Most people in England receive a good quality of care. Our ratings show that quality overall has been largely maintained from last year, and in some cases improved, despite the continuing challenges that providers face. Some services have improved due to the focus and hard work of care staf and their leadership teams. Others have declined in quality as providers have struggled with the challenges they face.
But quality and access to care are not consistent, and people’s overall experiences of care are varied. Some people have told us about the outstanding care they received and how some individual services have changed their lives for the better. Others have told us about the poor and sometimes disjointed care they have received. Public sentiment about health and care services remains largely positive – for example, 84% of patients said their GP practice was fairly good or very good. However, there are real concerns, such as the one in four (25%) of people receiving NHS mental health services who did not feel they got services often enough for their needs.
This year’s State of Care builds on our July 2018 report about the way that older people in 20 English local areas experienced care as they moved between the different services they need. We highlighted how services for many people with multiple or complex needs in these areas were not joined up around their individual needs: finding good joined-up care was sporadic and sometimes it occurred despite the lack of a systematic approach to put people at the centre of their care. We found that providers are often focused on their own corporate priorities and targets, rather than working with one another to make sure people get the best care possible.
The challenge for all local health and social care services is to recognise the needs of their local populations and find sustainable solutions that put people first. In this context, we have considered five factors that affect the sustainability of good care for people: access to care and support; the quality of care services; the workforce available to deliver that care; the capacity of providers to meet demand; and the funding and commissioning of services.
Access – In 2018, access to care varies from place to place across the country. Some people cannot access the services they need, or their only reasonable access is to providers with poor services. Age UK estimates 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. Friends and family carers must often fill the gap, and in a recent survey three quarters of carers had received no support to help them have a day’s break in the previous 12 months. While more than 40% of GP practices now provide access outside of their normal hours, the general practice workforce is increasingly stretched, and there was wide variation in the proportion of patients in local areas that were satisfied with the appointment times they were given, from 45% to 79%.
In the NHS, the number of patients waiting to start treatment in hospital 18 weeks after being referred rose by 55% from 2011 to 2018. Some people who need inpatient mental health care and support are having to travel long distances to obtain it, and this varies considerably depending on where people live.
Quality – The overall quality of care in the major health and care sectors has improved slightly. More than nine out of 10 (91%) of GP practices and 79% of adult social care services were rated as good at 31 July 2018. More than half (60%) of NHS hospital core services and 70% of NHS mental health core services were rated as good at that date. The hallmark of high-quality care is good leadership and governance, a strong organisational culture that embraces learning, and good partnership working – services looking externally to work with others and share what they know. At the same time, too many people are getting care that is not good enough. Our ratings show that, at 31 July 2018, around one in six adult social care services and one in five NHS mental health core services needed to improve, and one in 100 was rated as inadequate. Almost a third of NHS acute core services were rated as requires improvement and three in 100 were rated as inadequate. The safety of people who use health and social care services remains our biggest concern. There were improvements in safety in adult social care services and among GP practices. But while there were also small safety improvements in NHS acute hospitals, too many need to do better, with 40% of core services rated as requires improvement and 3% rated as inadequate. NHS mental health service also need to improve substantially, with 37% of core services rated as requires improvement and 2% as inadequate.
Workforce– Workforce problems have a direct impact on people’s care. Getting the right workforce is crucial in ensuring services can improve and provide high-quality, person-centred care. Each sector has its own workforce challenges, and many are struggling to recruit, retain and develop their staff to meet the needs of the people they care for. Recruiting and retaining newly qualified GPs is a problem in a profession where there is already an ageing workforce. In adult social care, the highest vacancy rates in all regions in 2017/18 were for the regulated professions that include registered nurses, allied health professionals and social workers. They reached 16% in the East of England and 15% in London. Vacancy and turnover rates for all staff groups are generally higher in domiciliary care agencies than in care homes. In our review of children and young people’s mental health services, low staffing levels were the most common reason for delays in children and young people receiving care. Demand and capacity – These workforce challenges are set against a backdrop of ever increasing need for care. Demand is rising inexorably, not only from an ageing population but from the increasing number of people living with complex, chronic or multiple conditions, such as diabetes, cancer, heart disease and dementia. Demand for urgent and emergency care services continued to rise in 2017/18, with more attendances at emergency departments than ever. The capacity of adult social care provision continues to be very constrained: the number of care home beds dropped very slightly in the year, but what was noticeable were the wide differences across the country. Across a two-year period, from April 2016 to 2018, changes in nursing home bed numbers ranged from a 44% rise in one local authority to a 58% reduction in another. Almost a third of adult social care directors (32%) said they had seen home care providers close or cease trading in the previous six months. Providers face the challenge of finding the right capacity to meet people’s needs. Services need to plan – together – to meet the predicted needs of their local populations, as well as planning for extremes of demand, such as sickness during winter and the impact this has on the system. Funding and commissioning – Care providers need to be able to plan provision of services for populations with the right resources, so good funding and commissioning structures and decision-making should be in place to help boost the ability of health and social care services to improve. Funding challenges of recent years are well known, and in June 2018 the government announced an extra £20.5 billion funding for the NHS by 2023/24. However, at the time of writing, there is no similar long-term funding solution for adult social care. A sustainable financial plan for adult social care will be an important element of both the forthcoming social care Green Paper and the wider Spending Review.