10 October 2014

Deteriorating quality in mental health services and worsening access to hospital care in England are evidence that some significant improvements in the quality of healthcare made over the past decade are starting to go into reverse, a new report finds today. 

‘Cause for Concern’ highlights clear signs of recent decline in quality across several areas

‘Cause for Concern’ is the second annual statement on care quality published by the Nuffield Trust and Health Foundation as part of their joint QualityWatch programme. Informed by over 200 quality metrics, the report finds that the overall quality of care across the NHS and social care system remains better than a decade ago, with real improvements in a number of areas including hospital safety, staffing levels and patient satisfaction.

But in contrast to last year’s statement, suggesting that quality was broadly holding up, ‘Cause for Concern’ highlights clear signs of recent decline in quality across several areas. Of particular concern are: severe pressure on access to mental health services; lengthening hospital waiting times; and a rise in reported work-related stress among NHS and social care staff.

Key findings include:

Inpatient services for mental health care are becoming harder to access for both children and adults:

  • There was a 17% rise in inpatient admissions for people detained under the Mental Health Act between 2008/9 and 2012/13, perhaps in response to reductions in inpatient beds and increased emergency admissions.
  • Average waiting times for people needing to see a specialist mental health team grew by a third between 2010/11 and 2012/13, reversing previous progress.
  • By 2013 mental health service users waited almost twice as long for a consultation as those with physical ailments, and were on average a fifth less likely to have their first outpatient appointment within 18 weeks.
  • Falling numbers of psychiatric nurses working in hospitals have not been offset by rising numbers in the community: full-time psychiatric nurses working in hospitals fell by 13% between 2010 and 2014 whilst those in the community fell by 1%.

After historic improvements in waiting times over the past decade, waits for emergency and planned hospital care have been on the rise, and worrying signs are emerging on access to GPs and social care:

  • For over a year major A&E departments have breached the national target for 95% of people to be admitted or discharged within four hours.
  • The numbers of patients experiencing a four-hour delay between the decision to admit them at A&E and their arrival on a ward (known as a ‘trolley wait’) has risen by 79% since 2010/11;
  • One in ten people waited longer than 18 weeks for planned treatments for much of 2014; the average patient now waits four days longer for planned treatments than they did in 2010.
  • People are reporting that it is harder to get a GP appointment, and over 250,000 fewer older people are receiving publicly funded social care.

There are signs that work-related stress is on the rise across the NHS: 

  • The proportion of NHS staff reporting stress-related illness rose by a tenth, from 28% in 2008 to 38% in 2013 (76,000 out of the 197,775 surveyed), reversing a declining trend prior to 2008.

Ian Blunt, Senior Research Analyst at the Nuffield Trust and one of the report’s authors, said:

“There have been some remarkable improvements in the quality of healthcare over the past decade, and care in the vast majority of cases continues to be better than it was 10 years ago. But this report presents worrying evidence that the quality of several services is starting to decline, particularly in mental health care and in how patients access hospital and social care services.”

Nigel Edwards, Chief Executive of the Nuffield Trust, said:

“It is clear that the NHS and social care are facing exceptional pressures as the population ages and funding remains extremely tight. The harsh realities of attempting to meet these pressures through increased efficiency alone are becoming evident, with users of mental health services in particular experiencing unacceptably long waits. There have been some positive signs this week that Government is seeking to address this issue. But care providers, policy makers and the public need to keep asking searching questions about the point at which declines in quality are no longer tolerable.”

Dr Jennifer Dixon, Chief Executive of the Health Foundation, said:

“While our figures show national averages, the true picture in some areas in England will be worse. Signs of deterioration in access to care for people who are mentally ill are particularly worrying, given how vulnerable people in this group are. Clearly financial pressures are now having an impact on the quality of NHS care. It is important to continue this scrutiny, especially for the most vulnerable people in our society.”

The report also examines England’s persistent health inequalities and the UK’s performance in international context. The report finds that the signs are more positive, although there is still room for improvement in both areas:

  • Considerable progress has been made in driving down avoidable deaths in the most deprived areas of the country; but inequity still exists when it comes to routine operations. The most affluent groups are 1.3 times more likely to have a hip replacement than the least.   
  • The UK has a higher mortality rate from breast cancer than most OECD countries, but the gap is narrowing and the UK looks set to overtake other countries in the future. The UK’s child mortality rates, by contrast, still lag behind other OECD countries and are double those of Sweden, the best performer.


The authors recognise that the available indicators examined represent just a snapshot of the quality of care that each service provides and call on policymakers and practitioners to continue to examine and monitor quality across health and social care.


Notes to editors

  • Cause for Concern is the second annual statement of the Nuffield Trust and Health Foundation’s QualityWatch programme. The programme analyses over 200 indicators to assess the quality of health and social care services in England.
  • Over the past year, analysis of the 200 indicators has been supplemented by in-depth ‘Focus On’ research reports on topics from A&E attendances to older people’s social care.
  • The Nuffield Trust is an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK. It conducts cutting edge research and influential analysis, informs and generates debate, supports leaders, and examines international best practice.
  • The Health Foundation is an independent charity working to improve the quality of healthcare in the UK.  It exists to support people working in healthcare practice and policy to make lasting improvements to health services. The Health Foundation carries out research and in-depth policy analysis, runs improvement programmes to put ideas into practice in the NHS, supports and develops leaders and shares evidence to encourage wider change.

For more information, please contact:

Leonora Merry: 020 7462 055/ 07920 043 709
Mark Dayan: 0207 462 0538/ 07779 227 129

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