CQC release their annual State of Care report

The State of Care report sums the position up as ‘timely access to good care continues to be a struggle for many, and that inequalities in care persist’ and highlights 8 areas of specific concern:

1. Maternity care
2. Children and young people’s access to services
3. 45% decline in Health Visitors for young children and their parents over the last 9 years
4. Only ¼ of people with a learning disability being recorded on the register
5. Autism assessment waiting times
6. Mental health services for black or black ethnic groups
7. Dementia care
8. DOLS system

Several maternity units were described as ‘not fit for purpose’ with staffing levels being a particular concern. 131 locations were inspected with 36% being rated as requires improvement and 12% inadequate Not one service achieved an outstanding rating for ‘safe’ and a significant amount of patient safety events were not reported.

The statement noted ‘huge’ differences in the way data was collated and used, with women from black and ethnic minority backgrounds continuing ‘to be more at risk of experiencing poor maternity care and outcomes’.

In relation to termination of pregnancy services, it was found that independent services were not evenly distributed around the country, leaving some women facing significant travel to access services. Continuity of care between independent and NHS services was also lacking.

Significant delays in children getting access to appropriate services were noted with the impacts being severe – delayed treatment potentially leading to less effective treatment, impact on education, family finances and general disruption of family life. Recruitment was noted as an issue with low numbers of qualified staff leading to delays, along with gaps in training in recognising sepsis and safeguarding.

Particular concern was raised about children and young people’s mental health services, with those who were able to access appropriate support describing themselves as ‘lucky’.

Inequality was the key theme here with life expectancy for those with a learning disability lower than the general population, deaths in the most deprived areas were three times higher than in the least deprived areas. Only around a quarter of people with a learning disability were recorded on the register meaning three quarters were missing out on the care and treatment they were entitled to.

The survey reported the average wait time between referral and assessment for autism was 328 days –  the NICE recommendation being three months. This was despite a drop in new referrals. Key issues were identified in relation to communication, reasonable adjustments being made, lack of a person-centred approach, waiting room environments and a lack of consideration for other protected characteristics.

Reviews also identified that those with autism or learning disabilities continued to be institutionalised inappropriately when they should be receiving community care and that excessive restrictive practices were still in use.

The 2023 survey identified that:

• Black or Black British people are over 3 and a half times more likely to be detained under the Mental Health Act than people in white ethnic groups.
• They are also 8 times more likely than people in white ethnic groups to be placed on a community treatment order (CTO), where supervised treatment is given in the local community.

It seems little has changed in a year with 13% of those surveyed waiting 3-6 months for NHS mental health services and 8% waiting more than 6 months with black men experiencing longer hospital stays than white men. The statement reports that people in black or black ethnic groups are 3.5 times more likely to be detained under the Mental Health Act as opposed to white ethnic groups.

The statement concluded that staff did not always understand the specific needs of people with dementia – despite 490,1963 people in England with a diagnosis in July 2024.  Busy waiting room environments, family carer ‘burn out’ and a lack of joined up care were also identified as issues – as well as the much repeated delays, increased service demand and recruitment difficulties.

The CQC state that they will be developing a ‘cross-sector dementia strategy shaped by the central question, ‘How can CQC use its role to improve the experience of using health and social care services for people living with dementia and their carers?’

Again, delay was a key problem resulting in people being left without legal protection or assessments and authorisations being completed without proper consideration of less restrictive options. Concerns about the system were raised in 2014 and on numerous occasions since but with the Liberty Protection safeguards being delayed it is unclear if or when reform will be coming.

The statement noted that in March 2024, ‘5 million people waited more than 2 weeks for a GP practice appointment, with 1.4 million waiting more than 4 weeks’ with the number of registered patients increasing 5% to 63 million in England between March 2020 and 2024.

The survey found that there were ‘notable regional variations’  in the provision of NHS dental treated – ranging from 48% to 97%, with rural areas tending to provide less NHS treatment.

Unsurprisingly, children in more deprived areas were found to be more than twice as likely to experience tooth decay and people in similar areas 3 times more likely to end up in hospital for treatment  that could have been avoided with ‘timely and effective care in the community’.

Worryingly, the statement notes that the number of  requests for adult social support care resulting in no service being provided has increased by 27% in the last 5 years, with waiting times for care home beds and home care accounting for 45% of delays in discharge from hospital (for those who had been in hospital for 14 days or more) –nearly 4,000 people a day on average ‘bed blocking’.

On the positive side, the number of people waiting for a needs assessment reduced by 8.9% in Spring 2024.  Staff vacancies in care homes were also shown to be at their lowest rate for three years. However, that does not seem to marry with the reported 81% decrease in overseas workers applying for health and social care worker visas (as comparing April to July 2024 to the same months in 2023).

The availability, or lack thereof, of mental health services is a hot topic – with demand for such services on the rise. The statement sets out that access to mental health services remains a challenge with people waiting months and even years for treatment – with the blame being pointed towards ’lack of resources, ageing estates and poorly designed facilities’.

The statement reports that ‘the attendance rates for urgent and emergency care for people living in the most deprived areas of England were nearly double those for people in the least deprived areas’ and that with those attending for mental health reasons, ‘the difference was over 3 times higher for those in the most deprived areas’.

The statement did not report a dramatic increase in the need for secondary care, performance was still poor with people facing long waiting times and waiting lists increasing (the waiting list for diagnostics test or procedures has increased by 52% since 2019).

The position is summed up as ‘urgent and emergency care services in crisis are a symptom of complex system problems that need resolving, by providing more services for people away from hospitals’ with the key issues being finance, joint forward planning and workforce depletion. i.e. less money, less staff and a lack of joined up thinking’.

Whilst there are some positive stories scattered throughout the statement, the general position is rather less positive. Bluntly, there are far more people who are in need of services, there are less well trained and experienced staff and less money in the pot to provide desperately needed services.

On any analysis, it is clear that spending money in primary care reduces the need for lengthy (and expensive) hospital stays and would go some way to address the delays in getting people discharged. Then there is the much more difficult issue of addressing the deprivation in some areas of the country that impact on people’s health and ultimately their need, and ability,  to access services.

The system is under immense strain and it doesn’t appear that the initiatives in place or those planned are going to do much to relieve that strain in the immediate future – increased people in training will need time to get qualified (whether that is as a GP, dentist or any other healthcare professional), Pharmacy First will only work if there are pharmacies to implement it and the warning in last year’s State of Care report of a, ‘two-tier healthcare system – where those who can afford to pay for treatment do so and those who can’t face longer waits and reduced access’ remains a concern.

However, the positive experience reported in the statement also indicate that there are providers who place people at the heart of their decision making and provide the best care they possibly can under ever increasing challenges.