The annual assessments of the state of health and social care in England from the Care Quality Commission (CQC) are always good reads. They contain key information on trends, challenges, successes, failures and opportunities. A national overview of performance assists in the planning and delivery of health and social care service provision.
In the latest of these reports (CQC, 2020a) there is an analysis of provision before and after COVID-19. There are important lessons to be learned from the report, which the pandemic has brought into sharp focus. There are also some trailing patient safety issues identified that were severe problems before the pandemic and continue to be so now during the second wave.
Before the pandemic
The report argues that before COVID-19 care was generally good, but with little overall improvement with some specific areas of concern identified. In terms of NHS acute care, there was some improvement over the year with 75% of core services being rated good or outstanding compared with 72% the previous year. A worrying alarm bell was sounded on some services:
‘… More than half of urgent and emergency care services in hospital were rated as requires improvement or inadequate as at 31 March 2020, as were almost a third of medical care and outpatient services. The quality of maternity services has barely changed, with at least one in four rated as requires improvement overall at 31 March 2020.’
The impact of the coronavirus pandemic, and looking ahead
The report chronicles well how health and social care in England adapted to the COVID-19 pandemic, its resilience under unprecedented pressure, and how staff adapted to work in different ways while maintaining safety. This column will focus on some patient safety issues raised in the report.
The problems that existed before the pandemic have not gone away:
‘People are still more likely to receive poorer care from some types of service, and from some providers, for the same reasons that they would have been more likely to receive poorer care pre-COVID.’
Delays and long waiting lists
Increased waiting lists and a backlog of urgent and elective care need to be addressed. Services need to assess and prioritise patients according to clinical need. Those who are on long waiting lists need to be kept safe. The clear message that now resonates throughout the NHS is:
‘Going forward, hospitals and other healthcare services need to finely balance the capacity to provide COVID and non-COVID care, and make sure that people have the confidence to come forward for the care and treatment they need.’
Litigation aspects of delay
The CQC calls for a balancing exercise to be taken in relation to COVID and non-COVID care. There are legal aspects to the issue of the delay of necessary and urgent tests and treatment. The chief executive of the patient safety and justice charity, Action Against Medical Accidents (AvMA) has also called for the balancing of care:
‘We have already been receiving enquiries from patients or their families where the unavailability of such services appears to have resulted in avoidable harm or even death.’
Delay in medical care and treatment is a major cause of clinical negligence. The National Audit Office (NAO) stated that long waiting times may lead to an increased risk of more negligence claims against the NHS:
‘Almost 40% of such negligence claims against the NHS are related to failures or delays in diagnosis or treatment. However, it is not possible to identify whether delays were due to long waiting times or whether due to other factors such as missed diagnoses. Excluding maternity, ambulance and emergency cases, which are not usually related to elective care, in 2017-18 about 3000 such claims were resolved by NHS Resolution. Damages were paid in 56% of these cases, at a total cost of some £600 million.’
Griffin (2020), writing in the BMJ, stated that more than 83 000 patients in England waited more than a year for NHS treatment in July, the highest number since October 2008 and an 81-fold increase from 1032 in July 2019. Waiting times in England have now reached record highs and the second wave of COVID-19 is not likely to improve matters. Lintern (2020a), writing in the Independent, discussed the full scale of the impact of the second wave of COVID-19 on hospitals, with some in England now treating more patients than they did during the spring.
The balancing exercise is now fully confronting hospitals in the second wave of the pandemic. Some patients will and have argued that they have been avoidably harmed by not being treated sooner, their cases raising important questions of tort and human rights law. For example, Novum Law solicitors listed some clients' harrowing stories relating to cancer treatment delays (Novum Law, 2020):
Maternity care
The CQC findings on maternity care are stark and make for worrying reading:
‘Looking across both “maternity” and the older “maternity and gynaecology” services, 41% were rated as requires improvement for safety and 1% were rated as inadequate for safety. We continued to see some services where staff did not have the right skills or knowledge, where poor working relationships between obstetricians, midwives and neonatologists posed a barrier to safe care, and where there was limited oversight of risk and a lack of investigation and learning when things go wrong.’
Reading this extract brings back stark memories of the Morecambe Bay inquiry. The Kirkup report (2015) was published 5 years ago and still the lessons have not permeated down into some maternity units.
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth “at any cost”; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.’
It is worrying that the CQC (2020a) cites poor working relations between different health professions as a continuing major issue in some maternity units, given it was highlighted by Kirkup 5 years earlier.
GP remote consultation
The State of Care report does acknowledge and commend health and care providers for responding to the COVID-19 challenges quickly, developing new ways of working and procedures. When the pandemic finally abates the NHS will carry on with some of the care changes made—the care landscape has been indelibly affected by COVID-19.
NHSX, the joint unit of the Department of Health and Social Care, NHS Improvement and NHS England that drives the digital transformation of care, is quoted as reporting that, by 1 June 2020, 87% of general practices were live with technology to enable online consultations. More than two-thirds of practices saw appointments booked online using GP Connect and there was positive patient feedback on this method of consultation.
Patients want access routes such as online appointments, telephone and video consultations to continue after COVID–19. However, the CQC (2020a) states that these remote forms of access were less popular with certain groups, such as people in low-income households. Not everybody uses the internet and some people have additional communication needs. While applauding the initiative it does address an important issue:
‘… Relying on telephone and online appointments raises concerns over GPs potentially missing diagnoses or not referring patients in a timely way. We are also concerned that people may not have been seeking help when they needed it because they did not have access to online or telephone care, were worried about catching COVID-19, or did not want to bother their GP at the time of a pandemic.’
Prosecutions and enforcement
A current trend in patient safety and health quality to be noted is that the CQC has increased its public profile by taking court action for breaches of regulations (CQC, 2020b; 2020c). Lintern (2020b) discussed CQC prosecutions and how they send a strong message to NHS trusts—especially those where ‘the old ways are proving hard to change’—on the importance of patient safety and bringing about greater public accountability.
Conclusion
The latest State of Care report presents both a holistic overview and drills down into discrete types of service provision. It points to major changes being made to our health and social care systems, as well as the heroic efforts of health and social care staff in responding to the pandemic. The NHS has had success during the pandemic, but it also must deal with some problems. Delays to treatment and long waiting lists are a problem exacerbated by COVID-19 and could result in litigation.
NHS maternity care provision stands out as one core service that stubbornly remains an acute problem. That poor staff relations on some maternity units still present a patient safety issue beggars belief.