CQC State Of Care 2021/22 – a system in Gridlock

The CQC annual ‘State of Care’ report has been published today. The report provides a damning assessment of the state of the health and social care system and gives particular prominence to the need to address the lack of capacity in adult social care, and staffing pressures right across the workforce at the heart of this.

The Report talks about a system in ‘gridlock’ with patients being ‘stuck’: 

• in hospital due to lack of capacity in social care (only 2 in 5 people are able to leave hospital when they are ready to do so);
• in emergency departments waiting for hospital beds (a shocking 65 times more people waiting more than 12 hours for admission from A&E than in 2019);
• in ambulances unable to be transferred into hospitals (more than 1 in 10 ambulance handovers taking over an hour, against a standard of 15 minutes); and
• at home waiting for ambulances.

The pressure on emergency services is compounded by people’s inability to access primary care, and the elective care waiting list is at a record high (6.7 million in June 2022).

In community mental health services – CQC’s annual survey found that only 2 in 5 respondents felt they had ‘definitely’ seen NHS mental health services enough for their needs in the last 12 months.

The gridlocked system is reflected in growing dissatisfaction amongst service users and staff.  And staff are voting with their feet resulting in alarmingly high vacancy rates – with 165,000 vacancies in adult social care alone:

• In the first 3 months of 2022, 2.2 million hours of homecare could not be delivered because of insufficient workforce capacity;
• care home occupancy, though improved at 82.5% in August, is still below pre-pandemic levels;
• in older people’s care homes, staffing costs as a percentage of turnover rose 3.8% in the six months to March 2022; and
• care home profit margins are at their lowest level since CQC’s monitoring under the Market Oversight scheme began in 2015.

Quality and Inequalities:

The report makes the point that, when people are able to access care, overall quality is generally good, with:

• 83% of adult social care services rated as Good or Outstanding.
• 96% of GP practices rated as Good or Outstanding.
• 75% of NHS acute core services rated as Good or Outstanding.
• 77% of all mental health core services (NHS and independent) rated as Good or Outstanding.

However, inequalities continue to widen with access to quality services less likely for people living in deprived areas, disabled people and people from ethnic minority groups.

Services of Concern

In terms of particular services of concern, where CQC will be focussing its monitoring activities, the report once again highlights continuing issues in:

• Maternity services – particularly for women from ethnic minority groups – with safety issues driven by shortfalls in training, relationships in staff teams and risk assessments
• Services for people with learning disability and autism – with too many people still in hospital settings, and concerns about their physical healthcare
• Mental health services – particularly in CAMHs services
• The use of the Deprivation of Liberty Safeguards (DoLS) and unlawful detention – due to staff’s lack of knowledge, and delays in the system with the average length of time to complete applications rising to 153 days.

Systems

The report acknowledges that 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. It stresses that local innovation and joint investment in social care by health and local government is crucial to unblocking the gridlock.

CQC emphasises that part of the solution lies with Integrated Care Systems with the need to develop:

• better quality demographic data to help understand and tackle inequalities in people’s experience of and access to care.
• More flexible workforce models
• Preventative health measures

and calls for funding and support for ICSs to deliver properly funded workforce plans, to address the adult social care workforce crisis.

Conclusion

It is helpful for the CQC report to shine a light on the current state of the system. However, as well as having a statutory objective to encourage the improvement of health and social care services, CQC also has powers to inspect, rate and take enforcement action against providers of services. It is to be hoped that, when exercising these policing powers in relation to individual providers, CQC properly takes account of the wider stresses that the system is under, as detailed at length in its report.

Many of the themes set out in the report repeat the same issues noted in last year’s report, albeit that the system feels at even more of a crisis point.

However, one point of change is that, from April 2023, CQC will begin its role of monitoring Integrated Care Boards (“ICBs”) and assessing leadership and how well services are integrated. CQC refer to the King’s Fund analysis in December 2021 that adult social care services have “vital experience and understanding” which need to be brought to play in ICSs. It remains to be seen whether CQC’s forthcoming role in monitoring ICBs increases the focus on integration and provides further impetus to try to shift some of the gridlock in the system.