More than half (52%) of A&E departments in England are now providing substandard care, according to the annual assessment of the state of health and social care in England from the Care Quality Commission (CQC). 

The pressure on over-stretched hospitals is ‘enormous’ notes the watchdog, due to a continued failure to provide better care in the community, and improve mental health services. This has been made worse by a total failure of the government to produce a long-term funding and reform policy for adult social care. There is an estimated 1.4 million elderly who do not have access to the care and support they need, according to the charity Age UK.

A&E departments are seeing increases of as much as 10% in the number of people seeking care, according to NHS data. July 2019 saw the largest percentage of patients waiting four hours or more in A&E within the last five years. 

Professor Ted Baker, the CQC’s chief inspector of hospitals, said that for many of the patients A&E is not the best place to go, but they have no choice because in many areas there were no specialist mental health services. This is particularly bad in the area of children’s mental health services, with children undergoing a mental health crisis, too often ending up in A&E.

Mental health and learning disability services were a focus of this year’s report, chosen because it is the sector which is showing the biggest impact on quality.

The CQC notes that there has been “a real deterioration in some specialist inpatient services”.  In figures, as of 30 September 2019:

  • 10% of inpatient services for people with learning disabilities and/or autism rated inadequate, compared to 1% in 2018;
  • 7% of child and adolescent mental health inpatient services rated inadequate (2018: 3%);
  • 3% of mental health trusts rated inadequate, compared to 1% in 2018;
  • And, 8% of acute wards for adults of working age and psychiatric intensive care units rated inadequate (2018: 2%).

Maintaining standards within mental health services seems to be a particular problem for the private sector. Since October 2018, the CQC has rated as “inadequate” and put into special measures 14 privately run mental health hospitals that admit people with a learning disability and/or autism. Three of these services are now closed, further reducing services for patients, one service is still registered but is closed to new admissions, just two of these services have improved since being rated. Companies that have had problems include Cygnet and The Priory. A large and growing proportion of mental health services are provided by the private sector.

NHS mental health units have also experienced major problems; five units at a trust in the North East were closed in September 2019 and 32 young people have had to be shipped to other units, which are likely to be crowded and further from their homes.

Ian Trenholm, Chief Executive of the CQC, noted that the CQC’s inspection reports highlight one of the main reasons for a fall in rating as staff shortages, or care delivered by staff who aren’t trained or supported to look after people with complex needs. He added that many people who need support have to wait until they are in crisis to get the help they need, and can end up being detained in unsuitable services far from home, or be unable to access care at all. There has been an 8% fall in nurses who specialise in caring for people with learning disabilities in the last year alone, according to NHS figures.

The pressure on A&E also comes from the problems within adult social care. The CQC is concerned over the stability of the entire sector, as it highlights the lack of consensus on how it is to be funded; twice in 2018 the watchdog had to warn local authorities that a company was on the brink of financial collapse which would bring considerable service disruption. Since the report’s cut off, the CQC has had to issue another warning.

Overall, the CQC’s report finds that although other services in the NHS have not seen the same fall in quality as mental health and learning disability services, there are still a significant number of services rated inadequate by the CQC, including medical care units (35%), outpatient departments (40%), and surgical departments (27%).

It is clear that the CQC report serves a warning that emergency departments are likely to face “extraordinary circumstances” this winter as the pressures on them increase and this should be of great concern for those in charge of the NHS and its funding.


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