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State of Care

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State of Care cover image

State of Care is our annual assessment of health care and social care in England.

The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.


Most of the care that we see across England is good quality and, overall, the quality is improving slightly.

But people do not always have good experiences of care and they have told us about the difficulties they face in trying to get care and support. Sometimes people don’t get the care they need until it’s too late and things have seriously worsened for them.

This struggle to access care can affect anyone.

Too many people find it hard to even get appointments, but the lack of access is especially worrying when it affects people who are less able to speak up for themselves – such as children and young people with mental health problems or people with a learning disability.

Too often, people must chase around different care services even to access basic support. In the worst cases, people end up in crisis or with the wrong kind of care.

The care given to people with a learning disability or autism is not acceptable

Some people are struggling to get access to the mental health services they need, when they need them.

This can mean that people reach a level of ‘crisis’ that requires immediate and costly intervention before getting the care they need, or that they end up in inappropriate parts of the system.


independent learning disability hospitals rated as inadequate and put into special measures

(October 2018 to September 2019)

Some people are detained in mental health services when this might have been avoided if they had been helped sooner, and then find themselves spending too long in services that are not suitable for them.

Too many people with a learning disability or autism are in hospital because of a lack of local, intensive community services.

We have concerns about the quality of inpatient wards that should be providing longer-term and highly specialised care for people.

We have shone a spotlight this year on the prolonged use of segregation for people with severe and complex problems – who should instead be receiving specialist care from staff with highly specialised skills, and in a setting that is fully tailored to their needs.

Since October 2018, we have rated as inadequate 14 independent mental health hospitals that admit people with a learning disability and/or autism, and put them into special measures.

This is an unacceptable situation. A better system of care is needed for people with a learning disability or autism who are, or are at risk of, being hospitalised, segregated and placed in overly restrictive environments. We must all work together to make this happen.

We also know that people with the most severe and enduring mental ill-health do not always have access to local, comprehensive rehabilitation services and are often in inappropriate placements far from home. This weakens support networks and the ability of family and commissioners to stay in close contact, sometimes with devastating consequences.

We are seeing issues with the availability of care. There has been a 14% fall in the number of mental health beds between 2014/15 and 2018/19. While this is in line with the national policy commitment to support people in the community, it is vital that people in crisis can access support when needed.

All of this is underpinned by significant issues around staffing and workforce.

Our inspectors are seeing too many mental health and learning disability services with people who lack the skills, training, experience or clinical support to care for patients with complex needs. In the majority of mental health inpatient services rated as inadequate or requires improvement since October 2018, the inspection reports identified a lack of appropriately skilled staff as an issue.

Other types of care are under pressure

There is pressure on all health and care services in England.

Waiting times for treatment in hospitals have continued to increase and, like many areas within the NHS, demand for elective and cancer treatments is growing, which risks making things worse.

In hospital emergency departments, performance has continued to get worse while attendances and admissions have continued to rise.


July 2019 saw the highest proportion of emergency patients spending more than four hours in A&E than any previous July for at least the last five years. What used to be a winter problem is now happening in summer as well. While other hospital services improved slightly this year, the quality of care in NHS urgent and emergency services in hospitals has deteriorated.

The stability of the adult social care market remains a particular concern.

There is still no consensus on how adult social care should be funded in the future. Twice in 2018 we had to exercise our legal duty to notify local authorities that there was a credible risk of service disruption because of potential failure of a provider’s business. An estimated 1.4 million older people (nearly one in seven) do not have access to all the care and support they need.

There are consequences, knock-on effects and extra pressures when people cannot easily access the care they need. In the 2019 GP Patient Survey, almost 1 in 8 people who did not take the appointment offered to them went to an emergency department instead.

More and better community care services are needed

More and better community services are needed to help people avoid crisis situations.

In our report on segregation, we described a common picture where people with a learning disability or autism had not had access to the help they needed as children from health, care and education services. When they encountered a crisis in their lives, there was nothing available locally to avoid going into hospital. For many, their hospital stay was prolonged because of delays in setting up the package of care they needed after they were discharged.

It takes two to three weeks to get an appointment when I’m away at university, but it takes about a week in my home town practice, so I travel back home as it's quicker to get an appointment.


In many cases, crises could have been averted if local health, care and education services had worked in unison to provide an integrated package to support them when they were young.

In all sectors, there is pressure on the availability of services to maintain people’s health and wellbeing. We have heard about the increasing concerns regarding getting care and support in the community – a lack of prevention services, early stage or low-level support, community-based NHS services and social care.

Care services and organisations need to work more closely together

The challenge for government, Parliament, commissioners, national organisations and providers is to change the way services work together so that the right services are being commissioned to deliver what people need in their local area.

Leaders need to have a more urgent focus on delivering care in innovative, collaborative ways.

Some places have better care than others. There are parts of the country with concentrations of relatively poor quality care – people living there may find it more difficult to access good care. Although there seems to be some narrowing of regional variations in quality, there are still considerable differences.

Better integrated and community services are needed to stop people being pushed into crisis.

Around the country there are a number of shared commissioning budgets between health and social care. In some areas, our staff have seen more evidence of joint commissioning approaches. For example, joint commissioning is part of the Greater Manchester Health and Social Care Partnership plan; in Manchester (one of the 10 Greater Manchester localities), there is joint commissioning governance across all health and social care. However, such integrated approaches to commissioning are not yet widespread.

When local health and social care providers work well together, people’s experience of care can be improved.

We highlighted last year, in our in-depth reviews of care for older people, the urgent necessity for change and that the barriers to working together can be broken down. Although progressing unevenly in different parts of the country, we have begun to see evidence of more integration and/or joint working emerging. Some local areas that we revisited have shown improvements.

More room and support need to be given for innovations in care

Innovation is at the heart of some of the high quality care we see – sometimes this is technological and specialised, or it might be the way in which services use smarter workforce planning to meet people’s care needs.

We encourage and support innovation that improves the quality of care for people and puts their safety first. However, where we see innovation happening, it is still more likely to be driven and supported by individual leaders or as a result of the determined efforts of local services.

Care staff are working in challenging and stressful working environments, and our work has highlighted regional variation in the ability of services to recruit and retain staff. We have seen providers and other care organisations adopting new approaches to tackling workforce issues, with a particular focus on retaining staff.

1 in 8 people

went to A&E instead of taking the GP appointment offered

Increased demand on services has prompted the development of new roles and an emphasis on upskilling existing staff. In primary care, there are increasing numbers of advanced nurse practitioners, nursing associates, physician associates, pharmacists, district nurses, mental health practitioners and social prescribing workers, all working within GP practices. The introduction of the nursing associate role has the potential to create development opportunities for staff in both adult social care and health care.

We have seen a range of technologies being used to deliver care in more effective ways and to help people get a better experience of care. This tends to be in those services with effective management and leadership, where it meets a specific need and is used to make care more person-centred. We have also seen some positive examples of technology being used to improve the experience of people with protected equality characteristics, but these have not been commonplace.

The challenge for providers and the wider local health and social care communities is to consider technology in a broader strategic sense, as an enabler of high-quality care. There is no doubt that good things are happening in many places that are benefitting people, but projects are often piecemeal. We do not yet find enough examples of joined-up thinking between commissioners and providers where new technology is central to improving the quality of care for people.

Previous State of Care reports

You can read our reports about the state of health and adult social care in England from previous years on The National Archives website.

Last updated:
22 September 2020