The skills and ongoing development of the mental health nursing workforce must be recognised, including by nurses themselves, if a new drive to improve services is to be a success, according to a senior NHS leader and nurse.
“Mental health nurses have not always been good at describing their own skillset”
England’s national director for mental health said a new “crusade” to improve mental health services, the like of which has not been seen since Victorian asylums were closed, has the backing of nurses but the profession must address an ongoing failure to talk about its skills to ensure success.
“I think mental health nurses and I am one, so I own this, have not always been good at describing their own skillset themselves,” said NHS England’s national mental health director Claire Murdoch.
It is because nurses either do not fully appreciate their contribution in the first place or are happy to just “get on with” the job, according to Ms Murdoch, who was appointed in April 2016 to oversee the introduction of a five-year plan for transforming mental health services.
“There is much to be said for having a skillset and quietly getting on and treating patients. A great deal indeed,” she told Nursing Times.
“But if you don’t talk about that within the profession, if you don’t consolidate and revisit continuously in a world that is changing – where there are advances and different treatments and interventions developing – then you ultimately do your patients a disservice,” she said. “Because you don’t sufficiently hone those skills because you’re not recognising them.”
Ensuring there are enough staff with the right skills is one of the key parts of the work Ms Murdoch is leading, which stems from the Five Year Forward View for Mental Health implementation plan.
Its report – the Five Year Forward View for Mental Health – concluded services were “inadequate” and leading to worsening outcomes, despite improving attitudes to mental health in society.
A raft of actions has subsequently been put in place to improve services, covering perinatal, children and young people’s mental health, community, acute and crisis care.
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The improvement plan also has the backing of extra funding that will rise to £1bn extra per year by 2020-21. Investment in perinatal services – £365m over the five years – has been one of the most high-profile areas.
“We have to be realistic, there is a considerable challenge around workforce”
According to Ms Murdoch, the setting up of new specialist community services for mothers with severe and complex mental health problems at 20 sites in the past year, with the support of £40m of the funding, has been “phenomenally successful”.
“When we took a baseline of our coverage at the beginning of the programme, something like only 14% of areas nationally had access to specialist services,” she said. “It was kind of a postcode lottery, very much the product of a passion or vision locally.
“We thought [the new services] would see 2,000 women in the first year. In fact, they have seen at least 4,000,” said Ms Murdoch, who joined the nursing register in 1987 and remains on it today.
National director for mental health
Four new mother and baby units are also being set up this year, alongside additional beds at 15 existing units in England.
To support the new services, bespoke top-up training has been given to specialist perinatal staff – including mental health nurses – but there is also a national programme updating the skills of 3,000 other professionals, such as health visitors, practice nurses and midwives.
This funded programme for the wider group will “bring them up to a place where they are working to the top of their licence”, said Ms Murdoch, in order “to spot the signs and be able to have the conversations”.
“What we are really mindful of is, we don’t want the specialist teams to be unable to refer back as soon as possible, so they can bring the next women and children in who need expert treatment,” she said.
Beyond perinatal mental health, Ms Murdoch noted there was recognition that nurses across other services needed more mental health training in general to transform care.
It was her vision that all types of nursing staff in the future would be as committed as each other to mental health, she said, but equally she wanted to see mental health staff “owning much more loudly the physical health agenda”.
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“We must as health professionals continually revisit pre- and post-registration training to make sure it is both expert enough in different branches/specialisms that one trains in, but generalist enough for all nurses to feel competent in basic assessment, treatment and intervention, and knowing when to refer on,” she said.
In addition, “ambitious” national workforce plans that promised an expansion in the number of nurses would require efforts to bring more people into the profession, and stop others from leaving, she warned.
For example, an announcement by the government in July last year promised 4,600 extra crisis care nurses and 2,000 more clinical staff, including nurses, in child and adolescent mental health services by 2020-21.
“One of the best ways to make that happen is you understand what is rewarding about the role, what’s important about it, and that you support, develop and nurture and train for those things,” said Ms Murdoch.
This was why a discussion “at every level” was needed between mental health nurses, and with nurses in other fields, about the value of their skills, she stated.
Figures from a recent report by workforce body Health Education England show that, in March 2017, 14% of mental health nursing posts in the NHS were vacant.
The latest official figures from NHS Digital, dating from November 2017, show a marginal increase in the size of the mental health nursing workforce – by 123 whole-time equivalents – compared with the same time the year before. But, overall, numbers have been decreasing steadily, by 10% since 2010, when there were 40,297 mental health nurses, in contrast with 36,177 in November 2017.
Norman Lamb, the Liberal Democrat MP and former health minister, has recently criticised the introduction of new standards for early intervention in psychosis, claiming they were not being fully met due to staffing and funding problems.
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The new standards, which are one of the key 2020-21 targets in the five-year mental health strategy, require at least 60% of people with first episode psychosis to begin treatment recommended by the National Institute for Health and Care Excellence within two weeks of referral.
NHS England said the former coalition government minister’s analysis was a “partial and dated” view of the progress being made, and highlighted that over three quarters of patients were getting treatment within two weeks.
Ms Murdoch told Nursing Times that tackling workforce challenges was even more important than ensuring money reached the frontline, in order for the mental health strategy to work.
“We have to be realistic, there is a considerable challenge around workforce currently,” she said. “Once you’ve acknowledged that, you can do the work you need to do to tackle the various issues that will be contributing to that.”
She said the challenge had been acknowledged by employers, universities and national organisations, including HEE and NHS England itself.
“The education establishments have a job of work to do to cut down on attrition of people leaving training before they’ve got to the end of it,” she said. “They need to work with the providers on that as well.
“When you’re training, you live in two worlds, between the university and clinical placement. Training is really hard, you have highs and lows, you have self-doubts, you have placements you might not like as much,” she said.
Employers also needed to support nurses, particularly in the “vulnerable” first-year after qualifying, said Ms Murdoch.
“There is a considerable role for HEE to make sure the ongoing training is there. With NHS England, our responsibility is to work with the whole system, to make sure we are sighted on what the workforce requirements are, that we’ve understood the clinical and service models,” she added.
For that reason, the national mental health strategy included a “granular” breakdown of the required roles needed, she noted.
“There are some brilliant mental health nurses on the same sort of crusade – they know what they want to achieve”
Ultimately, improvements needed in mental healthcare and the goal of securing parity with physical health services would not be achieved without a crusade by nurses, said Ms Murdoch.
“I’ve worked in the NHS for 35 years and trained at a time when there were big Victorian asylums,” said the national director, who is also chief executive of Central and North West London NHS Foundation Trust.
“We’ve come such a long way… but it seemed to me then that mental health nurses were clearly on a mission,” she said. “Their mission was to see less custodial care, to be part of the closing of those institutions, to be part of working with patients on a greater voice and greater choice – and they were championing it.
“As I look across the country now, and in my own trust, there are some brilliant mental health nurses who are on the same sort of crusade – they know what they want to achieve next,” said Ms Murdoch.
She described the new plan, as “in a way, the next crusade – the next set of ‘this is what we are going to change, because we mental health nurses are leading the way”.
February 2016: Five Year Forward View for Mental Health – an expert taskforce made the case for transforming mental health care in England
July 2016: Five Year Forward View for Mental Health Implementation Plan – blueprint for the delivery of the above report’s recommendations over the coming years to 2020-21
July 2017: Stepping Forward to 2020-21: Mental Health Workforce Plan for England – set out the additional staff required to deliver the transformation set out in the Five Year Forward View