The Care Quality Commission's (CQC) (2019) annual report on the state of health and social care is to be welcomed as it gives a true, unabashed account of health and social care in England. There are commonalities in the trends and challenges found each year in the reports. The NHS is stretched and is finding it difficult to meet current demands. This should come as no surprise. Ever since the NHS was founded in 1948, it has been short of resources and the demand for services has always outstripped supply. The population of England is also getting older and presenting to health services with more multiple, complex conditions. There are also acute healthcare service workforce challenges.
The NHS is used today for more health conditions than it was originally designed for. People today approach GPs for advice on lifestyle matters such as stress, work balance, and diet, not necessarily because they are suffering from some physical disease. Our expectations of the NHS are high, but it cannot deliver the treatment and care to satisfy everyone. There is an infinite demand for finite resources and sometimes difficult healthcare resource allocation decisions must be made.
The CQC report
The CQC (2019) presents a useful and real-time picture of health and social care in England. The report looks at trends and shares examples of outstanding, good and poor care practices. Like all CQC reports in my experience, it is balanced, open, honest and well-written. The report contains a lot of key information and provides a road map for delivering high-quality care. Its also address important patient safety issues.
The report states that people should be able to get high-quality health and social care when and where they need it:
‘When people can't access the services they need, the risk is that they are pushed into inappropriate care settings—ending up in emergency departments if they can't access GP care, or in crisis because they can't access mental health services quickly enough in the community.’
Evidence of health services strain
The report has evidence that all of this is happening in several healthcare services. We are seeing a healthcare system being severely stretched to meet current demands and problems are occurring. The report acknowledges that the NHS must keep up with people's needs, which reflect society as it is today:
‘Modern local services need to be designed around people's needs that reflect society as it is in 2019—not as it was in 1948.’
However, by its very nature the NHS will always fully absorb every financial resource given to it; since 1948 it has an insatiable appetite for resources. There is a necessity to budget, to allocate resources in a managed and reasoned way and the government of the day set the tone for doing this. Throwing money at a problem is not always the best solution.
Part 1: The state of care in England
In part 1 of the report, an overview of the state of care issues and themes is given. The overall quality of care that people receive in England has improved very slightly from last year and most people receive good quality care. Many people, however, struggle to get access to care when they need it, despite it being good, and a myriad of challenges can face them. The CQC analysed just under 60 000 comments shared online by people using services, members of the public and care workers. The comments were made on the CQC, ‘Share your experience’ form over a 3-year period between 2016 and 2019. The CQC also spoke to other organisations that represent service users and asked them about what people are saying:
‘These challenges range across a spectrum. At one end, people may face inconveniences in getting appointments, chasing referrals and following up on previous visits. At the other end, people may be unable to get any help or service at all, compounded by difficulties in navigating their local health and care services and knowing where to turn.’
The CQC state that there is variation in quality across England, which means that some populations may find it difficult to access good quality care.
Part 2: Hospitals, community and ambulance services
The CQC (2019) notes the relentless year-on-year rise in attendances at emergency departments and acute hospitals:
‘This trend has continued unabated over the last year, with urgent and emergency services bearing the brunt of this demand and struggling to provide high-quality care, with 44% rated as requires improvement and 8% as inadequate.’
NHS hospitals continued to provide good care during 2018/2019, with 65% of core services rated as ‘good’ and 7% rated as ‘outstanding’. However, a cautionary note about safety is made, which does appear annually in the CQC state of care reports. Safety remains the area of most concern as 36% of services are rated as ‘requires improvement’ and 3% as ‘inadequate’.
Access to services: delay
Access to the right care at the right time is one of the biggest challenges facing health and social care services, the report states. It is a particularly important issue for those seeking treatment in NHS acute hospitals. Over the past year there has been an increase in ‘referral to treatment times’, with 4.4 million people at the end of June 2019 waiting to start treatment. This is an increase of 40% since June 2014.
Litigation aspects of treatment delay and workforce challenges
The issue of delay can have important legal consequences and could form the basis of a legal action by a patient suing for compensation. Clarke Willmott solicitors (2019) is looking at delays at one ophthalmology department and states that 16 patients suffered significant permanent harm from delays:
‘BBC South Today recently reported about the significant problems facing the ophthalmology department at Southampton General Hospital at present. In June 2018, the hospital produced an internal report looking at the problems within this service. It noted that in 2017 a total of 4500 patients did not receive appointments at Southampton General Hospital for eye conditions within acceptable timeframes. Of those 4500 people, the hospital had identified 16 patients who had suffered significant permanent harm as a result of this delay in being seen. The harm suffered could be as serious as permanent loss of vision.’
Patient harm
Clarke Willmott has been instructed by one of the 16 patients who has been identified and who has suffered harm as a result. It is currently in the process of investigating this claim.
Ellery (2019) reports in The Times that 15 hospital patients were left blind or with severe sight loss after staff shortages led to delays in their treatment. An internal report into the treatment of glaucoma patients at University Hospital Southampton NHS Foundation Trust found a series of failings. A pregnant mother of three was left almost completely blind after the hospital delayed her appointment despite pleading with staff that she was losing her sight:
‘When the woman was seen by a consultant they burst into tears and told her that she was permanently blind. She has since given birth and has never seen her daughter's face.’
The Trust has paid compensation to the mother.
Moore Blatch solicitors (2019) has some litigation case studies on chronic delays in treatment leading to serious patient harm.
‘£3.2 million compensation received following failure to treat primary open-angle glaucoma … By the time the Claimant received an eye clinic appointment her intraocular pressures were extremely high. She was told that she would be reviewed in a month's time. The Claimant was reviewed on four occasions over 2 months, when no action was taken to correct her intraocular pressures and no surgery was undertaken by the eye clinic …’
Treatment delays can result in litigation
There seems to be a general public and government acceptance that delays are to be expected in the NHS due to workforce shortages and an increasing demand for services caused by a growing elderly population presenting with multiple complex conditions. This perception needs to be treated very carefully. This argument itself will not head off litigation brought by patients who have been injured by unreasonable delays in treatment.
Budget restrictions to save money may be implemented by Trusts at one end of the care spectrum, but expensive litigation that may result at the other end will cancel out any savings made. The CQC (2019) addresses workforce challenges, staffing levels and pressures on staff time, recognising that this can all have an impact on the quality of care that people receive.
Conclusion
The CQC (2019) shines a bright light on health and social care delivery in England and identifies key trends. The report provides a valuable road map for the future delivery of good quality healthcare services. There are major problems identified, such as workforce issues and delays to care. All these problems will also translate into patient safety issues and may well result in expensive litigation claims being brought by injured patients. It is acknowledged that Trusts must work in the reality of an ageing population presenting with more complex and multiple conditions, and that there are serious workforce challenges, but this does not mean that healthcare standards can be relaxed or compromised. The NHS should not be viewed as a special case when it comes to operational standards because of the seemingly insurmountable problems it faces.