Fears grow as staffing problems intensify in mental health workforce
RCN warning for one year old mental health workforce plan, suggesting initial targets will not be met to improve staff numbers
Care and services suffer as one year on, Health Education England's mental health workforce plan comes under scrutiny
One year on from the publication of a mental health workforce plan for England, nursing experts are concerned that planned targets will not be enough to support necessary system reform.
The RCN says that Health Education England (HEE) plans to employ 19,000 additional members of staff in mental health services by 2020 is only ‘a drop in the ocean’.
The college is warning the numbers will not address recruitment and retention challenges currently being seen in the mental health nursing workforce. While the Council of Deans of Health says 'immediate action' is needed to boost numbers.
HEE, which published the workforce plan in 2017, says it is working with others, including NHS Improvement, NHS England, the Royal College of Psychiatrists and providers, to increase the number of available posts in mental health.
According to NHS Digital figures, there are around 214,000 posts in specialist mental health services in England, 20,000 (9.3%) of those are vacant and largely filled by temporary bank and agency staff.
The mental health nursing workforce has the highest number of qualified staff in the sector, with 67,800 (32%) posts reported in 2016.
But, there are 7,600 (11.2%) vacancies in mental health nursing.
While the plan acknowledged that the mental health nursing workforce ‘forms the backbone of current and future services’, it also recognised that the number of posts available for qualified nurses had fallen in recent years. ‘By 2016, this was nearly 12% below the 2009 level. More worryingly, the effect of staff turnover in mental health nursing is currently negative, which means there are fewer mental health nurses employed each year (-4% each year compared to +2% for adult nursing),' the plan's authors wrote.
additional members of staff in mental health services to be recruited in England as part of Health Education England mental health workforce plan
However, HEE could not provide Mental Health Practice with any data to describe how many more staff have been recruited one third of a way along its timeline, saying it would be able to update ‘much more’ in the autumn.
‘This is a long-term key priority area and we are making good progress,’ says an HEE spokesperson.
New (and unregulated) roles
Part of the workforce plan allows for 8,000 new staff members in new (and as yet unregulated) roles in mental health, such as nursing associates, call handlers and peer support workers.
However, as with the 11,000 nurses, doctors and occupational health therapists to be recruited, none of the numbers have been broken down further to illustrate how many of each will be recruited within the overall numbers.
The HEE spokesperson says: ‘Nursing and physician associates are already playing a key part in expanding our mental health workforce.
‘Key areas of work include the adult Improving Access to Psychological Therapies Programme, children and young people’s mental health and early intervention in psychosis.
‘These are just some of the areas where HEE is making real progress and helping to deliver the next generation of workforce to help support and improve patient care.’
RCN professional lead for mental health Catherine Gamble says she has concerns that too much reliance was being placed on new, untested roles, such as nursing associates.
‘While these numbers look fantastic, the reality is – who are these people?’
Ms Gamble points out that neither Wales, Scotland nor Northern Ireland have chosen to develop these roles at the present time.
‘In principle, these roles still don’t have regulation by the Nursing and Midwifery Council, which is still looking at the consultation process, so there is a real need to establish and feedback concerns about how in mental health our nursing associates will be used.
‘While these numbers look fantastic, the reality is – who are these people?
‘At the moment, the assistant practitioners and nursing associates just won’t fill the sort of gaps that exist, and all of them require training and supervision by regulated staff.’
Fall in student applications
The government decision to scrap the nursing student bursary and introduce a loan system in September 2017 has already had an impact on the number of students on mental health nursing courses.
Health Education England targets for mental health workforce
In 2017, Health Education England published a mental health workforce plan to support the delivery of the Five Year Forward View for mental health in the country.
- This plan has set targets for the NHS to establish 21,000 posts and employ 19,000 additional staff in mental health services by 2020
- These 19,000 new staff will include 11,000 drawn from the ‘traditional’ pools of professionally regulated staff, such as nurses, doctors and occupational therapists
- There will also be 8,000 people moving into new (as yet unregulated) roles such as nursing associates, peer support workers, call handlers and so-called personal well-being practitioners
In England, Wales and Northern Ireland, the overall number of nursing student applicants fell, while in Scotland there was a modest increase, Universities and Colleges Admissions Service (UCAS) data shows.
There were 39,140 UK nursing student applicants by the 15 January deadline for 2018 courses – a 33% drop in two years. This is down from 43,590 applicants at the same point last year and 54,270 in 2016 – when the nursing student bursary was still in place.
Because mental health nursing students are typically older than other nursing students (27% of applicants in 2015-2016 were mature students), the end to bursary funding is likely to impact harder on this field of nursing.
The number of applicants by mature students dropped by 28% in England by the end of the application cycle, according to analysis by the RCN.
This is a sustained fall, with a 42% drop in applicants aged over 25 compared to the same time in 2016.
Ms Gamble says she is hugely concerned about the drop in mature students in mental health nursing.
‘We serve cradle to grave and so we really need experienced people with life experience and resilience, as well as those who are young.’
Council of Deans of Health chair Brian Webster-Henderson says: ‘If we are to see a significant increase in the number of mental health nurses, we need to see immediate action to support a growth in student numbers.’
Professor Webster-Henderson says this action includes ‘high-profile, national campaigns’ as well as strategic interventions.
‘At the same time, urgent improvements are needed to retain existing staff, including investment in continuing professional development (CPD).’
Funding for nurses’ CPD has been at the centre of controversial cuts in recent years that have led to outcry from health unions and organisations such as the Council of Deans of Health.
HEE’s workforce development budget, which the RCN claims is ‘largely used for CPD for nurses’, has been cut by 60% over the past two years: in 2015-2016 it was £205 million, this year it stands at just £83.49 million.
So, what are the solutions?
HEE said last year that ‘no single part of the system holds all the levers to implement the workforce plan’, but it did suggest strands of work for various arms-length bodies.
NHS Improvement has been implementing a national programme of mental health staff retention, targeting providers with high leaver clinical staff rates.
NHS Improvement director of nursing Mark Radford says: ‘The programme’s aim is to support an increase in whole time equivalent staff to the system, so service users can continue to benefit from the highly skilled and dedicated staff in NHS mental health organisations.
‘We recognise that retention is a complex and multi faceted challenge and that our direct support programme is only part of the solution. However, indicative data suggest a positive direction of travel for trusts participating in the programme.
‘Our goal is to support further development of best practice within trusts and look at how this can be scaled and replicated according to local context and retention drivers.’
'Three levels of vagueness'
Despite such intentions, workforce expert James Buchan says trying to develop an accurate assessment of the current situation with progress on mental health workforce staffing is being undermined by ‘three levels of vagueness’.
Professor Buchan, who is based at Queen Margaret University, Edinburgh, says it is not clear on what basis the staffing targets have been determined: ‘Clearly, there are shortages, as highlighted by vacancies, agency use and turnover, but the target is a very loose indicator.
‘It does not tell us where or on what types of staff we should focus the efforts for growth to best meet demand. Secondly, while the target can at least concentrate efforts on achieving overall numerical growth, it is so loosely calibrated across different professions and roles that it is difficult to assess staffing change.
vacancies in mental health nursing in England
(Source: NHS Digital figures)
‘It could be argued that this allows flexibility in response, but given the complete absence of any specificity on how much actual progress there has been in the different categories of staffing, or overall, we are left only with vague assurances.’
Professor Buchan also points out that while an emphasis on improved retention makes sense, what are described as new efforts are only what any good employer should have been doing already.
He says: ‘Improved retention will help on the margins, but to achieve the rapid staffing growth symbolised by the target, there will have to be a scale up of new staff.
‘It takes three years to train a nurse, so this puts any new student intakes beyond the target date.
‘This means that a short-term target to 2020, inevitably will now focus on short-term solutions – new staff roles that take months rather than years to develop, and retention or switching of current staff into mental health related work.’
Professor Buchan says the real underlying problems are funding, training capacity and actual demand from applicants to take up available places.
There remains a clear need for data that can demonstrate progress and help address the staffing problems endemic in the mental health workforce. It is only with this information that we can prove to the profession that the workforce plan is going to adequately support much-needed system reform.
Trust reduces turnover figures by 1.2% in under one year
Rotherham Doncaster and South Humber NHS Foundation Trust (RDASH) runs mental health services in Rotherham, Doncaster and north and north east Lincolnshire.
The trust has been working with NHS Improvement to improve its staff turnover figures, which in June 2017 stood at 12.6%.
Initiatives used to address the issue undertaken by staff include:
- Developing career pathways, roles and the internal transition processes
- Introducing rotational posts
- Holding ‘itchy feet’ conversations
- Targeting teams with the highest turnover rates, including district nursing and inpatient teams
- Accrediting a multi-professional preceptorship programme at master’s level working with a local university
- The trust is also implementing targeted mental health training for non-professionally qualified ward staff
RDASH deputy director for organisational development Judith Graham says: ‘We are fully embracing this support. In less than a year we have reduced turnover figures by 1.2%.
'We know we still have a way to go to reduce this even further, but we are on the right road to doing this. We are working to roll-out our range of initiatives and promoting them to our staff.’
Stephanie Jones-Berry is a freelance journalist