Care Quality Commission
Combination of cost-of-living crisis and workforce pressures risks ‘unfair care’ – longer waits, reduced access and poorer outcomes for some
The Care Quality Commission’s (CQC’s) annual assessment of the state of health and adult social care in England looks at the quality of care over the past year
This year has been a turbulent one for health and social care. In addition to the ongoing problem of ‘gridlocked’ care highlighted in last year’s State of Care, the cost-of-living crisis is biting harder for the public, staff, and providers – and workforce pressures have escalated. This combination risks leading to unfair care – where those who can afford to pay for treatment do so and those who can’t face longer waits and reduced access.
Adult social care providers are facing increased running costs, including food and electricity, with some struggling to pay their staff a wage in line with inflation, which affects recruitment and retention. This is likely to have an impact on people, both in the quality of care they receive and in providers’ ability to re-invest in care homes – data from CQC’s Market Oversight scheme shows that care home profitability remains at historically low levels.
Local authority budgets have failed to keep pace with rising costs and the increase in the number of people needing care. As local authority funded adult social care places are often less profitable, there is the risk that people who live in more deprived areas, and are more likely to receive local authority funded care, may not be able to get the care they need.
Some people who pay for their own care at home have had to cut back on visits to support their basic needs, with one homecare provider telling CQC: “Due to the cost of living crisis and increased fuel prices, we have had to increase the rates for service users… the outcome was that some people have reduced their care visits to a minimum… this has impacted on their quality of life.”
Workforce challenges have intensified, with unresolved industrial action by NHS staff unhappy with pay and conditions. The number of people on waiting lists for treatment has grown to record figures and in the face of longer waits, those who can afford it are increasingly turning to private healthcare. Research by YouGov shows that 8 in 10 of those who used private health care last year would previously have used the NHS, with separate research showing that 56% of people had tried to use the NHS before using private healthcare.
This situation is likely to exacerbate existing heath inequalities and increase the risk of a two-tier system of health care, with people who cannot afford to pay waiting longer for care. CQC’s adult inpatient survey, based on feedback from over 63,000 people, found that 41% felt their health deteriorated while they were on a waiting list to be admitted to hospital.
People may also be forced to make difficult financial choices; CQC heard from someone in receipt of benefits who resorted to extracting their own tooth because they were unable to find an NHS dentist. They then had to pay £1,200 on a credit card for private treatment, doing without household essentials until the debt was paid.
During 2022/23, CQC has continued to take a risk-based approach, focusing inspection activity on those core services that nationally are operating with an increased level of risk, and on individual providers where monitoring identifies safety concerns. Ratings data shows a mixed picture of quality, with a notable decline in maternity, mental health and ambulance services.
CQC has continued its focused programme of maternity inspections, with the overarching picture of a service and staff under huge pressure emerging. Ten per cent of maternity services are rated as inadequate overall, while 39% are rated as requires improvement. Safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for their safety and 12% rated as inadequate for being well-led.
While it has been encouraging that all units inspected so far have adjusted consultant cover to meet recommendations made in the Ockenden report, the cover model is often fragile, with rotas reliant on every consultant being available. We have seen examples of services taking action to manage staff shortages safely – but we have also seen issues with governance and lack of oversight from Boards, delays to care and lack of one-to-one care during labour, as well as poor communication with women and difficult working relationships between staff groups.
Additionally, women and babies from ethnic minority groups continue to experience higher risks around birth. Infant mortality rates for Black and Asian babies are still higher than for any other group and readmission rates of Black women during the 6-week postpartum period continue to rise and are significantly higher than for women of other ethnicities.
Alongside its programme of maternity inspections, CQC commissioned a series of interviews with midwives from ethnic minority groups to explore their experiences of working in maternity services and their insights into safety issues. A common theme from these interviews was that care for people using maternity services is affected by racial stereotypes and a lack of cultural awareness among staff. One midwife said, “The NHS is amazing, but it was built by white people for white people. We need to adapt, because now we have a diverse population and workforce.”
Access to and quality of mental health care also remain a key area of concern. Gaps in community care continue to put pressure on mental health inpatient services, with many inpatient services struggling to provide a bed, which in turn leads to people being cared for in inappropriate environments – often in A&E. One acute trust reported that there had been 42 mental health patients waiting for over 36 hours in their emergency department in one month alone. When people do get a bed in a mental health hospital, the quality of care is often not good enough. Safety continues to be an area of concern, with 40% of providers rated as requires improvement or inadequate for safety.
Recruitment and retention of staff remains one of the biggest challenges for the mental health sector, with the use of bank and agency staff remaining high and almost 1 in 5 mental health nursing posts vacant. CQC has raised concerns that staffing issues in mental health services are leading to the over-use of restrictive practices, including restraint, seclusion, and segregation, and called on providers to recognise and take steps to address this.
Ian Trenholm, CQC’s Chief Executive, said:
“The combination of the cost-of-living crisis and workforce challenges risks leading to unfair care, with those who can afford to pay for treatment doing so, and those who can’t facing longer waits and reduced access. And the impact of unresolved industrial action on people can’t be ignored – it’s crucial that both parties work towards an agreement so strikes do not continue into the winter, when disruption will have to be managed alongside increased demand for urgent care and staff sickness.
“Of course, workforce challenges for the health and social care sector long pre-date the current industrial action. The publication of the NHS Long Term Workforce plan has been a positive step but implementation will be challenging – particularly without a social care workforce strategy to sit alongside it. We continue to call for a national workforce strategy that raises the status of the adult social care workforce and ensures that career progression, pay and rewards attract and retain the right professional staff in the right numbers. It is encouraging that Skills for Care has made this an area of focus.
“We remain concerned that some people are more likely to have a poorer experience of care. To better understand barriers to equality, we’ve commissioned research with midwives from ethnic minority groups, and with people from ethnic minority groups with long-term conditions. We’ve also worked with our expert advisory group for autistic people and people with a learning disability to develop a clearer and stronger position on the use of restrictive practice – we expect all providers to recognise restrictive practice and to actively work to reduce its use."
“Maternity services and mental health services have been a particular area of inspection focus for us this year, and while we have seen some good practice, we have seen too many examples of poor care, and have taken action to protect people when necessary.
“However, it’s important to say that we have also seen staff and leaders across all sectors mitigating risks arising from staffing shortages and working hard to deliver good care in very challenging conditions.”
Ian Dilks, Chair of CQC, said:
“The challenges described in this year’s State of Care are to some degree caused by a lack of joined-up planning, investment, and delivery of care.
“Integrated care systems present the opportunity of bringing together local health and care leaders with the populations they support to understand, plan, and deliver care at a local level. This would in time move some of the focus of care away from big institutions and towards local and self-care provision, with autonomy to act on local population needs and an increased focus on preventing poor health, not just treating it.
“However, in our first look across local care systems, we found that while all systems have some equality and health inequalities objectives, these plans do not all have timeframes and measures. All systems need clear and realistic goals – and support to achieve these – that reflect how they will address unwarranted variations in population health and disparities in access, outcomes, and experience of health and social care.
“This opportunity must be grasped to ensure fairer care for everyone – so people get the care they need, not just the care they can afford.”
About the Care Quality Commission
The Care Quality Commission (CQC) is the independent regulator of health and social care in England.
We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.
We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.
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