Response to the CQC state of healthcare and adult social care report

The Care Quality Commission (CQC) has today published its annual report: The state of health care and adult social care in England 2022/23. It finds NHS waiting lists continue to expand; access to emergency and urgent care is becoming more difficult; and dissatisfaction about pay and conditions of work is growing.

• In 2022, 51% of respondents to a CQC survey said they waited more than an hour in urgent and emergency care units before being examined by a nurse or doctor, up from 28% in 2020.
• 7.6 million people are waiting for planned care, an increase of 12% since June 2022.
• Staff report feeling exhausted and stressed and feel that staff shortages stop them providing effective care.
• Only 26% of NHS staff were satisfied with their level of pay – 12% lower than before the pandemic.

Dr Fiona Donald, President of the Royal College of Anaesthetists said:

“The CQC report provides a valuable but extremely concerning assessment of health and social care in England. The findings show a health service in distress, with workforce shortages affecting patient waiting times, deteriorating wellbeing and morale amongst staff and rising costs. Action on these fronts is vital to improve staff retention, increase the resilience of health and care services and meet the needs of patients.

“While the overall picture is worrying, it is encouraging to see examples of innovation that are benefiting patients and staff, such as the use of digital technologies and AI.”

To address these issues, the RCoA suggests a number of measures in line with the three aims of the NHS Long Term Workforce Plan: Train, Retain, Reform.

1. An urgent plan to address specialty training bottlenecks, including for anaesthetists

Growing NHS waiting lists for elective care and delays in seeing doctors in urgent and emergency care are being fuelled by shortages of doctors and other healthcare workers.

The NHS long term workforce plan pledged to increase medical school places, but medical school is only the first part of a lengthy training pathway to become a doctor.

The medical training pathway involves many distinct stages. For anaesthetists this usually involves medical school, foundation training, core specialist training, and higher specialist training. There are bottlenecks along this pathway that mean people can’t progress – including an extremely problematic bottleneck between core and higher specialist training for anaesthetists. This means people cannot progress and complete their training – which is a huge source of frustration for doctors in training and deprives patients of the help they need.

While a sustained campaign by the RCoA has led to some increases in the number of training places and a reduction in the bottleneck, we urgently need more. Doctors in higher specialist anaesthetic training provide large amounts of direct clinical care to patients, so expanding these training places rapidly expands NHS capacity. The NHS needs more doctors now – so a plan to address specialist training bottlenecks is vital and urgent.

2. Workforce issues, including pay, most be addressed to improve retention

There are a number of workforce issues facing doctors. These include pay and poor working conditions such as the lack of access to rest and refreshment facilities. Failure to tackle these issues makes it more difficult for the NHS to retain doctors with obvious and regrettable knock-on effects on patient care.

We urge the government to engage in constructive negotiation on pay with both consultants and junior doctors. We also urge the government and the NHS to fulfil the promises set out in the long-term workforce plan around wider retention issues, including rest and refreshment facilities. These are basic necessities.

3. The surgical pathway needs to be optimised

In addition to addressing training bottlenecks and improving retention, there are ways the NHS could operate more efficiently.

At present 15 to 25 % of patients undergoing major operations suffer a complication which can worsen outcomes and increase length of stay in hospital. Many of these complications are predictable and might have been preventable. There are also around 135,000 cancellations on-the-day of surgery per year, which is estimated to cost the NHS up to £400 million annually in lost operating theatre time, not to mention the distress to patients and their families.

A key factor behind these issues is that patients often have unaddressed co-morbidities or poor health behaviours ahead of surgery. They may smoke, have untreated anaemia or diabetes, be overweight, have poor diets, or do little exercise – all of which could lead to a cancellation or complication.

We believe waiting lists need to be turned into preparation lists. This can be done via preassessment, prehabilitation, and medical optimisation. Prehabilitation is the process of helping people become as healthy as possible before surgery through interventions such as physical exercise, smoking cessation, nutrition, psychological preparation, and alcohol moderation. Medical optimisation involves addressing comorbid conditions like diabetes or anaemia prior to surgery.

Research from the Centre for Perioperative Care show prehabilitation and optimisation can reduce the length of hospital stay and lead to reductions in complications by 30% – 80%. This would free up staff time and hospital beds allowing more patients to be seen more quickly.

The NHS has plans to expand access to preassessment and prehabilitation. These efforts must continue and receive appropriate funding and workforce.