Cost-of-living crisis and workforce pressures risks ‘unfair care’

New analysis paints the picture of a turbulent year for health and social care.

The Care Quality Commission’s annual State of Care report has highlighted the ongoing problem of ‘gridlocked’ care highlighted in last year’s report, with additional concerns arising from the cost-of-living crisis.

The regulator of health and social care in England said rising prices are biting harder for the public, staff, and providers – and workforce pressures have escalated. This combination risks leading to unfair care – where those who can afford to pay for treatment do so and those who can’t face longer waits and reduced access.

It added that 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 the regulator’s Market Oversight scheme shows that care home profitability remains at historically low levels.

Local authority budgets have also failed to keep pace with rising costs and the increase in the number of people needing care. 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 are more likely to receive local authority funded care, may not be able to get the care they need.

Workforce challenges have further intensified, with unresolved 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 by 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.

This situation is likely to exacerbate existing heath inequalities and increase the risk of a two-tier system of health care, with people who cannot afford to pay waiting longer for care. CQC’s 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.

During 2022/23, CQC has continued to take a risk-based approach, focusing inspection activity on those core services that nationally are operating with an increased level of risk, and on individual providers where monitoring identifies safety concerns. Ratings data shows a mixed picture of quality, with a notable decline in maternity, mental health and ambulance services.

Access to – and quality of – mental health care “remains a key area of concern,” the regulator said. Gaps in community care continue to put pressure on mental health inpatient services, with many inpatient services struggling to provide a bed, which in turn leads to people being cared for in inappropriate environments – often in A&E. One acute trust reported that there had been 42 mental health patients waiting for over 36 hours in their 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 one in five mental health nursing posts vacant. CQC has raised concerns that staffing issues in mental health services are leading to the over-use of restrictive practices, including restraint, seclusion, and segregation, and called on providers to recognise and take steps to address this.

Ian Trenholm, CQC’s Chief Executive, said the combination of the cost-of-living crisis and workforce challenges risks leading to ‘unfair care’.

“The impact of unresolved industrial action on people can’t be ignored – it’s crucial that both parties work towards an agreement so strikes do not continue into the winter, when disruption will have to be managed alongside increased demand for urgent care and staff sickness.

“We remain concerned that some people are more likely to have a poorer experience of care. To better understand barriers to equality, we’ve commissioned research with midwives from ethnic minority groups, and with people from ethnic minority groups with long-term conditions. We’ve also worked with our expert advisory group for autistic people and people with a learning disability to develop a clearer and stronger position on the use of restrictive practice – we expect all providers to recognise restrictive practice and to actively work to reduce its use.

Skills for Care CEO Oonagh Smyth said the findings reflect many of the trends in their own reports, highlighting the ongoing recruitment and retention challenges in both social care and health.

“With thousands leaving care jobs every year, fixing that leaky bucket remains a priority for us, and we were pleased to see that this report welcomes our recent announcement that we are developing a workforce strategy for adult social care with partners including CQC.

“The trends in health around racism and discrimination in this report are concerning and, while we don’t have the same data for social care, we know that Black, Asian and minoritised ethnic people working in social care have told Skills for Care that they often feel that they are not offered the same development opportunities and can experience discrimination in the workplace. We agree with the report’s focus on the importance of open and inclusive cultures.”