Get the balance right: what the NHS has to do to improve mental health services
A report by The King's Fund reveals the fundamental problems that mental health services in England face compared with other services, which has created an increasingly unstable working environment
Cash shortages and unsafe staffing levels are stopping the government achieving ‘parity of esteem’ between physical and mental health, according to a recent King’s Fund report.
In 2013, the investment to boost mental health services consisted of the government committing £1.25 billion for child and adolescent mental healthcare and £1 billion to support the delivery of its national strategy for adult mental health.
The King’s Fund research revealed that between 2012-13 and 2013-14, approximately 40% of mental health trusts received a reduction in their budgets, rising to 50% in 2014-15 to 2015-16. However, in 2016-2017, 84% of mental health trusts received an increase in funding.
Inadequate funding and its effects
Reduction in full-time equivalent mental health nurses between September 2009 and August 2017
The report, Funding and Staffing of NHS Mental Health Providers: Still Waiting for Parity, links a lack of adequate funding with a negative impact on mental health staffing: between September 2009 and August 2017 there has been a 13% reduction in the number of full-time equivalent mental health nurses.
RCN’s professional lead for mental health Catherine Gamble suggests that newly qualified mental health nurses entering the profession are different from their predecessors and want different things from employers.
‘They are entering organisations that have worked the same way for years,’ Ms Gamble says. ‘Our newly qualified nurses want to have more flexible employment and innovative career pathways, they want much more supervision support and an understanding of how their career is going to progress.’
Redesigned roles with opportunities for development
To address these concerns, the report states that many trusts have redesigned roles, which provide opportunities for development, including nurse prescribers, advanced nurse practitioners and physician’s associates.
As the number of mental health nurses has fallen, trusts have turned to hiring nursing support staff, nursing assistants/auxiliaries and nursing assistant practitioners. The number of support staff has grown to such an extent that in 2016 they outnumbered qualified nursing staff for the first time.
Author of the report Helen Gilburt, who is a King’s Fund fellow, says: ‘We may be swapping registered nursing staff for a greater proportion of healthcare and support workers, but we are not clear whether that delivers the same safety or even the same quality of care.’
The shortage of mental health staff is pervasive, with approximately 10% of all posts in specialist mental health services in England currently vacant. But regional variations are significant: in the North East vacancy rates are at 8.1%, but in London 25.7% of posts are vacant. And the staff group with the highest vacancies is nursing.
Affordable housing and travel
Ms Gamble says the lack of affordable accommodation in big cities is a concern and many vital staff struggle to even rent somewhere, leading to gaps in staffing across England.
‘In London, for example, the capital nurse project is progressively looking at ways to support nurses travelling around London. Although they may eventually find somewhere to live across the other side of London, they often cannot afford to travel. So there are various initiatives to make it easier for them.
‘Rural areas don't have such a problem in recruiting. From my understanding, some areas are better off because the communities don't change as rapidly as they would do in some of the cities.’
Of all posts in specialist mental health services in England are vacant
She says there are also problems with an ageing workforce, and the prospect of large numbers of nurses retiring in the next few years, particularly in the far north and south of England.
The King’s Fund report reveals that the biggest reason for leaving NHS employment was ‘optional resignation’, with retirement being the second most common reason given. A common reason given for staff absences from work was ‘stress and anxiety-related issues’.
With such staffing problems and the fact that mental health nurses are one of the hardest groups to recruit, it is hard to judge what safe staffing should look like. This situation is compounded by the fact that, unlike for acute hospitals, appropriate staffing levels have not been defined for mental health trusts.
As Ms Gilburt says: ‘We are still waiting on NHS Improvement’s ongoing work to establish safe staffing levels.’
The King's Fund report reveals that trusts are reliant on the use of bank and agency staff to meet safe staffing requirements, but despite this, ‘insufficient availability of temporary staff means that services remained understaffed’. In an effort to provide safe care some trusts admitted that they sometimes substitute registered mental health nurses with healthcare assistants.
The report draws on a Care Quality Commission inspection report suggesting that high staff turnover, reliance on agency staff, insufficient staff numbers and an inappropriate skill mix can all have negative effects on safe care.
The most commonly reported effects of staff shortages
• Inconsistency of staffing and continuity of care provided to patients
• Increased risk of suicide and self-harm on wards
• Delays and cancellation of escorted leave from wards and interruption to therapeutic activities
• High caseloads in community teams limiting the time available to spend with patients
• Delays in treatment and limited access to care in the community
• Closure of beds due to staffing shortages
The King’s Fund 2018
While mental health services are struggling financially and with staffing, nursing in primary care is in a stronger position. Staffing numbers in community settings were stable between 2011 and 2013, and while there was a drop in 2014, between 2015 and 2017 there was an increase.
Mind chief executive officer Paul Farmer acknowledges the role that primary care services can play in supporting people with mental health issues. ‘Given how big a role primary care staff play for people with mental health problems, we are calling for all GPs and practice nurses to receive structured mental health training that is comprehensive, relevant and supports their ongoing development.
'Offering more training would help patients get the best outcomes, while also alleviating some of the pressure GPs and practice nurses experience on a daily basis.’
The report concludes that ‘a vicious circle exists between the availability of trained staff and investment to support that workforce,’ and implies that for 11,000 ‘traditional’ posts to be created for regulated professionals, including nurses, organisations will have to ‘pull every lever to deliver’.
Highlighting valuable work
Amount the government committed to supporting child and adolescent mental health in 2013
The Mental Health Taskforce’s Five Year Forward View for Mental Health suggests there will be a total of 21,000 additional posts by 2021. Ms Gamble thinks that will be a stretch, but it is achievable.
‘I may well be optimistic, but it’s achievable. It’s great that there is a whole portion of the King’s Fund report on mental health nursing alone. It highlights that we are valued,’ she says.
The King’s Fund’s report acknowledges that, in the past two years, there has been an increase in funding of mental health services. But, as even NHS England's national director for mental health Claire Murdoch says: ‘It will take time to undo years of underinvestment’.
For parity between mental and physical health to be achieved, the report says, there needs to be a recruitment drive in mental health, with registered mental health nurses being highlighted as a major contributing group, rather than allowing trusts to depend on nursing support staff.