The State of Care report raises some uncomfortable questions about health and social care – so how can we answer them, asks Jennifer Dixon
Leave aside your builders’ tea, this week’s Care Quality Commission State of Care report merits a stiff drink or two. It’s as clear an analysis as we’ve seen to date of the state we’re in, through the lens of inspecting practically all health and social care providers in England, plus analysis of supporting data.
We know that social care is on the slide – CQC gives ample testimony as to how fragile the market is. It’s not so much the quality of care – 72 per cent of providers are rated good or outstanding – but access to it. Relentless funding cuts have meant 25 per cent fewer people receiving local authority funded care in the last five years (see charts 1 and 2), with the gap between those that need and those that get widest for, guess who…? Yes, the poorest in society (chart 3).
With the rates paid by local authorities for residential and nursing care dropping and costs rising, CQC’s social care market oversight work is showing the strain on a set of “difficult to replace” social care providers who may walk away from local authority contracts, as others are now doing. CQC uses uncommonly strong language for a straight bat regulator – “the evidence”, they say, “suggests we may be approaching a tipping point”.
Anyone working in the NHS can see the impact, although research is still to catch up to quantify it. Interestingly in the State of Care’s chapters on acute care, there is a big gap in the ratings for different types of core services, with urgent, emergency and other medical rated poorer on quality than services for children and critical care. This suggests pressures are concentrated in areas that mainly treat older people.
Further deterioration in social care will drag down NHS performance with it. This high risk situation needs an urgent political solution. The evidence shows that new funding streams for social care in the 2015 Spending Review are not enough. The autumn statement is an obvious opportunity for the government to make more progress.
The State of Care also raises some uncomfortable questions about why some parts of the NHS have deteriorated while others have improved
But this mustn’t feed the understandable habit of all organisations, public or private, to identify the source of problems as coming from the outside. There is a long list of external pressures in the NHS: lack of funding; the national tariff; too much demand; shortages in the workforce through inadequate national planning; weak commissioning; data gaps and information governance blocks and so on. The hollowing out of management over the last five years hasn’t helped.
I’ve lost count of the presentations and reports, some from my own organisation, citing these very real challenges. There is an impressive amount of national and local work going on to address them. They are combining to test local management more than at any stage in the NHS’s history. But the State of Care also raises some uncomfortable questions about why some parts of the NHS have deteriorated while others have improved.
First is the finding that there is an association between the quality ratings of acute trusts and their financial health: trusts rated good or outstanding were more likely to be better at balancing their budgets (or have smaller deficits) than those rated inadequate. This was also found by colleagues at the Health Foundation: yes, association is not causation, but the implication is that even allowing for the systemic issues creating a outside, good local management pays off. This implication merits more exploration.
Second, managing patient flow was one of the main concerns in CQCs inspections of acute hospitals. Improving flow can be slow hard work, but there is enough evidence of impact now to ask why isn’t flow management central in the NHS’s DNA?
The Sheffield Discharge to Assess team that the Health Foundation has funded and supported has reduced the time taken to discharge patients from over five days to just over 24 hours – over 10,000 patients in the last year have been transferred out of hospital into this “active recovery” service. It is now coaching other trusts to discover similar solutions. Why aren’t similar approaches more widespread? And if the NHS doesn’t ask this question, won’t the Treasury this autumn?
In the NHS, the riskiest, largest and most complex organisation in Europe, the pressure is uncovering rocks which higher levels of funding kept submerged
Third, the time taken to turn around the performance of Wexham Park Hospital from a rating of inadequate to a rating of good by its local neighbour Frimley Park Hospital was just over one year. How? By tackling organisational culture and improving leadership and management at several levels, including among clinicians. No-one pretends it is easy to turn things around, but it can be done, and good local management is a key factor.
Current pressures would test the very best organisations in the UK to the limit. In the NHS, the riskiest, largest and most complex organisation in Europe, the pressure is uncovering rocks which higher levels of funding kept submerged. There is no doubting current levels of commitment, motivation or hard work. The key issues lie elsewhere and need to be brought to the surface if more rapid change, or even change, gets off powerpoint and into reality. Support, headspace, skilling up, the right culture, clinicians on board and leading. We know most of the answers, and can see the evidence of impact in the State of Care report. To be continued….
Dr Jennifer Dixon is chief executive of the Health Foundation