The NHS is straining at the seams as it juggles problems with staffing shortages, rising demand and increasing numbers of patients with preventable illnesses, health and care inspectors have said.
A new Care Quality Commission (CQC) report warns that health and care services are at full stretch and that the quality of future care is precarious.
It said the NHS is "struggling to cope with 21st century problems" including increasing numbers of people with illnesses linked to unhealthy lifestyle choices like obesity and heart disease.
As well as coping with new demand, the service works with insufficient staff numbers in some areas, the regulator added.
Hospital bed occupancy reached record levels as the system faced substantial rises in the number of patients needing care.
In social care, nursing home beds are falling and unmet need is increasing, the report added.
As a result, some services previously deemed to be good are deteriorating, and two thirds of hospital A&Es are not performing well enough over safety.
There are fewer beds and longer waits for treatment, the report states.
The new CQC report is based on the regulator's inspections across the health and care sector in England including hospitals, ambulance services, GP surgeries and mental health care.
Regulators highlighted pressures facing the health service including the changing nature of demand.
The report told of increasing numbers of frail older patients, many with dementia, and more people with long-term complex conditions placing unprecedented pressure on the system.
"The NHS was created in the middle of the 20th century when the big issues it was attempting to deal with were diseases like TB and polio," said CQC chief executive Sir David Behan.
"Today, the NHS and social care are dealing with obesity, diabetes, coronary heart disease, cancers, dementia. All of which are driven less by those diseases of the middle of the last century and more by lifestyle choices.
"Our healthy life expectancy is not keeping pace with our life expectancy and it is that which is driving the demand.
"From 2014 to 2034 we are going to see an increase in people aged over 85 from 1.5 million to 3.2 million people.
"We are living longer but are not living healthier so I think what we are signalling is that the system now and into the future has got to deal with those increased numbers of older people who are going to have more than one condition.
"In the future, as a response to these diseases such as obesity, diabetes etc, the system is increasingly going to have to work together."
The report says future quality is precarious as the system struggles with increasingly complex demand, access and cost.
Sir David added: "We are going to see a fall in the quality of services that are offered to people and that may mean that the safety of some people is compromised."
Overall, the regulator said that, compared with last year, the quality of care was maintained thanks to staff efforts but health and care workers are under huge pressure and staff resilience is not inexhaustible.
The report said the number of vacancies across all NHS settings rose by 16% from March 2015 to March 2017.
"There are some areas where there are clearly insufficient staff - I'm calling out the availability of nurses in nursing homes," said Sir David.
"But some of this is not just about the quantum of staff available but it is about how your staff are deployed and made available.
"These are staffing issues which are making an impact on quality of care."
There were around 67 full-time GPs per 100,000 people in the population in 2014. The figure fell to 62 in 2016, the report states.
Meanwhile, some services previously rated as good deteriorated when reinspected.
Inspectors found that among services it reinspected last year, 26% of mental health services and 23% of adult social care services originally rated good dropped at least one rating.
Two out of the 11 NHS acute hospitals reinspected also fell in ratings.
CQC said safety remained its biggest concern.
As of 31 July 2017, 5% of acute hospital core services were rated as inadequate for safety, as were 3% of core services in NHS mental health trusts.
Meanwhile, 11% of hospital A&Es were told the safety of their service was inadequate and 55% were deemed to need improvement - meaning 66% were not performing well enough.
Last year, the regulator warned that social care was at tipping point which was impacting on the broader health and care system.
A year on, it found care down in areas including: fewer nursing homes, more people having an unmet need and care providers still handing contracts back to local authorities as they struggle to provide care based on the money councils can provide.
The report said the overall picture remains precarious with no long-term solution in sight.
It also portrays soaring demand by highlighting that bed occupancy in acute hospitals reached record highs this year, ambulance calls increased by 20% since 2011/12 and hospitals saw substantial rises in patients.
Sir David added: "The fact that the quality of care has been maintained in the toughest climate that most can remember is testament to the efforts of frontline staff, managers and leaders.
"Many providers have used our inspection reports to improve and we have seen improvements in safety in particular, although this area remains a big concern and focus for us.
"However, as people's health and care needs change and become more complex, a model of care designed for the 20th century is at full stretch and struggling to cope with 21st-century problems.
"The impact of this on people is particularly evident where sectors come together - or fail to come together as the complex patchwork of health and social care strains at the seams.
"If services are to deliver consistently for people, there must be better co-ordination of care to create a sustainable and effective health and care system.
"Staff and leaders can't work any harder; the answer must be to work more collaboratively, not just between sectors but between agencies and professionals, supported and incentivised by the national health and care organisations."
Professor Jane Cummings, Chief Nursing Officer for England, based at NHS England, said: "It's good that the CQC has found widespread improvements across the NHS, with many more hospitals, mental health services and GPs rated good than last year.
"Progress in the face of great pressure is a testimony to NHS staff. The CQC rightly highlights the rising health and social care needs of elderly and vulnerable people of all ages, which clearly require a sensible funding solution."
Health minister Philip Dunne said: "Today the CQC has again recognised that the vast majority of patients are getting good care and many parts of the NHS have improved.
"With record funding and more doctors and nurses, the NHS was recently judged the best healthcare system in the world, despite the pressures from increasing demand.
"We are determined to make the NHS the safest healthcare system in the world and are investing in more staff and in services - including £2 billion extra for social care, £1.4 billion to improve young people's mental health services and an extra £100 million this winter to help A&E departments cope with demand."
The figures that reveal the pressures on the health and care system
Here are some facts and figures from the CQC's State of Health and Care 2016/17 report highlighting pressures on the system.
- The number of people with "unmet" social care need has reached 1.2 million - up from 1 million last year.
- Around 2.5 million people spent longer than the recommended four hours in A&E in 2016/17 - up from 1.8 million the year before.
- Delayed turnaround times in A&E meant ambulances "lost" 680,000 hours while waiting to transfer patients to emergency hospital care.
- NHS issues led to 1.3 million days of patients stuck in hospital when they were medically fit to be discharged. Problems with adult social care beds added another 780,000 days.
- Acute hospital bed occupancy reached record levels between January and March this year. An average of 91.4% of beds were occupied - way above the safe recommended level of 85%.
- The report highlights a number of staffing issues including: 90,000 staff vacancies across adult social care, the number of psychiatric nurses has fallen by 12% in seven years and 60% of GP vacancies have been open for more than three months - indicating a recruitment problem.
- CQC rated 3% of NHS acute hospital core services, 2% of GP practices and 1% of adult social care and NHS mental health core services as "inadequate".
- In addition, 37% of NHS acute core services were rated as requires improvement, as were 24% of NHS mental health core services, 19% of adult social care services and 6% of GP practices.
- A number of services also showed deterioration having previously been rated as "good" - 26% of mental health services and 23% of adult social care services dropped at least one rating, as did 18% of acute hospitals.
- CQC said safety remains a "big concern" - Particular issues were highlighted in A&Es with 11% rated as inadequate for safety and 55% deemed to require improvement.
- There are 4,000 fewer nursing home beds compared with 2015.
- In hospitals demand for care has risen but the number of beds has gradually reduced - from the last quarter of 2010/11 to the last quarter of 2016/17, decisions to admit rose by 16% while available beds fell by 8%.
- Cancer patients are having to wait longer for treatment - the proportion of people getting their first treatment in two months has dropped from 87% in 2013/14 to 81% in 2016/17.
- Safety for people using ambulance services is a "major concern", the report says. As of July 31, five out of 10 NHS ambulance trusts were rated as "requires improvement" for safety and one was rated "inadequate".
- The report says NHS trust finances remain under "severe pressure". Officials calculated the total deficit was £791 million at the end of 2016/17 but policy experts have suggested the figure could be much higher.
- There has been a steady rise in the number of people in contact with mental health services - an estimated 1.8 million were in touch with adult mental health and learning disability services in 2015/16 - about 3.4% of the adult population in England.
- The CQC report is based on ratings for 21,256 adult social care services, 152 NHS acute hospital trusts, 197 independent acute hospitals, 18 community health trusts, 54 NHS mental health trusts, 226 independent mental health providers, 10 NHS ambulance trusts and 7,028 primary medical care services.
Copyright (c) Press Association Ltd. 2017, All Rights Reserved. Picture (c) Peter Byrne / PA Wire.