A turbulent year for UK healthcare has opened up a divide among the population where those who can afford to pay for treatment do so and those who cannot face longer waits and reduced access.
This is according to the Care Quality Commission’s (CQC’s) annual assessment of the state of health and adult social care in England looks at the quality of care over the past year.
Divide opening up
The report points to an ongoing problem of ‘gridlocked’ care highlighted in last year’s State of Care report, the cost-of-living crisis biting harder for the public, staff, and providers – and escalating workforce pressures. The CQC concludes that the resulting combination of risks is 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”.
The report points to intensifying workforce challenges, with unresolved industrial action by NHS staff unhappy with pay and conditions.
Record waits for treatment pushing people to go private
It adds that “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 eight in 10 of those who used private healthcare 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.
According to the CQC the current 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 own 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.
Difficult financial choices
But the CQC also found people may also be forced to make “difficult financial choices”. It revealed it had heard from someone in receipt of benefits who resorted to extracting their own tooth because they were unable to find an NHS dentist. They then had to pay £1,200 on a credit card for private treatment, doing without household essentials until the debt was paid.
Over 2022/23, the CQC maintained it 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.
It further revealed ratings data indicates a mixed picture of quality, amid “a notable decline in maternity, mental health and ambulance services”.
Maternity services under huge pressure
CQC added it has continued its focused programme of maternity inspections, with the overarching picture of a service and staff under “huge pressure” emerging. Its data shows 10% of maternity services are rated as inadequate overall, while 39% are rated as requires improvement.
Safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for their safety and 12% rated as inadequate for being well-led.
The CQC said that while it has been “encouraging” that all units inspected so far have adjusted consultant cover to meet recommendations made in the Ockenden report, the cover model is “often fragile, with rotas reliant on every consultant being available”.
And it revealed while it has seen examples of services taking action to manage staff shortages safely, it has also seen “issues with governance and lack of oversight from boards, delays to care and lack of one-to-one care during labour, as well as poor communication with women and difficult working relationships between staff groups”.
And it also pointed out that women and babies from ethnic minority groups continue to experience higher risks around birth. It said infant mortality rates for Black and Asian babies are still higher than for any other group and readmission rates of Black women during the six-week postpartum period continue to rise and are “significantly higher” than for women of other ethnicities.
Built by white people for white people
Alongside its programme of maternity inspections, CQC also commissioned a series of interviews with midwives from ethnic minority groups to explore their experiences of working in maternity services and their insights into safety issues. It said a common theme from these interviews was that care for people using maternity services is affected by racial stereotypes and a lack of cultural awareness among staff.
One midwife said, “The NHS is amazing, but it was built by white people for white people. We need to adapt, because now we have a diverse population and workforce.”
Poor access to mental healthcare
Access to and quality of mental healthcare also remains a key area of concern.
The CQC found 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.
It revealed 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 and that 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, it added.
Staff recruitment and retention issues
Added into the mix, the CQC pointed out that 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.
The CQC revealed it 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.
Crucial strikes do not go into winter
Ian Trenholm, CEO of the CQC, said: “The combination of the cost-of-living crisis and workforce challenges risks leading to unfair care, with those who can afford to pay for treatment doing so, and those who can’t facing longer waits and reduced access.
“And 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.
“Of course, workforce challenges for the health and social care sector long pre-date the current industrial action.
“The publication of the NHS Long Term Workforce plan has been a positive step but implementation will be challenging – particularly without a social care workforce strategy to sit alongside it.
“We continue to call for a national workforce strategy that raises the status of the adult social care workforce and ensures that career progression, pay and rewards attract and retain the right professional staff in the right numbers. It is encouraging that Skills for Care has made this an area of focus.
“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.”
“Maternity services and mental health services have been a particular area of inspection focus for us this year, and while we have seen some good practice, we have seen too many examples of poor care, and have taken action to protect people when necessary.
“However, it’s important to say that we have also seen staff and leaders across all sectors mitigating risks arising from staffing shortages and working hard to deliver good care in very challenging conditions.”
Lack of joined up planning
Ian Dilks, chairman of the CQC, added: “The challenges described in this year’s State of Care are to some degree caused by a lack of joined-up planning, investment, and delivery of care.
“Integrated care systems present the opportunity of bringing together local health and care leaders with the populations they support to understand, plan, and deliver care at a local level. This would in time move some of the focus of care away from big institutions and towards local and self-care provision, with autonomy to act on local population needs and an increased focus on preventing poor health, not just treating it.
“However, in our first look across local care systems, we found that while all systems have some equality and health inequalities objectives, these plans do not all have timeframes and measures.
“All systems need clear and realistic goals – and support to achieve these – that reflect how they will address unwarranted variations in population health and disparities in access, outcomes, and experience of health and social care.
“This opportunity must be grasped to ensure fairer care for everyone – so people get the care they need, not just the care they can afford.”