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

This year has been a turbulent one for health and social care.

In addition to the ongoing problem of ‘gridlocked’ care highlighted in last year’s State of Care, the cost of living crisis is biting harder for the public, staff, and providers – and workforce pressures have escalated. This combination increases the risk of unfair care – where those who can afford to pay for treatment do so, and those who can’t face longer waits and reduced access.

Adult social care providers are facing increased running costs, including food and electricity, with some struggling to pay their staff a wage in line with inflation, which affects recruitment and retention. This is likely to have an impact on people, both in the quality of care they receive and in providers’ ability to re-invest in care homes – data from our Market Oversight scheme shows that care home profitability remains at historically low levels.

Local authority budgets have failed to keep pace with rising costs and the increase in the number of people needing care. As adult social care places funded by a local authority are often less profitable, there is the risk that people who live in more deprived areas, and are more likely to receive local authority-funded care, may not be able to get the care they need.

Some people who pay for their own care at home have had to cut back on visits to support their basic needs. One homecare provider told us that, due to the cost of living crisis and increased fuel prices, it had to increase the rates charged. Because of this, some people had to reduce their care visits to a minimum, which had an impact on their quality of life.

Workforce pressures, already a huge challenge, have further intensified, with ongoing industrial action by NHS staff unhappy with pay and conditions. The number of people on waiting lists for treatment has grown to record figures and in the face of longer waits, those who can afford it are increasingly turning to private healthcare. Research from YouGov shows that 8 in 10 of those who used private health care last year would previously have used the NHS, with separate research showing that 56% of people had tried to use the NHS before using private healthcare.

The danger is that the combination of the cost of living crisis and workforce challenges exacerbate existing heath inequalities, increasing the risk of a two-tier system of health care. People who cannot afford to pay could end up waiting longer for care while their health deteriorates. Our adult inpatient survey, based on feedback from over 63,000 people, found that 41% felt their health deteriorated while they were on a waiting list to be admitted to hospital.

People may also be forced to make difficult financial choices. We heard from someone who receives benefits who resorted to extracting their own tooth because they were unable to find an NHS dentist. They then had to pay £1,200 on a credit card for private treatment, doing without household essentials until the debt was paid.

While the publication of the NHS Long Term Workforce plan has been a positive step in addressing workforce pressures, implementation will be challenging – particularly without a social care workforce strategy to sit alongside it. We continue to call for a national workforce strategy that raises the status of the adult social care workforce and ensures that career progression, pay and rewards attract and retain the right professional staff in the right numbers. It is encouraging that Skills for Care has made this an area of focus.

In our inspection activity, we have continued to take a risk-based approach this year, focusing our inspection activity on those core services that, nationally, are operating with an increased level of risk, and on individual providers where our monitoring identifies safety concerns. Ratings data shows a mixed picture of quality, with a notable decline in mental health and ambulance services.

We have continued our focused programme of maternity inspections, with the overarching picture emerging of a service and staff under huge pressure. Ten per cent of maternity services are rated as inadequate overall, while 39% are rated as requires improvement. Safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for their safety and 12% rated as inadequate for being well-led.

While it has been encouraging that all maternity units inspected so far have adjusted the level of consultant cover to meet recommendations made in the Ockenden report, the cover model is often fragile, with rotas relying on every consultant being available. We have seen examples of services taking action to manage staff shortages safely – but we have also seen issues with governance and lack of oversight from trust boards, delays to care and lack of one-to-one care during labour, as well as poor communication with women and difficult working relationships between staff groups.

Alongside our programme of maternity inspections, we have commissioned a series of interviews with midwives from ethnic minority groups to explore their experiences of working in maternity services and their insights into safety issues. A common theme from these interviews was that care for people using maternity services is affected by racial stereotypes and a lack of cultural awareness among staff. One midwife told us; “The NHS is amazing, but it was built by white people for white people. We need to adapt, because now we have a diverse population and workforce.

Access to and quality of mental health care also remain key areas of concern, with gaps in community care continuing to put pressure on mental health inpatient services and many inpatient services struggling to provide beds. This, in turn, is leading to people being cared for in inappropriate environments – often in emergency departments. One acute trust told us that there had been 42 mental health patients waiting for over 36 hours in the emergency department in one month alone. When people do get a bed in a mental health hospital, the quality of care is often not good enough. Safety continues to be an area of concern, with 40% of providers rated as requires improvement or inadequate for safety.

Recruitment and retention of staff remains one of the biggest challenges for the mental health sector, with the use of bank and agency staff remaining high and almost 1 in 5 mental health nursing posts vacant. We’ve raised concerns that staffing issues in mental health services are leading to the over-use of restrictive practices, and we’ve worked with our expert advisory group for autistic people and people with a learning disability to develop a clearer and stronger position on these practices, including restraint, seclusion, and segregation. We expect all providers of health and social care to recognise restrictive practice and to actively work to reduce its use.

Many of the challenges described in this year’s State of Care are to some degree caused by a lack of joined-up planning, investment, and delivery of care. Integrated care systems present the opportunity of bringing together local health and care leaders with the populations they support to understand, plan, and deliver care at a local level. This would, in time, move some of the focus of care away from big institutions and towards local and self-care provision, with autonomy to act on the needs of a local population and an increased focus on preventing poor health – not just treating it.

However, in our first look across local care systems, we found that while all systems have some equality and health inequalities objectives, not all these plans have timeframes and measures. All systems need clear and realistic goals, and support to achieve these, that reflect how they will address unwarranted variations in population health and disparities in access, outcomes, and experience of health and social care.

This opportunity must be grasped to ensure fairer care for everyone – so people get the care they need, not just the care they can afford.

Ian Trenholm
Chief Executive

Ian Dilks OBE

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State of Care 2022/23