CQC warns of growing ‘care injustice’

Quality of care varies from area to area with impact on A&E departments

Published on 15th October 2018

A&E department

People’s experience of care still varies depending on where they live, the Care Quality Commission has warned.

The Care Quality Commission’s annual assessment of the quality of health and social care in England shows that overall, quality has been largely maintained, and in some cases improved, from last year.

Yet people's experiences of care are often determined by how well different parts of local systems work together.
"Some people can easily access good care, while others cannot access the services they need, experience ‘disjointed’ care, or only have access to providers with poor services," said the report.

This is not so much a ‘postcode lottery’ as an ‘integration lottery’.

CQC’s reviews of local health and care systems found that ineffective collaboration between local health and care services can result in people not being able to access the care and support services in the community that would avoid unnecessary admissions to hospital, which in turn leads to increased demand for acute services.

Ian Trenholm, Chief Executive of the Care Quality Commission, said: “This year’s State of Care highlights both the resilience and the potential vulnerability of a health and care system where most people receive good care, but where access to this care increasingly depends on where in the country you live and how well your local health system works together. This is not so much a ‘postcode lottery’ as an ‘integration lottery’.

“We’ve seen some examples of providers working together to give people joined-up care based on their individual needs. But until this happens everywhere, individual providers will increasingly struggle to cope with demand – with quality suffering as a result," he added.

The CQC highlights that the quality has largely been maintained despite continuing challenges around demand and funding, coupled with significant workforce pressures as all sectors struggle to recruit and retain staff. The efforts of staff, leaders and carers to ensure that people continue to receive good, safe care despite these challenges must be recognised and applauded, it says.

Crisis point

The most visible impact ineffective collaboration between local health and care services  is the pressure on emergency departments as demand continues to rise. In fact, in July 2018 there was the highest number of attendances on record.  Emergency departments are the core hospital service most likely to be rated requires improvement (41%) or inadequate (7%). But a struggling local hospital can be symptomatic of a struggling local health care system and this indicates that – although good and outstanding primary care is more evenly distributed – there are parts of the country where people are less likely to get good care.

The report highlights that a less immediately visible impact when health and care services do not work well together is on people who use mental health services, who may already have more difficulty accessing support or who have to travel unreasonable distances to get it. For example, inappropriate out of area mental health placements – with some people being placed hundreds of miles from their homes – vary considerably by region. And CQC’s review of children and young people’s mental health services found that some children and young people were ‘at crisis point’ before they got the specialist care and support they needed, with average waiting times varying significantly according to local processes, systems and targets.

The continued fragility of the adult social care market continues to pose a threat to effective collaboration between health and social care, with providers closing or ceasing to trade and contracts being handed back to local authorities. It adds that unmet need continues to rise, with Age UK estimating that 1.4 million older people do not have access to the care and support they need.

Care injustice

Ian Trenholm added: "There need to be incentives that bring local health and care leaders together, rather than drive them apart. That might mean changes to funding that allow health and social care services to pool resources; for example, to invest in technology that improves quality of care. Like the digital monitoring devices for patients’ clinical observations that have saved thousands of nursing hours, the e-prescribing in oncology that’s helping people directly, and the electronic immediate discharge summaries that have improved patient safety.

“The challenge for Parliament, national and local leaders and providers is to change the way services are funded, the way they work together and how and where people are cared for and supported. The alternative is a future in which care injustice will increase and where some people will be failed by the services that are meant to support them, with their health and quality of life suffering as result," he concluded.

Julia Scott, Chief Executive of the Royal College of Occupational Therapists said: "One of the key barriers to better-quality care indicated in today’s CQC report is the fact that a third of NHS acute services require improvement.

“The Royal College has robust evidence from the front line to demonstrate that intelligent use of occupational therapy reduces pressure on hospitals. Our Improving lives, Saving Money reports document the many ways that occupational therapy does this, from supporting swift discharges by leading on the planning and transition from hospitals into therapy-led rehabilitation – ensuring patients do not need re-admittance to hospita – to preventing many older, vulnerable or frail individuals from entering the acute system in the first instance by enabling them to be supported and kept well at home through primary, social and community services.

“We welcome Mr Trenholm’s observations on the effectiveness of occupational therapy and urge health and social care leaders and commissioners to utilise occupational therapy services to drive forward higher standards of care," she added.

Action is needed

Responding to the report, Cllr Ian Hudspeth, Chairman of the LGA’s Community Wellbeing Board, said: “This report raises important concerns and highlights the brilliant work across the system to maintain quality of care, something that becomes harder each year as the consequences of pressures build further. It also provides yet more evidence of a system under significant pressure and in desperate need of securing a more long-term and sustainable solution for how, as a country, we pay for social care.

“Councils across the country are working closely with their counterparts in health for the benefit of people requiring services, however with people living longer, increases in costs and decreases in funding, adult social care is at breaking point and its potential for helping people to live the lives they want to lead is at risk.

“Over recent years, councils have protected adult social care relative to other services. But the scale of the overall funding picture for local government as a whole means adult social care services still face a £3.5 billion funding gap by 2025, just to maintain existing standards of care. The likely consequences of this are more and more people being unable to get quality and reliable care and support, which enables them to live more fulfilling lives.

“Action is needed, which is why, following government’s decision to delay its green paper on adult social care, the LGA published its own green paper consultation to drive forward the public debate on what sort of care and support we need to improve people’s wellbeing and independence, the need to focus on prevention work, and, crucially, how we fund these vital services.

“The government must use the Budget and Spending Review to inject desperately needed funding into adult social care and use the green paper to secure the long-term sustainability of the system," he concluded.

The State of Care in England

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