While most health and adult social care services in England provide safe, high quality, compassionate care currently, the Care Quality Commission (CQC) has warned that pressure rising on demand, access and cost mean that this may not last.
In response, health and social care organisations have called on the government to urgently address the underfunding of social care.
In its annual assessment of the quality of health and adult social care in England, the CQC found that despite challenging circumstances, as at July 31:
• 71% of the adult social care services that CQC had inspected were rated ‘good’ and 1% were ‘outstanding’
• 83% of GP practices inspected were ‘good’ and 4% were ‘outstanding’
• 51% of the core services provided by NHS acute hospital trusts were ‘good’ and 5% were ‘outstanding’.
However, 2% of adult social care services, 3% of GP practices and 5% of hospital core services were rated ‘inadequate’.
There was evidence that services could improve too, with 76% of NHS services, care homes, general practices and other services that had been rated as ‘inadequate’ by CQC improving their ratings following re-inspection. Of those, 23% went from ‘inadequate’ to ‘good’ and 53% went from ‘inadequate’ to ‘requires improvement’.
But 47% of providers that were re-inspected following a rating of ‘requires improvement’ were not able to improve their rating. Worryingly, in 8% of cases, the quality of care deteriorated so much that the rating was downgraded to ‘inadequate’.
Additionally, CQC has raised concerns that the sustainability of the adult social care market is approaching a tipping point. This view is based on the evidence of inspections, information received through CQC’s market oversight function, and a variety of external data.
For instance, the regulator has seen examples of providers starting to hand back contracts as being undeliverable; and local authorities warn of more to come. This is due to pressures on fees that funders of care are able or willing to pay, and cost pressures that include the impact of the national living wage, which was introduced in April.
The fragility of the adult social care market is now beginning to impact on the people who rely on these services and on the performance of NHS care, the CQC added. The combination of a growing and ageing population, more people with long-term conditions, and a challenging economic climate means greater demand on services and more problems for people in accessing care. This is translating to increased A&E attendances, emergency admissions and delays to people leaving hospital, which in turn is affecting the ability of a growing number of trusts to meet their performance and financial targets.
In terms of mental health, the report found that while the quality of care received in NHS mental health trusts is broadly similar to that in acute trusts, there is an even higher level of variability within providers as well as between them – community services are more likely to be rated ‘good’ and ‘outstanding’ than inpatient services, such as wards for working age adults and psychiatric intensive care units. In particular, CQC has concerns about the safety of acute mental health services. Problems with physical environments frequently contributed to ratings of ‘requires improvement’ or ‘inadequate’ for inpatient services.
David Behan, chief executive of the CQC, said: “The good news is that, despite challenging circumstances, most people are still getting high quality care and there are encouraging levels of improvement taking place. This is something to celebrate. However, there continues to be wide variation in quality, some providers are struggling to improve and there is emerging evidence of deterioration in quality.
“We are becoming concerned about the fragility of the adult social care market, with evidence suggesting that it might be approaching a ‘tipping point’. The combination of a growing, ageing population, more people with long-term conditions and a challenging financial climate means increased need but reduced access. The result is that some people are not getting the help they need - which in turn creates problems in other parts of the health and care system, such as overstretched A&E departments or delays in people leaving hospital.
“While there are no easy answers or quick fixes, what distinguishes many of the good and outstanding services is the way they work with others – hospitals working with GPs; GPs working with social care and all providers working with people who use services. Unless the health and social care system finds a better way to work together, I have no doubt that next year there will be more people whose needs aren’t meet, less improvement and more deterioration.”
The report has been welcomed by health and social care organisations, but they also echo the CQC’s warnings on the future provision of care. Andrew Cannon, co-chair of Learning Disability Voices – which includes Voyage Care, United Response, Lifeways, The Wilf Ward Family Trust, Hft and Mencap – said: “Adult social care is in crisis and our ability to provide learning disability services on the current terms set by the government is unsustainable.
“As a sector we cannot rely on private fees, and cash-strapped local authorities are our only customer. More funding is vital to ensure we can continue to support many of those who cannot help themselves.”
Diane Lightfoot, co-chair of Learning Disability Voices, added: “Learning disability services are a lifeline to many, yet services are being withdrawn or they are failing because of the intense pressure on our budgets.
“Unless the government acts to address funding in the sector, services will fail and lives will be put at risk. We now require urgent clarity about how this crisis is going to be averted.”
Vicky McDermott, chair of the Care and Support Alliance – which represents more than 90 charities – said: “Today's Care Quality Commission report highlights the fragility of the social care sector because of government underfunding. This report highlights that after all the warnings the system is now approaching a 'tipping point'. Disabled and older people rely on social care when they are fragile and often in crisis - people deserve a system they can rely on, not a neglected service in crisis.
“Social care is a lifeline for vulnerable people in this country, helping them with basic needs like washing or getting dressed. Underfunding social care puts more pressure on the NHS - with people needing more expensive care in hospital because they can't get basic care at home. We are seeing an increase in emergency admissions to Accident and Emergency services as well as delays in discharging people from hospitals.
“Now that [Health Secretary] Jeremy Hunt has overwhelming evidence that the system is buckling from underfunding, he must ensure that money is immediately put into the social care system, to stop the crisis escalating and work to ensure that as a country we have a debate about the future funding of social care."
Professor Martin Green OBE, chief executive of Care England, agreed: “Despite the excellent work of social care workers and managers, underfunding is damaging the sector. The current funding settlement entirely disregards demographic change, the pressure on the market, and the impact on people receiving care. As CQC highlights, more and more people are living with unmet needs for care, and more providers are pulling out of unaffordable caring activities like nursing. CQC’s emphasis on providers turning down contracts reflects the impossible market for care: Care England members are still being asked to care for adults with complex needs for as little as £2.25 per hour. This undoubtedly affects the NHS, where delayed discharge figures will not improve while social care remains starved.
“The fragility of the market cannot be overstated: as this week’s media coverage has also shown, providers are being put in a perilous position by a lack of political will to meet the funding needs of social care. The CQC is a trusted voice, and is right to use its role to highlight sector difficulties: now the government must take heed and action to reverse a trend of gradual but definite erosion of this sector, a lifeline for many vulnerable people.”
Meanwhile, Professor Rhidian Hughes, head of VODG (Voluntary Organisations Disability Group) called for government action. “Great social care enables people to live the life they choose,” he said. “But providers cannot deliver high quality care at any cost. Unless we balance disabled people’s needs with sufficient funding we jeopardise day-to-day support and quality of life for 11.9 million people in this country. It is imperative that government uses the Autumn Statement to put things right for social care.”