“The health and care system is gridlocked and unable to operate effectively. This means that people are stuck - stuck in hospital because there isn’t the social care support in place for them to leave, stuck in emergency departments waiting for a hospital bed to get the treatment they need, and stuck waiting for ambulances that don’t arrive because those same ambulances are stuck outside hospitals waiting to transfer patients.” Those are the words of Ian Trenholm, Chief Executive of the Care Quality Commission (CQC), commenting on the finding’s of the annual assessment of the state of health and social care in England.
This year - based on CQC’s inspection activity, information received from the public and those who deliver care alongside other evidence - the assessment is that the health and care system is gridlocked and unable to operate effectively.
Most people are still receiving good care when they can access it. Rated as good or outstanding at July 31, 2022:
• 75% of NHS acute core services
• 77% of all mental health core services (NHS and independent
• 83% of adult social care services
• 96% of GP practices.
However, too often people are not able to access the care they need. Capacity in adult social care has reduced and unmet need has increased. Only two in five patients are able to leave hospital when they are ready to do so, contributing to record-breaking waits in emergency departments following a decision to admit, and dangerous ambulance handover delays.
As part of this work, that included a series of coordinated inspections across the urgent and emergency care pathway in 10 Integrated Care Systems (ICSs), CQC convened a group of 250 health and care leaders. They described the system they work in as “in crisis” and shared their fears that the risk of people coming to harm represents a worrying new status quo.
Impact on staff recruitment & retention
Health and care staff want to provide good, safe care but are struggling to do so in a gridlocked system. This is reflected in growing public dissatisfaction with health and care services - which is mirrored in staff dissatisfaction. More staff than ever before are leaving health and social care and providers are finding it increasingly challenging to recruit, resulting in alarmingly high vacancy rates which have a direct impact on patient care.
Without action now, staff retention will continue to decline across health and care, increasing pressure across the system and leading to worse outcomes for people. Services will be further stretched, and people will be at greater risk of harm as staff try to deal with the consequences of a lack of access to community services, including adult social care. This will be especially visible in areas of higher economic deprivation where access to care outside hospitals is most under pressure. In addition to the increased risk of harm to patients, more people will be forced out of the labour market either through ill health or because they are supporting family members who need care*.
Historical underinvestment
Many of the challenges services are now facing are linked to historical underinvestment and lack of sustained recognition and reward for the social care workforce. The crucial role of social care is increasingly being recognised by healthcare leaders - with some taking action to jointly invest in and commission social care services with partners in local government in recognition of the benefits for their whole local system. While there is no silver bullet, joining up these pockets of local innovation has the potential to help to ease the gridlock and improve outcomes for people.
Long-term, system approach
Solutions to the problems that affect people’s care can only come from long-term planning and investment, with local areas taking a whole system view that recognises the relationship between health and social care and addresses the root causes behind the immediate and obvious problems. To understand what is driving performance, local leaders need to bring together data and information from providers and other local stakeholders and agree success measures that are focused on patients’ overall experience of care, not limited to organisation or sector.
Better quality data and increased data sharing are critical, not only to planning for people’s care needs but to understanding and tackling inequalities in the patient’s experience of and access to care. CQC’s work across local areas has highlighted that the current recording of demographic data, especially on ethnicity and disability, is not good enough.
Workforce shortages across all sectors need to be addressed through innovative initiatives that look to the future. The focus should be on shaping more flexible workforce models that help local systems meet the needs of people - all people - who are in turn empowered to take a more active role in their own wellbeing. In adult social care, where workforce shortages are particularly acute, there needs to be increased funding and support for ICSs so they can own and deliver a properly funded workforce plan that recognises the adult social care workforce crisis as a national issue and ensures that pay and rewards attract and retain staff.
Problem areas
In this year’s report, CQC also highlights its concerns about specific service areas, in particular maternity services and those that care for people with a learning disability and autistic people – areas where inspections continue to find issues with culture, leadership, and a lack of genuine engagement with people who use services. In response to the national challenges faced by maternity services, CQC has begun a new maternity inspection programme, which aims to help services improve, both at local and national level. Next year, its ongoing programme of work focusing on services for people with a learning disability and autistic people will be extended to residential mental health settings.
Steps to be taken
Ian Trenholm says: “There’s lots of great care out there – from the GP practice in Manchester carrying out ward rounds in care homes, to the new initiatives introduced by a hospital in Newcastle upon Tyne which have improved people’s access to and experience of cancer treatments, to the ICS in Cornwall using inclusive technology to help give people more control of the services they use.
“However, the fact is that it’s hard for health and care staff to deliver good care in a gridlocked system. There are no quick fixes, but there are steps to be taken now on planning, investment and workforce that will help to avoid continuing deterioration in people’s access to and experience of care. By working together to address the issues that lie behind the gridlock, we can create conditions that mean that next year, more people can access good, safe health and social care - delivered by a better-supported workforce who have more reason to be optimistic about the future.”
Kate Terroni, Chief Inspector of Adult Social Care, Integrated Care and Interim Chief Operating Officer, says: “In this report, we’ve highlighted examples of local innovation - joining up these pockets of innovation has the potential to help unblock the gridlock. However, this can only happen in conjunction with a real focus on planning, investment, and workforce.
“The money announced by Government to help speed up the discharge of people from hospital when they are medically fit to leave, as well as to retain and recruit more care workers is welcome - but there needs to be more focus on long-term planning and investment rather than short-term sticking plasters. With 165,000 vacancies in adult social care, there needs to be a real step change in thinking about how to attract and retain staff, with better pay, rewards and training linked to career progression. If this doesn’t happen, people will be at increased risk of harm.
“Through our inspection activity we see much good and outstanding care - as well as issues with culture and leadership which can lead to increased risk for people, as we’ve highlighted in maternity services and services for people with learning disabilities and autistic people. However, through our work on local areas and systems and our oversight of the whole health and care system, we also see increasingly clearly how a lack of investment in one part of the system has consequences for the whole, and the impact this has on whether people get good care.”
Parliamentary Ombudsman responds
Ombudsman Rob Behrens describes the gridlock in the system as a “perfect storm” presenting challenges in access to care and in workforce provision. It is: “A breeding ground for mistakes in critical services. Failure in any part of the system can have catastrophic effects on patient care.”
The Ombudsman stresses that patients and their families should know they have the right to complain and be listened to when mistakes are made and advises: “The NHS must embrace a learning culture to avoid repeatedly making the same mistakes and to improve services for the future.”
* For more on this theme, see the NHS Confederation’s analysis: ‘The link between investing in health and economic growth’
