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.
It draws on inspection activity, findings from CQC’s national NHS patient survey programme and statutory reports, bespoke research into people’s experiences, insight from key stakeholders and evidence collected by the regulator throughout the year about the quality and safety of services in all areas of health and care.
Getting the right care, at the right time and in the right place is important for everyone. For children and young people, however, 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. This year’s State of Care report highlights 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.
More broadly, timely access to good care continues to be a struggle for many, and inequalities in care persist. And issues 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. Analysis conducted for CQC showed that for people attending for mental health reasons, the difference was over three times higher for those in the most deprived areas.
The safety and quality of some services is not good enough. CQC’s review of maternity services shows that women and babies are still not receiving the high-quality maternity care they deserve, and women from Black and ethnic minority backgrounds continue to be more at risk of experiencing poor maternity care and outcomes.
Mental health services are also a cause for serious concern. Lack of resources, ageing estates and poorly designed facilities are affecting the safety of inpatient wards. CQC’s special review of the care provided by Nottinghamshire Healthcare NHS Foundation Trust also identified wider concerns around community mental health services, leading to recommendations to improve oversight and treatment of people with serious mental health issues.
CQC has 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 often begin in childhood or young adulthood. Early intervention increases the prospects of good mental health in later life – but delayed or inadequate intervention decreases these chances.
CQC commissioned work to gain further insight into the experiences of children and young people when using mental health services. From this, one young person described 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.
Further research commissioned by CQC into attendances at urgent and emergency care settings by people with a mental health issue 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 to people’s symptoms to deteriorate and they can then end up in crisis and/or inappropriate environments, such as urgent and emergency care.
CQC’s inspections of urgent and emergency care services found issues around triage and patient flow that affect care for all patients but 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. CQC 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 that access issues had a clear impact on children and young people.
Parents said they felt pressured to go private and found it difficult to get appointments, even in emergencies, and that children were 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.
The report also highlights concerns about care for autistic people and people with a learning disability – both the quality of care and access to it. 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.
In inspections of providers, CQC has seen examples where specialist services for children and families with complex needs were pivotal in leading multi-agency working and sharing learning. A limited review of integrated care system (ICS) plans, undertaken before the pause in CQC’s assessments of ICSs also saw 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.
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. There was 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, 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 and communication with children and their families.
Ian Dilks, Chair of CQC, said:
This year’s State of Care describes issues with access to and quality of care and the impact on people who use health and care services - with particular focus on the many children and young people who are not getting the care they need when they need it.
While some children are receiving timely, appropriate care, we know that there are more who don’t, with potential long-term repercussions for their mental and physical health. Action now – targeted funding for early intervention, better understanding of local need and improved management of demand, and genuine two-way communication with children and families – will help to ensure a healthier population tomorrow.
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.
James Bullion, Interim Chief Executive of CQC, said:
We have consistently highlighted the fragility of the adult social care sector – and the situation remains precarious.
The number of new requests for local authority adult social care support that resulted in no service being provided has increased by over quarter over the last 5 years. And in April this year, waits for care home beds and home-based care accounted for almost half of delays in discharging patients who’d been in hospital for more than 14 days. Nearly 4,000 people are delayed on an average day – that’s 50 double-decker buses full.
While vacancies in adult social care have dropped slightly, the average staff vacancy rate in social care is still nearly three times higher than in the national workforce – and care workers, despite the crucial job they do, remain among the lowest paid members of society.
Some providers are struggling to provide good, safe care – but there are also many outstanding adult social care providers who put the people they care for at the centre of their decision making, as the case studies included in this report demonstrate.