Mental health services are under “significant and increasing” pressure, with a continuing decline in the number of mental health nurses, regulators have warned.
The Care Quality Commission highlighted a crash in mental health nurse numbers over the past seven years as “underpinning” a range of concerns facing the sector.
“The sector must overcome an unprecedented set of challenges”
As part of a major review of mental health services, the regulator highlighted that there had been a 12% fall in nurses working in the field between January 2010 and January 2017.
At the same time, inpatient psychiatric beds had been reduced by 4% between 2014-15 and 2016-17, and detentions under the Mental Health Act had risen by 26% between 2012-13 and 2015-16.
These factors were combining to create significant challenges and pressures for the mental health sector, said the CQC, resulting in some places in too much use of physical restraint and isolation.
The CQC has today published a summary of the findings from its three years of inspections of all specialist mental health services, which it said gave the most complete picture ever of the quality of care provision for people in England.
“Nurses in both the NHS and independent sector are very clearly holding the service together”
Inspectors found “too much” poor care and “far too much” variation in quality and access across different services, which was “particularly concerning” due to rising demand for them, said the CQC in its report – titled The State of Care in Mental Health Services.
The regulator noted that 68% of core services provided by NHS trusts and 72% of independent mental health locations were rated as “good”, with 6% and 3% rated as “outstanding”, respectively.
In addition, nearly all NHS and independent services were rated as “good” or “outstanding” for having caring and compassionate staff, it said.
But the regulator’s report identified several key areas of concern, including physical environments not designed to keep people safe and care that was over-restrictive and institutional in nature.
For example, there were about 3,500 beds in locked mental health rehabilitation wards, with about two-thirds managed in the independent sector.
These wards were often situated a long way from the patient’s home, meaning that people are isolated from their friends and families, said the CQC.
“Without the right number of staff, mental health care will continue to lag behind physical health services”
Inspectors were concerned that some of these locked rehabilitation hospitals were in fact long stay wards that risked institutionalising patients.
Another area of concern was the great variation between wards in how frequently staff use physical restraint to manage challenging behaviour.
The poor recording and sharing of information, which undermined the efforts of staff to work together to make sure that people get the right care at the right time, was also concerning, it said.
Many clinical staff told inspectors they had difficulty recording and retrieving information that was critical to patient care, and had to work with a combination of electronic systems and paper.
In addition, the CQC warned that the area in which services were most likely to perform poorly in its inspections was safety, with only 59% NHS and 61% private sector services rated as “good”.
On too many wards, the combination of a high number of detained patients, old and unsuitable buildings, staff shortages and a lack of basic training, made it more likely harm would occur, it said.
The regulator acknowledged that mental health providers had “tough decisions to make, and there are no easy answers”.
“What we urgently need now is a strong and robust workforce fit for the future”
However, it encouraged them to treat people as “active participants” in their own care, saying that it promoted recovery and lessened dependence on services.
It also encouraged investing in better services locally to prevent the need for costly out of area placements that risked isolating people from their family and friends.
Investing in information technology that enabled staff to enter and retrieve clinical information while on the move would also reduce wasted staff time and make care safer, said the CQC.
It said the best mental health services in England – citing Northumberland, Tyne and Wear NHS Foundation Trust and East London NHS Foundation Trust as examples – displayed clear leadership, ensured staff had systems to enable them to do their jobs properly and shaped care around patients.
Dr Paul Lelliott
Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals and lead for mental health, described the mental health sector as being at a “crossroads.”
He highlighted the Five Year Forward View for Mental Health, which “pointed the way” to a future where people had easy access to high quality care close to home and were able to exercise choice.
“To achieve this vision, the sector must overcome an unprecedented set of challenges – high demand, workforce shortages, unsuitable buildings and poor clinical information systems,” he warned.
“Some services remain rooted in the past – providing care that is over-restrictive and that is not tailored to each person’s individual needs,” he said. “This can leave people feeling helpless and powerless.
“But the best services are looking to the future by working in partnership with the people whose care they deliver, empowering their staff and looking for opportunities to work with other parts of the health and care system,” he added.
Responding to the report, unions highlighted the need to urgently reverse the fall in the number of mental health nurses.
Unite, which hosts the Mental Health Nurses Association, warned that increased caseloads and staff shortages were leaving nurses at risk of burn-out, and stretched too thin to provide the one to one care needed to avoid detentions.
Unite professional officer Dave Munday said: “It is deeply worrying that the growing demand for mental health services has been accompanied by a sharp fall in the number of NHS mental health nurses.
“If the government is serious about improving mental health services it needs to urgently reverse the cuts to mental health nursing and start investing in their development,” he said.
He added: “It is a testament to the dedication and professionalism of the country’s mental health nurses that nearly all services have been rated as good or outstanding for having caring and compassionate staff, despite the very serious pressures they face.”
“Nurses in both the NHS and independent sector are very clearly holding the service together, without their dedication there is a very serious chance that things will collapse, but many are now at risk of burning out,” he said.
The situation had been made worse by the government’s seven years of public sector pay restraint, said Mr Munday.
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Janet Davies, chief executive and general secretary of the Royal College of Nursing, said: “Despite promises of investment, there are 4,800 fewer mental health nurses under this government, which helps to explain why patients in some areas are being failed.
“Across the NHS, patient care deteriorates when the number of nurses drops,” she said. “Without the right number of staff, mental health care will continue to lag behind physical health services.
“To avoid further deterioration in staff numbers and patient care, the government must also act on the 1% pay [rise] cap that stands in the way,” she also said, echoing Unite.
Sean Duggan, the chief executive of the Mental Health Network, which is part of the NHS Confederation, said: “What we urgently need now is a strong and robust workforce fit for the future to help deliver the necessary transformation.
“We await the upcoming workforce strategy and continue to press the government to invest appropriately in mental health services,” he said. “Getting mental health services right will relieve pressure on other parts of the health system.”
Saffron Cordery, the director of policy and strategy at NHS Providers, also part of the confederation, noted that the report set out the “extraordinary challenges” faced by mental health trusts.
“Safety is paramount,” she said. “The CQC has identified a number of issues that must be addressed, including people being detained inappropriately, unsuitable buildings, staff shortages and inadequate training.”