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

Access to care

Problems with people’s access to care in England is an enduring issue that we have raised in successive State of Care reports.

Getting access to services remains a fundamental problem, particularly for people with protected equality characteristics. Along the health and care journey, people are struggling to get the care they need when they need it.

Record numbers of people are waiting for planned care and treatment, with over 7 million people on elective care waiting lists in June 2023. But the true number of people could be much higher, as some people who need treatment are struggling to get a referral from their GP.

In the community, people are facing ongoing struggles with getting GP and dental appointments. As a result, some people are using urgent and emergency care services as the first point of contact, or not seeking help until their condition has worsened.

Once at hospital, people are facing longer delays in getting the care they need. In 2022, over half (51%) of respondents to our urgent and emergency care survey said they waited more than an hour before being examined by a nurse or doctor, up from 28% in 2020.

Insufficient capacity in adult social care is continuing to contribute to delays in discharging people from hospital. Ongoing staffing and financial pressures in residential and community services are having an impact on the quality of people’s care, with some at greater risk of not receiving the care they need.

Quality of care

The quality of care that people experience is affected by many different factors.

Increasing demand and pressures on staff are taking a toll on their mental health and wellbeing. Staff have told us how, without the appropriate support, this is affecting the quality of care they deliver.

Many people are still not receiving the safe, good quality maternity care that they deserve, with issues around leadership, staffing and communication. Ingrained inequality and the impact on people from ethnic minority groups remains a key concern.

The quality of mental health services is an ongoing area of concern, with recruitment and retention of staff still one of the biggest challenges for this sector.

Innovation and improvement varies, but the use of artificial intelligence (AI) in health care has the potential to bring huge improvements for people. Given the speed of growth of AI, it is important to ensure that new innovations do not entrench existing inequalities.


In our State of Care report in October 2022, we reported that inequalities pervade and persist – this year we highlight some people who are more likely to face inequalities in access and experience when using health and care services.

Midwives from ethnic minority groups say that care for people using maternity services is affected by racial stereotypes and a lack of cultural awareness among staff. They described a ‘normalised’ culture where staff tolerate discrimination from colleagues, and say they are less likely to be represented in leadership and managerial roles.

People from ethnic minority groups who have a long-term condition felt they were talked down to about their treatment and were not treated as individuals. They also said a lack of cultural competency was a barrier to receiving good quality care.

These people were also more than 2.5 times more likely to say that staff in the emergency department talked as if they were not there, compared with people in White ethnic groups who did not have a long-term condition.

Failures in the system and a lack of funding can mean that budgets are prioritised above truly person-centred approaches to support in supported living services.

The health and care workforce

Staff regularly fed back to us of being overworked, exhausted and stressed – sometimes to the point of becoming ill, injured or leaving their job altogether. They say this can affect their ability to provide safe and effective care to people.

Just over a quarter (26%) of NHS staff were satisfied with their level of pay. This is 12 percentage points lower than before the pandemic. Dissatisfaction with pay is linked to industrial action by healthcare staff during 2023.

In adult social care, some providers are struggling to pay their staff a wage in line with inflation.

Over half of the respondents to our survey of adult social care providers in England said they were having challenges recruiting new staff, and 31% said they were having challenges in retaining them.

Despite this, there has been a steady decrease in staff vacancy rates for care homes, from 11% in January to March 2022 to 7% in April to June 2023.

In 2022/23, approximately 70,000 people arriving to work in the UK from overseas started direct care roles in the independent adult social care sector, compared with around 20,000 in 2021/22. Providers of adult social care services have told us that recruiting staff from overseas has enhanced the diversity and skills of their team and helped resolve staffing issues.

But there is a growing trend of unethical international recruitment practices. In 2022/23, we made 37 referrals for concerns regarding modern slavery, labour exploitation and international visas – more than 4 times the number made in 2021/22.

Deprivation of Liberty Safeguards

There are ongoing problems with the current Deprivation of Liberty Safeguards (DoLS) system that have left many people who are in vulnerable circumstances without legal protection for extended periods.

In 2022/23, the number of applications to deprive a person of their liberty increased to over 300,000, with only 19% of standard applications completed within the statutory 21-day timeframe.

Delays in implementing the Liberty Protection Safeguards mean these challenges are likely to continue.


The way health and social care works in England has changed significantly over the past year, with new integrated care systems now formalised.

Local systems should now implement plans to address unwarranted variations in population health and disparities in people’s access, outcomes, and experience of health and social care.

Local authorities are tackling workforce problems in adult social care and trying to address gaps in care as they plan for the future. But they will need to demonstrate an understanding and preparedness for the changing and complex needs of local populations.

Assessing carers’ needs is vital. Carers, including many unpaid carers, are a critical part of all local care systems and they are not always getting the support they need – there is variation across the country and many carers are facing financial problems.

The effectiveness of urgent and emergency care services can indicate how effectively health and care services are co-ordinated across a local system. But we’ve seen that people’s experience in urgent and emergency care continues to be poor and the problems are pointing to issues that require a local system level response.

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