The state of health care and adult social care in England 2023/24

This year’s State of Care draws on findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care.

Across our activity and analysis, it is clear that timely access to good care continues to be a struggle for many, and that inequalities in care persist. For example, in March 2024, 5 million people waited more than 2 weeks for a GP practice appointment, with 1.4 million waiting more than 4 weeks. The number of new requests for local authority adult social care support that resulted in no service being provided has increased by 27% over the last 5 years. In April 2024, waits for care home beds and home-based care accounted for 45% of delays in discharging people who had been in an acute hospital for 14 days or more, with nearly 4,000 people delayed on an average day.

And issues with getting access to services are often exacerbated by deprivation: in 2023/24, attendance rates for urgent and emergency care for people living in the most deprived areas of England were nearly double those for people in the least deprived areas. Furthermore, analysis conducted for CQC showed that for people attending for mental health reasons, the difference was over 3 times higher for those in the most deprived areas.

The safety and quality of some services is not good enough – our review of maternity services shows that women and babies are still not receiving the high-quality maternity care they deserve. Women from Black and ethnic minority backgrounds continue to be more at risk of experiencing poor maternity care and outcomes, and we found huge differences in the way trusts collect and use demographic data, particularly ethnicity data, to address health inequalities in their local population. We have made recommendations for both providers and the wider system, aimed at improving safety for every mother and baby.

We also have serious concerns about mental health services. Lack of resources, ageing estates and poorly designed facilities are affecting the safety of inpatient wards. In community mental health services, following our special review of the care provided by Nottinghamshire Healthcare NHS Foundation Trust, we also identified wider concerns. In response, we have made clear recommendations to improve oversight and treatment of people with serious mental health issues. We also called for national action to tackle systemic issues in community mental health – including a shortage of mental health staff and lack of integration between mental health services and other healthcare, social care and support services – so that people get the right care, treatment and support when and where they need it.

Getting the right care, at the right time and in the right place is important for everyone. However, for children and young people, delays can have especially significant and lasting consequences. Some treatments and interventions are less effective if not administered at a specific age or developmental stage – and the opportunity to intervene can be missed completely if the wait for diagnosis is too long.

Many children and young people are not currently getting the support they need. We are highlighting this as a risk not just for today, but for the future. Children who do not receive the care they need today are at increased risk of becoming adults with long-term mental or physical illnesses, which could affect their quality of life and their ability to contribute to society tomorrow.

We have particular concerns about children and young people’s mental health services, where demand continues to rise. In 2023, 1 in 5 children and young people between the ages of 8 and 25 were estimated to have a mental health disorder. While the mental health workforce has grown, problems with staffing and skill mix remain. Across the country, services are facing challenges in recruiting staff including nurses, psychologists, occupational therapists, and consultant psychiatrists – all of which are having an impact on capacity, and therefore on the availability and regularity of appointments.

Mental health difficulties experienced as an adult can begin in childhood or young adulthood, as pointed out by the Mental Health Foundation. Early intervention increases the prospects of good mental health in later life – but delayed or inadequate intervention decreases these chances.

To explore the experiences of children and young people when using mental health services, we commissioned work to gain further insight. From this, one young person describes the consequences of what they felt to be inadequate support from community services, leading to long-term hospitalisation:

I didn't know what to do because I didn't have any GCSEs and I thought no one's gonna want to give me a job and I'm not gonna be able to go to college…I wasn't a normal person of my age because I was in hospital and I missed out on all the things

Conversely, a young person who had a positive experience reflected:

I do still think back on my time at CAMHS and I was like, if I didn't [get that support], I would be in such a different place today… I got very lucky.

Sadly, for every child who gets ‘lucky’ by receiving timely, appropriate support, we know that there are many more who don’t, potentially affecting their chances of a healthy adulthood.

We commissioned further research into attendances at urgent and emergency care settings by people with a mental health issue. This found that those aged 18 to 21 consistently have the highest rates of presentation for mental health issues at both emergency departments and urgent care centres. Not getting the right help at the right time can lead people’s symptoms to deteriorate and then they can end up in crisis and/or in inappropriate environments, such as urgent and emergency care.

Our inspections in urgent and emergency care found issues around triage and patient flow that affect care for all patients. This includes the link between delayed hospital discharges and availability of home-based care and care home beds, which is acutely apparent.

Inspections in these settings also identified specific issues around care for deteriorating children. Low numbers of children's nurses and gaps in staff training in safeguarding and recognising sepsis meant that in some services, there was a risk that a deteriorating child might not be identified quickly, with patients at risk of sepsis not being assessed and treated promptly. Actively involving parents in their child’s care decisions and addressing their concerns promptly is critical to safety.

Last year’s State of Care warned about movement to a two-tier healthcare system – where those who can afford to pay for treatment do so and those who can’t face longer waits and reduced access. This remains a concern, starkly illustrated in dental care. We conducted a dental access survey of 1,000 people earlier this year, which found that people relied more on private care where NHS activity is lowest, and we also heard how access issues had a clear impact on children and young people.

Parents told us they felt pressured to go private and found it difficult to get appointments, even in emergencies, and we heard about children left in pain while waiting for an emergency appointment. It is notable that the tooth extraction rate related to decay is nearly 3 and a half times higher for children and young people in the most deprived communities, compared with the most affluent.

Another area of concern for CQC is about care for autistic people and people with a learning disability – both the quality of care and access to it. We are currently exploring the barriers and inequalities faced by these groups of people in accessing primary care, including the quality and consistency of annual health checks and action plans by GPs. The waiting time to begin assessment for a possible autism diagnosis is far too long, with average waiting times even longer for children and young people – 356 days in April 2024 compared with 238 days for adults. An autism diagnosis can be vital to getting the right help and support and can make a critical difference for children who are struggling at school.

Our inspections of providers revealed some examples where specialist services for children and families with complex needs were pivotal in leading multi-agency working and sharing learning. Our work on formal integrated care system (ICS) assessments is currently paused. But in our limited review of ICS plans, we have seen some early positive signs, including transformation plans for children and young people’s services. Some ICSs have children and young people scrutiny boards to provide governance and monitor planned implementation.

But waiting times for services remain a problem within ICSs, and the main challenge is demand versus supply – a significant increase in requests at the same time as workforce shortages. We found variation between some published ICS plans or a lack of clarity about their intended outcomes. But some ICSs had examples of action already taken – for example, one described virtual wards that had supported more than 1,150 children.

However, a greater focus on children and young people’s services at both a national and local level is needed. This should include:

• consistent funding targeted to areas of early intervention
• a better understanding by systems of the gaps in provision of care and treatment for their population to ensure that local areas can meet the needs of their children
• improved management of demand
• better communication with children and their families.

The health and wellbeing of a nation’s children has been described as the best predictor of its future prosperity; failing to ensure good, safe care for our children today also risks failing their future.

Ian Dilks OBE
Chair