Dr Rosie Benneyworth, Interim Chief Executive, has commented extensively on the report saying:
“The State of Care is an important publication, sharing powerful insights into the urgent challenges facing the health and care system, and the significant demands on the NHS workforce.
“We view the fragmented nature of care, and the issues that arise at crucial transition points, as one of the most pressing patient safety risks highlighted throughout the report. Our investigations have repeatedly identified these challenges — including poor communication and collaboration between providers, and the impact that the resource and capacity issues in primary and community services have on the continuity of care, especially for patients with long-term or complex conditions.
“The report’s focus on digital integration and how this can present a barrier to care is welcomed – our work has shown that when digital systems and tools are introduced without proper alignment or interoperability, patient safety risks can emerge. In some cases where implementation of a new system has not been done effectively this can disrupt workflows, creating the risk that vital information is lost – delaying treatment, discharge from hospital or a timely diagnosis. As the NHS becomes increasingly digital, this report reinforces the need for technology to anticipate unintended consequences and address potential safety risks and gaps.
“Mental health is one of the most urgent challenges facing healthcare today. Across our mental health inpatient investigations published over the past year, we’ve identified recurring issues and concerns that align to those seen in community mental health services. This includes the ability to provide person-centred care, the provision of safe and therapeutic environments and involving patients and families in decision-making.
“It is not a surprise that that a lack of integration and coordination, and issues with access to services has had the biggest impact on the most vulnerable patients, and it is worrying that there continues to be longstanding inequalities for many groups of people across the country. It is crucial that people within those groups are listened to – not only should their voice be heard in relation to healthcare decisions and issues they experience but also urgently acted upon.
“Amongst the more difficult messages, it is positive that the report highlights examples of good practice, and innovation, it also mentions where the CQC have seen how effective leadership promotes cultures of openness and learning which we know has a positive impact on safety. During our investigations, we have witnessed the dedication and commitment of frontline colleagues, who despite working under immense pressure, deliver the best care they can for patients.
It is a time of seismic shifts in healthcare, especially with the advancement of technology, and the vision for the future is embedded in the 10 Year Plan. The State of Care is a timely reminder that to achieve these ambitions the health and care sector must be proactive about quality and safety of care. Only through true collaboration, innovation, and a strong commitment to learning from harm can we truly improve care for patients nationwide.”
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