(BMJ 2017;359:j4799 ) This is worrying and there is inadequate funding, but the word omitted by Mr Ham is “rationing” – of course.
The annual assessment of health and social care by the Care Quality Commission (CQC) provides a veritable treasure trove of information about the state of services in England.1 Based on inspections of 21 256 adult social care services, 152 NHS acute trusts, 197 independent acute hospitals, 18 NHS community health trusts, 54 NHS mental health trusts, 226 independent mental health locations, 10 NHS ambulance trusts, and 7028 primary care services over three years, the assessment offers grounds for concern and reassurance in equal measure.
The CQC’s headline finding is that most services are good and many providers have improved the quality and safety of care since inspections. Behind this headline lies a much more nuanced assessment, with variations between and within services and evidence of growing pressures on staff and deterioration of quality in some services. Adult social care is identified as a particular concern, with a reduction in nursing home beds, providers of domiciliary care handing back contracts to dozens of local authorities, and an estimated 48% increase in the number of older people not receiving the help they need since 2010.
The CQC argues that health and care services are working at full stretch and that staff resilience is not inexhaustible. It is hard to escape the conclusion that standards in many services are likely to fall in future as a result of continuing financial pressures. Support for this view can be found in evidence by Simon Stevens, chief executive of NHS England, to the House of Commons Health Committee on the day the report was published. Stevens warned that low levels of funding growth for the NHS in the next two years would result in deteriorations in care, a reminder if one were needed of the dangers that lie ahead.2
Challenges for NHS, government, and CQC
The challenge for the NHS arising from CQC’s assessment is to learn lessons from the experience of NHS trusts that are performing well even in the face of financial and operational pressures. According to the CQC, the characteristics of acute hospital trusts that have improved care include strong leadership, engaged staff, cultures that empower staff to improve care, a shared vision, and an outward looking approach. There is more work to do to embed these characteristics in all NHS providers to ensure that patients receive the best possible care.
The challenge for the government is to find a sustainable solution for the future funding of adult social care, described by the CQC as “one of the greatest unresolved public policy issues of our time.” The promised green paper on adult social care provides an opportunity to tackle this problem if the will exists within the government to examine all the options and to move beyond the sticking plaster solutions like the Better Care Fund that have so far failed to deliver.3 A good starting point is the report of the Barker Commission, which laid out the hard choices on tax and spending that need to be confronted in securing sustainable funding for the future.4
The challenge for CQC is to use the intelligence and understanding it has acquired to support improvements in care and not just to hold up a mirror to how services perform now. It also has more work to do to assess the performance of local systems of care as well as the organisations providing care. Its observation that high quality care is delivered when services are joined up around the needs of people reinforces the importance of work to integrate care through implementing the NHS five year forward and sustainability and transformation plans.5
Continuing to give priority to the development of these new care models will not be easy when so much management and clinical time is focused on reducing financial deficits and meeting waiting time targets. The CQC’s warnings about the perilous state of some services could have the unintended effect of strengthening the focus on these operational matters at the expense of work to transform care. Securing the future of health and social care depends on doing things differently, not doing more of the same a bit better, and leaders at all levels have a responsibility to make sure this happens. This must include providing additional funding to sustain services while options for the longer term are explored in work on the green paper.