The health and social care system remains fragmented and under severe strain as it prepares for a major shift from hospital to community care, the Care Quality Commission (CQC) has warned in its annual State of Care report.
While there is some encouraging evidence of innovation, community services need significant investment in both capacity and capability to deliver the transformation in people’s care called for in the government’s 10 Year Health Plan for England.
Without more support to help community services deliver the vision of the plan, there is real risk of erosion in care quality, with people struggling to get the care they need and the most vulnerable groups likely to be hit hardest through longer waits, reduced access and poorer outcomes.
The report also highlights longstanding inequalities with some groups of people – including older people, people with dementia, people with a learning disability, and those with complex mental health needs – more likely to struggle to navigate services, often meaning their families and unpaid carers carry increasing burdens.
Mounting pressures across mental health services
Since the pandemic, there has been a steady increase in the number of people referred to mental health services – with many people waiting too long to get the help they need.
CQC’s 2024 Community Mental Health Survey found 1 in 3 respondents reported waiting three months or more – rising to almost 1 in 2 for those waiting for child and adolescent mental health services. Across all respondents, 14% reported waiting more than six months between their assessment and first appointment for treatment. The longer people waited, the more likely they were to report that their mental health deteriorated.
After identifying concerns about systemic issues across community mental health care, including a shortage of mental health staff and a lack of integration between services, CQC has begun a comprehensive inspection programme of community mental health services for working-age adults and crisis services.
As part of this programme, CQC engaged with providers who said that a lack of investment in community mental health services made it difficult to attract and retain staff with the right skills and to deliver good care. People who used community mental health services described the destabilising impact of moving between different services and of not having a single point of contact for their care.
When people don’t receive timely care, they can end up in crisis. Over the last year, the number of urgent and very urgent referrals to crisis services has risen sharply.
Adult social care under strain
Demand for local authority-funded social care support continued to rise in 2023/24. While vacancies in the workforce have fallen to pre-pandemic levels, the vacancy rate in adult social care is still three times higher than in the wider job market. Homecare services are particularly affected, with vacancy rates more than twice as high as those in care homes.
The end of new care worker visas is likely to put further pressure on recruitment, making it more important than ever that a sector-wide workforce strategy is agreed and the recently announced fair pay agreement has an impact.
More community services are urgently needed to help people stay in their own homes longer. However, CQC has identified factors that could limit the growth of the homecare sector. Providers are handing back contracts to deliver care back to commissioners due to rising costs and an increasing proportion of the market is made up of very small providers that may be less financially resilient than larger providers.
CQC’s local authority assurance work has found delays for people in getting access to homecare due to shortages of both homecare staff and in the workforce delivering short-term care to people recovering at home after a hospital stay. Capacity in rehabilitation, reablement and recovery services is consistently the biggest cause of delayed discharges nationally.
Hospital discharge delays persist
On any given day in March 2025, nearly 6 in 10 patients who were ready to be discharged experienced a delay. This reduces the number of beds available for new patients and creates knock-on effects for people’s care across the whole system, from how quickly they get seen in A&E to the length of time they wait for planned medical procedures.
Over the last ten years there has been a steady increase in percentage of emergency readmissions, with older people and people living in more deprived areas more likely to be readmitted within 30 days of being discharged from hospital.
CQC commissioned research from National Voices into people’s experience of the discharge process – although this includes positive experiences, it also describes very poor experiences, including someone whose hospital stay and discharge left them feeling dehumanised.
Primary and community care capacity challenges contribute to system-wide pressures
Although the number of trainee GPs has risen per head of population this year and work is underway to increase capacity and improve access, the number of fully qualified GPs per head of population has fallen, and demand continues to grow.
Based on the information and insight from our regulatory work, as well from the GP Patient Survey 2025, access to GP appointments remains a challenge, with evidence that some groups find it harder than others. This includes those living in the most deprived areas, autistic people and people with a learning disability, and people with a mental health condition.
When people can’t get help from their GP, it may mean they go to a service not designed to meet their needs. The GP Patient Survey 2025 found that when people couldn’t contact their GP or didn’t know what the next step would be, 1 in 15 went to A&E. This was higher for people living in the most deprived areas. However, some people did not seek further help at all, risking a deterioration in their health. This was more likely to be the case for people over 85, who are also more likely to experience serious outcomes from poor health.
District nursing services are key to shifting care from hospital settings into the community – but the number of qualified district nurses per 10,000 people aged 65 and over has dropped by 50% in the last 14 years. CQC analysis of NHS electronic staff record data found that the total annual numbers of new trainees are rarely more than half the number of staff leaving the profession.
Dr Arun Chopra, Interim Chief Executive of CQC, said:
“The Government’s 10-year plan is a real chance to improve care by putting people’s needs first. But for the plan to succeed, community health and care services need more support. Without this, there’s a risk fewer people will be able to access good care, with vulnerable groups hit hardest.
“Right now, community services tell us they’re struggling because the way care is funded and organised is designed around hospitals. That’s also true of how data about care is collected and how outcomes are measured. All these things make it harder to move towards care that keeps people well, delivered closer to home.
“We’re calling for more investment in care outside hospital, and more emphasis on measuring quality of care, not just numbers of procedures. Services need to focus on really understanding the needs of their local population – especially in deprived areas – and on working together to address those needs.
“We’ll play our part – with a renewed focus on listening to what people tell us about their care and acting on their feedback. When we find poor care, we’ll take steps to protect people. We’ll work with healthcare providers and local systems to make care better, and we’ll find and share examples of good, innovative care that puts people first. And where we see barriers to good care, we’ll work with partners to find solutions.”
Professor Sir Mike Richards, Chair of CQC, said:
“Our inspections and oversight have found some excellent examples of health and social care services working together to put people first. We highlight neighbourhood health services with high patient satisfaction; artificial intelligence helping reduce admin for GPs; and a new integrated urgent community response service that’s improved ambulance response times and is helping keep people out of hospital if they can get the care they need nearer home.”
“But we’ve also found too many examples where poor coordination between health and social care, inadequate information sharing, and lack of digital integration stand in the way of joined up care. The current fragmented system means vulnerable people are falling through the gaps.
“The 10-year plan provides a roadmap to fix these problems, with both community care and social care playing a vital role. The Casey Commission will be an important step in reforming social care – but it won’t solve the core funding problem. We continue to call for long-term, sustainable funding for adult social care.”
