Our healthcare team have produced a series of articles looking at key issues in adult health and social care following the publication of the CQC's State of Care Report. The verdict from the CQC is that the vast majority of adult social care services in England are delivering good care but there are major concerns about overall sustainability.
In its annual report, the Care Quality Commission (CQC) found that almost 60% of all services were providing good or outstanding care; 85% of services [which includes nursing and residential homes and domiciliary care] were found to be caring but 10% were rated as inadequate when it came to safety. As has been the case previously, nursing homes performed worse than residential homes and homecare services with one in 10 nursing homes rated as providing inadequate care, and less than 50% as good or outstanding. There have been calls from the sector for further analysis in relation to low financial rates for care provision when funded by local authorities and those with an inadequate or requires improvement rating.
We understand the collective voice of the sector and now the regulator emphasising the fragility of adult social care, however it is more clear than ever that the chasm between the baseline of delivering high quality services and the rates commissioners pay is widening further. Further warnings have been issued by the Local Government Association which has called on the Government to provide more cash for social care through the Autumn Statement, with a call for at least £1.3bn of additional funding to immediately to stabilise the market, and a further £1.3bn needed by 2019-20. Current markers illustrating the instability of the current system were identified as follows:
More than half of local authorities in England saw a home care/residential care provider exit the market in the first half of 2016.
NHS England have stated that it would not be prudent to assume any additional NHS funding over the next several years as the argument is there that it should be spent on social care.
Councils identified significant price increases for providers were becoming necessary in order to meet demand, but these were not sustainable in the face of the extensive savings that local authorities still had to make.
Both Camden and Sefton Council have warned that they are facing significant challenges meeting their duties under the Care Act due to budgetary restrictions.
The NHS Health Select Committee expressed concern that cuts to social care funding have exhausted the capacity for significant further efficiencies in this area and that people with genuine social care needs may no longer be receiving the care they need to due to resource.
The Royal College of Psychiatrists has expressed concern that the Care Act risks becoming “an unrealistic wish list of exemplary services that no one ever receives” unless the funding situation is improved.
The decrease in real terms in the number of nursing beds available will continue to place pressure on hospital bed occupancy rates, which until January – March 2016 were running at 91%, the highest quarterly rate for at least 6 years. This highlights a need for continuing collaboration between acute services and care home providers. For some reason, there is a disjointed focus on the NHS and the cost to acute services of those who are medically fit for discharge but remain in hospital. The evidence is clear that cuts to social care services increase pressure on the health service, with GP visits, A&E attendance and admissions all on the rise.
Interestingly, the CQC has seen the impact of the cuts and efficiency savings first-hand through their market oversight team which has access to detailed financial information about the largest adult social care providers. They acknowledge that profit margins have reduced – both due to pressures on fees that funders of care are able or willing to pay, and cost pressures that include the impact of the national living wage. We are aware of large providers handing back contracts they think are uneconomic and undeliverable as operators jockey to find their place in the market and revaluate legacy loss making contractual arrangements.
Another strong thematic concern from the CQC across all sectors related to safety. Providing a cautionary note for the inspection focus for the year ahead, the CQC perceive that the quality of leadership has a direct bearing on safety. Significantly, the CQC are becoming much more interested in the executive leadership team beyond the registered manager to determine whether senior figures are fit and proper to be a controlling mind in a care entity. We know from earlier in the year that the CQC will focus on the financial state of the business when determining whether an operator is well led, which signifies a more thorough approach to that we have seen previously. Staffing is perhaps the most significant concern, with care providers struggling to give older people safe, good quality care when the staff turnover rate is 25% and as many as one in five home care nursing positions are vacant at any one time. Unless there is a significant change that includes short and longer term investment, the care crisis will materialise, the only question is when will it happen.
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