patients’ clinical observations that have saved thousands of nursing hours, the e-prescribing in oncology that’s helping people directly, and the electronic immediate discharge summaries that have improved patient safety.
“The challenge for Parliament, national and local leaders and providers is to change the way services are funded, the way they work together and how and where people are cared for and supported. The alternative is a future in which care injustice will increase and where some people will be failed by the services that are meant to support them, with their health and quality of life suffering as result.”
Peter Wyman, Chair of the Care Quality Commission said:
“The fact that quality has been broadly maintained in the face of enormous challenges on demand, funding and workforce is a huge testament to staff and leaders.
“But we cannot ignore the fact that not everyone is getting good care. Safety remains a real concern: although there have been some small improvements 40% of NHS acute hospitals’ core services and 37% of NHS mental health trusts’ core services were rated as requires improvement on safety. All providers are facing similar challenges – in acute hospitals, the pressure on emergency departments is especially visible – but while many are responding in a way that maintains quality of care, some are not.
“Our other big concern is the fragility of the adult social care market. Two years ago, we warned that social care was ‘approaching a tipping point’ – as unmet need continues to rise, this tipping point has already been reached for some people who are not getting the good quality care they need. It is increasingly clear without a long-term funding settlement for adult social care, the additional funding for the NHS will be spent treating people with complex conditions for whom care in the community would have been more effective both in terms of their health and wellbeing and use of public money.”
This year’s State of Care draws on quantitative analysis of inspection ratings of almost 30,000 services and providers, in addition to other monitoring information including staff and public surveys, and performance. It also draws on qualitative analysis of interviews with people who use services, Experts by Experience and CQC inspection staff.
Responding to the Care Quality Commission’s State of Care report, Cllr Ian Hudspeth, Chairman of the LGA’s Community Wellbeing Board, said:
“This report raises important concerns and highlights the brilliant work across the system to maintain quality of care, something that becomes harder each year as the consequences of pressures build further. It also provides yet more evidence of a system under significant pressure and in desperate need of securing a more long-term and sustainable solution for how, as a country, we pay for social care.
“Councils across the country are working closely with their counterparts in health for the benefit of people requiring services, however with people living longer, increases in costs and decreases in funding, adult social care is at breaking point and its potential for helping people to live the lives they want to lead is at risk.
“Over recent years, councils have protected adult social care relative to other services. But the scale of the overall funding picture for local government as a whole means adult social care services still face a £3.5 billion funding gap by 2025, just to maintain existing standards of care. The likely consequences of this are more and more people being unable to get quality and reliable care and support, which enable them to live more fulfilling lives.
“Action is needed, which is why, following government’s decision to delay its green paper on adult social care, the LGA published its own green paper consultation to drive forward the public debate on what sort of care and support we need to improve people’s wellbeing and independence, the need to focus on prevention work, and, crucially, how we fund these vital services.
“The Government must use the Budget and Spending Review to inject desperately needed funding into adult social care and use the green paper to secure the long-term sustainability of the system.”
Call for urgent action to end ‘fragility’ of social care system
Care providers are calling for urgent action to end the ‘fragility’ of the social care system which has seen a 20% increase in the number of people living without the care they need.
The Independent Care Group has called on the Government to bring forward its Green Paper on future funding of social care so that more older and vulnerable adults can get care.
Responding to today’s publication of the Care Quality Commission’s State of Care report, the Group’s Chair, Mike Padgham, said: “The talking has gone on long enough, it is time for some meaningful action to address the crisis in social care.
“Today we have the Government’s own inspection body, the Care Quality Commission, talking about the fragility of the adult social care market and warning that unless a funding solution is found, money being pumped into the NHS will be spent treating people with complex conditions who should have been picked up by social care earlier.
“We need an end to the situation where the care you get depends on where you live and action taken to stem the rising number of people who just aren’t getting care at all.
“The harsh reality is that social care has reached – and in many cases – gone beyond tipping point. 1.4m people are living without the care they need, that’s a 20% rise in two years, to one in seven.”
Mr Padgham said the fact that social care providers were managing to maintain standards was down to their ‘superhuman efforts’.
“It is amazing that where you can get access to care, that care is remaining good quality. That is down to the incredible commitment of those delivering care,” he added. “But that is not sustainable and it hides the fact that in many areas you cannot get access to care at all because funding for social care has fallen by £7bn in the past eight years. The CQC itself highlights social care providers closing, ceasing to trade or handing back contracts. Enough is enough, something has to be done and done quickly.”
Major report into state of national care and health services must drive further improvement
Today’s influential report into England’s care and health services reflects the high quality of provision, but also underlines the urgent need to sustain and protect the embattled social care sector. VODG (the Voluntary Organisations Disability Group), the national body representing leading not-for-profit disability support providers, welcomes the comprehensive picture as well as the warnings about future services in State of Care, the annual analysis from regulator Care Quality Commission (CQC).
VODG has long highlighted the precarious financial state of the social care sector and the growing demands placed on it, most recently in its report Stitch in Time. VODG’s report warns that successive governments’ failure to properly fund social care leaves millions at risk of losing essential support and may negatively impact on the NHS due to increased demand for emergency care. CQC have now explicitly recognised that a tipping point has been reached as some people do not receive the care they need.
VODG believes that the CQC’s annual focus on care and health should extend further to include full independent performance assessments of local health and social care commissioning. This is crucial in cases where councils are in financial difficulties, so inspection can ensure that statutory social care duties are fully met.
VODG also hopes that today’s authoritative analysis will encourage the government to expedite the publication of the long-awaited green paper, which needs to set out government’s vision and funding for disability and older people’s services alike.
VODG chief executive Dr Rhidian Hughes said:
“We welcome CQC’s continued spotlight onto quality issues in the sector and its unique perspective which gives us a broad view across health and social care. The review of how local systems are working, and must join up, is especially welcome, as are CQC’s clear statements about the consequences of underfunding in social care. It is deeply concerning that a tipping point in the sector has been reached and that some people are not having their care needs met.
Social care is suffering from decades of underfunding at the same time as demand for such provision is increasing. Today’s evidence adds to warnings from across the sector and government must now act swiftly to invest in and protect vital services.”
Professor Martin Green OBE, Chief Executive of Care England commented:
“CQC’s report makes it clear that there is no room for complacency. It recognises that tipping point has been reached for some people who are not getting the care that they need; however the fortunes for next year are ominous”.
Care England’s analysis has identified that over a third of councils (56 in total) will lose access to £739 million ring fenced funding for adult social care due to exhausting their social care precept flexibility and the ending of the adult social care support grant. This comes at a time of great uncertainty and perpetrates the post code lottery being experienced by vulnerable people across the country. CQC’s report can be found at https://www.cqc.org.uk/publications/major-report/state-care
Martin Green continued;
“If health and social care really are hand in glove as the Government purports it is important to offer the same opportunities in terms of recruitment, retention and training to all staff whether in health or social care. Otherwise we are in danger of an integration lottery and this is all the more concerning with the perpetual winter pressures impacting on the acute services and beyond”.
Emily Holzhausen OBE, Carers UK Director of Policy and Public Affairs said:
“A rising tide of demand for acute services is being fuelled by the lack of consistent accessible community health and care services. Today’s report shows many areas are struggling with the challenge of delivering good quality and joined up care in this environment.
The experience of families is that it can be a battle to get the right support through their GP, from a care worker or from a district nurse. Many feel forced to turn to acute accident and emergency services because of a lack of alternatives in the community.
The growing funding gap for social care services, the pressure on acute hospitals to discharge patients back into the community and the disjointed approach of health and care services evidenced in this report all add up to family and friends picking up more intensive and complicated caring roles at home. This increasing reliance on unpaid care to pick up the pieces of a fragmented and inconsistent system is not sustainable.
We urge the Chancellor to use the forthcoming budget to invest in care now to close the £2billion funding gap expected by 2020 and to put social care on a sustainable footing for the future. Without this the impact will continue to be felt by families already seeing a strain on their own health, careers and relationships from caring without access to breaks and support.”
The annual State of Care report, which found that the quality of health and social care in England has been largely maintained over the past year – but that people’s experience of care varies depending on where they live and how well different parts of local systems work together.
The report shows that some people can easily access good care while others experience ‘disjointed’ care, only have access to poor quality services or cannot get the help they need at all. A clear impact of this is pressure on emergency departments, with demand continuing to rise when local health and care systems fail to protect vulnerable people. The CQC warns that recently announced funding injections for the NHS and adult social care risk being undermined by the lack of a long-term solution.
Jeremy Hughes, Chief Executive at Alzheimer’s Society, commented: “People with dementia are the biggest users of adult social care and yet they experience poorer quality care than everyone else, with more than a fifth of dementia care providers failing CQC inspections – a higher proportion than care providers generally.[i] Families call our Helpline in despair because a loved one with dementia needs support but there is nothing available locally or the only care home they can get into is inadequate.
“In 2016 the CQC warned social care was at a tipping point, and this adds to our evidence that the system has clearly passed that point now, leaving 850,000 people with dementia at the mercy of a potentially unsafe system and putting yet more pressure on the NHS. People with dementia have a right to care, and their postcode should not affect that.”
Neil Tester, Deputy Director of Healthwatch England said:
“We know from our conversations with the public that people recognise the challenges health and social care services are facing.
“Today’s report offers some reassurance that, despite the pressures, our country’s hospitals, GP surgeries and social care services are usually coping and providing good quality care. However, we must also acknowledge that some people are struggling to get the help they need.
“As the CQC found earlier in the year in its local system reviews, the best and most efficient care happens when the NHS and councils work together with people and their families to provide joined-up support. The best way of assessing this is to track people’s experiences of the support they receive, underpinned by payment mechanisms and regulation that incentivise care designed around people’s needs rather than systems.
Responding specifically on the concerns raised about social care:
“The regional variation in quality of care highlighted by the CQC is being made worse by the lack of proper advice and information out there to help people understand and plan for potential care needs. So even where services are outstanding the process of accessing help can still be incredibly distressing for people and their loved ones.
“Councils are facing growing demand for social care services, and are struggling to cope. By developing better information and advice services they can help people plan earlier and therefore reduce the urgent, ‘crisis point’ needs they currently have to deal with.
“Helping people to prepare for something that may not happen, but will have a huge impact on quality of life if it does, is the very real and very human challenge that the Government’s forthcoming proposals for the social care sector will need to address.
“Politicians and policy makers need to hear CQC’s words today and address the capacity issues in social care, but this alone will not create an environment that enables people to get the best out of life. We need to build a system that encourages earlier planning, starting with the lowest level of need and creating a culture where accessing care and support becomes a normal part of the ageing process.”