Adult social care ‘approaching tipping point’, warns quality regulator

October 2016

Most health and adult social care services in England are providing people with safe, high quality and compassionate care – but with pressures rising on demand, access and cost, the quality regulator is raising concerns about how long this can last.

In its annual assessment of the quality of health and adult social care in England, the Care Quality Commission (CQC) has found that despite challenging circumstances, as at 31 July 2016:

  • 71% of the adult social care (ASC) services that CQC had inspected were rated ‘good’ and 1% were ‘outstanding’;
  • 83% of the GP practices inspected were ‘good’ and 4% were ‘outstanding’; and
  • 51% of the core services provided by NHS acute hospital trusts were ‘good’ and 5% were ‘outstanding’.

However, some people still received very poor care; 2% of adult social care services, 3% of GP practices and 5% of hospital core services were rated ‘inadequate’.

Around three-quarters (76%) of NHS services, care homes, general practices and other services that had been rated as ‘inadequate’ by CQC were able to improve their ratings following re-inspection. 23% went from ‘inadequate’ to ‘good’ and 53% went from ‘inadequate’ to ‘requires improvement’.

While this shows that regulation can support providers to offer people better care, CQC’s analysis also reveals that some services are failing to improve despite being given clear information on where improvement is needed.

47% of providers that were re-inspected following a rating of ‘requires improvement’ were not able to improve their rating. Most worryingly, in 8% of cases, the quality of care had deteriorated so much that the rating was downgraded to ‘inadequate’.

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.

  • Although three quarters of ASC services that were initially rated ‘inadequate’ improved following re-inspection, nearly a quarter of re-inspected services were not able to improve their ratings. Half of services rated as ‘requires improvement’ that were re-inspected (904 out of 1,850) had no change to their rating. In 153 cases we found that the care had become inadequate.
  • CQC data shows that a five-year period of steady increase in the number of nursing home beds – going from 205,000 beds in 2009 to 224,000 beds in March 2015 – has now stalled, with numbers remaining static since that time.
  • Already CQC has seen examples of providers starting to hand back contracts as being undeliverable; 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 (introduced in April 2016).
  • In 2015, Age UK estimated that more than a million older people in England were living with unmet social care needs (such as not receiving assistance with bathing and dressing); a rise from 800,000 in 2010.
  • The number of older people receiving local authority-funded social care fell 26% from more than 1.1 million in 2009 to around 850,000 in 2013/14. Also, 81% of local authorities have reduced their real-term spending on social care for older people over the last five years.

The fragility of the adult social care market is now beginning to impact both on the people who rely on these services and on the performance of NHS care. 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.

Despite the well-documented financial challenges that the NHS faces, CQC found much good and outstanding care – particularly in children’s and young people’s services and critical care. CQC has awarded ‘outstanding’ ratings to five acute NHS trusts and two mental health NHS trusts. Also, five NHS trusts have exited special measures since April 2015.

However, CQC has also found too much acute care that has been ‘inadequate’ – particularly urgent and emergency services and medical services. It will be increasingly difficult for NHS trusts to make improvements to these services unless they are able to work more closely with adequately funded adult social care and primary care providers.

David Behan, chief executive of the Care Quality Commission, 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.”

Peter Wyman, Chair of the Care Quality Commission, said: “We know that tough financial conditions are having an impact on providers. But the focus on the financial problems of the NHS has to some extent masked other issues – reduced access to adult social care and vacancies in primary medical services have led to increased demand in secondary care, which is often not in the best interests of people while generally being considerably more costly.

“Our evidence suggests that finance and quality are not necessarily opposing demands; many providers are continuing to deliver good quality care within the resources available by beginning to transform the way they work through collaboration with other services and sectors. Leaders now need to think outside traditional organisational boundaries – no amount of money will be able to support the system if this doesn’t happen.

“We will continue to highlight good and outstanding care, support improvement and take action to protect people where necessary. And we’ll use the uniquely detailed information we hold on quality to help those that lead, work in and use health and care services to make the right decisions. All of us all want the same thing – good, safe care that’s sustainable into the future”

The annual State of Care report, out today (Thursday 13 October) provides the most comprehensive view yet of CQC’s inspection findings from its new regulatory approach, which it rolled out two years ago. This involves expert-led inspections, which in most cases then lead to ratings of ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’ to help people make informed choices about their care.

The report finds that the quality of care received in NHS mental health trusts is broadly similar to that in acute trusts, but with 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.

The quality of care provided by primary medical services (PMS) remains high. Despite a context of increased demand, coupled with a shortage of GPs and increasing vacancy levels, 83% of the GP practices CQC has rated so far are ‘good’ and 4% are ‘outstanding’.

The challenge for PMS, as for the rest of the system, is to consider what responses to increasingly difficult conditions will maintain quality, now and in the future. There has been more evidence of collaboration in primary care, while general practices have formed new models of care, including joining together in federations, involving people who use their services in their conversations from an early stage.