Another year, another CQC State of Care report. And once again, a familiar picture emerges. Growing demand, stretched services, persistent inequalities, some encouraging improvements and some worrying gaps.
There's plenty to digest in the latest report, published on 23 October. But three things particularly caught my attention: what we know about people's experiences, the power of commissioning to shape better care, and what all of this means for the people sitting around Board tables.
They are closely connected. And I think we sometimes make the mistake of treating them as separate conversations.
1. People and communities: what aren't we seeing?
Let's start with some numbers. More than 80,000 children and young people have been waiting over a year for a community health appointment. That's almost 11 times the number of adults waiting that long. Meanwhile, the number of children waiting for their first contact with mental health services has risen by nearly a third in two years.
And although some overall waiting times are improving, those improvements are not being experienced equally.
CQC highlights substantial differences in access, quality and outcomes depending on where people live and who they are. Children living in the most deprived areas are more than twice as likely to experience tooth decay as those in the least deprived areas. Access to annual physical health checks for people with severe mental illness varies considerably between ICB areas.
But these aren't just uncomfortable statistics. They tell us something about the limitations of the way we understand quality. We are awash with data in health and care. Activity, waiting times, performance dashboards, financial positions, quality indicators. Much of it is essential. But averages can be very reassuring, right up until you look at who is missing out.
It’s worth remembering, people don't experience health and care as a collection of performance indicators. They experience trying to get an appointment, explaining their circumstances for the fifth time, waiting for support, navigating services that don't quite join up, or finding that the help they need simply isn't available.
That's why people's experiences are not a nice addition to performance data. They are an essential part of understanding whether care is working. But I would go further.
Listening to people and working in partnership with them are not the same thing.
We have become reasonably good at asking people what they think. Surveys, feedback, engagement events, patient stories. All have their place. The more challenging question is what happens to that knowledge. Does it change what we prioritise? Does it influence where resources go? Does it challenge our assumptions about what good care looks like? Crucially, are people involved in making those decisions, or just invited to comment on them?
? When our performance figures tell us things are improving, how do we know whose experiences are getting worse?
2. Commissioning: one of the most powerful levers we've got
Something else jumped out at me. CQC describes commissioning as one of the most powerful levers for improving quality, equity and sustainability in adult social care. That's quite a statement. And one I agree with.
The report describes an adult social care market changing rapidly. Homecare is becoming more fragmented, while care home provision is increasingly concentrated in larger homes. Financial pressures are influencing what providers can offer and who can access care. CQC warns that the market is being reshaped largely by accident rather than design.
There's a rather important distinction. Commissioning should be about deliberately shaping services and support around the needs of people and communities. Not simply purchasing what happens to be available, managing contracts or trying to balance the books.
Of course, commissioners are operating under enormous financial and organisational pressure. Nobody needs reminding of that. But those pressures make the choices we make about commissioning even more important. The report offers a useful example from Wigan, where the council has worked with providers and people using services to shape local provision, tackle inequalities and reduce reliance on care placements outside the borough. It's a reminder that commissioning can be creative, collaborative and purposeful.
It brings me back to people's knowledge. If we're serious about commissioning for better outcomes, we need to understand more than who is currently using services.
Who isn't getting through the door? What support would have made a difference earlier? What matters to people that our existing service specifications don't capture? What are communities already doing that we could build on rather than replace?
And perhaps most importantly, who gets to help decide?
I spend quite a bit of time working with commissioners who want to do things differently. There is no shortage of experience, commitment or good ideas. But creating the conditions to use commissioning as a lever for change requires permission, curiosity and sometimes a bit of bravery. The CQC report offers a useful reminder of why that matters.
? If we started with what people and communities need, rather than the services and contracts we already have, how different would our commissioning priorities look?
3. Board leadership: are we asking the right questions?
Which brings me to Boards. CQC identifies leadership as an important area for improvement. In the care homes it assessed, around a third were rated as requiring improvement or inadequate for being well-led.
But I think the bigger leadership challenge emerging from this report is about how Boards understand their responsibilities for quality. A Board can receive a reassuring performance report and still know surprisingly little about how care is experienced by particular groups of people. It can be assured that an individual service is performing well, while people using that service are struggling with everything that happens before and after it. It can have perfectly respectable arrangements for patient and public involvement without being able to point to many significant decisions that have changed as a result.
None of this necessarily means people aren't working hard or trying to do the right thing.
It means we need to ask better questions. I've been doing quite a bit of work recently exploring how NHS Boards understand quality through people, communities and culture. One of the recurring themes is the difference between receiving assurance and being genuinely curious.
Assurance matters. Of course it does. But a Board's responsibility isn't simply to be reassured. It's to understand, to challenge, to make decisions and to recognise what it doesn't yet know. That includes understanding the consequences of decisions beyond organisational boundaries. Because people don't experience an ICB, a trust, a local authority and a collection of providers as separate governance arrangements. They experience the combined consequences of how those organisations work, or don't work, together. And that requires a different kind of leadership. One that sees meaningful partnership with people and communities as part of how the Board does its business, rather than an additional item on the agenda.
? When was the last time something we learned from people and communities fundamentally changed a Board's understanding of a problem, rather than simply confirming what it already believed?
Bringing it together: three conversations that need to become one
What strikes me most about this year's State of Care report is how connected the problems are. Inequalities in access. Gaps between services. Commissioning arrangements that don't always reflect local needs. Leadership and accountability that can remain focused on individual organisations.
We can address each of these separately. And undoubtedly make some progress.
But I wonder whether we would get further by connecting them more deliberately. People and communities help us understand what matters, what's missing and where things aren't working. Commissioning provides some of the levers to respond, shaping services, resources and relationships around those needs and Boards have a responsibility to ensure that decisions are informed by that knowledge, that resources are used wisely and that the outcomes being achieved really do make a difference.
It sounds straightforward. We all know it's not. It means being willing to challenge established ways of working, recognise the limits of our own knowledge and share influence over decisions.
It also means moving beyond the idea that patient and public involvement is something we do to support the real business of running health and care services. It is part of the real business.
? If we know that the quality of care depends on people's experiences, commissioning choices and leadership decisions, why do we still so often consider these things separately?
