Care regulator warns of “tsunami of unmet need” as providers hand back registrations

The Care Quality Commission’s (CQC’s) annual assessment of the state of health and social care in England has warned that measures must be taken to mitigate the risk of large numbers of people facing unmet need.

The State of Care report, which looks at the quality of care over the past year, is the first of such reports to cover a full year of the pandemic.

Despite the success of the vaccination programme, the report has recognised that COVID-19 will continue to cast a long shadow over all aspects of life, especially the health and care system.

It says the system has not collapsed – but the system is composed of individuals who deliver and receive care, and the toll taken on many of these individuals has been heavy. It argues the workforce who face the challenges ahead are drained in terms of both resilience and capacity, which has the potential to impact on the quality of care they deliver.

COVID-19 was once again found to have exacerbated inequalities and continues to do so, meaning that people who were less likely to receive good care before and during the pandemic are in many cases the same groups disproportionally impacted by the virus.

People with a learning disability, for example, are significantly more at risk from COVID-19 – but the inspectorate’s review of community care for people with a learning disability found that their physical health, including how COVID-19 may present, was not always considered. Inspections of services for people with a learning disability or autistic people continue to find examples of care so poor that action is needed to keep people safe.

Staffing pressures are being felt across all health and care settings, the report says with the impact being seen most acutely in adult social care, where providers are competing for staff with the retail and hospitality industries. Data from information submitted to the CQC by providers of residential care shows the vacancy rate rising month-on-month from 6% in April to 10.2% in September. Some care homes whose attempts at recruitment have failed are now having to cancel their registration to provide nursing care, leaving residents looking for new homes in local areas that are already at, or close to, capacity.

The regulator says the £5.4 billion investment from the Government to help address the challenges faced by social care is ‘welcome’ but says for this money is to make a difference, it must be used to enable new ways of working that recognise the interdependency of all health and care settings, not just to prop up existing approaches and to plug demand in acute care. Five hundred million pounds has been committed to support the adult social care workforce, which is urgently needed for improvements on training, career development and terms and conditions in order to attract and retain staff. It adds that work needs to begin now to address the immediate problem of rising vacancy rates as well as planning for the future.

It says that increased stability in social care is the key to unlocking not only improved access and quality of care for the people who use it, but to ease pressure on the NHS by reducing emergency attendances and enabling people to leave hospital in a timely way. There is short-term funding currently in place to help discharge patients who are no longer in need of hospital care but who may still require care services – and this has allowed the NHS to treat more patients and has made a crucial difference to the viability of some social care providers.

However, the regulator stresses that if this funding were to be committed to for a longer period, care providers could begin to make longer term investments in staffing to provide much-needed step-down care. It says they could also build more meaningful relationships with primary, secondary and community care services – as well with third sector organisations and with carers, who it says have “too often been the missing piece of the jigsaw”. The report argues there is also a need for additional funding to be made available now, rather than next year, to areas that will otherwise struggle to meet people’s needs over the coming winter.

As the number of people seeking emergency care continues to rise, leading to ‘unacceptable’ waiting times for ambulances and in emergency departments, the CQC says measures that improve capacity and patient flow are ‘urgently needed’. Close working between providers, commissioners and all other parts of the health and care system will be essential to safely manage risk through the forthcoming winter, it says.

The regulator says that, ultimately, new models of care are necessary to ensure that people receive the care they need where and when they need it. This would mean people are less likely to be inappropriately funnelled into emergency departments – and that primary care services are able to focus on those with complex co-morbidities, rather than patients who could be better treated in other settings and by other allied health professionals. As waiting lists for investigations and treatment lengthen, ensuring that they are managed well, fairly, and safely will be vital – closer collaboration with primary care services and third sector organisations will be key to this.

The CQC says, in the longer term, the role of Integrated Care Systems (ICSs) will be to ensure that all parts of the health and care system work better together to respond to the needs of their local community – a transformation that may well require fundamental changes to funding, oversight, and commissioning. Designing services around local need must be the priority, ensuring people get the right treatment in the right place at the right time, with good, safe care delivered by a workforce who are valued and supported.

Ian Trenholm, Chief Executive of CQC, said more people than ever have contacted the regulator with feedback and concerns about care this year.

“As we go into winter, the health and care workforce are exhausted and depleted – which has clear implications for the vital care they deliver.

“While staffing is an issue for all sectors, we’re particularly concerned about adult social care. We’re seeing rising vacancy rates, some providers having to hand back their registrations as they don’t have enough staff to deliver care, and examples of quality suffering due to lack of staff.”

“If the new Government funding is to have an impact, it needs to be used to do things differently and to develop genuinely collaborative ways of working across all care settings. And staff need to be supported and rewarded.

“Increased stability on funding and a clear workforce plan for social care benefits everyone – but further instability could result in a ripple effect across the wider health and care system which risks becoming a tsunami of unmet need across all sectors, with increasing numbers of people unable to access care.”

Responding to the report, Cathie Williams, ADASS Chief Executive welcomed the highlighting of the dreadful impact of the pandemic and the “stark effect it had in exposing and exacerbating inequalities, inequalities that resulted in the deaths of so many people.”

On the subject of funding, Williams added that the further short-term injection of funding for the workforce is welcome, but that it was a small proportion of what is needed and was very late in the day given the worsening recruitment and retention situation.

“One-off COVID funding has ensured the short-term, but not the long-term viability of struggling providers. Little has been done to reward and retain the dedicated and compassionate people working in social care. Too many people are missing out on vital care and support.

“We look forward to the Spending Review and to the consultation documents which the government promises will address the short and longer term challenges and enable those of us who are older or disabled and who are carers to live the lives we want to live. Without further action, a bleak winter lies ahead.”

The Local Government and Social Care Ombudsman, Michael King, welcomed the spotlight being shone on the adult social care sector and the issues it faces, saying its own review of complaints identified a system that is increasingly failing those who need it most.

“The faults we find are not usually one-off mistakes – they are more frequently being caused by measures taken to balance the books in a system under immense funding pressures. Our evidence shows the majority of care workers are doing an excellent job in spite of the pressures they are under. It is not the staff, but the pressure that is the problem.

“All too often, people who use adult social care services don’t have the freedom to shop around for their care or change their circumstances once they are in the system. Without that choice, service failings have an impact on the health and wellbeing of people in care and their families.”