The state of health care and adult social care in England 2023/24

Primary and community care

More people are struggling to get appointments to see a GP at the same time as the number of people registered with a GP has increased.

In our survey of 1,600 adults who had accessed care in the last year, the 2 services that people had the most difficulty accessing were GP services (59%) and dental services (23%).

Between March 2020 and March 2024, the number of patients registered with a GP in England has increased by 5%, from 60 to 63 million. The number of people waiting more than 2 weeks for a GP practice appointment increased by 18% from 4.2 million in February 2020 to 5 million in March 2024. The number waiting over 4 weeks also increased, from approximately 1 million in February 2020, to 1.4 million in March 2024.

The 10 integrated care system areas with the highest proportions of patients waiting over 2 weeks for a GP appointment were in comparatively rural areas – with half of these in the South West of England.

Demand and capacity pressures on NHS primary dental services contribute to problems in accessing care that are leading to the deterioration in people’s oral health.

There is notable regional variation in the proportion of NHS dental work being completed – ranging from 48% to 97% – with rural areas tending to provide less NHS treatment.

Schoolchildren living in the most deprived areas were more than twice as likely to experience tooth decay than those living in the least deprived areas. And people in the most deprived areas of England were nearly 3 times more likely to be admitted to hospital for treatment that could potentially be avoided with timely and effective care in the community.

Our targeted assessments of the responsiveness of GP practices found that some practices demonstrated improved availability and accessibility of appointments and provided proactive outreach to patients.

Adult social care

The need for social care continues to increase, including needs when people are discharged from hospital. However, supply has not always kept pace, meaning more people are not getting the support they need.

The increase in the number of new requests for local authority adult social care support in 2022/23 was not matched by the number of requests granted with long-term care or short-term care to maximise people’s independence. The number of new requests that did not result in a service being provided increased by 27% since 2017/18.

In April 2024, 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. Although some of these delays will have involved waits for health rather than social care services, social care is likely to have been a significant factor in these delays.

For much of 2023/24, the North East and Yorkshire region had the highest proportion of delayed acute hospital discharges due to waiting for home-based care, and the North East region had the fewest homecare services per 100,000 population of older people. Meanwhile, London had proportionally the most delayed discharges from acute hospital due to waiting for a bed in a care home, and the fewest residential care home beds per 100,000 population of older people.

At 5.4%, staff vacancies in care homes at the end of 2023/24 were at their lowest rate for the last 3 years. Increases in international recruitment showed signs of levelling off over 2023/24, and there has been a steep fall in the number of overseas workers applying for health and care worker visas – representing an 81% decrease in the period April to July 2024 compared with the same period in 2023.

In 2023/24, we made 106 referrals to partner agencies regarding concerns about modern slavery and labour exploitation – nearly 3 times as many as last year.

Despite the challenges described in our report, outstanding adult social care providers are putting people at the heart of all decision making. Person-centred care, delivered with compassion and integrity, still makes a big difference to people’s lives.

Mental health

The demand for adult mental health services continues to grow, and even more so for children and young people, with ever increasing numbers seeking care and support for their mental health.

Access to mental health services remains a challenge for many people. Research from the Strategy Unit shows that people who live in deprived areas, women, and people from ‘other’ ethnic minority groups with mental health needs are more likely to attend urgent and emergency care departments.

Our regulatory activity, including our special review of Nottinghamshire Healthcare NHS Foundation Trust, has found evidence of people having to wait several months – and in some cases several years – for treatment in the community.

While the mental health workforce has grown, problems with staffing and skill mix remain. Across the country, services are facing challenges in recruiting staff – all of which are having an impact on capacity, and the availability and regularity of appointments.

The safety of mental health wards continues to cause concern. Lack of resources, ageing estates and poorly designed facilities can lead to issues around privacy and dignity for patients, as well as compromising the safety of both patients and staff.

Secondary care

High demand for services and ongoing pressure in all parts of the system mean that many people, including children, are not getting the care they need when they need it. This is leading to a deterioration in people’s health conditions, which then need more intensive support and treatment, and results in longer stays in hospital.

Although demand has not increased dramatically, overall, the performance of services to meet the need for care is below the expected standard – and in some cases it is getting worse. By operating continuously in these environments, there is the risk that it becomes normal to accept care that is below standard.

People are facing long waits for diagnostic tests. As at March 2024, there were around 1.62 million people waiting for a diagnostic test or procedure. And waiting lists are increasing. In total, the waiting list for a diagnostic test or procedure has increased by 52% since 2019.

People continue to experience delays in referrals and diagnosis for cancer. Figures from NHS England show that the 3 waiting standard measures are not being consistently met, with the exception of the 28-day faster diagnosis standard, which was met for the first time in February 2024. Performance varies considerably between types of cancer and between regional health and care systems.

Areas of specific concern

In our 2023/24 report, we have highlighted some areas of specific concern. The concerns involve issues around safety, quality, workforce, and inequalities, including:

• Too many women are still not receiving the high-quality maternity care they deserve. Of the 131 locations we inspected in our national maternity inspection programme, almost half were rated as either requires improvement (36%) or inadequate (12%).
• We have concerns that children and young people are not always able to access services in a timely way – both planned and in an emergency. Anecdotal evidence suggests that parents and carers are well placed to recognise when their child is very unwell, but many feel they are not being listened to.
• The number of health visitors, who give individual support for young children and their parents, has declined by 45% over the last 9 years.
• Only around a quarter of people with a learning disability were recorded on the learning disability register, which means that many people are missing out on the proactive care and treatment they are entitled to.
• Despite fewer new referrals for autism diagnoses over 2023/24, the average waiting time to start an assessment reached a peak of nearly a year (328 days) in April 2024, rather than the recommended 3 months.
• People in Black or Black British ethnic groups are over 3 and a half times more likely to be detained under the Mental Health Act than people in white ethnic groups.
• Work on our cross-sector dementia strategy is highlighting the compassionate care and initiatives that are improving people’s lives, but staff do not always understand the specific needs of people with dementia.

Deprivation of Liberty Safeguards

Too many people are waiting too long for a Deprivation of Liberty Safeguards (DoLS) authorisation, despite multiple examples of local authorities trying their best to reduce backlogs and ensure sustainable improvement.

We remain worried about the rights of people at the heart of the DoLS system. We continue to see people in vulnerable circumstances without legal protection, which not only affects them but also their families, carers, staff and local authorities.

The system has needed reform for over 10 years. Unless there is substantial intervention, we are concerned that these challenges will continue.

Local system response

Finance, joint forward planning and workforce depletion are among the main challenges for integrated care boards as people struggle to access the care they need.

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.

Systems are focused on tackling health and care inequalities. They need to understand their populations to address issues that affect everyone, from children who need dental care to older people with dementia, but they face financial pressures and competing priorities.

There are mixed views among integrated care systems (ICSs) about their capability to address local health inequalities. There are challenges and barriers around data and analysis skills, governance and accountability, and capacity and capability in the system. CQC’s formal work on ICS assessments is currently paused.

Carers play a vital role in millions of people’s lives. At all the local authorities we have assessed so far, there is work needed to identify carers – and raise awareness that carers are entitled to an assessment and services to support them in their role. This was needed more for people in ethnic minority groups.

Local authorities have taken steps to address known inequalities and understand the demographics of local populations. But there is a need for better engagement with the voluntary sector and community groups, which have seen some success in identifying groups that are seldom heard and at greater risk of inequality.

Local authorities have a focus on safety through collaboration. Shared data and information is helping this, as it is made available across services and care pathways, improving safety for people moving between hospitals and the community.