Tory Austerity: NHS standards hit hardest showing Inadequate inpatient services

More than half of A&E units are failing as hospitals buckle under pressure from the broken social care system, a damning report warns today.

The Care Quality Commission (CQC) found standards of care in casualty wards has plummeted in the last year – with 52 per cent now rated as either inadequate or requiring improvement.

The watchdog’s annual report said inadequate social care is forcing patients to go to A&E because it is ‘the only part of the system where doors are always open’.

Dementia patients are among the worst affected – with charities warning they are ‘rushed to hospital with falls, dehydration, infections, and other avoidable emergencies’.

Inadequate inpatient services for people with learning disabilities and/or autism rises from 1% to 10% in the last year alone.

The quality of care provided at inpatient units across England for those with mental health, learning disability and autism has deteriorated in the last year, regulators have said.

Concerns over safety on these wards, staffing levels and inappropriate care has been highlighted in the Care Quality Commission’s (CQC) annual State of Care report, which looks at all health and social care across the country, including NHS and the independent sector.

Some 10% of inpatient services for people with learning disabilities and/or autism were rated as inadequate – the lowest rating – by inspectors, compared to 1% the year before.

Fourteen independent mental health hospitals that admit people with learning disability and autism have been placed into special measures since last October, with three closing permanently.

And 7% of child and adolescent mental health inpatient services were rated inadequate, up on 3% the year before.

Last October, it was revealed that 40 people with a learning disability or autism have died while admitted to secure treatment units since 2015 – and told the story of a man who has spent 19 years in one unit.

And earlier this year, Sky News revealed that poor care in privately-run child and adolescent mental health services (CAMHS) units is putting vulnerable young people at risk.

In other services, the CQC said they are also increasingly concerned about the pressure on hospitals as new figures show more than half of A&E departments are inadequate or require improvement.

Inspectors said A&E departments had not had their usual “breathing space” over the summer to prepare for the coming winter months, which can see high numbers of patients suffering flu and existing illnesses made worse.

Mr Trenholm added: “It is about increasing demand. We’ve heard some stories in some emergency departments seeing a 10% increase during the last year alone.

“This isn’t something the emergency department or even the hospital can handle on their own. We are calling for the whole system to work together – GPs, hospitals, social care – to come together.”

The CQC’s Chief Executive, Ian Trenholm, described some services as “not fit for purpose”, adding: “Increased demand combined with challenges around workforce and access risk creating a perfect storm, meaning people who need support from mental health, learning disability or autism services may receive poor care, have to wait until they are at crisis point to get the help they need, be detained in unsuitable services far from home, or be unable to access care at all.”

Too many people with a learning disability or autism are in hospital because of a lack of local, intensive community services, inspectors have warned.

They called for ‘more and better community care services’ in the latest annual State of Care report from the Care Quality Commission (CQC) published today (15 October).

Many people with a learning disability or autism in hospital ‘have been there for a long time and are in a hospital that is out of their local area’, the document highlighted.

It went on to raise concerns around the ‘quality of inpatient wards that should be providing longer-term and highly specialised care for people’.

The CQC has rated 10% of inpatient services for people with learning disabilities and/or autism as inadequate as of September 2019, up from 1% in the year before.

Meanwhile, the number of mental health beds has fallen by 14% between 2014/15 and 2018/19 and there are 2% fewer mental health nurses in April 2019 than in April 2014.

Over the same period, the number of community mental health nurses rose, which may reflect the policy of moving away from hospital-based care but still represents an ‘unacceptable situation’, the report found.

Community services must also improve to address the situation, the document went onto stress.

For many with a learning disability or autism, ‘their hospital stay was prolonged because of delays in setting up the package of care they needed after they were discharged’, it explained. ‘In many cases, crises could have been averted if local health, care and education services had worked in unison to provide an integrated package to support them when they were young.’

Organisations representing patients told inspectors that patients had increasing concerns around the availability of care and support services in the community such as the GP, added the report.

The report also branded adult social care a ‘particular concern’.

It highlighted ‘fewer beds in nursing homes and care homes’, staff turnover rising ‘for the sixth year running’ and the registered nurse vacancy rate soaring from 4.1% in 2012/13 to 9.9% in 2018/19.

The document added: ‘An estimated 1.4 million older people (nearly one in seven) do not have access to all the care and support they need.’

Staff in the sector shared major challenges ‘including a lack of qualified nursing staff, not enough high-quality registered managers, and high vacancy rates and staff turnover leading to a high use of agency staff’.

Staffing is the ‘make and break issue’ 

‘All of this underpinned by significant issues around staffing and workforce,’ the report concluded on the problems facing the NHS and social care. For example, there are 8% fewer learning disability nurses registered with the Nursing and Midwifery Council in 2019 than in 2015.

The document went on to stress that the removal of nurse bursaries ‘has led to a reduction of people able to retrain’ and preceded a fall in applications to study nursing. However, it countered that the total number accepted into training each year has remained fairly stable at over 28,000.

England director for the Royal College of Nursing (RCN) Patricia Marquis said the CQC report demonstrates that ‘official inspectors are putting England’s nursing shortage front and centre as a key reason for poor care’.

She continued: ‘Now that their concern is on record, it leaves Ministers with nowhere to turn – they must take immediate and firm action to address the 40,000 unfilled nurse jobs’.

Government need to put at least £1 billion extra per year into nursing education

Ms Marquis went onto repeat the RCN’s call for the Government to put at least £1 billion extra per year into nursing education ‘if it hopes to recover lost ground and fill these vital jobs’.

Also commenting on the report, director of policy at health and social care charity The King’s Fund, Sally Warren said it showed that ‘staffing is the make-or-break issue across the NHS and social care’.

Ms Warren continued: ‘Staff are working under enormous strain as services struggle to recruit, train and retain enough staff with the necessary skills.’

She raised concerns around the reduction in mental health nurses, stressing that ‘long held ambitions to put mental health on a par with physical health can only be delivered if sufficient numbers of suitably qualfiied and skilled staff are available’.

‘To address the issues raised by the CQC and improve access to appropriate mental health and learning disability services will require urgent action to workforce shortages and put in place models of care that provide high quality care and support,’ she added.

Ian Trenholm, chief exectutive of the CQC, said the report ‘highlighted mental health and learning disability inpatient services because that’s where we are starting to see an impact on quality – and on people’.

He added: ‘Increased demand combined with challenges around workforce and access risk creating a perfect storm – meaning people who need support from mental health, learning disability or autism services may receive poor care, have to wait until they are at crisis point to get the help they need, be detained in unsuitable services far from home, or be unable to access care at all.’

The report comes as the latest vacancy statistics for England show 43,617 nursing vacancies, leaving 12% of full-time nursing posts now unfilled. This is an increase of more than 10% since the previous quarter.

They said difficulties recruiting nurses specialising in these areas meant vulnerable patients were too often being cared for by staff who lacked the skills and expertise to meet their needs.

“Increased demand combined with challenges around workforce and access risk creating a perfect storm”

Ian Trenholm

In its latest annual assessment of health and social care in England, the Care Quality Commission highlighted that 14 independent mental health hospitals that admit people with a learning disability and/or autism had been rated “inadequate” and gone into special measures since October last year.

Overall, the number of inpatient services for people with these conditions tagged with the lowest rating had increased by nine percentage points, from 1% in 2017-18 to 10% in 2018-19.

Meanwhile, 7% of child and adolescent mental health inpatient services were rated “inadequate”, up from 3% in 2017-18.

The percentage of adult psychiatric intensive care units with the worst rating also increased from 2% to 8%.

“This is an unacceptable situation,” said the report, called The State of Health Care and Adult Social Care in England 2018-19.

It noted that lack of appropriately trained staff was identified as an issue in the majority of mental health and learning disability inpatient services rated “inadequate” over the past year.

The CQC pointed out that the number of learning disability nurses registered with the Nursing and Midwifery Council had dropped by 8% since 2015, while in mental health nursing the decline was 2%.

Shortages in these nurses meant skill mix on wards did not always reflect the needs of the people being treated, noted the regulator.

It said lack of registered learning disability nursing time was being “routinely addressed by relying on high numbers of healthcare assistants or other non-registered roles”.

Inspectors from the commission also noticed an increase in agency staff use since last year.

“As demand increases, under-supported staff are leaving in droves”

Paul Farmer

In addition, the CQC cautioned that people with a mental health condition, learning disability or autism often ended up in inappropriate parts of the system or left to reach crisis point before they received help.

The watchdog said lack of comprehensive community support meant people were wrongly hospitalised and left on wards for too long.

Meanwhile, shortages of specialist beds meant patients were sent to placements miles away from their homes and families or left waiting in unfamiliar surroundings for prolonged periods of time.

The report highlighted a 14% decline in the number of mental health beds from 2014-15 and 2018-19.

While this was in line with national ambitions to support people out of hospital, the CQC said it was concerned that community provision was not compensating for the reduction in inpatient beds.

During a media briefing ahead of the publication of the document, Professor Ted Baker, chief inspector of hospitals at the CQC, said the nurse shortages were a “significant factor” in the decline in quality of these services.

The regulator’s director of engagement, Chris Day, said the CQC had been in talks with both NHS England and Health Education England about future funding arrangements for mature student nurses.

He said he recognised that learning disability and mental health nursing “disproportionately” relied on older students to enter the professions.

In the year following the removal of the student bursary for nursing students in England, the number of mature students starting a learning disability nursing course fell by 43%, while for mental health nursing it was 10%.

“I think the idea of providing some form of income support for those groups is important,” said Mr Day.

Ian Trenholm, chief executive of the CQC, said: “Increased demand combined with challenges around workforce and access risk creating a perfect storm – meaning people who need support from mental health, learning disability or autism services may receive poor care, have to wait until they are at crisis point to get the help they need, be detained in unsuitable services far from home, or be unable to access care at all.”

In response to the findings of the quality of inpatient care, the CQC is reviewing how it assesses all wards in mental health and learning disabilities.

Future inspections will focus on staffing, quality of leadership, patient access to care, sexual safety of mental health wards, minimising restrictive interventions and the physical ward environments.

Mr Trenholm said the CQC would continue to call out staffing issues at a provider level but “system-wide action on workforce planning” needed to be put in place.

Responding to the report, Sean Duggan, chief executive of the Mental Health Network, which is part of the NHS Confederation, said it was “clear” that more funding needed to reach mental health services, particularly for those that included learning disability care.

“We all want high quality care for everyone who needs it, and we look forward to working with the CQC as it seeks to create a more robust and consistent approach to assessing mental health services,” he added.

“This can only be achieved once the huge gaps in workforce are addressed and urgent capital funding is released to improve outdated inpatient services.”

Paul Farmer, chief executive of mental health charity Mind, said it was “disturbing” that the CQC continued to highlight the same issues with the quality of mental health care “time and time again”.

He called on the government to “urgently address the diminishing workforce”.

“As demand increases, under-supported staff are leaving in droves,” added Mr Farmer.

“This report shows that understaffed and under-resourced services don’t deliver quality care.”

Sally Warren, director of policy at the King’s Fund think-tank, said the report showed further evidence that staffing was the “make-or-break issue across the NHS and social care”.

“Long held ambitions to put mental health on a par with physical health can only be delivered if sufficient numbers of suitably qualified and skilled staff are available,” she said.

“The alarming decline in the quality of specialist inpatient services is a particular concern as these services care for some of society’s most vulnerable people.

“The alarming decline in the quality of specialist inpatient services is a particular concern”

Sally Warren

“Too many people with a learning disability or autism are still being unnecessarily warehoused in out-of-sight facilities due to a dearth of community-based support,” she said. “This must stop, with more services delivered safely in community settings.

“To address the issues raised by the CQC and improve access to appropriate mental health and learning disability services will require urgent action to workforce shortages and put in place models of care that provide high quality care and support.”

Andrea Sutcliffe, chief executive and registrar at the Nursing and Midwifery Council, said: “Today’s report paints a sobering picture of the continuing pressures felt across the health and care system, particularly for people using and working in mental health and learning disability services.

“As a consequence, it’s clear that it’s more difficult than ever before for nurses and midwives – the cornerstone of the health and care workforce – to meet the care needs of a changing population.”

She also called for “system-wide solutions” the staffing problems to be put in place including effective workforce planning, a joined-up approach for social care and ongoing support for continuing professional development.

Patricia Marquis, director of the Royal College of Nursing in England, said: “With this report, the official inspectors are putting England’s nursing shortage front and centre as a key reason for poor care – no area of care appears safe from the engulfing workforce crisis.

“Now that their concern is on record, it leaves ministers with nowhere to turn – they must take immediate and firm action to address the 40,000 unfilled nurse jobs.”

Unison head of health Sara Gorton said: “There’s not enough funding for social care, and out of hours support and NHS 111 are a mess.

“This cocktail of calamities is pushing people into A&E who shouldn’t be there, with patients and staff the losers,” she said.  “The NHS budget is already overstretched and can’t cope with this extra burden.

“What’s needed is vastly improved funding for both the NHS and social care now,” she added.