Access to care

Published: 20 October 2023 Page last updated: 20 October 2023

Long waits for care

Access to services remains a fundamental problem. At every point along the health and care journey, people are struggling to get the care they need when they need it.

This is reflected in the number of patients waiting for treatment. Over the last year, this has continued to increase. In June 2023, the number of people waiting for treatment was 12% higher than in June 2022. This reached record levels with almost 7.6 million people on the waiting list for planned hospital treatment (figure 1).

Figure 1: Number of people waiting for treatment, April 2021 to June 2023

Chart showing a rise in the number of people waiting for treatment

Source: NHS England Consultant-led referral to treatment times

Our recently published adult inpatient survey is based on feedback from over 63,000 people who were in hospital in November 2022. This found that 39% of patients who were on a waiting list would like to have been admitted sooner, and 41% felt their health got worse while they were on a waiting list to be admitted to hospital.

This picture is unlikely to be improved by a year of industrial action.

NHS England published information collected from NHS hospitals which indicates that, as at the end of September 2023, 119,153 operations and 895,914 outpatient appointments were rescheduled over the 48 days of strikes since December last year. However, analysis from the Nuffield Trust suggests that strikes alone are not to blame for continued long waits, given that the number of planned operations hadn’t yet recovered even to pre-pandemic levels before the strikes began.

To address the problem of long waiting lists, in February 2022 NHS England published its elective recovery plan. This set out its commitment that by April 2023, no one would have to wait more than 78 weeks for treatment. Although there has been substantial progress towards this goal, figures show that as at June 2023, there were still more than 7,000 patients waiting more than 78 weeks (down from more than 69,000 when the plan was published in February 2022).

The NHS Constitution sets out that patients should wait no longer than 18 weeks from a GP referral to starting treatment. However, the percentage of patients starting treatment within 18 weeks has continued to get worse (declining from 72% in April 2022 to 67% in June 2023). The proportion of people waiting for more than 52 weeks as at June 2023 varied between the regions in England: from 3% in both the London region and the North East and Yorkshire region, to 7% in the North West region.

Often, people are struggling to get a referral in the first place. Results of a survey by Healthwatch, published in April this year, looked at the experience of 1,500 people trying to get a referral for a hospital appointment from their GP. It highlighted the ‘hidden waiting list’ of people needing a referral for hospital treatment and found that nearly 1 in 5 people (18%) had to visit their GP 4 or more times before getting a referral. Furthermore, the survey found 11% of people had to wait over 4 months from their first GP appointment to being referred. GPs are being encouraged to use Advice and Guidance services and other community pathways before referring people to hospital, which may have contributed to this.

Waiting for treatment is not only a risk to people’s physical health, but also their mental wellbeing. In its December 2022 Winter Survey, the Office for National Statistics (ONS) reported that of the 2,524 respondents around a third (34%) of adults currently waiting to start NHS treatment said the wait had a strong negative impact on their life, while 42% reported it had a slight negative impact on their life. The most commonly reported negative impacts were:

  • ‘my wellbeing is being affected’ (59%)
  • ‘it has made my condition worse’ (36%)
  • ‘my ability to exercise is being affected’ (34%)
  • ‘my mobility is being affected’ (33%)

In the face of longer waits, some people are turning to private health care.

A recent survey of 2,000 people commissioned by the Independent Healthcare Provider Network showed that 46% of those who’d used private health care said being unable to get an NHS appointment was a factor in their decision. It also showed that 56% of people had tried to use the NHS before using private healthcare.

Furthermore, a YouGov survey of over 8,000 adults earlier this year showed that 1 in 8 respondents had used private health care in the last 12 months. Of these people, 33% said it was the first time they had used private health care instead of the NHS. A further 48% said while it was not their first time using private health care, they would usually use an NHS service. This means that around 8 in 10 of those who used private health care last year were people who previously would have always or typically used the NHS. Over half (53%) of people who had used private healthcare said it was so they could be seen more quickly.

This is likely to exacerbate existing health inequalities and increase the risk of a two-tier system of health care, with people who can’t afford to pay having to wait longer for care and risking deteriorating health.

Referrals for cancer treatment

In last year’s State of Care, we highlighted our concerns around the length of time people were waiting for elective care and cancer treatment from NHS services, with people living in the worst performing areas more than twice as likely to wait more than 18 weeks for treatment as people living in the best performing areas.

In a bid to address lengthy wait times, NHS England introduced a new target called the Faster Diagnosis Standard (FDS) in April 2021. The target is that, by March 2024, at least 75% of people should either receive a cancer diagnosis or have it ruled out within 4 weeks (28 days) of an urgent GP referral.

In August 2023, NHS England confirmed plans to consolidate the 10 performance standards for cancer, including the FDS, into 3 key standards. This includes the ‘28-day Faster Diagnosis Standard’, which outlines that patients with suspected cancer who are referred for checks by a GP, screening programme, or other route should be diagnosed or have cancer ruled out within 28 days.

It is important to acknowledge that national data does not always fully reflect people’s experiences. Research from Healthwatch published in July 2023 highlighted an additional ‘hidden wait’ specifically for cancer care. In this survey of 385 adults who were referred or expected to be referred for cancer treatment, almost half (45%) said they were not referred for suspected cancer at their first appointment, and over 1 in 4 (28%) had to wait up to a month after their first appointment to be told they were being referred.

As with the delays in GP referrals for other conditions, in some cases, people said this was because the GP team wanted to try other treatment or medication first before referring them. But in other cases, people described feeling that their condition was not being taken seriously, or that they felt they struggled to make themselves heard or understood.

Once they received a referral, people said they often faced ongoing delays. This is supported by data from NHS England, which shows that overall waiting times for people waiting to start cancer treatment are continuing to get worse. In the period April to June 2023, of those receiving their first treatment, 18,193 people (40%) had waited more than 2 months to start treatment following an urgent GP referral (figure 2).

Figure 2: Two-month wait from GP urgent referral to a first treatment for cancer by quarter, April 2019 to June 2023

Chart with data from NHS England showing that overall waiting times for people waiting to start cancer treatment are continuing to get worse

Source: NHS England Cancer Waiting Times
Note: Total number of patients to receive a first treatment for cancer following a decision to treat, both within and outside the target, per quarter.

In its July report, Healthwatch England also found that nearly a quarter (23%) of people who experienced a delay in their cancer referral said their condition deteriorated. Respondents also highlighted the negative impact on their mental health and wellbeing.

This is supported by the findings of an April 2023 survey of 1,000 UK adults who have had or currently have cancer. Carried out by cancer charity Maggie's, it found that 3 in 5 (58%) respondents said they felt that the mental challenge of cancer is harder to cope with than the physical treatment and side effects. In addition, 52% of people with cancer who responded said they felt there was support for the physical impact of cancer, but not for the emotional effects.

Access to GP practice appointments

For many people, getting an appointment at an NHS GP practice is the first challenge. The 2023 NHS GP Patient Survey shows that people are finding it more and more difficult to contact their practice. This year, only half (50%) of the respondents said it was easy to get through to someone at their GP practice on the phone (figure 3). This is lower than all previous years since the question was introduced in 2012.

Figure 3: 2023 GP Patient Survey – how easy is it to get through to someone at your GP practice on the phone?

Chart showing that people are finding it more and more difficult to contact their GP practice by phone

Source: NHS England GP Patient Survey
Note: Easy = ‘very easy’ + ‘fairly easy’, Not easy = ‘not very easy’ + ‘not at all easy’

At the same time, data from NHS England shows that over the last 2 years, more people are waiting for over 2 weeks for an appointment with a healthcare professional from their GP practice, as 16% of appointments are taking place more than 2 weeks after they were booked.

While some of these appointments will be deliberately booked for 2 weeks or more ahead, findings from the GP Patient survey show that satisfaction with appointment times has decreased to the lowest level across the last 6 years. Out of over 750,000 respondents to the survey, 16% said they were not initially able to get an appointment when they last tried to make one (either they did not take the appointment offered or they were not offered an appointment). Of these:

  • 43% said they were not offered an appointment (an increase from the 2022 and 2021 surveys)
  • 32% said there were no appointments available for the time or day they wanted
  • over 11% said the appointment wasn’t soon enough

Some people are at greater risk of not being able to see their GP. For example, for people living in areas of higher deprivation the ratio of GPs to patients is much lower than in more affluent areas. Data from the ONS shows that, at October 2022, GP practices in the most deprived areas in England had 2,400 patients for each fully-qualified doctor, compared with 2,100 patients for each fully-qualified doctor in the least deprived areas. Although the number of patients per fully-qualified doctor has increased since 2018 regardless of the level of deprivation, the numbers of patients per qualified doctor have increased more slowly in areas with the lowest levels of income deprivation.

On average, people living in more deprived areas have shorter lives and spend more time living with diagnosed long-term illness and, as a result, will need to see their GP more often. Having more patients for each GP means that people in these areas are at higher risk of not being able to see their GP and get the care they need, in turn compounding existing health inequalities. The findings of the 2023 GP Patient Survey also show that people living in the most deprived areas reported a less positive overall experience.

We have seen some positive examples of providers taking steps to address issues of inequality when trying to access care. In the following example, a project took proactive steps to improve the heart health of people in a local population by spotting the early signs of heart disease and preventing the need for an urgent GP appointment.

The same issue also affects people receiving adult social care. Some adult social care service providers have told us about the difficulties in getting an appointment at their GP practice for the people they care for. Anecdotally, we have heard this is particularly hard for people in supported living services, with some reports of managers having to wait on hold on the phone for hours to get a GP appointment.

When people cannot have regular health check-ups, treatments and specialist services, their existing medical conditions are more difficult to manage and this can lead to their health getting worse.

Access to primary and preventative health care is a particular risk for autistic people and people with a learning disability. Data from the 2021 Learning from Lives and Deaths – people with a learning disability and autistic people (LeDeR) report showed that 49% of deaths of people with a learning disability were avoidable, compared with 22% for the general population.

The section in this report on autistic people and people with a learning disability provides more detail about the experiences of health and social care for this group.

Access to dental care

In last year’s State of Care, we highlighted the huge impact of COVID-19 on dental services. Although there had been some improvement, the amount of dental treatment being delivered (measured in units of dental activity) was 30% lower than before the pandemic. This year, recovery has continued to be slow with data from NHS England for 2022/23 showing that the average quarterly units of NHS dental activity were 14% lower than the average activity in the 2 years before the pandemic. However, this had improved by the end of 2022/23, with units of dental activity reaching pre-pandemic levels in January to March 2023.

But getting access to NHS dentists is still a key concern for people. Issues with access to NHS dental care are widespread, affecting almost every part of the country. In last year’s State of Care, we highlighted research from the British Dental Association (BDA) showing that across England, 9 out of 10 (91%) NHS dental practices were not accepting new adult patients. Data from a March 2023 YouGov survey of 2,104 people found that 1 in 5 respondents (22%) were not ’registered’ with a dentist. Of those, 37% said this was because they couldn’t find an NHS dentist.

Looking across England, data from NHS England shows that up to the end of June 2023, only 38% of adults in the South East had seen an NHS dentist in the previous 2 years, compared with 48% in both the North West and North East and Yorkshire. In London, 50% of children had seen an NHS dentist in the previous 12 months compared with almost two-thirds (61%) in the North West of England.

In the 2023 NHS GP Patient Survey, 53% of those who responded said they had tried to get an NHS dental appointment in the last 2 years (compared with 52% in 2022 and 56% in 2021). Of those who hadn’t tried, over 1 in 5 (22%) said it was because they didn’t think they could get an NHS dentist. This is an increase from 18% in the 2022 survey. Of the people who had tried to get an appointment, 10% said they were unable to as the dentist was not taking on new patients, and 10% said there weren’t any appointments available.

We reflected a similar picture in our progress reporton oral health care in residential care homes. This found that people living in care homes are still missing out on vital care from dental practitioners – both at the right time and in the right place. Between our original review in 2019 and the progress report this year, the proportion of care home providers saying that people who use their services could ‘never’ access NHS dental care rose by more than 4 times – from just 6% in 2019 to 25% in 2022.

Not getting the care they need, when they need it, is leading to some people feeling they need to take matters into their own hands. The YouGov survey reported that 1 in 10 respondents (10%) admitted attempting their own dental work. Of those who said they’ve performed DIY dentistry, most (56%) did so within the last 2 years, including 36% within the last year.

Even when people were able to get dental care, more people reported having a poor experience. In the 2023 NHS GP Patient Survey, 18% of respondents said they had a poor experience, up from 16% in the 2022 survey (figure 4).

Figure 4: 2023 GP Patient Survey – how would you describe your experience of NHS dental services?

Chart showing a rise in the number of people saying they had a poor experience with a NHS dental service

Source: NHS England GP Patient Survey

The Department of Health and Social Care has set out some of the steps it is taking to help people to get access to NHS dental treatment. As well as investing £3 billion a year to deliver NHS dentistry, the government has introduced changes to the dentistry contract to encourage more dentists to offer NHS work to increase the number of available appointments, and is making efforts to grow the dental workforce.

However, in July 2023, the Health and Social Care Committee's report on NHS dentistry was clear that current efforts were not enough and that NHS dentistry needs “urgent and fundamental reform” to ensure people get the care they need.

Access to urgent and emergency care

The difficulty in getting care from a GP practice has a knock-on effect for other services. We can see this through the 2022 NHS urgent and emergency care patient survey, which showed that 24% of people approached urgent and emergency care services as the first point of contact because they did not think the GP practice would be able to help with their condition. Of the respondents, 12% said they could not get a GP appointment.

The survey also showed that of those who had contacted another service before attending an emergency department (A&E), such as NHS 111 or a GP, fewer people had been referred (down from 69% in 2020 to 64% in 2022). Additionally, more people were attending A&E because they couldn't get a GP appointment quickly enough or whose condition had got worse.

NHS England’s Hospital Accident & Emergency Activity highlights geographical inequalities in care. Rates of A&E attendances per head of population for people living in the most deprived areas are nearly double those of the least deprived areas. When looked at alongside data on the numbers of GPs for people in the local population, one implication is that people in deprived areas may be more likely to end up in hospital because they can’t get the help they need, early enough, in the community.

It is well known that the challenges in accessing care, and the resulting pressure on services, are made worse every year with the onset of cold weather and increases in respiratory conditions. While this pressure has been building over the last few years, December 2022 saw a spike in the number of people needing care and treatment for flu, putting even more burden on services and the people working within them.

Figures from NHS England show that in December 2022, NHS 111 received nearly 3 million calls. Excluding 2 weeks in the first month of the COVID-19 pandemic (March 2020), this period included the highest number of 111 calls ever recorded. During this period, a high volume of callers to NHS 111 ended the call without speaking to someone, with an abandonment rate of 41% – over double for the average for the rest of the year (figure 5).

Figure 5: NHS 111 call abandonment rate, April 2019 to June 2023

Chart showing an abandonment rate of 41% for calls to NHS 111 in December 2022

Source: Integrated Urgent Care Aggregate Data Collection (IUC ADC)

In 2022, we reported on a ‘gridlock’ in the health and care system that led to some very poor experiences for people when they needed care the most. The situation remains the same for many, with people facing longer waits to be seen in urgent and emergency care.

The 2022 urgent and emergency care survey showed a large increase in the percentage of people saying they waited more than an hour before being examined by a nurse or doctor, from 28% in 2020 to 51% in 2022.

People are still facing lengthy waits in A&E. Data from NHS England shows that in July 2023, from their arrival at A&E, over half a million patients waited more than 4 hours to be either admitted, transferred or discharged. In the 2022 urgent and emergency care survey, people who spent longer than 4 hours in A&E reported poorer than average experiences. In addition, while there has been some improvement, in July 2023 there were almost 24,000 people waiting over 12 hours from the decision to admit to actually being admitted to hospital.

Each year, we talk about the increasing pressures on the health and care system – including on the staff – during winter. Last winter was no exception and again was considerably more challenging than previous years. Reasons for this included ongoing problems with patient flow through hospitals, combined with additional disruptions from more cases of seasonal flu and workforce issues, including industrial action.

In response, in January 2023 the Department of Health and Social Care and NHS England set out plans to boost capacity and speed up discharge of patients through the Delivery plan for recovering urgent and emergency care services. This includes scaling up intermediate care to relieve pressure on hospitals and move people into settings that are better suited for their needs. The plan has been supported by £1 billion of dedicated funding to support capacity in urgent and emergency services, alongside £250 million worth of capital investment to deliver additional capacity, and £200 million for ambulance services to increase the number of ambulance hours on the road.

NHS England has also announced its plans to deliver operational resilience across the NHS this winter. This includes introducing care ‘traffic control’ centres to speed up discharge, delivering additional ambulance hours on the road, and providing extra beds. It has also published its 2023/24 winter plan earlier than usual this year.

As highlighted in last year’s State of Care, and repeated in our September 2023 blog Planning for the coming winter, the focus of winter pressures is often on emergency departments. But what we see there is symptomatic of a much wider capacity problem across the whole health and care system. This means it is essential to co-ordinate any changes and improvements across the whole system to keep people safe and provide the best quality care possible.

Access to emergency ambulance services

One of the greatest challenges for ambulance services is when there are problems with moving people through care pathways within a hospital. In last year’s State of Care, we reported that a significant impact of delays in emergency departments is people being held in ambulances outside departments, known as ‘handover delays’, which in turn affects the care they’re able to provide.

Data from the Association of Ambulance Chief Executives (AACE) shows ongoing delays in ambulance handovers. In December 2022, nearly a quarter of handovers took more than an hour, compared with 10% in December 2021. Data shows that delayed handovers have generally improved so far this year. However, 22,769 handovers took more than an hour in July 2023 (figure 6).

Figure 6: Number of ambulance handovers taking over 60 mins, April 2021 to July 2023

Chart showing ongoing delays in ambulance handovers

Source: Association of Ambulance Chief Executives (AACE)

Delays in handovers at hospital can have a direct impact on the ability of services to respond to calls. We can see this in NHS England’s data on ambulance response times. During December 2022, when demand was at its highest, response times for category 2 calls were 1 hour 33 minutes on average against the target of 18 minutes. Calls classed as a category 2 involve people who are in a potentially serious condition that may require rapid assessment, urgent on-scene intervention or urgent transport. For example, a person may have had a heart attack or stroke or be suffering from sepsis or major burns.

This year, we’ve heard about the impact of shortages of ambulance staff on waiting times – both for calls to be answered and for ambulances to arrive. Evidence from our provider information return for adult social care providers suggests that existing challenges facing ambulance services have been exacerbated by industrial action across the NHS, as the following quote shows:

Barriers within the NHS that are challenging are the current strike actions, which affect the residents when they need emergency treatment or following a fall. Ambulances can take hours, sometimes more than 21 hours, before any assistance arrives. This is not good for the resident and can be quite an anxious time for the care staff who are trying to look after the resident with no medical knowledge

(Feedback from CQC provider information return)

As well as delays in emergency care leading to poorer outcomes for people, anecdotally, and through our provider information return, we’ve heard about the impact on care homes, both for the resident and care home staff:

Current waiting times for ambulances have also caused an obstacle. [Waits for] residents that require emergency medical attention are far longer than normal. This tends to affect residents [who express their feelings through their behaviour] the most, as they have cognitive impairments and are [not] able to understand the situation that's posed before them. This then means when emergency services do arrive and support them, it often takes longer than normal as we need to de-escalate challenging situations.

Feedback from CQC provider information return

Through engaging with homecare services, we have heard about the knock-on effects of ambulance delays when supporting people who have fallen. For example, one homecare provider told us of a local authority directive that a member of homecare staff had to remain with someone who was waiting for an ambulance. As well as the impact on the people waiting for an ambulance, the provider said this created significant challenges in scheduling care visits, with ambulance wait times over 10 hours for category 3 calls in the local area. Not only did this mean people were left on the ground for extensive periods, which evidence suggests leads to worse health outcomes, but it also led to unexpected increased care needs.

In response to these challenges and long ambulance waits, through our Regulators’ Pioneer Fund work, we heard from a homecare provider looking for innovative ways to reduce demand for an ambulance, get people off the ground faster and free up staff to deliver care who would otherwise need to wait with someone until an ambulance arrived.

The provider told us how they developed an 8-week trial of technology that safely lifts a person off the ground after having a fall. The new technology was coupled with a post falls assessment tool to determine when a person could be lifted safely. The trial resulted in a 76% reduction in ambulance callouts and prevented an estimated 2,912 hours of annual additional care.

We have also seen examples of ambulance services innovating to improve care. 

Access to adult social care

Problems and delays in one type of service or sector have a knock-on effect on others. For example, a factor affecting patient flow through hospitals is their inability to move patients back into the community once they have been assessed as no longer needing to be an inpatient. As at August 2023, the number of patients waiting in hospital who no longer met the criteria to reside was nearly 12,000. This is down from a peak of 14,000 in January 2023.

Delays in discharging people from hospital settings can result from a lack of capacity in adult social care. Data from our provider information returns show that of the beds in CQC-registered care homes, 84% were occupied in July 2023, an increase from 82% in July 2022. This is approaching pre-pandemic occupancy rates of 85% as published by the Office for National Statistics (ONS) based on our provider information returns between August 2019 and February 2020.

While occupancy rates have increased, our register of adult social care services shows that the number of registered beds decreased by 0.6% (2,905) between July 2023 and July 2022. Alongside this, our data on registrations show fewer care home locations compared with last year.

As we report in our section on systems, the new integrated care boards (ICBs) are responsible for developing plans for meeting the health and care needs of their local populations, which includes enabling sufficient access to care homes and community-based services. A recent survey by the Association of Directors of Adult Social Services (ADASS) received responses from directors of adult social services in 94% of the 153 councils in England. This found that 99% of respondents agree increased pressures on the NHS will result in additional pressures for adult social care in the next year.

Adult social care services can be either fully or partly funded by a local authority, also called state-funded care. Services funded by local authorities are increasingly struggling to keep up with demand. NHS England data shows that the total number of new requests to councils for adult social care support increased by 3% between 2020/21 and 2021/22 to reach nearly 2 million requests. However, of the requests made for services, more than half a million (568,685) did not result in additional support, an increase of over 4%. A further 522,850 received only universal services or were advised to contact non-council services (such as the voluntary sector), an increase of 2% on the previous year.

Since 2017/18, the rate of new requests for adult social care support has increased by 5% from 4,214 to 4,419 per 100,000 population aged 18 and over. Over the same period, the rate of new requests granted with either short-term care to maximise independence or long-term care has decreased by over 2%, from 915 to 895 per 100,000 population aged 18 and over (figure 7).

Figure 7: Percentage change in requests for support and number granted with either long or short-term care, per 100,000 population, compared with 2017/18

Chart showing changes in requests for support and number granted with either long or short-term care

Source: CQC analysis of NHS England Adult Social Care Activity and Finance Reports
Note: ST-Max is a time limited period of short-term support intended to maximise the independence of clients and reduce, or prevent, longer-term reliance on social care

In particular, requests for support from adults of working age have increased over the last 5 years. Although they make up the minority of new requests for adult social care support (31% in 2021/22), the rate of requests from working age adults per 100,000 population increased by 15% over the last 5 years, equating to over 87,000 more requests. In 2021/22, over 205,000 adults aged 18 to 64 were not provided with adult social care support when they requested it.

At the same time, the number of new requests to councils for support for older people increased by around 47,000 over the same 5-year period. As a rate per 100,000 population, it has remained relatively unchanged.

The ADASS survey results show the number of people waiting for an assessment, care and support to begin, or for a review of their care plan, has reduced from 491,663 in August 2022 to 434,243 in March this year. However, the number of people waiting more than 6 months for an assessment of their care needs remains high, increasing from 81,000 to 82,000 over the same time period.

As well as an assessment of needs, people also need a financial assessment or ‘means test’ to check if they are eligible to receive local authority funded care. People with more than £23,250 in savings will not be able to receive care funded by their local authority. This threshold has not increased in line with inflation since 2010/11, if it had increased more people would qualify for support. As part of wider reforms of adult social care, the government announced in 2022 that from October 2025 the upper threshold will be increased to £100,000.

The ONS has estimated the size of the ‘self-funding’ (privately funded) population in care homes in England (see also figure 8). Published in July 2023, key findings show:

  • From 1 March 2022 to 28 February 2023, there was a significant 3% increase in the number of people living in a care home. Of these, 37% funded their own care, which is an increase from last year.
  • Most care homes (60%) had a mix of self-funded and state-funded residents.
  • The South East remained the region with the highest proportion of self-funded care in care homes (48%), which is significantly higher than the North East, which had the lowest proportion of self-funded care (26%).
  • Care homes providing care for older people remained those with the highest proportion of self-funded care (49%), which was significantly higher than all other care home types. Care homes for younger adults remained the lowest (2%).
  • Smaller care homes, with 1 to 19 beds, remained those with the lowest proportion of self-funded care (12%), which is significantly lower than all other sizes of care homes.
  • Of care homes with a CQC rating, those rated as outstanding remained the care homes with the highest proportion of self-funded care (51%), which was significantly higher than care homes rated as inadequate, which remained the lowest (24%).

Figure 8: Proportion of self and state-funded care home residents by region, 2022 to 2023

Chart showing the proportion of self and state-funded care home residents by region

Source: ONS Care homes and estimating the self-funding population, England: 2022 to 2023. Analysis based on CQC Provider Information Return data.

Our Market Oversight scheme helps us to monitor adult social care providers that have a large national, local or regional presence which, if they were to fail, could disrupt continuity of care in a local authority area. From this, we have seen that a greater proportion of care home fees have been privately funded over the last year. Data from the ONS also supports these findings.

When there is less access to state-funded care, there’s a greater risk of inequality. Data shows that the proportion of care home residents who receive state-funded care increases as the levels of deprivation increase. In areas with the lowest levels of deprivation, just over 2 in 5 care home residents are state-funded (43%) whereas in areas with highest deprivation 4 in 5 residents (80%) receive state-funded care.

People who cannot access state-funded adult social care may not be able to fund their own care because of the cost of living crisis and could become more reliant on friends, family and voluntary organisations for support. In some cases people may not have access to family or community support.

Earlier this year, a survey by Age UK found that 1 in 3 older carers “have felt overwhelmed because of the care and support they provide”. This is supported by a survey of adult social services directors, in which 91% agreed that unpaid carers came forward with an increased level of need in their area over the last 12 months. The survey also showed that directors ranked burnout as the number one reason that has contributed to an increase in carer breakdown over the past year.<

In the section on systems we point out that most local authorities have not published a recent carers’ strategy.

Challenges facing adult social care services

During 2022/23, a few providers told us they received more referrals to their services, but they weren’t able to accept the new clients as they don’t have enough care staff to meet their needs:

Because recruitment is an issue, increasing the number of clients is always a balancing act, we always need to be under capacity to cover sickness and holidays without putting too much strain on the team. This means hospital discharges for new [packages of care] are more limited than we would like. When carers have sickness, we may need to cut short certain visits such as [social visits] to prioritise the more critical visits

(Feedback from CQC provider information return)

The Autumn 2022 survey from ADASS received responses from directors of adult social services in 76% of the 152 councils in place last year. This echoed these views, as it found more than 9 in 10 adult social services directors in England did not believe there was the ‘funding’ or ‘workforce’ to meet care needs of older and disabled people in their area ahead of winter 2022/23.

Staff in both residential homes and care homes with nursing have also described feeling they are unable to provide adequate care and support due to a shortage of staff, lack of funds and absent or poor management.

Concerns about ongoing financial pressures on adult social care providers are not new. Last year, we highlighted the impact of financial pressure – both on capacity within the market and on the wider NHS. Over the last year, the cost of living crisis has continued to increase this pressure, with adult social care providers struggling with escalating staff and running costs.

Providers tell us that the adult social care system is under-resourced, and that local authority budgets have failed to keep pace with rising costs and the increase in the number of people needing care:

Another barrier that is very relevant is the funding from local authority. The fees paid from the local authority… have not kept up with inflation. While this currently does not impact the standard of care we deliver, it does limit the improvements that we can make in areas such as the care home environment, technology, and innovations.

(Feedback from CQC provider information return)

To build capacity and improve market sustainability, in June 2023 the Department for Health and Social Care announced that it would be providing almost £2 billion funding over 2023/24 and 2024/25 through its Market Sustainability and Improvement funds.

In July 2023, we carried out a survey of adult social care services to find out more about the challenges they face. We received 1,928 responses and, while the survey does not represent the adult social care sector as a whole, it has provided valuable insights into concerns around unused capacity, workforce and funding.

The survey found that nearly a third of respondents (29%) said they were worried about the financial stability of their service. Over a quarter (26%) of services said they had considered leaving the adult social care sector in the past 12-months. As local authority-funded adult social care places are often less profitable, there is the risk that people who live in more deprived areas, and receive local authority-funded care, may not be able to get the care they need.

Similarly, in community adult social care we’ve heard how less urgent visits are not being prioritised. This includes, for example:

  • calls that should have 2 care workers being delivered by only one person, with too little time allocated to each visit
  • overloaded rotas
  • overlapping call times
  • not allowing for travel time between clients.

Again, this was echoed in the comments we received through our Give feedback on care service:

We are constantly short staffed… We are not given enough travel time, which means we are unable to spend the correct amount of time with people. We are always late to visits. It makes us look really bad. In the evenings sometimes from 3pm to 10pm, I have up to 10 people to prepare dinner for and personal care and get into bed... It's an accident waiting to happen.

For some people paying for their own care, the rising cost of living means they have not been able to prioritise their health needs and, in some cases, they have had to cut back on the amount of care they were receiving:

There are some financial barriers. Due to the cost of living crisis, increased fuel prices etc, we have had to increase the rates for service users. To retain staff, wages have been increased. The outcome was that some of our services users, mainly self-funders have reduced their care visits to a minimum of what is required. This has had an impact on their quality of life.

(Feedback from CQC provider information return)

Less time spent with people reduces the amount of care they are receiving, which can lead to a deterioration in their quality of life.

Information from our Market Oversight scheme shows continued financial pressures on providers. While only a snapshot of a section of the market, it shows that care home profitability has remained at historically low levels during 2022/23. While much of this pressure has been a result of staff costs, between October 2022 and March 2023, we have seen the impact on profitability because of increases in non-staff costs, specifically gas and electricity price rises, as well as inflation in food and other costs.

Increasing financial constraints are likely to have an impact on people, both in the quality and consistency of care they receive and in providers’ ability to re-invest in care homes.

Analysis of our provider information return suggests that smaller providers are experiencing additional sustainability issues during the cost of living crisis. For example, one smaller provider explained losing out on care packages to larger companies that can deliver care at a lower price. Staff from community adult social care providers have told us about packages of care being cut, delayed or not delivered at all.

The number of care hours delivered in the 3 months to March 2023 by providers covered by our Market Oversight scheme was nearly 15% lower than in the equivalent period to March 2021, with providers changing or limiting the hours delivered and the packages of care they offer.

Despite ongoing problems with capacity in the adult social care sector, over the last year we have seen increasing pressure to discharge people from hospital. In the face of this pressure, we have heard examples of people being discharged too early without appropriate risk assessment or having a care package or intermediate care in place. Unsafe discharges are putting people at risk, potentially leading to poorer outcomes in their health and care, and being re-admitted to hospital. During the 12 months to June 2023, on average around 9% of people had to go back to the emergency department within 7 days of their previous attendance.

Recognising that NHS performance relies on the adult social care system, in its Autumn 2022 statement, the government announced up to £2.8 billion in 2023/24 and £4.7 billion in 2024/25 to help support adult social care and discharge from hospital.

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