CQC: State of Care Report 2023/24 - NHS Trust

In its State of Care report in 2022, CQC commented on a healthcare system emerging from the pandemic and noted a system in gridlock. In this year’s report, CQC highlights that increased running costs and workforce challenges have escalated pressures on services even further, increasing health inequalities and producing a system where, increasingly, those who can afford to pay for treatment do so, and those who can’t face reduced access to services and longer waits whilst their conditions deteriorate.

In terms of NHS Trusts, CQC finds that people are facing longer delays in getting the care they need. CQC reports that midwives and people using midwifery services in particular are facing inequality and discrimination. Further, 12% more NHS staff are dissatisfied with their level of pay compared to before the pandemic.

Some key points arising from the report specific to NHS Trust providers are:

Access to Care

• The number of people on NHS waiting lists for treatment has grown to record figures, with 7.6 million people on elective care waiting lists as at June 2023.
• There are ongoing difficulties for people to access primary care which means more people are turning to emergency care services, and there are longer delays in urgent care with 51% of survey respondents waiting more than an hour for examination (up from 28% in 2020).
• In addition, a Healthwatch survey in April 2023 reported nearly 1 in 5 people needing hospital treatment had to visit their GP 4 or more times before getting a referral.
• Cancer Waiting Times - 40% of patents are waiting more than two months from GP urgent referral to their first treatment for cancer (up from 22% in April 2019).
• CQC adds that insufficient capacity in adult social care is continuing to contribute to delays in discharging people from hospital.
• In mental health, insufficiency of community care services continues to increase pressure on inpatient services, with a lack of available beds, leading to people being cared for in inappropriate environments.
• CQC notes that its first look across local care systems, using its new powers to regulate local authorities and ICBs, shows that not all systems have sufficiently clear timeframes and measures in place to reduce health inequalities in terms of access to and experience of health and social care.

Quality of Care

• Ratings data shows a mixed picture of quality, with a notable decline in mental health and ambulance services and continued problems in maternity services, with 10% rated ‘Inadequate’ and 39% ‘Requires improvement’.
• Leadership in maternity services remains an area of concern with 12% rated as inadequate for being well-led. CQC noted issues with governance, lack of oversight from boards, challenges in identifying issues and packages of support, and concerns about problematic working relationships between service level managers, neonatal, midwifery and obstetric leaders.
• Staffing challenges, and the impact on patient care in maternity services was an emerging theme, with many people describing staff as overstretched and overworked.
• There was a mixture of good practice and concerns around miscommunication in maternity services, with just 59% of women and other people using maternity services saying they were always given the information and explanations they needed during their care in hospital.
• In mental health services, safety concerns are increasing, with 41% of providers rated as ‘Requires improvement’ or ‘Inadequate’ for the key question of ‘Safe?’
• There are particular concerns around waiting times for children and young people seeking help.
• Unavailability of community care continues to put pressure on mental health inpatient services, with many services struggling to provide a bed, leading to people being cared for in inappropriate environments. In particular, CQC is concerned with the use of dormitories and mixed sex wards.
• Staffing challenges are particularly prevalent in mental health services, with almost 1 in 5 mental health nursing posts vacant. CQC expresses concern that staffing issues are leading to excessive use of restrictive practices, and increased risks to people using services through the use of agency staff.
• Staff reported that increased demand and pressures are taking a toll on their mental health and wellbeing, which is in turn (without the appropriate support) affecting the quality of care they deliver.
• The NHS staff survey showed that a third of staff said they saw errors, near misses or incidents in the last month that could have hurt staff or service users, with ambulance staff being those most likely to have witnessed errors.
• Although 86% of staff said their organisation encouraged reporting errors, near misses or incidents, the NHS staff survey showed a deterioration in staff who would feel secure raising concerns about unsafe clinical practice.
• There are concerns in relation to medicines where care is shared between NHS providers and independent or private services, with CQC seeing evidence of clinicians prescribing controlled drugs to patients without the relevant medical and medication history.
• CQC remains concerned around the over-prescribing of medicines that cause dependence and withdrawal, including opioid medicines for pain, gabapentinoids, benzodiazepines and Z-drugs, and antidepressants.
• CQC finds that a lack of integration and compatibility between digital systems in acute, community trusts and primary care made transferring information challenging.
• CQC was encouraged to see evidence of providers using innovation – both technology and non-technology driven – to improve the quality of care.

Inequalities

• The pandemic and cost of living crisis have widened and exacerbated inequalities, both for people using health and social care services and those who work in these services.
• Midwives from ethnic minority backgrounds have reported that racial stereotypes, and a lack of cultural awareness among staff, affect the care provided to people using maternity services. They described a culture where discrimination from colleagues is tolerated, and they face challenges in being represented in leadership and managerial roles.
• Patients from ethnic minority groups with long terms conditions were more than 2.5 times more likely to feel ignored by staff in the ED compared to white ethnic groups without long-term conditions. They did not feel they were treated as individuals. A lack of culture competency was identified as a barrier to receiving high-quality care.

Deprivation of Liberty Safeguards

• The number of applications has continued to increase (by 11% since last year) and CQC remains concerned that the current system is unable to cope with the demand for assessments, leaving many in vulnerable circumstances without legal protection for extended periods.
• Only 19% of standard applications to deprive a person of their liberty were completed within the statutory 21-day timeframe, with the average application taking 156 days (over 7 times the statutory timeframe).
• The delay of the implementation of Liberty Protection Safeguards (“LPS”) is of concern. Those who are disabled or old are likely to be disproportionately affected by the decision to delay LPS.
• Existing challenges with the Deprivation of Liberty Safeguards (“DoLS”) system will likely continue unless short-to-medium term changes are introduced.
• There remains a concern that some providers have a limited understanding of the DoLS framework, resulting in the overuse of restrictive practices and staff not always implementing the conditions attached to a DoLS authorisation. Some providers are not delivering adequate training on DoLS.
• In mental health settings, there was a variable understanding of the interface between the Mental Capacity Act and the Mental Health Act and it was not always clear how staff decided that using the DoLS framework would be most appropriate for a particular patient.
• People subject to DoLS authorisations in mental health settings were not always clear about the details of their situation, and their families did not always understand the DoLS system and were not given information about their roles and rights.

Health and care workforce

• Even though there has been an increase in full time equivalent staff working in the NHS, there are ongoing staffing challenges, including shortages in certain healthcare professions. CQC states that there’s a need for effective workforce planning and recruitment strategies to address these challenges.
• Levels of stress and anxiety remain high and the main reason staff give is that there is insufficient staff and there are low levels of satisfaction with pay. CQC states there a need for supportive working environments, access to mental health support and initiatives to promote staff well-being.
• There is a need to significantly invest in training and development opportunities for NHS staff. CQC highlights the need for continuous learning, upskilling and career progression to ensure that healthcare professionals have the necessary skills and knowledge to provide high quality care.
• The report recognises the significance of promoting the wellbeing of staff and building a culture that invests in staff and their wellbeing. There is a need to create supportive working environments and systems to address issues such as stress and burnout.

Systems

• CQC finds that there is a need for respite, reablement and step-down/discharge-to-assess services to help support the speedy discharge of people from hospital.
• CQC note that its first look across local care systems, using its new powers to regulate local authorities and ICBs, shows that not all systems have sufficiently clear timeframes and measures in place to reduce health inequalities in terms of access to and experience of health and social care. They note that they not seen evidence of equity in access on ICB board agendas – either as a set agenda item or a strategic key performance indicator.

Ratings

There are a number of ratings statistics in the report. CQC states that it looked at the ratings as at 1 August 2023 and so it is a snapshot of one point in time. Many of the statistics represent overall service types combining the figures for both NHS and Independent Healthcare services. However, specific NHS statistics are as follows:

• NHS Acute Core Services: 72% of Providers were rated Good or Outstanding (compared to 74% in 2022), with 25% rated as Requires Improvement and 2% rated as Inadequate (23% and 2% respectively in 2022).
• NHS Ambulance Trusts: 50% of Providers were rated as Good in 2023 down from 80% in 2022. To put this in context, there were 8 Trusts rated as Good in 2023 and now there are 5. One Trust (10%) remains Outstanding. 30% of Providers have an overall Requires Improvement rating in 2023 (from 10% in 2022) and one Trust was rated as inadequate this year meaning that 10% of Providers are rated inadequate in 2023 as opposed to 0% in 2022.

CQC has focused on maternity services in particular in this year’s report and states that it continues to have concerns around the quality of maternity services. It reports that 10% of maternity services are rated inadequate overall, with 39% rated as requires improvement.

To view the full ratings see Appendix: CQC ratings charts - Care Quality Commission. It will be interesting to see how the new Single Assessment Framework, soon to be introduced, will impact the overall ratings for services in the sector moving forward.

To read the full report, click here: State of Care - Care Quality Commission (cqc.org.uk)

If you would like to discuss the issues raised in this report in more detail, or have a regulatory query, please get in touch with Carlton Sadler, Partner, Siwan Griffiths, Partner or Amelia Bauer, Solicitor.