On the day briefing: The state of health care and adult social care in England 2023/24

Today, 25 October, the Care Quality Commission (CQC) published State of Care, its annual assessment of the state of health and care in England. This briefing summarises the content of the report and includes NHS Providers’ view.

This year’s State of Care report is based on evidence from CQC’s inspection activity, findings from CQC’s national NHS patient survey programme, statutory reports, bespoke research into people’s experiences, insight from key stakeholders, and other evidence collected by the regulator throughout the year.

In line with findings from previous years, this year’s report highlights significant issues around timely access to good care, and persistent inequalities in health and care access, experience and outcomes. While it recognises that getting the right care at the right time and in the right place is important for everyone, it acknowledges that children and young people in particular suffer if they are unable to access care when they need it.

The report highlights several areas of specific concern including maternity care, Black men’s mental health, people with dementia, and termination of pregnancy services. It also examines the contribution of local systems in joining up care.

A CQC survey found that the two services that people had the most difficulty accessing in the past year were GP and dental services. Demand and capacity were issues for both services, limiting access and leading to deterioration in people’s health and outcomes. Regional variation in the proportion of NHS dental work was found to be significant, with schoolchildren living in the most deprived areas being more than twice as likely to experience tooth decay than those living in the least deprived areas.

Similarly, the need for adult social care services was not always matched by adequate access and provision, leaving many without the support they need, and exacerbating delayed hospital discharges. The review shows that waits for care home beds and home-based care accounted for 45% of delays in discharging people who had been in an acute hospital for 14 days or more, with nearly 4,000 people delayed on an average day. 

This year’s report also highlights serious concerns about mental health services. It finds that a lack of resources, ageing estates, and poorly designed facilities are affecting the safety of mental health inpatient wards. CQC also identifies systemic issues in community mental health, including a shortage of staff and lack of integration between mental health services and other healthcare, social care and support services.

Maternity care

CQC’s review concludes that women and babies are still not receiving the high-quality maternity care they deserve. Of the 131 locations inspected under CQC’s national maternity inspection programme, almost half were rated as either requires improvement (36%) or inadequate (12%). Women from Black and ethnic minority backgrounds continued to be more at risk of experiencing poor maternity care and outcomes, and there were huge differences in the way trusts collected and used demographic data, particularly ethnicity data, to address health inequalities in their local population.

Children and young people’s health

The report highlights that many children and young people are not currently getting the support they need, with impacts on their quality of life and health and care outcomes, potentially lasting well into adulthood. Particular concerns are noted around children and young people’s mental health services, in which rising demand is not being matched by the right staffing levels, capacity and skill mix.

Care for autistic people and people with a learning disability

The report concludes that waiting times for assessment for a possible autism diagnosis are much too long, especially for children and young people. It shows that only around a quarter of people with a learning disability were recorded on the learning disability register.

Black men’s mental health

For this year’s State of Care report, CQC looked in detail at responses to the NHS community mental health survey from Black men and men from a mixed Black ethnic background. While many men were happy with the care they received, some reported concerns around timely access to care, including a long wait for talking therapies, and a lack of follow-up care. It also found that Black men had longer stays in hospital as compared to white men. 

People with dementia

Ongoing work on CQC’s cross-sector dementia strategy is highlighting examples of compassionate care and initiatives that are improving people’s lives, but CQC has found that staff do not always understand the specific needs of people with dementia.

Termination of pregnancy services

According to CQC, the demand for termination of pregnancy services is increasing, and the regulator is concerned that not enough women can access such services close to where they live, at a time when they need them. When women are able to access termination of pregnancy service, there are concerns about the quality of care they receive. 

Deprivation of Liberty Safeguards (DoLS)

The report finds that too many people are waiting too long for a DoLS authorisation, despite multiple examples of local authorities trying their best to reduce backlogs and ensure sustainable improvement.

This year's State of Care report also explores local system response, acknowledging that the poor care and poor access to care that some people experience is often influenced or caused by services not being joined up, or not working well together. It concludes that urgent and emergency care services in crisis are a symptom of complex system problems that need resolving, by providing more services for people away from hospitals.

Although it has only limited experience undertaking its new statutory role in assessing integrated care systems (ICSs), CQC has found that finance, joint forward planning and workforce depletion are some of the main challenges for integrated care boards. It has also found variation in the levels of capacity and capability among systems, as well as challenges and barriers around data and analysis skills, governance and accountability. 

The report concludes that, while being focused on tackling health and care inequalities, systems need to understand their populations better, in order to address issues that affect everyone, from children who need dental care to older people with dementia.

From its work in assessing local authorities (LAs) against their Care Act duties, CQC has found that LAs have taken steps to address known inequalities and understand the demographics of local populations; however, there was a need for better engagement with the voluntary sector and community groups to identify groups that are seldom heard and those at greater risk of inequality. The report also finds that all local authorities need to do further work to identify carers and raise awareness about carer assessment and services to support them in their caring role. This need was found to be more acute in the case of ethnic minority groups, who may not see themselves as carers.

This year’s State of Care report is a clear reminder of the need to focus on early intervention, community services and mental health, as we seek to improve access to good quality care in England. This is in keeping with the five shared commitments NHS Providers has proposed to deliver the next generation NHS.

We particularly welcome the report’s emphasis on care and services for children and young people. Our report, Forgotten Generation: Shaping Better Services for Children and Young People called for adequate prioritisation and increased investment in children’s services. It also advocated for early intervention, for making children and young people a central focus in policy development, and for supporting healthcare staff to enhance morale and service delivery in this area.

We welcome the strong focus on health inequalities in this year’s State of Care report. We appreciate CQC’s commitment to improving maternal care, and the insights into the experiences of ethnic minority women are particularly valuable in highlighting where changes are urgently needed.

We are particularly encouraged by CQC’s recognition of the need to address health inequalities at a system level (as reflected in our own work). The report provides valuable insights into the efforts of ICSs and local authorities to tackle these disparities. However, it also rightly highlights the need for further work to align strategic goals across systems and to overcome barriers such as population health data, governance, accountability, and ensuring adequate funding and capacity. We look forward to working with CQC when it resumes developing its approach to assessing ICSs.

We fully agree with CQC’s emphasis on the importance of having an ethnically diverse workforce that reflects the population served. While the noted increase in staff from ethnic minority groups is promising, the ongoing discrimination faced by these staff members is deeply concerning, and unacceptable.

We look forward to working with CQC as it works to rebuild the trust of the provider sector, and confidence in its processes, so it can support providers to deliver high-quality services for all patients and service users in England.