In this year's State of Care, the Care Quality Commission (CQC) reports on a social care market in flux, changing shape rapidly but without a clear destination.
Meanwhile, persistent inequalities across the whole health and care system mean people's experience of care is fractured and heavily dependent on where they live and who they are.
Demand for health and adult social care continues to grow, and in many areas, including community mental health services, need is also becoming more complex. There are signs of improvement, including more GP appointments, increased use of digital solutions, and shorter waits for elective care. The report highlights examples of local innovation, including neighbourhood models and integrated teams.
But improvement is struggling to keep pace with rising demand. The report finds unwarranted variation in access to services, the quality of care and outcomes for people across every part of the system CQC regulates.
Inequalities across health and care, with children hit hardest
Children and young people are experiencing some of the sharpest increases in need and waiting times, even as some adult waiting times have improved. This is illustrated particularly starkly in community health services, where over 80,000 children and young people – almost 11 times the number of adults – have been waiting over a year for an appointment. At the same time, the number of children waiting for their first contact with mental health services rose 31% in 2 years. Health visitor and school nursing numbers continue to decline despite growing demand, undermining early identification of need and safeguarding for children and young people.
Deprivation continues to shape people’s outcomes from care. Hospital admission rates for children and young people with conditions including bronchiolitis, asthma and diabetes with links to social deprivation vary sharply by region, and levels of tooth decay for children living in the most deprived areas are more than double those in the least deprived areas.
Unwarranted variation extends across the system. In primary care, ratios of staff to registered patients vary considerably by area, which can affect the quality of care people receive. Uptake of annual health checks for people with severe mental illness ranges widely by ICB area, despite this group facing a significantly increased risk of premature death. In hospitals, CQC's analysis found variation in maternal readmissions by ethnicity, reflecting entrenched disparities in maternal safety for Black women.
A social care market changing shape by accident, not design
The adult social care market is changing rapidly. Underpinning much of this change is the varying ability of local authorities to plan for the care their communities need in line with a clear strategy, alongside a funding model that remains fragile. This is leaving care providers and local authorities exposed to pressures that are reshaping the market by accident rather than design. Homecare is fragmenting, with a growing number of small providers entering the market, while care homes are consolidating, with more of the available care home beds now located in large care homes and recent increases in institutional investors acquiring homes. These divergent trends – consolidation of care home ownership by institutional investors, and fragmentation of community-based provision – look likely to continue. CQC will continue to monitor quality carefully to ensure this does not have an impact on either personalisation of, or access to, care.
Commissioning is one of the most powerful levers to drive quality, equity and sustainability in social care, as CQC's local authority assessments have highlighted. Where it is done well, it can make a real difference to people’s care both now and in the future. In Wigan, CQC’s assessment rated the council as outstanding, as it worked collaboratively with providers and people who use services to shape the local market and tackle health inequalities. By developing more local provision, it reduced reliance on care placements outside the borough. Its reablement service, rated outstanding and delivered jointly with health partners, means fewer people need ongoing support a year after leaving.
But within this changing market, some local authorities are struggling to meet people's needs, and providers are increasingly seeking people who can self-fund their care in order to remain viable. This risks reducing choice and capacity for people who rely on council-funded support, which is already subject to significant regional variation.
This comes despite some improvements in social care staffing, with vacancy and turnover rates falling slightly, although concerns remain about reduced international recruitment. It is a testament to hard-working care staff that almost three-quarters of the sector is rated as good or outstanding, but CQC has identified leadership as the area most in need of improvement. Inspections show clearly that well-led services deliver safer, more person-centred care.
Chris Badger, Chief Inspector of Adult Social Care and Integrated Care, said:
This year's State of Care report finds the social care market changing shape rapidly, while inequalities persist across the whole health and care system.
In social care, we're seeing sharply divergent trends, with more of the available care home beds concentrating in large homes, alongside a recent increase in institutional investors acquiring care homes - while homecare fragments into a growing number of smaller providers. This reshaping is happening largely by accident rather than design; driven by a combination of economic pressure and local authorities' differing abilities to plan for and shape the care their communities will need.
A clearer vision is needed. In addition to the sustainable funding solution CQC has consistently called for, commissioning needs to improve so the market can be shaped around what's best for people, and in a way that ensures care staff can be employed fairly. Our assessments of local authorities have found that done well, commissioning can help build more resilient care markets where more people are helped to stay out of hospital and get care closer to home. Investment in leadership capability is also needed – well-led services deliver safer, better care.
Ten years ago, we warned that adult social care was approaching a tipping point. Successive governments have not resolved the issue of long-term funding for the sector. Now, this government's renewed focus on social care offers an important opportunity for meaningful solutions in social care that improve outcomes across the whole health and care landscape – but only if reforms address workforce, funding, commissioning, prevention and inequalities together.
None of this can be considered in isolation. Pressures in one part of the system compound others and are exposing fractures right across health and care, from mental health support to maternity and primary care, and in widening inequalities for children and young people. Success can't be measured by how well each part of the system performs on its own – it's how well those parts work together for the people who need them, regardless of who they are or where they live.
Baroness Julia Neuberger, CQC's Chair, said:
This year's State of Care report shows a health and care system under real strain, but one where some things are also working well.
Demand continues to rise, and in some services people are presenting with more complex needs than before. At the same time, we're seeing real improvements, from more GP appointments to shorter elective waits. But these improvements aren't keeping pace with demand everywhere, and where they fall short, it's often the same people and places bearing the consequences.
What strikes me most is how connected these pressures are. Challenges in social care provision are contributing to delays in hospital discharge. Gaps in community mental health provision are pushing more people towards crisis care.
To repair a fracturing system, there must be a collective response. Providers, regulators, commissioners and government all have a role to play in improving care, and we’ll be judged not by what we achieve alone, but by what we achieve together.
We're committed to playing our part – encouraging innovation and improvement and accelerating the progress we’ve made as an organisation. We’ll be drilling down into the areas that give us cause for concern, drawing on what we hear from people who use health and care services, as well as from their families and carers, and what we see through our regulatory work.