CQC: COVID-19 is magnifying inequalities and “risks turning fault lines into chasms” – focus now must be on shaping a health and care system that delivers for everyone
The Care Quality Commission's (CQC's) annual assessment of the state of health and social care in England looks at the quality of care over the past year. This includes the period before the full impact of COVID-19 began to be felt and CQC's routine inspections were suspended as a result of the pandemic.
Pre-COVID-19, care was generally good, but with little overall improvement and some specific areas of concern:
In the NHS, improvement in some areas, including emergency care, maternity and mental health, was slower than others. More than half of urgent and emergency care services were rated as requires improvement or inadequate as at 31 March 2020, while a quarter of maternity services were rated as requires improvement.
- In mental health services, inspectors continued to find 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% – almost entirely based on deterioration in independent services, rather than NHS services.
- The social care sector was fragile as a result of the lack of a long-term funding solution, and in need of investment and workforce planning. In March 2020, CQC's Market Oversight report highlighted that, in the absence of mitigating action, any further shocks to the labour market would be expected to increase the existing level of market fragility, place more pressure on local authority finances and could increase unmet care needs. There have been short-term interventions since that point but the need for a longer-term funding plan has still not been addressed.
- In primary medical services, the fact that the overall ratings picture remained almost unchanged, with 89% of GP practices rated good and 5% outstanding masked a more volatile picture, with some practices deteriorating and a similar number improving.
Since the arrival of COVID-19, all these things remain true, but so much else has changed. In considering the health and care system's initial response to the pandemic, in order to learn lessons for the future, there are elements to build on – and elements to reassess.
The progress achieved in transforming the way care is delivered has been extraordinary. In a matter of days, services developed new procedures and ways of working, often taking advantage of technology. Changes which were expected to take years – like the switch to more flexible GP consultations by phone and online – took place almost overnight. This report highlights many examples of collaboration among services which have made a real difference to people's care.
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.
At the start of the pandemic, the focus on acute COVID-19 care was driven by the urgent imperative that the NHS should not be overwhelmed. Decisions were made in order to ensure capacity as quickly as possible – but now priorities need to be reset in a more sophisticated way to ensure that the longer-term response includes everyone, regardless of what kind of care they need, or where they receive it.
This resetting of priorities starts with local leaders seizing the opportunity to collaborate and building capacity to respond together to the needs of their area. The fact that the impact of Covid has been felt more severely by those who were already more likely to have poorer health outcomes – including people from Black and minority ethnic backgrounds, people with disabilities and people living in more deprived areas – makes the need for health and care services to be designed around people's needs all the more critical.
Over the summer, CQC reviewed the way health, social care and other local services worked together in 11 parts of the country. There were differences in the way they responded to the pandemic but there was evidence that the places with established working relationships and an understanding of need in their local areas were better able to care for the local population in a time of crisis.
The reviews have brought into focus the learning that needs to be used to help plan for a longer-term response to the virus. It is essential that the right support is available for all parts of a local health and social care system to drive improvements where they are needed, and to involve voluntary and community organisations in promoting health and wellbeing.
In social care, COVID-19 has not only exposed but exacerbated existing problems. The sector, already fragile, faced significant challenges around access to PPE, testing and staffing – and coordinated support was less readily available than for the NHS. The long-standing need for reform, investment and workforce planning in adult social care has been thrown into stark relief by the pandemic.
Today's report makes clear that these issues need to be urgently addressed – underpinned by a new deal for the care workforce, which develops clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation.
In the NHS, emergency departments now face the prospect of a winter which combines pre-existing pressures with the urgent demands of the pandemic. As other services restart, physical distancing will provide significant challenges, both logistically and in terms of managing capacity, alongside a backlog of people who were unable to access care during lockdown.
The impact of COVID-19 on the NHS in terms of elective, diagnostic and screening work has been enormous. Some life-changing operations have still not been rescheduled and there are people whose cancer has not been diagnosed or treated. As we enter a second wave, there must be learning to ensure that non-COVID-19 patients are not left behind. The NHS is already working hard to develop innovative solutions – collaborative partnerships between providers could help to protect services so people get the care they need.
It will also be particularly important that those services where improvement was already not quick enough – for example mental health and maternity – do not fall further behind. Concerns about these service areas have led to risk-based inspections during the pandemic with enforcement action taken as a result. With the recognition that COVID-19 has fundamentally changed so much, it is important to recognise what has not changed. Problems that existed before the pandemic have not gone away – and people are still more likely to receive poorer care from some types of services for reasons that pre-date COVID-19.
CQC will maintain scrutiny on these services, supporting improvement and taking action to protect people where necessary – and will continue to highlight factors, including commissioning and staffing, which impact on care but cannot be resolved at provider level alone and demand a national response.
Alongside this, CQC will also carry out targeted programmes of work specifically focused on building resilience across the health and care system as it continues to respond to COVID-19, and look for opportunities to actively support providers who are trying new ways to improve people's care.
Ian Trenholm, Chief Executive of CQC, said:
"Pre-Covid, the health and care system was often characterised as resistant to change. Covid has demonstrated that this is not the case. The challenge now is to maintain the momentum of transformation, but to do so in a sustainable way that delivers for everyone – driven by local leadership with a shared vision and supported by integrated funding for health and care.
"There is an opportunity now for Government, Parliament and health and care leaders to agree and lay out a vision for the future at both a national and local level. Key to this will be tackling longstanding issues in adult social care around funding and operational support, underpinned by a new deal for the care workforce. This needs to happen now – not at some point in the future.
"Covid is magnifying inequalities across the health and care system – a seismic upheaval which has disproportionately affected some more than others and risks turning fault lines into chasms. As we adjust to a Covid age, the focus must be on shaping a fairer health and care system – both for people who use services, and for those who work in them."
Peter Wyman, Chair of CQC, said:
"Previous State of Care reports have highlighted areas of significant concern about, and opportunities to improve, the quality of health and social care provision. This report is no different in this respect – the areas we were concerned about before the pandemic remain areas of concern today.
"What the response to Covid has demonstrated is how better joined up system working can improve both the quality of care and people's experience of it. The increased pressures that the pandemic has placed on health and social care make it more crucial than ever to seize the opportunities available to rethink the delivery of care – or risk poorer care for some of the most vulnerable, and more patients left behind as a result of the pandemic.
"The pace of change also makes it more important than ever that there is a safety culture across health and social care where staff, patients and their families feel able to speak up openly about what has worked and what has not, and that learning is then shared and acted on."
The state of health care and adult social care in England 2019/20 is based on inspections and ratings data, along with other information, including that from people who use services, their families and carers, to inform CQC's judgements of the quality of care.
This includes quantitative analysis of inspection ratings of 31,000 services and providers, drawing on other monitoring information including staff and public surveys, and performance. In previous years, ratings have been as at 31 July, to enable as contemporaneous a view as possible. Due to the suspension of CQC's routine inspections in March 2020 as a result of the pandemic, the ratings in this report are as at 31 March 2020 and all comparisons with the previous year are to ratings as at 31 July 2019.
As at 31 March 2020:
- 80% of adult social care services were rated as good and 5% as outstanding (31 July 2019: 80%, 4%)
- 89% of GP practices were rated as good and 5% as outstanding (31 July 2019: 90%, 5%)
- 67% of NHS acute core services were rated as good and 8% as outstanding (31 July 2019: 65%, 7%)
- 71% of NHS mental health core services were rated as good and 11% as outstanding (31 July 2019: 71%, 10%)