This is the 2021/22 edition of State of Care
- In our survey of people aged 65 and over who had recently used health or social care services, more than a third (37%) who said they were on a health waiting list did not feel well supported. Two in 5 (41%) said their ability to carry out day-to-day activities had got worse while they were waiting.
- There is variation across the country in waiting times for elective care and cancer treatment. People living in the worst performing areas were more than twice as likely to wait more than 18 weeks for treatment as people in the best performing areas.
- In our Community mental health survey 2021, 41% of all respondents reported feeling they had ‘definitely’ seen NHS mental health services often enough for their needs in the last 12 months. This was the lowest score across the period from 2014 to 2021.
- Over a third of people didn’t see or speak to anyone when they couldn’t get an appointment at their GP practice. More than 1 in 10 went to A&E.
- There has been a significant reduction in the availability of NHS dental care, particularly for children and young people.
- Around half a million people may be waiting either for an adult social care assessment, for care or a direct payment to begin, or for a review of their care. In the first 3 months of 2022, 2.2 million hours of homecare could not be delivered because of insufficient workforce capacity, leading to unmet and under-met needs.
Waiting for care
The repercussions of the COVID-19 pandemic continue to be felt by individuals, families and care staff. After the initial prioritisation of urgent care, there was a gradual push to bring health and care systems back in line with pre-pandemic levels. That recovery continues, but people are still being affected by problems ranging from frustrations in accessing regular appointments to delays that stop people getting the life-saving treatment they need when they need it. Many people are still waiting for the health and social care support and treatment they need, and many are waiting too long.
We commissioned Ipsos to carry out, in May and June 2022, a representative telephone survey of more than 4,000 people aged 65 and over who had used health or social care services in the previous 6 months. Over 1 in 5 respondents (22%) said they were currently on a waiting list for healthcare services like diagnostic tests, mental health services, consultant appointments, an operation or a therapeutic service such as physiotherapy.
We asked people whether they felt supported by health and social care services while they were on a waiting list for health services. Although just over half (53%) said they felt very or fairly well supported, more than a third (37%) did not (figure 3). As an estimate, this equates to around 800,000 older people in England who do not feel well supported while they are on a waiting list for healthcare services.
Figure 3: How supported do you feel by health and social care services while you are on a waiting list for health services?
People were also asked how the condition for which they were on a waiting list had an impact on their ability to carry out day-to-day activities.
Two in 5 people on a waiting list for health services (41%) said that the impact of their condition on their ability to carry out day-to-day activities was worse than when they were first referred, while 1 in 10 (11%) said their ability to carry out activities was better (figure 4).
People who felt they were getting worse while waiting consistently reported poorer experiences of health and social care services compared with the average across the whole sample. For example, they were less likely to rate the care and support received for their health and wellbeing over the last 6 months as good (68% compared with 78% on average), and more likely than average to rate it as poor (21% compared with 11%).
Figure 4: Thinking about the condition you are on a waiting list for, what is its impact on your ability to carry out day-to-day activities in comparison with when you were first referred?
We asked people what information, activities or services would help them to manage their condition while they were waiting for health services. Leaving aside those who said they didn’t need more help (39%), the most common answers were knowing where they were on the waiting list or how much longer they would have to wait (22%) and knowing that they were still on the list and had not been forgotten (14%).
Waiting for hospital treatment
The size and impact of people waiting for health services is explored at length in data and reports from commentators across the sector. NHS England data shows that the waiting list for planned elective NHS treatment has grown steadily since June 2020. In June 2022, there were more people than ever waiting for elective NHS care (6.7 million), which our analysis shows is an increase of over 50% since the pandemic began.
The latest results from our Adult inpatient survey show that people are having to wait longer than they would like to for their treatment and care before being admitted to hospital. The results show a decline of 3 percentage points from the previous year in satisfaction with the length of time people were on a waiting list before their hospital admission (68% to 65%).
In August 2022, the British Medical Association noted that waiting times were much longer than they were before the pandemic. The NHS England data for June 2022 showed there were more than 350,000 people who had waited over a year for treatment – a figure that is over 220 times higher than it was before the pandemic. The number of people waiting more than 18 weeks for treatment was at its highest ever level at over 2.5 million (figure 5).
Figure 5: Patients waiting more than 18 and 52 weeks for consultant-led elective treatment, England, April 2018 to June 2022
Source: NHS England, Consultant-led Referral to Treatment Waiting Times
In March 2022, the House of Commons Committee of Public Accounts noted wide variation across areas of the country in waiting times for elective care and cancer treatment. People living in the worst performing areas were more than twice as likely to wait more than 18 weeks for treatment as people in the best performing areas. And the proportion of people waiting over a year for treatment in the worst performing areas was 12 times higher than in the best performing areas.
Healthwatch has conducted research on how NHS waiting lists have affected people. Of the 2,500 people they spoke with between August and October 2021, nearly 1 in 10 (8%) said they had been waiting for more than 2 years to receive care. Treatments being cancelled was also a key concern. Healthwatch found that over the previous 18 months, 1 in 3 people (32%) had a procedure cancelled at least once; 15% had a procedure cancelled more than once.
“The first cancellation in July 2021, I was being wheeled down to surgery when they turned me around and took me back to the ward as no ICU bed available. They promised to do the surgery on 26 July 2021 and would make sure no one took my bed. I started a week in isolation at home prior to surgery, only to receive a phone call 3 days before the procedure that it was cancelled and couldn't give me another date. I have heard nothing since about another date.”
Healthwatch research – November 2021
In addition, just 15% of the people Healthwatch engaged with said they had received interim support, such as pain relief, physiotherapy or mental health support, while they waited for their hospital treatment.
“My health and mobility is decreasing with every month that goes past. Without intervention I will be wheelchair-bound instead of me walking the dog every day. I will soon need help with personal care, cleaning etc, because my conditions have not been adequately monitored and treated for 18 months.”
Healthwatch research – November 2021
Healthwatch followed this up with a survey in February 2022 of 1,000 adults on an NHS waiting list. It found that in the current hospital backlog, people from poorer households, people from ethnic minority groups, disabled people and women were more likely to have a worse experience of waiting for care. For example, it reported that:
- Almost twice as many people from poorer households (52%) who responded to their survey said long waits affected their mental health when compared with responses from more affluent households (28%).
- Over half of respondents from ethnic minority groups (57%) faced a delay to or cancellation of hospital treatment, compared with 42% of White British respondents.
The government’s Build Back Better plan in September 2021 promised to deal with the backlog by doubling its commitment in 2021/22 and spending £2 billion to start reducing the backlog, and then dedicating more than £8 billion over the subsequent 3 years to tackle it.
In February 2022 NHS England set out an ambitious delivery plan for the NHS in England to be delivering 30% more elective activity than before the pandemic by 2024/25. It set a timeline of milestones to tackle long waiting times, including ambitions that:
- By July 2022, no one would be waiting over 2 years.
- By March 2025, no one would be waiting over a year.
At the beginning of August 2022, the NHS chief executive praised NHS staff for “virtually eliminating” the 2-year waiting times – the first milestone in the delivery plan. Although there were more than 22,500 people who had been waiting 2 years or more for scans, checks, surgical procedures and other routine treatment at the start of the year, this had been reduced to 2,777, of whom 1,579 opted to defer treatment and 1,030 were very complex cases.
The delivery plan also acknowledged the challenge of predicting how quickly elective services will recover, stating that waiting lists may only begin to fall from March 2024, in expectation that around half of the 8 million ‘missing’ patients who put off seeking NHS care during the pandemic come forward.
The British Medical Association has commented on these missing patients, referring to ‘the hidden backlog’ that is storing up greater problems for the future and likely to result in worsened conditions down the line, leading to greater demand on health services.
Treating cancer patients at home in Newcastle
Some services are trying to overcome backlogs and cope with demand by expanding or being more flexible in the way they deliver care. As part of the NHS Long-Term Plan, Newcastle upon Tyne Hospitals NHS Foundation Trust has introduced 2 new initiatives.
Its day treatment cancer service previously ran 5 days a week in the Freeman Hospital’s Northern Centre for Cancer Care. This managed emergency admissions and over 60 patients a day for chemotherapy treatment. Now it runs 7 days a week with an extra 400 appointments each month, supporting patients to receive treatment more quickly and with greater flexibility.
Combined with advances in cancer treatments, the service also gives some patients greater flexibility with appointments as they continue their day-to-day lives where possible.
Alongside this, the hospital has a new ambulatory care unit (ACU) that supports haematology and oncology patients regionally. ACUs assess, diagnose and treat patients, enabling them to go home the same day, without being admitted into hospital overnight.
This ACU has increased capacity across cancer services after implementing the CAR-T programme, an initiative also aimed to improve the experiences of those receiving treatment for cancer.
Patient care pathways have been designed to reduce inpatient bed days and unplanned admissions, and to support those patients who are eligible to receive care at home.
Patients who would usually need to be admitted an inpatient can be treated at home using new technology. This involves a programmed infusion pump that can deliver treatment twice a day at home, with only a short outpatient appointment needed to change pump cassettes. A remote system is used to monitor treatment delivery in real time, allowing the specialist team to troubleshoot without the need for patients to travel to hospital.
People cared for through this ambulatory care pathway have given positive feedback to the trust. The benefits have included better sleep, more quality time at home with family, and more involvement in decisions about care, as well as more comfortable surroundings and fewer delays. The trust is planning to further expand its ACU pathways.
During the pandemic, independent acute health providers supported NHS organisations to maintain some level of surgical procedures. These providers have also seen an increase in their self-pay and insurance-funded services since the impact of the pandemic has reduced.
This is reflected in figures from The Private Healthcare Information Network. From April to June 2019, 50,000 people opted to self-fund private treatment. For the corresponding months in 2021 (as the pandemic restrictions eased), 65,000 people chose this route. This indicates a rise of 30% in people paying for their own treatment between these 2 periods.
Rising demand for mental health care
Last year, we raised concerns about the impact of the pandemic on people’s mental health, and their ability to access the care and support they needed when they needed it. In our community mental health survey 2021, 41% of all respondents reported feeling they had ‘definitely’ seen NHS mental health services often enough for their needs in the last 12 months. This was the lowest score across the period from 2014 to 2021.
The findings from a survey of over 5,000 people by the charity Mind, published in February 2022, suggest these access problems are likely to worsen as demand increases, with 1 in 4 adults surveyed (25%) who experienced a worsening of their mental health for the first time during the pandemic saying they were yet to have a first conversation about it.
Not getting the right care at the right time can lead to people’s symptoms worsening and people seeking support from emergency departments. This year, we continued to see increasing numbers of people with mental health needs attending emergency departments in crisis and need of support.
A lack of mental health beds has then led to people staying in acute hospitals for too long or being admitted to unsuitable settings. For example, at one trust we found that patients overstaying in acute mental health facilities was a regular occurrence, with the trust reporting over 20 12-hour A&E breaches in a single month that related to patients with mental health needs. While we recognise acute trusts often take action to meet patients’ needs as best they can, these types of breaches mean that patients are not always receiving the right care and treatment when they need it.
Healthwatch carried out a review of feedback it received during 2021/22 about adult mental health services. This included analysing feedback from 581 adults as well as reviewing 28 local Healthwatch reports and one Healthwatch England report that represented the views of 4,054 people. The findings included:
- GPs vary in how well-equipped they are to support people with mental health issues, and people can struggle to get their GP to refer them for specialist mental health support.
- Waiting times are long at all stages of the mental health system.
- Crisis services are over-subscribed and therefore often inaccessible.
- Assessments can feel perfunctory and often do not lead to the outcome people want.
- Treatment often ends too early, before people feel they are ready, and without adequate follow-up support.
Through our work looking at the progress from our thematic review ‘Out of sight – Who Cares?’ , NHS England and NHS Improvement told us they are investing £2.3 billion of additional funding in mental health services by 2023/24 as part of the NHS Mental Health Implementation Plan. Some of the investment includes:
- almost £1 billion additional funding for new models of integrated primary and community services for adults with serious mental illness
- around £300 million in enhancing adult mental health crisis services, including a range of alternative crisis services in every part of the country
- all mental health crisis services to be ‘open access’, through 24-hour urgent mental health helplines, by 2024. This means that anyone can self-refer and there should be no exclusions. NHS England and NHS Improvement will share guidance on making reasonable adjustments for people with a learning disability and autistic people who call these lines
- ring-fenced investment in models such as crisis houses, sanctuaries and crisis cafes in all parts of the country.
While we welcome this additional funding, this needs to be supported by plans to ensure that there is a workforce to deliver these services.
Through our work this year, we have found that issues around workforce and staffing shortages remain the greatest challenge for the sector. Not having enough staff with the right skill mix can affect the safety of people who use services and have a negative effect on the quality of care they receive. As highlighted last year in our July 2021 insight report, issues with staff competence and training, and weak leadership and lack of oversight can increase the risk of closed cultures developing.
During our provider collaboration review on the mental health care of children and young people during the COVID-19 pandemic, we heard examples of systems taking steps to try and mitigate staffing shortages. Other areas spoke about how they had ‘upskilled’ new and existing staff to try to meet demand and manage shortages.
However, the shortage of qualified mental health staff is an issue which requires a system-wide approach to ensure that there is a continual ‘pipeline’ of trained mental health professionals.
Waiting for social care
In our survey of more than 4,000 people aged 65 and over who had used health and social care services in the previous 6 months, 102 (3%, weighted base) people said that they were waiting for a care needs assessment from their local authority. Given the small sample size, the following results should be treated with caution. Of these 102 people, while more than half (57%) said they felt very or fairly well supported while they were waiting, over a third (36%) felt they were not very well or not at all well supported.
Two in 5 of those waiting for a care needs assessment (40%) said that their ability to carry out day-to-day activities was now worse than when the assessment was requested, while 15% said it was now better. These views are similar to those expressed by those in the same survey who reported being on a waiting list for health services.
We asked what information, activities or services would help to keep people safe while they wait for the needs assessment. Leaving aside those who said they didn’t need anything else (31%), the most common answers were knowing when they will have the needs assessment (19%) and getting more information about how social care services work and how to access them (17%).
Survey findings from the Association of Directors of Adult Social Services (ADASS) indicated that, at the end of February 2022, around half a million people may be waiting either for an adult social care assessment, for care or a direct payment to start, or for a review of their care. The report said that:
- In January and March 2022, more than 6 in 10 councils that responded (61%) said they were having to prioritise assessments and were only able to respond to people where abuse or neglect was highlighted, for hospital discharge or after a temporary period of residential care to support recovery and reablement.
- Between January and March 2022, a total of over 2.2 million hours of homecare could not be delivered because of insufficient workforce capacity. This figure is 7 times greater than it was in spring 2021 – an average of over 170,000 hours of homecare not being delivered each week, leading to unmet and under-met needs.
During our urgent and emergency care reviews we saw that reduced access to local authority assessment, and re-assessment when needs changed, caused delayed discharges from hospitals.
The impact of these issues is reflected in analysis published in September 2022 by Age UK for the Care and Support Alliance on the numbers of people who require assistance with one or more activities of daily living, like washing and eating. They estimate that 2.6 million people aged 50 and above are living with some form of unmet need for care in England.
Waiting for a care assessment
Faizan supports his grandmother, Sharnaz who is in her 80s and lives in her own home. She is diabetic and has problems with mobility, so needs help with taking her medication and personal care, such as washing and dressing.
For several years, the family have supported Sharnaz by juggling informal care between them. But this is a big commitment, and Faizan feels guilty about not always being able to see her as much as he’d like, or to respond to her calls quickly enough because he is working or looking after his own children.
In summer 2021, because Sharnaz’s care needs had increased, Faizan contacted his local council to request a needs assessment to provide more formal care. They soon called him back to take some details, so that they could arrange a visit.
A year on, and that assessment has still not taken place. Two visits have been postponed by the social care team. After the second postponement, Faizan called to investigate. A social worker explained that they were really struggling with demand and staffing issues, especially COVID-19 sickness absence, and were having to prioritise emergencies, such as people who have had a fall.
In the meantime, Sharnaz’s needs have increased further, and she’s become more anxious. Faizan thinks this has been made worse by the pandemic, because she feels isolated, so she doesn’t have anyone to share her worries with, so they get bottled up.
The family have so far managed to meet Sharnaz’s support needs through semi-formal arrangements with contacts in the local Pakistani community, but this is not sufficient in the long-term. Faizan can feel embarrassed because he doesn’t want to over-burden friends and acquaintances. Also, Sharnaz can feel uncomfortable having some members of her community supporting her with more personal care, so has delayed having a bath until a family member has arrived.
Although Faizan understands the pressures that social care services are under, he is getting more and more anxious and keen to organise his grandmother’s care in a professional, dignified way that keeps her safe and promotes her health and wellbeing.
Interview with a member of the public
Accessing primary care
The main interaction with health and social care services for many people is with their local GP practice or NHS dental practice. Good access to these services helps people to get care in the right place for their needs, and relieves pressure on other parts of the local health and care system.
Overall, people are less happy with primary care services than with other NHS services. In the 2021 British Social Attitudes Survey, people were most likely to be dissatisfied with NHS dental services – bottom out of all NHS services. Satisfaction with GP services was second to bottom. Responding to this survey, a joint report from the King’s Fund and Nuffield Trust highlighted an “unprecedented” change. Satisfaction with GP services fell by 30 percentage points, from 68% of people reporting being satisfied in 2019 to only 38% in 2021. This is the lowest level recorded since the survey began in 1983. The numbers who were dissatisfied rose from 20% to 42%. Until 2018, GP services were always the highest rated in the survey.
General practice is busier than ever – general practice appointments were the highest ever recorded during the winter of 2021/22. NHS Digital's experimental data shows that in June 2022, just under half (49%) of appointments were with a GP, while others were with nurses and various other healthcare professionals. Nearly two-thirds (65%) of appointments were recorded as face-to-face. Of all appointments, 44% happened the same day as booked, and nearly 3 in 10 people (29%) waited 8 days or longer for their appointment.
In August 2022, the Royal College of GPs highlighted the hard work, dedication and resilience of GP teams, working in the face of intense workload and workforce challenges, to deliver timely, appropriate care for their patients; and how 26 million consultations to patients were delivered in July 2022, considerably more than in the corresponding month in 2019, before the pandemic.
The 2022 GP Patient Survey shows that people’s overall experience of making an appointment worsened considerably, compared with 2021, with the percentage of respondents who said they had a good experience falling from 71% to 56%. Where people did not get an appointment, more than 4 in 10 (42%) said this was because they were not offered one, while over a quarter (28%) said this was because there weren’t any appointments available for the time or day they wanted.
More people overall have been trying to make appointments this year (71% compared with 63% last year). But the survey also shows that more people said they had avoided making appointments – over half (55%) compared with 42% last year. Previously, people said they didn’t want to catch COVID-19 or burden the NHS – now they say they are not trying to make appointments because they find it too difficult.
More than 1 in 10 people (11%) who did not get an appointment at their GP practice said they went to A&E and just under 11% called NHS 111. However, over a third of respondents (34%) said they didn’t see or speak to anyone. This is concerning as delayed or missed diagnosis could lead to worsening health and outcomes.
We found similar sentiment from an online survey we commissioned about people’s access to a GP practice and their experiences in November 2021. The sample was 2,087 adults in England who had tried, successfully or not, to access a GP service in the previous 12 months. Where respondents did not get an appointment:
- 25% didn’t see or speak to anyone.
- 25% decided to contact their practice at another time.
- 16% attempted to self-diagnose using an internet search.
- 10% went to A&E.
We collect information from people about all kinds of health and social care services – this often comes through our website and our Give Feedback on Care service. From this feedback, we can see that the experience of accessing GP care was frustrating for many people who contacted us.
From our analysis of a random sample of feedback received through Give Feedback on Care during October 2021 (410 comments), the most common issue for people was trying to book an appointment on the phone – nearly a third (31%) of the comments in our sample mentioned this. Over a fifth (22%) said there were no appointments available – and 18% felt the person they spoke to was a barrier to getting an appointment. Nearly 1 in 10 (9%) thought their GP was not addressing all their concerns or taking their symptoms seriously. These issues were also prevalent in a more recent random sample of Give Feedback on Care comments we reviewed (113 comments, January to March 2022).
In our November 2021 online survey about access to a GP practice, a third (34%) of people said it was ‘not very easy’ or ‘not at all easy’ to book their most recent appointment – and another 14% said they were unsuccessful. Regionally, people in the Midlands and East of England were more likely to report challenges in trying to get an appointment.
“Trying to get an appointment is near impossible every time… on more than one occasion I have had to use the NHS 111 service and accident and emergency as I can never speak to someone about my child. Any time I have received an appointment for my child, the doctors and staff always seem very dismissive. They are patronising and disregard information, making me feel belittled. Due to COVID we haven't been able to change surgery. I know I am not the only person who attends this practice to feel like this. It is unfair to have such a bad and unorganised medical practice running."
Anonymous, through Give Feedback on Care
“I have rung numerous times and have been in a queue for nearly one hour, with no answer. One time recently I went into the surgery, whilst still in the queue on my phone, and the phone wasn’t even ringing in reception! I asked the receptionist why… they said it had been muted because they were busy… but there were no patients in the waiting room.”
Anonymous, through Give Feedback on Care
The GP Patient Survey showed that people’s overall experience of their GP practice has also deteriorated considerably in 2022, falling by more than 10 percentage points since last year. In 2022 just over 7 in 10 respondents (72%) described their overall experience of their GP practice as ‘good’. This is the lowest level it has been in 5 years. The proportion of people describing their overall experience as ‘very poor’ more than doubled from 2.4% in 2021 to 5.6% in 2022.
Across the country, areas in the South West and West Midlands reported the best experience of their GP practices, while London, Essex, Kent and parts of central Midlands reported the worst experience. Inequalities in experiences are also apparent, with people from more deprived areas, disabled people, carers, people from Bangladeshi, Pakistani, and Gypsy or Irish Traveller backgrounds, people from Muslim and Sikh communities, people whose gender identity is different to their sex registered at birth, people who prefer to self-describe their gender identity or identify as non-binary, and gay, lesbian and bisexual people all reporting worse overall experiences.
Shafi was unhappy with the service he was getting from his GP practice. He’d rung up several times to get appointments for his children, but they kept being pushed back, so they weren’t being seen at the right time. He put a complaint into the practice.
As a result of the complaint, Shafi was seen by one of the practice partners, who explained simply how much pressure they’d been under during the pandemic. For example, the GP said he’d often been the only one working because of staff sickness.
Shafi found the GP’s explanation to be very honest and open, and typified other conversations he’d had with health and care professionals over the pandemic. Despite the many terrible outcomes from COVID-19, he thinks the pandemic has broken down some barriers between professionals and people using health and care services, and created a culture of improved transparency and honesty.
Interview with a member of the public
In our online survey about access to a GP practice, we asked people to tell us whether their appointments met their health and care needs. Of the respondents, 42% said their needs were definitely met and the same percentage said they were partly met, while 15% said their needs were ‘not at all’ met by their appointments. More than half of the people who responded (58%) told us that they felt their access to GPs had worsened since the pandemic. This varied by region – for example, higher proportions of people in the North and the Midlands said it had worsened (59% and 61% respectively) and a lower proportion said the same in London (52%).
COVID-19 had a severe impact on dental services and there was a significant reduction in the number of treatments delivered for people.
Units of dental activity provide a measure of how much NHS dental treatment has been delivered (with more complicated courses of treatment being made up of more units). Data from NHS Digital for 2021/22 shows that the average quarterly units of NHS dental activity were nearly 30% lower than the average levels of activity in the 2 years before the pandemic, although activity was picking up towards the end of the year (figure 6).
Figure 6. Total units of NHS dental activity, England, 2018/19 to 2021/22
The data shows geographical variation. For example, London had the lowest figures up to the end of June 2022: only a third (33%) of adults had seen an NHS dentist in the previous 2 years and just 4 in 10 children (41%) had seen an NHS dentist in the previous year. In contrast, over 40% of adults in the North East and Yorkshire and half (50%) of children in the North West had seen an NHS dentist over the same respective periods.
The main shortfall in treatment was in ‘Band 1’, which covers routine check-ups and simple treatments. Band 2 and Band 3 treatments, which cover increasingly complex treatments, were also lower than pre-pandemic levels. The number of urgent treatments in 2021/22 was slightly higher than pre-pandemic levels.
In January 2022, NHS England announced a one-off £50 million fund to enable up to 350,000 additional dental appointments, for a limited time. This was split regionally – the priority was to treat children, people with a learning disability, autistic people, and people with severe mental health problems. The initiative aimed to catch up on missed dental appointments, with extra money for dentists delivering care outside core hours, such as early mornings and weekends.
In a May 2022 report, the Association of Dental Groups said the funding was unlikely to recover the backlog of care or “shore up the finances of the many practices struggling to provide NHS services”.
From reviewing a random sample of comments from our Give Feedback on Care service about dental services (127 contacts, March to May 2022), we know that problems with booking NHS dental appointments continues to be a prominent theme. People reported being told there are no appointments available for days or sometimes months ahead. They have also told us about the frustration of appointments being cancelled with little warning or explanation.
“My children are registered with this dentist and have been unable to receive a check up, with the practice cancelling appointments several times with no reason given.”
Anonymous, Give Feedback on Care
“I am concerned that my children have not been seen by a dentist at this practice for over two years. This is in part due to COVID, but also because the practice keeps cancelling appointments. They typically say that this is down to them not having an NHS dentist available at the time booked and they advise that they will contact me to rearrange the appointment, but I never hear anything more. It is then up to me to chase another appointment, which invariably gets cancelled by them again. I fear for the state of my children's teeth as it has now been so long since they have had a check-up.”
Anonymous, through Give Feedback on Care
There is distress for people who have not been able to get regular dental check-ups for extended periods. Some people told us they were left in pain or with worsening dental issues.
Some people told us they felt pressured to choose private dental care because they could not get NHS care. They noticed a lack of NHS appointments, while private appointments were available.
We also heard about people feeling unwelcome as NHS patients, particularly if they needed urgent treatment – and some said they were left in pain or discomfort because they chose not to pay for private treatment.
“I am a registered NHS patient at this practice… I attended for an urgent appointment due to a dental emergency… the dentist made no attempt to build rapport with me. Instead they moved quickly into upselling different private treatments. [I was] advised the procedure was very expensive… they said, because it was no longer covered under the NHS treatment offer. They were aggressively trying to sell the treatment and in no way made any effort to help. I ended the consultation after the first x-ray as I feared this treatment would begin to cost too much. I left the dental practice after paying a fee with no dental work completed and I now have severe pain.”
Anonymous, through Give Feedback on Care
Other issues included being deregistered as an NHS patient at a dental practice without warning – some were told it was because they had not attended appointments during the pandemic. Some people told us how they struggled to get the care they needed through the NHS. In one example from feedback submitted in April 2022, we were told that a dentist told the patient that “none of the procedures are available on the NHS”.
These experiences of trying to get NHS dental care are corroborated in other reports. The 2022 GP Patient Survey that ran between January and April 2022 found the number of people trying to get NHS dental care had continued on a downward trend (down to under 52% from 56% the previous year). In this survey, of the people who had tried to get an appointment over the past 2 years, more than 1 in 10 (12%) said they could not get an appointment because none were available. The same survey shows a continuation in the decline of people’s experience of NHS dental care.
Healthwatch analysed data supplied by NHS Digital in December 2021. It found that 7 of the 42 integrated care systems reported having no practices taking on new adult NHS patients.
In August 2022, the BBC published the results of an investigation that was supported by the British Dental Association (BDA) and in which the BDA expressed the feeling of crisis that dentists share alongside their patients. The BDA reports that it worked with the BBC, which identified 8,533 dental practices across the UK that were believed to hold NHS contracts. The BDA says that the BBC attempted to call them all and nearly 7,000 were contacted. Their survey shows:
- Across England, 9 out of 10 (91%) NHS dental practices were not accepting new adult patients (4,933 of 5,416). This was highest in the East Midlands (97%), South West, North West and Yorkshire and the Humber (98% respectively).
- Where English practices were not taking on adult patients, nearly a quarter (23%) said they had an open waiting list, while 16% said the wait time was a year or longer, or they were unable to say how long it would be.
- BBC researchers were unable to reach any practices who were accepting new adult NHS patients in over a third (37%) of the 152 local authorities in England.
- Across England, 8 out of 10 (79%) NHS dental practices were not accepting new child patients (4,293 of 5,416).
In June 2019, we published Smiling matters, a report on the state of oral health in care homes. We plan to update on the findings from this report in the coming months.
Prisons and secure settings
The main challenges to accessing health care for people in prisons and other secure settings during 2021/22 were mostly influenced by COVID-19-related restrictions.
COVID restrictions continued within secure settings beyond the timeframes seen in the community. Prisoners frequently missed appointments during the pandemic because the prison officers who were needed to collect and escort them to healthcare appointments were ill or testing positive. This shortage made it more difficult for dental patients because some prisons required a trained officer to wear full personal protective equipment and wait outside the dental room in case of an incident.
However, the pandemic sparked more innovative ways of working. Some of these were temporary due to restrictions but others are expected to continue and will improve patient access. There was improved cross-working between prison and healthcare staff as increased reliance was placed on working together to ensure prisoners received health care, and also improved working relationships between healthcare services in secure settings and local hospitals receiving patients for treatment.
The NHS Mental Health Secure Care Programme was established in 2016 to deliver the recommendations in the Five Year Forward View for Mental Health for care in the least restrictive setting, as close to home as possible and with a stronger focus on recovery. The programme aims to improve the experience and outcomes of people using secure mental health services, substantially reduce the number of people sent ‘out of area’ for care, and reduce the dependency on hospital beds through increased community provision.
Between April and May 2021, CQC and other agencies supported HM Inspectorate of Probation in carrying out a joint thematic inspection. This followed the progress of people with mental health needs through the criminal justice system, from first contact with the police to release from prison. Liaison and diversion services identify people who have mental health needs, a learning disability, substance misuse or other vulnerabilities when they first come into contact with the criminal justice system as suspects, defendants or offenders. These services can then support people through the early stages of criminal system pathway, refer them for appropriate health or social care, or enable them to be diverted away from the criminal justice system into a more appropriate setting, if needed.
The review found that:
- There was significant inconsistency across the country in the provision and input from liaison and diversion services into court settings. We identified various reasons for this including commissioning arrangements, the capacity of providers, and the pandemic. This can affect information sharing and joint working with probation teams.
- Different areas use different operational systems, which can work well where the same providers deliver liaison and diversion as well as community mental health services, and when community and prison health providers use the same systems and share access. However, not having access to operational systems can be a barrier when different providers are commissioned, and different ones are in use. This can affect the timeliness and quality of information sharing with partners.
- Since the previous thematic review, there had been an improvement in staffing models, with a variety of different roles within liaison and diversion teams including social workers, learning disability nurses, psychologists and mental health nurses.
- The use of peer mentors was invaluable during the pandemic to maintain contact with patients, offer practical support, and encourage them to engage with services.
In February 2022, the Justice Select Committee published the government’s response to its fifth report on mental health in prisons. This noted that the Ministry of Justice, HM Prison and Probation Service, the Department of Health and Social Care and NHS England continue to work together to identify and meet the mental health needs of prisoners, as well as putting measures in place to ensure they can access treatment in the right place.
Capacity and stability in adult social care
Adult social care plays a vital role in keeping people well – either in their own homes or in residential settings.
For a large part of 2021/22, care home visiting has been restricted. This has meant that people were often unable to visit services to decide whether they or their family member wished to become a resident. Restrictions also had an impact on residents’ wellbeing, as family members were often not able to visit and some residents could only see family members through a window. This could be particularly hard for people who may not have been able to understand the reasons for the restrictions, including people with dementia, which can lead to feelings of isolation and confusion.
The impact of this on people living in these services and their loved ones cannot be underestimated. At times, these restrictions have been at odds with those imposed on most of society.
The pandemic has disrupted the delivery of care within the service. The units and staff have for a large part been operated as self-contained units. All home activities such as external entertainers have been largely absent and visiting by family members severely restricted. Visits by the local school children have been stopped. This was normally a joyous occasion for our residents to interact with these children. Visits behind clear screens felt unnatural and although we utilise video calling, all this lacks the emotions of a proper visit with a hug. This has been very upsetting for all. Staff have been wonderful in maintaining personal interaction with residents. Incidents of self-isolation for residents have been particularly difficult and are contrary to the inclusive culture of our home. This is especially true for new admissions when we feel mixing with others and gaining familiarity within the wider home is most important.
Submission to CQC care home provider information return (April/May 2022)
However, many care home staff have helped people to have regular contact with their relatives throughout the pandemic, and some providers have learned lessons from it for the future. When social restrictions ended, one provider continued to provide outreach support to people who had not always had the opportunity to engage in social activities and meet other people, due to the closure of many facilities. This helped to protect people from the risks of social isolation and enabled them to engage in the community. A family member told us, “Even when we had lockdown they had exercises on the computer and got in touch. [My family member] was so excited to see her friends and the staff, it was a way of keeping in touch.”
Other access issues have been influenced by the pandemic. For example, people’s choices about social care have been affected, with people staying at home longer rather than move into residential care. This increase in demand for homecare services, at a time when workforces are stretched, has led to large waiting lists. It has also led to delayed discharges from hospitals when there is no appropriate homecare available to facilitate a safe and person-centred discharge back home. In some cases, healthcare leaders are taking action to build more capacity in social care, to tackle unmet need in an area, and in recognition of the benefits for their whole local system. One example was the announcement by Northumbria Healthcare NHS Foundation Trust of its intention to provide home care services in North Tyneside and Northumberland.
In July 2022, the Association of Directors of Adult Social Services signalled the rising demand for adult social care in its Spring Budget Survey 2022. Responses from 144 out of 152 councils, in May to June 2022, included:
- 78% of directors said more people are seeking support because ofmental health issues.
- 67% said they are seeing more people because of domestic abuse and safeguarding concerns.
- 73% reported rising numbers of breakdowns of unpaid carer arrangements.
Furthermore, directors said they are receiving more and more requests for support because of pressures elsewhere – for example,82% reported increased referrals for people discharged from hospital.
In July 2022, Skills for Care reported a 50,000 fall in filled posts across the whole of adult social care between 2020/21 and 2021/22. This reflects figures in a Nuffield Trust report in December 2021 suggesting that the reduction in staff “is fuelling an invisible care crisis in people’s own homes with many unable to access the care they need, increasing care burdens on unpaid carers and impacting hospital discharges”.
Some areas have seen homecare providers handing care packages back to the local authority, as they are unable to fulfil their obligations to the people who use their services. One provider gave up 800 hours of care contracts due to insufficient numbers of staff and their inability to recruit.
We have seen a similar picture in other regions. Local authorities have told us they are concerned providers were handing back care contracts because they could not manage workforce shortages and demand.
However, we also continue to hear about local authorities that commission homecare in 15-minute blocks, which can lead to rushed or poor care. Some providers have refused to take up local authority contracts and only offer their service to people who pay for their own care. These providers tend to focus on 60-minute minimum care calls. They tend to have improved staff retention and recruitment (as they offer higher hourly rates) and overall satisfaction from people who use their service.
The pandemic also continued to have a significant impact on people’s access to care homes during 2021/22.
When care homes had outbreaks of COVID-19, many were unable to admit people for prolonged periods. In some areas this had a very significant impact on hospital discharges and transfers of care.
Workforce shortages and infection outbreaks have resulted in a reduction in care home capacity, which has been particularly acute in some regions. A number of registered providers have chosen to hold empty beds because they were unable to provide care workers to staff them.
Experimental data published by ONSusing CQC’s provider information returns shows that between March 2021 and February 2022, 77.8% of care home beds were occupied.
More recent data from our provider information returns suggests occupancy is increasing, with figures for August 2022 up to 82.5%. However, this is still below the pre-pandemic occupancy rates of 84.7% captured in provider information returns between August 2019 and February 2020, and published by ONS.
Data from our register of adult social care services shows that it was not only care home occupancy that has been affected, as we have continued to see changes in the market. Between March 2021 and August 2022, there was a 2.4% reduction in the number of registered care homes (366 fewer locations). The South East had the biggest reduction in the number of care homes (96 fewer locations). However, proportionally the reduction was greatest in the South West (a reduction of 3.7%, amounting to 75 locations).
While the number of services has reduced, the total number of care home beds appears to have only reduced by 0.35% over this period, although this does amount to 1,611 fewer beds. The South West had the biggest reduction in care home beds, both proportionally and in number, with a reduction of 1.6%, amounting to 855 fewer beds. The South West therefore accounts for over half (53%) of the national loss in care home beds between March 2021 and August 2022.
There were particular challenges around assessment of people’s needs before being admitted to a care home. Health and social care professionals were not always able or available to carry out needs assessments in people’s own homes. Any assessments that did take place were focused on people with the highest care needs. This resulted in many people experiencing unmet needs.
Similarly, care home staff were unable to carry out face-to-face assessments and had to rely on either video technology, or the view of other healthcare professionals who were not familiar with the specific care home environment. This meant people were at risk of being admitted to services that were not able to meet their needs, either because of staff skill sets or lack of specific equipment. It also meant that people who were not digitally aware were unable to access these assessments.
We want to get to know the residents before they come to the home. We typically discuss the placement with the resident, families, friends, social workers and any professionals who are involved in their care. We have unfortunately found that professionals and social workers are stretched for time and typically haven't met the resident. Families/friends struggle with highlighting some areas of their care. You don’t get to know the resident in the same manner as you cannot sit with them and see their expressions or visibly see them walk. To ensure that we remain safe and can meet the needs of residents, we’ve been more cautious in our approach. We’ve kept all admissions to residents with no areas of concern and rejected admissions if there are potential concerns. We ensure that we talk to several professionals and family/friends where possible to ensure we have consistent, good quality information for the resident.
Submission to CQC care home provider information return (April/May 2022)
In the section on workforce in this report, we highlight that providers are struggling to recruit and retain enough skilled staff, which is having a knock-on effect on access to care services and leading to unmet needs. In adult social care, which is predominantly private-sector based and dependent on profit, these challenges are also influencing the financial stability and sustainability of providers.
Data from our Market Oversight scheme gives insight into the state of the adult social care market. The scheme covers providers that have a large local or regional presence which, if they were to fail, could disrupt continuity of care in a local authority area.
For non-specialist care homes (principally those that care for older people), although staff costs decreased throughout 2021, reflecting a reduction in bed occupancy, they have started to rise in 2021/22, partly due to the need to pay more to recruit and retain staff. Between September 2021 and March 2022, staff costs as a percentage of turnover rose by 3.8 percentage points.
This will also be affected by increased use of agency staff. By the end of March 2022, agency staff costs made up 13.2% of total staff costs. This is 4 percentage points above what it was at the end of March 2020 (the start of the pandemic), and well over double what it accounted for at the end of June 2021, when there were restrictions on staff movement between care homes, which included agency and bank staff (figure 7). The increasing cost of living is likely to have a further impact, which may result in more staff leaving care services for better-paid work.
Figure 7: Quarterly agency staff costs in non-specialist care homes as a percentage of all staff costs, England, January 2020 to March 2022
Increasing staff and operating costs, and the lack of full recovery in care home occupancy, are having a significant reduction on profitability in non-specialist care homes. Profit margins (as calculated using ‘EBITDARM’, which is a high-level measure of profit that excludes key expenses such as rent, depreciation and interest charges) have fluctuated over the course of the pandemic, but at March 2022 were at their lowest levels since the pandemic began, and even since the Market Oversight scheme began in 2015 (figure 8).
Figure 8: Quarterly profitability (as measured by EBITDARM) in non-specialist care homes, England, January 2020 to March 2022
We can see a similar pattern of increasing costs and reducing profit margins in non-specialist homecare providers in the Market Oversight scheme.
As staffing costs increased, profit margins for homecare providers in the scheme started to fall after June 2021, decreasing from 15.3% to 13.2% at the end of March 2022.
The Homecare Association says that the minimum hourly rate for homecare services should be £23.20.
However, the average national rate that commissioners pay for homecare is £18 an hour. Providers regularly state this has a negative impact on recruitment and retention, as well as their ability to appropriately reward their staff. Skills for Care and the Association of Directors of Adult Social Services recently organised a conference in the East Midlands (where the hourly rate ranges from £15.50 to £19.50 an hour). The event included presentations to homecare providers on how to advise their staff about accessing local foodbanks or claiming benefits to top up their wages.
Petrol and diesel prices have also had an impact on homecare staff who rely on a car to get them to their visits. Our adult social care workforce survey showed that, of the homecare services that provided information about retention challenges, nearly a quarter (23%) reported challenges related to the increased cost of petrol.
Some providers have told us they are having to increase fuel allowances to avoid losing staff to care homes and other sectors, but we also still see providers who do not pay for travel expenses or travel time, or who have not increased their pay to reflect the increase in these costs.
We are also hearing how the increasing cost of car ownership is not matched by increasing car allowance – and that some providers have put an annual ceiling on mileage which workers reached in 6 months, so they either leave or have to pay for their own mileage. In the South East, we heard of an unprecedented number of care worker resignations during May and June 2022, citing fuel costs (which peaked in June) as the reason for their decision.
Inflationary pressures are being felt in domestic households across the country, driven by cost increases in essentials such as food, electricity and gas. These soaring energy bills and food prices are also hitting care homes very hard.
The combination of increased wages to retain staff, increased running costs and the withdrawal of short-term government COVID-19 support, such as the infection control fund at the end of March 2022, have all increased the financial pressures on social care.
The Association of Directors of Adult Social Services, in its Spring Budget Survey 2022, reported that market instability is a major concern for directors, with 67% reporting that providers in their area had closed, ceased trading, or handed back local authority contracts. This is a significantly worse picture than last year and before the pandemic. It is also reflected by the fact that 64% of directors say they were concerned about their legal responsibilities in relation to market stability, and they believe the situation will get worse into next year.
We are concerned that, if financial pressures continue, capacity in the adult social care market will be further constrained, and this will have knock-on implications for the NHS – all of which could make for a winter that is likely to be far tougher than anything experienced previously. If there is a repeat of the levels of COVID-19 community infection rates seen in previous winters, leading to increased staff sickness and care home lockdowns, these capacity challenges will only increase further.
“The impact of the increases in national living wage, fuel prices, insurance costs (more than doubled this year), employers national insurance, food etc is having an unprecedented impact on life at the care home, as profit is necessary to operate and reinvest. Savings will not last for ever.
For the last 2+ years the messages in the public media have been largely negative in terms of care home living. They have focused on the devastating impact COVID-19 has had. The upshot of COVID-19 for us is we shut down, we slowly had more and more empty beds, and now the threat is beginning to lift, we are seeing virtually no private enquiries, so we have been compelled to fill beds with local authority-funded people at a loss. At the time of writing this we have 6 empty beds out of 28 and zero private enquiries. The director writes an article in a free, local monthly magazine trying to be upbeat about residential care, but the message needs to be national.
Submission to CQC care home provider information return (April/May 2022)
Increased stability in social care is needed because it is also key in easing pressure on the NHS at both the front and back doors, by reducing emergency attendances and delayed discharges. This can support the development of new models for urgent and emergency care, in which people are less likely to be inappropriately funnelled towards emergency departments, and where primary care services are able to focus on those with multiple health conditions.
We welcome the government’s 10-year reform programme of adult social care, set out in its People at the Heart of Care white paper, and the investment to reform social care. However, providers have told us they are confused by the plans. And we note that organisations, such as the Local Government Association, have questioned whether the funding allocated will fully resource councils and providers in delivering the government’s objectives.
We therefore urge government and other stakeholders to continue to engage with people who use services, registered care providers, and their workforce to make sure that investment and reform work effectively to transform adult social care so that it can carry out its essential role of enhancing the day-to-day health, wellbeing and experiences of people using services in their community.