Care Quality Commission : The state of health care and social care in England 2018/19
Growing pressures on access and staffing risk creating ‘perfect storm’ for people using mental health and learning disability services
The Care Quality Commission’s (CQC) annual assessment of the state of health and social care in England shows that quality ratings have been maintained overall – but people’s experience of care is determined by whether they can access good care when they need it.
Providing the right access to the right care at the right time is increasingly key to the sustainability of health and social care as services struggle to cope with increased demand. When people can’t access the services they need, the risk is that they are pushed into inappropriate care settings – ending up in emergency departments because they can’t access the care they need outside hospital, or in crisis because they can’t access community based mental health and learning disability services.
Difficulties in accessing the right care can mean that people with a learning disability or autism end up detained in unsuitable hospitals. CQC’s ongoing thematic review, which began in 2018, highlighted the prolonged use of segregation for people with severe and complex problems who should instead be receiving specialist care from staff with highly specialised skills.
This year’s State of Care considers the pressures faced by health and social care as a whole – but focuses particularly on inpatient mental health and learning disability services, the area where CQC is seeing an impact on quality.
While the overall quality picture for the mental health sector, which includes community mental health services, remains stable, this masks a real deterioration in some specialist inpatient services which has continued after 31 July 2019, the cut-off point for the data included in the report. As at 30 September 20191:
- 10% of inpatient services for people with learning disabilities and/or autism were rated inadequate, as compared to 1% in 2018
- 7% of child and adolescent mental health inpatient services were rated inadequate (2018: 3%)
- 8% of acute wards for adults of working age and psychiatric intensive care units were rated inadequate (2018: 2%).
Since October 2018, 14 independent mental health hospitals that admit people with a learning disability and/or autism have been rated inadequate and put into special measures. Two of these services have since improved, three are now closed and one service is still registered but is closed to new admissions with no people resident.
Although inspectors have seen much good and some outstanding care, they have also seen too many people using mental health and learning disability services being looked after by staff who lack the skills, training, experience or support from clinical staff to care for people with complex needs. In the majority of mental health inpatient services rated inadequate or requires improvement, a lack of appropriately skilled staff was identified as an issue in the inspection report. This reflects a national shortage of nurses in these areas of practice, with 8% fewer learning disability nurses registered with the Nursing and Midwifery Council in 2019 than 2015.
Access and staffing are presenting challenges across all care settings, with geographic disparities – as highlighted in last year’s State of Care – presenting particular barriers in some parts of the country. People sharing their experiences with CQC have described having to ‘chase’ care in order to receive basic services, or experiencing worsening health as they move from service to service, unable to access the care they need.
Where patients struggle to access non-urgent services in their local community, including GP and dental services, this can have a direct impact on secondary care services. Figures for emergency admissions after attending the emergency department are continuing to rise year-on-year. This peaked at 31.2% of attendances in December 2018, and in July 2019 it was 28.9% – the highest figure for July in at least the last five years. There has also been an increase in referral to treatment times over the last year, with 4.4 million people at the end of June 2019 waiting to start treatment – an increase of 40% since June 2014.
In adult social care, issues around workforce – including a lack of qualified staff – and funding continue to contribute to the fragility of the sector. 2018/19 saw providers continuing to exit the market and in 2018, CQC twice exercised its legal duty to notify local authorities that there was a credible risk of service disruption because of provider business failure. These were the first notifications of this type CQC has issued in four years of running its Market Oversight scheme.
Ian Trenholm, Chief Executive of the Care Quality Commission (CQC) said:
“In this year’s State of Care, we have highlighted mental health and learning disability inpatient services because that’s where we are starting to see an impact on quality – and on people. There has been a deterioration in ratings in these services – and our inspection reports highlight staff shortages, or care delivered by staff who aren’t trained or supported to look after people with complex needs, as a reason for this.
“Increased demand combined with challenges around workforce and access risk creating a perfect storm – meaning people who need support from mental health, learning disability or autism services may receive poor care, have to wait until they are at crisis point to get the help they need, be detained in unsuitable services far from home, or be unable to access care at all.
“We are strengthening our approach to how we look at these services, and how we use the information that people share with us, so that we can act more quickly to spot and act on poor care. But having the right staff to deliver good care is crucial to turning the tide – as are better integrated community services to prevent people ending up in the wrong place. We’ve seen some excellent care where services collaborate and we want to see more local services working together.
“While we’ll continue to call out staffing issues at provider level when these have an impact on care, we’re also calling for system-wide action on workforce planning which encourages more flexible and collaborative approaches to staff skills and career paths. The ambitious plans to expand the mental health workforce to meet an increase in demand must be accelerated.
“We’ll continue to celebrate the providers – like those highlighted in this report – who are thinking beyond barriers to work together in new ways that not only improve quality but give their teams more development opportunities and flexibility to work across different settings, supporting them to deliver great care.”
Peter Wyman, Chair of the Care Quality Commission, said:
“The fact that quality ratings across health and social care remain broadly stable – due to the dedication and hard work of staff and leaders – should be celebrated. But at the same time, we need to acknowledge that people’s experience of care is not always good – too many people are facing unacceptable challenges and cannot get the right care in the right place and at the right time.
“Last year we warned that the continuing lack of a long-term sustainable funding solution for adult social care was having a damaging impact on the quality and quantity of available care. There is an urgent need for this solution to be prioritised by Parliament and Government – the failure to find a consensus for a future funding model continues to drive instability in this sector. Organisations that represent people who use services are telling us that the challenges faced by people, their families and their carers in getting the care and support they need are strongly related to pressures on local authority budgets and a lack of social care funding.
“The impact of these pressures is being felt across all health and care settings. We head into winter after a summer which saw a record-breaking number of patients attending A&E. Staff continue to do an incredible job, but the strain is starting to show – emergency departments were the core service that our inspectors were most likely to rate as Inadequate or Requires Improvement.
“This report points to examples that show how providers are working together more effectively – often using technology to help – to ensure that people get the care they need when they need it. But their efforts must be supported by Parliament, commissioners and national and local leaders in order to deliver real change in how and where people are cared for, and how they are supported to stay well.”
This year’s State of Care draws on quantitative analysis of inspection ratings of almost 32,000 services and providers, in addition to other monitoring information including staff and public surveys, and performance. It also draws on qualitative analysis of interviews and focus groups with CQC inspection staff and voluntary organisations, secondary analysis of ‘Share Your Experience’ comments and inspection reports, and case studies of the experiences of people who use services and innovative providers.
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1 Data cited here is 31 July 2018 – 30 September 2019.