• CQC local system reviews find “physical, psychological and social harm” caused by patients waiting “far too long” for hospital discharge
  • Focus on delayed discharges of care was “diverting attention from important issues” such as social care and GP capacity
  • Individual organisational targets “hindering” joined up health and social care
  • Social care market and workforce capacity raised as serious risks

The Care Quality Commission has “found examples of avoidable and unintentional harm” created by a fragmented health and care system.

In its interim report on the local system reviews it was asked to carry out by the Department of Health, the regulator said it saw “too many examples of people not being treated in the right place, by the right person, at the right time”.

The report, shared exclusively with HSJ, also raised concerns that:

  • “unnecessary pressure [is] placed on services that are not designed to meet the needs of people who use them”;
  • a focus on delayed discharges of care was “diverting attention from important issues” such as social care and GP capacity; and
  • funding flows and performance metrics means joined up care is “hindered” as individual organisations try to meet their targets.

Avoidable harm

Professor Steve Field, the CQC’s primary care and integrated care chief inspector, told HSJ “physical, psychological and social harm” had been experienced by people staying in hospital “far too long” and deteriorating while waiting for discharge.

He said he had seen cases where “people had ended up in the emergency department when they could have been looked after at home”. By the time care packages were arranged, he added, people were no longer “fit enough to get back [home] but if they weren’t admitted in the first place they could have stayed [living independently] at home for longer”.

The individual local reports from which the interim report was drawn found examples of people who experienced “hospital stays of over a year and their health condition deteriorated as a result”. Lengthy stays also resulted in hospital acquired delirium. In Stoke, the CQC found people “suffered detriment” to their health because of delays to hospital discharge and that people had faced an “undignified and distressing experience” due to delayed discharges when they were at the end of their life.

The report found a lack of out of hours support services resulted in people being admitted to “secondary care when it is unnecessary”. Inappropriate clinical information being sent to care home providers resulted in “inappropriate placements, delays to [care] packages… which can also compromise the safety of the discharge”.

Delayed discharges

But the report warned that focusing on delayed transfers of care “in isolation will not resolve the problems that local systems are facing”. The CQC said DTOCs can “divert attention from important issues” such as preventative measures and addressing primary and social care capacity. Its report said: “Strong integration of primary and community care services in systems is essential for people to remain safe and well in their usual place of residence.”

Professor Field said local systems need to look at the “cycle” of care not just patient discharges. He said: “I would put a lot of effort into primary care and social care prevention but also how do you support [patients] immediately after they come out of hospital so they don’t go back in. It really is total person care from start to finish.”

He added that he was “optimistic that leaders have got it [around DTOCs], in every area it feels like they are committed to moving in the right direction”.

CQC engagement director Chris Day said: “We have seen with the use of the [additional Treasury funding of £2bn] that it has been used to stabilise the markets in some areas and innovatively used to buy extra capacity or bring capacity together. I don’t think it was designed to be a long term fix but to provide stabilisation to allow long term planning.”

Messages to the centre

The CQC report also said system flow is “being overshadowed by the drive to meeting individual organisational targets”. It said a “narrow focus on achieving individual metrics” means joined up care is “hindered”.

It called on national bodies to look at how performance metrics and “funding flows… incentivise behaviour” to collaborate.

However, the CQC will not be asking for any changes to legislation or how trusts are measured at this time as it has only conducted six out of the 20 reviews it was commissioned to do.

The final report on local system reviews is due out in the summer. Mr Day said: “At the end of the exercise there may be some more points we want to flag…

“These reports show the real costs of failure, the financial costs as well as the individual costs. That clicks in peoples’ mind that actually they need to work more effectively with adult social care and primary care as a secondary care provider as that is how they will achieve what is for them a difficult budgetary settlement, and only by working it well can they hope to achieve the savings in their areas that they need to achieve.”

The report also said that national bodies need to “address the risks in the social care market as a matter of priority” and workforce capacity was “a major issue in every system” the CQC visited.

Professor Field said: “Some of the most important people caring for the most vulnerable in society are earning so little, it is not surprising they go and work elsewhere like shops.”

Mr Day added: “We want stability in the sector and having the right capacity and this might look like having the right pay and resources in these important areas.”