Foreword

For the services we regulate – as for the rest of the world – the past year is divided into two parts.

Pre-COVID, care was generally good, but with little overall improvement. In the NHS, improvement in some areas – for example, emergency care, maternity and mental health – was slower than others. The social care sector was fragile as a result of the lack of a long-term funding solution, and in need of investment and workforce planning. In primary medical services, the fact that the overall ratings picture remained broadly unchanged masked a more volatile picture of deterioration and improvement.

Since the arrival of COVID-19, we inhabit a different world, in which all these things remain true, but so much else has changed. As we take stock of the health and care system’s initial response to the pandemic in order to learn lessons for the future, there are elements to build on – and elements to reassess.

The professionalism and dedication of the people who work and volunteer in health and care has always been the system’s key strength – and from March onwards, this was more obvious than ever, as staff went to extraordinary lengths to protect those they cared for. This is cause for celebration – as well as for reflection on how to ensure that all staff are recognised for their work, regardless of the sector in which they deliver care.

The progress achieved in transforming the way care is delivered is also deeply impressive. In a matter of days, services developed new procedures and ways of working, often taking advantage of technology. Changes that were expected to take years – like the switch to more flexible GP consultations by phone and online – took place almost overnight. This report highlights many examples of how collaboration among services has made a real difference to people’s care.

The challenge now will be to keep and develop the best aspects of these new ways of delivering services while making sure that no one is disadvantaged in the process. COVID-19 has magnified inequalities across the health and care system – a seismic upheaval that risks turning fault lines into chasms.

At the start of the pandemic, the focus on acute care was driven by the urgent imperative that the NHS should not be overwhelmed. Decisions were made in order to ensure capacity as quickly as possible – but as we move past the initial peak of the pandemic, priorities need to be reset in a more sophisticated way to ensure that the longer-term response includes everyone, regardless of what type of care they need or where they receive it.

This resetting of priorities starts with local leaders being empowered and having the capacity to respond together to the needs of their area. The fact that the impact of COVID-19 has been felt more severely by those who were already more likely to have poorer health outcomes, including people from Black and minority ethnic backgrounds, people with disabilities and people living in more deprived areas, makes the need for health and care services to be designed around people’s needs all the more critical.

Over the summer, CQC reviewed the way health, social care and other local services worked together in 11 parts of the country. There were differences in the way they responded to the pandemic, but there is evidence that the places with established working relationships and an understanding of need in their local area were better able to care for their local population in a time of crisis.

The reviews have brought into focus the learning that needs to be used to help plan for a longer-term response to the virus. It is essential that the right support is available for all parts of a local health and social care system to drive improvements where they are needed, and to involve voluntary and community organisations in promoting health and wellbeing.

In social care, COVID not only exposed but exacerbated existing problems. The sector, already fragile, faced significant challenges around timely access to PPE, testing and staffing – and coordinated support was less readily available than it was for the NHS.

The pandemic highlighted the unstructured relationship between government and a sector comprised of a collection of over 25,000 businesses, some of which receive public funding and some of which do not. Over a few days, COVID required the redrawing of that relationship. It also reinforced the need for more clearly defined expectations on both sides, with more extensive oversight and understanding of financial performance of businesses in order to target support.

Social care’s longstanding need for reform, investment and workforce planning has been thrown into stark relief by the pandemic. The legacy of COVID-19 must be the recognition that issues around funding, staffing and operational support need to be tackled now – not at some point in the future.

Alongside this, there needs to be a new deal for the care workforce, which develops clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation.

In the NHS, emergency departments now face the prospect of a winter that combines pre-existing pressures with the urgent demands of a pandemic. As other services restart, physical distancing will provide significant challenges, both logistically and in terms of managing capacity, alongside a backlog of people who could not access care during lockdown.

The impact of COVID-19 on the NHS in terms of elective and diagnostic work has been enormous. For people, this means life-changing operations that have still not been rescheduled, and people whose cancer remains undiagnosed or untreated. The NHS is working hard to develop innovative solutions, but it is difficult to predict the long-term consequences of these delays. These services must be protected in future so that more people do not suffer.

It will also be particularly important that those services where improvement was already not quick enough – for example mental health and maternity – do not fall further behind. While we paused routine inspections at the start of the pandemic, we have carried out risk-based inspections in response to concerns about these service areas and taken enforcement action as a result.

Alongside the recognition that COVID-19 has fundamentally changed so much, it is important to recognise what has not changed. Problems that existed before the pandemic have not gone away – and people are still more likely to receive poorer care from some types of service, and from some providers, for reasons that pre-date COVID. We will maintain scrutiny on these services, supporting improvement and taking action to protect people where necessary – and we will continue to highlight factors, including commissioning and staffing, that impact on care but cannot be resolved at provider level alone and demand a national response.

We will also be conducting targeted programmes of work specifically focused on building resilience in the health and care system as it continues to respond to COVID, and looking for opportunities to actively support providers who are trying new ways to improve people’s care.

What could the future look like? Pre-COVID, the health and care system was frequently characterised as resistant to change. COVID has demonstrated that this is not the case. The challenge now is to maintain the momentum of transformation and innovation, but to do so in a sustainable way that delivers for everyone. And the pace of change makes it more important than ever that there is a safety culture across health and social care where staff, patients and their families feel able to speak up openly about what has worked and what has not, and that learning is then shared and acted on.

There is an opportunity now for government, Parliament and health and care leaders to agree and lay out a vision for the future at both a national and local level. This should include plans for addressing the inequalities accentuated by COVID, the workforce challenges that have become even more acute, and the necessary investment in technology.

As we adjust to a COVID age, the focus must be on shaping a fairer health and care system – both for people who use services, and for those who work in them.

Ian Trenholm
Chief Executive

Peter Wyman
Chair

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State of Care 2019/20