Summary

 

The care that people received in 2019/20 was mostly of good quality. But while the quality of care was largely maintained compared with the previous year, there was generally no improvement overall. And in the space of a few short months since then, the pandemic has placed the severest of challenges on the whole health and care system in England.

Quality of care before the pandemic

There was some improvement in NHS acute care, where 75% of core services were rated as good or outstanding compared with 72% the previous year. But there are still services where the quality of care needs to improve substantially – more than half of urgent and emergency care services in hospital were rated as requires improvement or inadequate as at 31 March 2020, as were almost a third of medical care and outpatient services. The quality of maternity services has barely changed, with at least one in four rated as requires improvement overall at 31 March 2020.

Among mental health services, we continued to find more poor care in inpatient wards for people with a learning disability and/or autistic people. The overall proportion of services rated as inadequate rose from 4% to 13%.

Before the arrival of the coronavirus pandemic, we remained concerned about a number of issues. While most care is rated as good across different settings, there were some areas that remained a great cause for concern. These were typically in those areas where care was harder to plan for – where providers cannot by themselves control the flow of people into their services and, as a result, they have to plan for an unpredictable level of care.

The social care sector continued to be fragile as a result of the lack of a long-term funding solution, and in need of investment and workforce planning, and there was a continued need for Parliament and government to make this a priority.

Some of the poorest services struggled to make any improvement. A very small proportion of GP services (1% of all practices) have never been rated better than requires improvement. In adult social care, 3% of care homes have never been rated better than this.

Across all sectors, some people were not able to access the care they needed when they needed it. Challenges included:

• pressures on emergency departments due to local demand, often linked to access issues elsewhere in the system
• NHS trusts struggling to meet referral-to-treatment times – the total number of people waiting for treatment carried on rising, reaching 4.4 million in February 2020
• significant gaps in access to good quality mental health care, with particular difficulties in accessing child and adolescent mental health services.

There were persistent inequalities in some aspects of care and there remained considerable variation between different areas and services in how well they consider the needs of people from different groups – particularly people from Black and minority ethnic groups, people from religious groups and disabled people.

The impact of the coronavirus pandemic

As the pandemic gathered pace, health and care staff across all roles and services showed resilience under unprecedented pressures and adapted quickly to work in different ways to keep people safe.

In hospitals and care homes, staff worked long hours in difficult circumstances to care for people who were very sick with COVID-19 and, despite their efforts to protect people, tragically they saw many of those they cared for die. Some staff also had to deal with the loss of colleagues to COVID.

Very quickly, care homes stopped visits from family and friends to try and control the virus. Measures put in place had a huge impact on people, with some residents confined to their rooms, social events cancelled, and shared areas in the home – such as dining rooms and lounges – closed due to physical distancing. The impact on people not being able to visit partners or spouses during lockdown has increased loneliness and stress.

The impact of COVID-19 on people in terms of delays to elective and diagnostic care, and urgent services such as cancer and cardiac services, is enormous. In real terms, this means people who have not yet had the life-changing operations they need, and people whose cancer remains undiagnosed or untreated. And overall, the pandemic has had a significant impact on many people’s mental health and wellbeing.

Among the many challenges faced by providers in recent months, services have had to make sure they have enough employees with the right skills to cope with new and increased demands. A key challenge for providers has also been maintaining a safe environment – managing the need to socially distance or isolate people. Effective infection prevention and control will remain essential to protect people from acquiring COVID-19. Providers need to make sure they are taking action to minimise the risk of cross-infection. For all health and care services, this includes maintaining the highest standards of infection control in all areas, as well as mitigating the challenges caused by social distancing rules, such as reduced capacity in waiting rooms and reception areas.

The speed and scale of the pandemic required health and care providers to respond in new ways. The crisis has accelerated innovation that had previously proved difficult to mainstream, such as GP practices moving rapidly to remote consultations. The effectiveness of these changes are yet to be fully evaluated, but during the pandemic they have proved beneficial to, and popular with, many. However, many of these innovations exclude people who do not have good digital access, and some have been rushed into place during the pandemic.

Arrangements and planning for people who are vulnerable to digital exclusion must not be lost in the rush to prioritise innovative and resource-saving online options. The challenge now will be to keep and develop the best aspects of these new ways of delivering services while making sure that no one is disadvantaged in the process.

It has become clear that COVID-19 has had a disproportionate effect on some people with protected characteristics: people from Black and minority ethnic backgrounds, older people, and people with some long-term health conditions and other disabilities have been hit harder by the pandemic and its knock-on effects. These unequal effects have affected health and social care workers as well as people in need of care.

While we are yet to understand all the reasons for these disparities, they do serve to shine a light on existing inequality in the health and social care system.

Collaboration between providers

Over the summer, CQC reviewed the way health, social care and other local services worked together in 11 parts of the country. The reviews have brought into focus the learning that needs to be used to help plan for resurgences of the virus.

We found that the success of collaboration among providers to keep people safe was varied, often affected by the maturity of pre-existing relationships within the system. Understanding the needs of the local population, including cultural differences, was especially important. At times the pace of change felt overwhelming for health and social care providers.

Where we found well planned governance, clear decision-making arrangements and escalation plans, those system-wide responses were most effective. In contrast, where we found multiple or unclear governance arrangements, those areas experienced higher levels of confusion and duplication of effort.

Sectors did not feel consistently engaged in the coordination of responses to the crisis. The views of sector partners varied as to the effectiveness of joint and supportive working arrangements, particularly between care homes and GP practices.

System areas benefitted from the pace of effort to secure a regional level grip across communication, support and joint working approaches, in response to confusion from the pace of national guidance.

Strategies to manage staff and resources across sectors and partnerships were inconsistently navigated, causing varied success of collaboration within systems. The voluntary sector played a critical role in supporting health and social care to keep people safe. System-wide leaders were concerned about capacity to meet the demands of subsequent peaks without this support.

Accelerated and shared digital approaches supported providers to work together and keep connected well. However, advanced IT and technology did not always assist with efficient and timely access to care for people.

Looking forward, the challenges and opportunities ahead

The problems that existed before the pandemic have not gone away. People are still more likely to receive poorer care from some types of service, and from some providers, for the same reasons that they would have been more likely to receive poorer care pre-COVID.

The fact that the impact of COVID has been felt more severely by those who were already likely to have poorer health outcomes makes the need for services to be designed around people’s needs all the more critical. It is important that new pathways and practices are developed in ways that reduce health inequalities and improve people’s lives.

Social care’s longstanding need for reform, investment and workforce planning has been thrown into stark relief by the pandemic. There needs to be a new deal for the adult social care workforce that reaches across health and care – one that develops clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation. The legacy of COVID-19 must be the recognition that issues around funding, staffing and operational support need to be tackled now – not at some point in the future.

The increased waiting lists and backlog of urgent and elective care need to be addressed – services need to assess and prioritise patients so that they are treated according to clinical need and that people waiting for long periods for treatment are kept safe. Going forward, hospitals and other healthcare services need to finely balance the capacity to provide COVID and non-COVID care, and make sure that people have the confidence to come forward for the care and treatment they need.

Primary care services similarly need to make sure that people are given the confidence to interact with them early, provide a range of ways for them to access the care they need, and make it easy for them to do so.

Mental health is a key area where we have previously raised concerns about the lack of community care and early diagnosis and support. It is likely that people who have been unable to access mental health services since the start of the pandemic will be looking for more help once services are re-established. Enhanced mental health support will be needed for people and communities.

Health and social care providers across the country need an equal and consistent offer of improvement. Providers and systems need access to shared learning, information, advice and support, so they can be empowered to help themselves. Information is needed so they can understand their performance against similar services, which in turn can help them access the specific support they need to implement changes.

As the health and care system continues to wrestle with the pandemic, providers, regulators and system partners need to maintain the appetite to work together and at pace. We must make sure that we learn from the response to the crisis, that we lock in positive changes, and that we drive a new way of working that is supported at a national, regional and local level by the whole health and care system.

The way we plan, commission and deliver health and care must be shaped by the experience of dealing with a national health emergency, which has shown so very clearly how interdependent health and care truly are.

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Part 1: Quality of care before the pandemic

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Foreword