As well as highlighting “gridlock” across the health and care system amid dire workforce shortages, the CQC’s annual State of Care report outlines several ways ICSs can improve health outcomes and how they can be supported in doing so.
The report cites “historical underinvestment” in health and social care, as well as a “lack of sustained recognition and reward for the social care workforce”. It warns that “without action now, staff retention will continue to decline…services will be further stretched, and people will be at greater risk of harm.”
The CQC stresses that ICSs must improve their understanding of the health and care needs of local populations and highlights several examples of where effective local partnerships are improving health outcomes. For example, findings in the first annual report by the NHS Confederation’s ICS Network show that 90 per cent of system leaders reported an improvement in joint, collaborative working across their system.
Where ICS development needs support
Better system-level planning, along with local and place-based partnerships, the report argues, are central to addressing health inequality across the country.
However, The State of Care cites a study from the NHS Confederation reports uncertainty among primary care leaders about how “the experiences and insights of those leading primary care services at neighbourhood level inform system-level planning and strategy.” This dynamic undermines the integral purpose that ICSs have of using local experience and empirical evidence to inform proactive, localised strategies that will address health and care inequalities.
To improve the links between services and the populations they serve, the State of Care recommends an increase in the sharing of quality data, and advocates that local leaders be given data from providers and other local stakeholders to develop comprehensive understandings of population health at ground level. It argues that it is critical for ICS leadership and stakeholders to “agree success measures that are focused on people’s overall experience of care”, rather than arbitrary targets or outdated metrics.
The report refers to the CQC’s inspection of Cornwall and Isles of Scilly, where community nurses were focused on helping residents avoid hospital admissions and improving hospital discharges. Work in this area spanned health and social care services. Cornwall has developed an agile response framework, whereby an ‘emergency car’ can respond to 999 and 111 calls faster than ambulances typically could. This has allowed patients to be effectively triaged at home, where a decision can be made over whether an ambulance or hospital visit is necessary. This approach has helped take pressure off the local ambulance service and acute admissions in the ICS, and should serve as an example of outcome-based metrics for success.
On health inequalities, the State of Care advocates for an increase in data sharing, particularly demographic data, and especially data on ethnicity and disability, which is described as “not good enough” at present. It states that “better quality data and increased data sharing are critical…to understanding and tackling inequalities in people’s experience of and access to care.”
Citing some of the recommendations contained in the government’s independent Health and Social Care Review, the CQC argue the importance of hardwiring collaborative behaviours into ICS leadership to produce “broader cross-sector awareness and understanding” and address the “institutional inadequacy in the way that leadership and management is trained, developed and valued.”
A gridlocked system – where next?
At the heart of this year’s State of Care report is the presence of “gridlock” within the wider health and care system. A vicious cycle has manifested, in which preventative approaches to healthcare are failing, leaving more people requiring medical interventions. At the same time, a lack of resource in primary care and social care is driving people into hospitals where they do not necessarily need to be; this is evidenced by record-high ambulance and A&E waiting times.
This “gridlocked” system is leading to rapidly deteriorating levels of public trust and satisfaction. public satisfaction with the NHS overall has dropped from 53 per cent to 36 per cent, while those who reported a good overall experience of their GP practice dropped from 83 per cent to 72 per cent. This dissatisfaction is also reflected in levels of staff satisfaction, with more staff than ever before leaving health and social care and providers “finding increasingly challenging to recruit”, leading to “alarmingly high vacancy rates”.
National performance estimates cited in the report show that more than five million A&E attendees waited for more than four hours for treatment in 2021-22, compared to just over 3.5 million in 2019-20. Meanwhile, the number of people waiting more than 12 hours to be admitted to a ward from A&E has risen by nearly 65 times in just three years. While only 452 waited this long in July 2019, in July 2022, the figure rose to 29,317.
Social care has long been viewed as a “pressure valve” to acute care, allowing patients to be discharged from hospital back into the community, but again, this system is failing. Underinvestment in the sector has created an environment where poor wages and morale are driving workers away from social care and into the arms of higher paying careers. Record-high vacancy rates in the sector (165,000 in adult social care alone) mean that social care is effectively operating under a skeleton crew and is not equipped to handle the increase in demand that an ageing population with increasingly complex needs requires.
According to three in four of the system leaders surveyed by the NHS Confederation, the biggest obstacle hindering further progress is national workforce shortages. The CQC calls for “innovative initiatives” to address pervasive workforce shortages across the health and care system, as well as “increased funding and support for ICSs so they can deliver a properly funded workforce plan” that will tackle the “particularly acute” staffing shortages in adult social care.
Although 90 per cent of independent acute services are now rated as ‘good’ or ‘outstanding’ by the CQC, the report makes clear “that it is difficult for health and care staff to deliver good care in a system that is gridlocked.” It urges on the government to “deliver a properly funded workforce plan that recognises the adult social care workforce crisis as a national issue and offers staff better pay.”
As recently reported by the Health Foundation, in-work poverty has risen sharply among the social care workforce; one in 10 social care workers experienced regular food insecurity between April 2017 and April 2020 (before the recent surges in the cost of living), while 13 per cent of the children of social care workers were living in material deprivation during this period. Care home staff were also found to be twice as likely to be in receipt of in-work benefits compared to all workers, with some 20 per cent of the residential care workforce drawing on universal credit and other legacy benefits from 2017-2020. Few could argue that this is a healthy or sustainable situation.
The report continues that: “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. This will be especially visible in areas of higher economic deprivation where access to care outside hospitals is most under pressure.”
“Ignoring the urgent need to inject funding into the workforce is unthinkable”
Commenting on the State of Care report, NHS Providers’ Interim Chief Executive, Saffron Cordery said: “The regulator’s hard-hitting report makes clear that people’s care is affected by chronic staff shortages across the health and care system and must be a wake-up call for the government.
“Inadequate funding for and lack of capacity in social care have serious knock-on effects on an overloaded NHS. People need support to stay well and live independently in the community which would in many cases prevent, or delay, the need for hospital care.”
The National Care Forum’s CEO, Vic Rayner OBE, said: “This report, like so many others, highlights starkly the real impact on people when social care is underfunded and under resourced. Recognition of the heroic efforts, dedication and hard work of the care workforce to continue to support people in very difficult circumstances despite all the pressures is welcome. The government cannot continue to ignore the very real human impact on the millions of people who need care and support and the people working relentlessly every day to provide it.
“The possibility that the Chancellor is planning to delay social care reform and impose spending cuts is disastrous, especially given current pressure on the NHS and the looming winter pressures. This will impact on the already ‘gridlocked system’ CQC identified. Equally, failing to increase public spending on social care in line with rising costs and ignoring the urgent need to inject funding into the workforce is unthinkable.”
Dr Sarah Clarke, President of the Royal College of Physicians, said: “Usually this would make for stark reading, but unfortunately it is another in a line of reports that show the results of sustained underfunding of both health and social care.
“People are unable to see their GP or dentist, waiting in ambulances and emergency departments, lying on trolleys in corridors and languishing in hospital beds. Inequality in access and outcomes persists. NHS and social care staff are leaving saying conditions and the pressure are too much.
“As we have been saying for a long time now, we need proper workforce planning, funding for that plan, and a cross-government approach to preventing ill health and reducing inequality. This must be a priority for the next Prime Minister.”
Professor Martin Green OBE, Chief Executive of Care England, said: “This report paints a stark reality of the frontline. A gridlocked system, catalysed by a lack of funding and workforce pressures, prevents the system from operating efficiently and sustainably. If this gridlock is to be overcome, there must be an appropriate level of investment to stabilise the immediate and systematic workforce pressures currently experienced in the social care sector.”
The Nuffield Trust’s Deputy Director of Research, Sarah Scobie, commented: “The Care Quality Commission report paints a familiar but deeply troubling picture of a health and care system on the brink. Progress to plug severe staffing gaps across health and care and the effects of years of underinvestment have left the service ill-equipped to work through the backlog it already had, let alone the sharp increases in waits we have seen since the pandemic.”
