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State of Care Review: the future of quality in the NHS and social care is precarious

The quality of health and social care has been maintained despite very real challenges and the majority of people are getting good, safe care.

This is the conclusion of the quality inspectorate in their annual review. But future quality is precarious, the CQC says, as the system struggles with complex new types of demand, access and cost.

The CQC annual assessment of the quality of health and social care in England contains much that is encouraging. As at 31 July 2017, 78% of adult social care services were rated good (71% were rated good at 31 July 2016) as were 55% of NHS acute hospital core services (2016: 51%); 68% of NHS mental health care services (2016: 61%) and 89% of GP practices (2016: 83%).

From this analysis, it is clear that the quality of care has been maintained. Two percent of adult social care services, 6% of NHS acute hospital and mental health care services, and 4% of GP practices are rated outstanding. Many services that were originally rated as inadequate have used the findings of CQC’s inspection reports to make the necessary changes and have improved.

However, the changing nature of demand – increasingly numbers of older people who are physically frail, many with dementia, more people with long term complex conditions – is placing unprecedented pressure on the system. In acute hospitals, this means more people waiting over four hours at A&E; more planned operations cancelled, and people waiting longer for treatment.

And in adult social care, the number of beds in nursing homes has decreased across most of England and domiciliary care contracts are being handed back to councils because providers say the funding is insufficient to meet people’s needs; estimates show that one in eight older people are not receiving the help they need.

A very small minority of care was found to be failing people – between 1% and 3% of providers across the services CQC regulates were rated inadequate. There is also much care that needs to improve: 19% (2016: 26%) of adult social care services; 37% (2016: 39%) of NHS acute core services; 24% (2016: 33%) of NHS mental health core services; and 6% (2016: 10%) of GP practices were rated as requires improvement.

Sir David Behan, Chief Executive of the CQC, said: “The fact that the quality of care has been maintained in the toughest climate that most can remember is testament to the efforts of frontline staff, managers and leaders.

“However, as people’s health and care needs change and become more complex, a model of care designed for the 20th century is at full stretch and struggling to cope with 21st century problems.

“The impact of this on people is particularly evident where sectors come together – or fail to come together, as the complex patchwork of health and social care strains at the seams.

“Last year, CQC warned that social care was ‘approaching tipping point’ – a point where deterioration in quality would outpace improvement and there would be a significant increase in people whose needs weren’t being met. We said this based on five pieces of evidence – on bed numbers, market fragility, unmet need and local authority funding and quality. This year, nursing home bed numbers are down, more contracts have been handed back and Age UK estimates that there is more unmet need.

“Helpfully, however, an extra £2bn has been made available through the Better Care Fund – and improvement in quality continues to outpace deterioration, although the rate of improvement has slowed.

“The future of the social care system is one of the greatest unresolved public policy issues of our time – a long term sustainable solution is urgently required. The anticipated green paper on adult social care will provide the opportunity for Parliament, the public and professionals to consider how we can collectively develop an appropriately funded social care system that can meet people’s needs, now and in the future.

“If services are to deliver consistently for people, there must be better coordination of care to create a sustainable and effective health and care system. Staff and leaders can’t work any harder; the answer must be to work more collaboratively, not just between sectors but between agencies and professionals, supported and incentivised by the national health and care organisations. People should be able to expect consistent, personalised, safe care, and to be able to access that care when they need it – whether that’s delivered in an acute hospital, a nursing home, a community mental health hospital, a GP surgery or in their own home.”

This year’s analysis found that 82% of adult social care services originally rated as inadequate and re-inspected (606 out of 740) improved their rating, 12 out of the 15 hospitals originally rated as inadequate and re-inspected improved, all of the nine mental health services (NHS trusts or independent hospitals) originally rated as inadequate and re-inspected improved their rating and 80% of GP practices originally rated as inadequate and re-inspected (156 out of 196) improved.

While recognising improvements, there is also deterioration that must be addressed. Looking at providers rated good overall the first time CQC inspected, the majority have remained good. But of the services that were re-inspected, 26% of mental health services and 23% of adult social care services originally rated good dropped at least one rating. Also, two out of the 11 NHS acute hospitals that we re-inspected had deteriorated, and only 2% of re-inspected GP practices deteriorated

Since CQC introduced its new approach to inspection and rating, there has been a clear improvement overall in safety across all of the sectors regulated and rated.

Where CQC has seen improvements, providers have good monitoring that gives staff a clear, accurate and current picture, which allows risk to be assessed in real time, clear systems and governance in place, which enable learning from incidents and a positive culture where staff are encouraged to raise concerns.

Despite this progress, there remain many opportunities for further improvement and many providers could and should do more; safety remains CQC’s key focus and biggest concern across all sectors. As at 31 July 2017, 5% (31 July 2016: 6%) of acute hospital core services were rated as inadequate for safety, as were 3% (2016: 7%) of core services in NHS mental health trusts, 2% (2016: 3%) of adult social care services and 2% (2016: 2%) of GP practices.

CQC will use a targeted approach to work with these providers in order to drive improvement, and to take action to protect people where necessary.

RCP president, Professor Jane Dacre, said: “This is yet another report outlining that health and care services are at full stretch, with quality only being maintained because of the tireless efforts of staff. The CQC is right to say services need to modernise, but the elephant in the room is the fact that the Department of Health’s budget is growing, in real terms, at about a quarter of the average since the NHS was established.

“There needs to be the opportunity for innovation, but modernisation cannot happen while staff are working flat out just to keep services running.”

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