Mental health trusts must carry out evidence based reviews of staffing levels to ensure patients are cared for safely, under new guidance from NHS Improvement.
The draft document, published on Wednesday, is one of seven safe staffing resources being developed by the regulator in response to recommendations made in the Mid Staffordshire inquiry.
“Mental health has a diverse but unique workforce, which is under considerable strain”
The document recommends an annual strategic staffing review by each provider, followed six months later by a comprehensive staffing report to the board. This should “confirm workforce plans are still appropriate and being achieved”, the guidance said.
However, one member of the steering group which worked on the guidance said he was unsure the guidance – titled Safe, sustainable and productive staffing in mental health services – went far enough.
John Baker, professor of mental health nursing at the Leeds University, said: “It’s reassuring that the work of NICE [the National Institute for Health and Care Excellence] that was stopped has been rekindled. Mental health has a diverse but unique workforce, which is under considerable strain.
“Although I am part of the working group, I remain unsure this work currently pushes the boundaries of safe, sustainable and productive staffing far enough,” he said.
Latest safe staffing guidance for mental health unveiled
“I would appeal to service users, carers and staff to let NHS Improvement know what they think of this draft,” he told Health Service Journal.
Examples of staff metrics the guidance recommends trusts collect included – sickness rates, turnover, vacancies, agency use, the staff survey, completion of training rates, and the new care hours per patient day measure.
Patient measures trusts could collect include – use of restraint; prone restraint, incidents of harm, ligature incidents, complaints, the duty of candour; cancelled one to one sessions, self-harm; and unexpected deaths.
For process-related indicators trusts should consider: complaints; do not attend rates; waiting times; level of incident reporting; readmission rates, lengths of stay; delayed discharges; and medication errors.
The work was led by Ray Walker, director of nursing at Mersey Care NHS Foundation Trust. It has been produced following the decision by NHS England and the government to suspend work by NICE in 2015. NHS Improvement will develop safe staffing guidance for seven healthcare settings in total.
Latest safe staffing guidance for mental health unveiled
The new document states: “Studies reveal that lower staffing levels in mental health services can affect staff morale, increase stress, decrease job satisfaction and increase concerns about personal safety.”
It also highlighted a significant challenge that many mental health staff were approaching retirement, with 32% of mental health nurses over 50 in 2013 and a vacancy rate in 2015 and 2016 of 13%.
In line with other recently published staffing guidance, the document cited the need for professional judgement in establishing staffing levels, but said it must be cross-checked with data and evidence.
It said: “A structured professional judgement model is of limited use on its own as decisions may be subjective, lack evidence and be influenced by individual preferences.
“To counter this, you should have a process for challenging and peer-reviewing staffing decisions. You should also monitor the experience, confidence and competence of those involved in making staffing decisions,” said the guidance.
It also emphasised the importance of continuity of care for patients. It said: “There is evidence of a link between the presence of regular (familiar) staff on mental health wards and mental health teams and lower rates of physical aggression and self-harm: more incidents occurred when regular staff were on leave.
“This reinforces how important the continuity of these relationships is, and mental health services should be designed with this in mind,” it added.
“To deliver these ambitions, the mental health workforce must change significantly”
However, an appendix in the draft guideline suggested that to achieve NHS England’s ambitions for the sector would require the mental health workforce to “change significantly”.
The Five Year Forward View for Mental Health identified mental illness as the single largest cause of disability in the UK and noted that people with severe and prolonged mental illness died on average 15 to 20 years earlier than others.
Its implementation plan described development and investment in mental health services for adults, older adults and children and young people in England, noted the appendix – based on a review by the National Collaborating Centre for Mental Health.
“To deliver these ambitions, the mental health workforce must change significantly,” it said. “This includes numbers of staff, competences across the workforce, leadership, governance and support provided to staff.
”There is currently no standardised method to determine safe staffing levels in mental health settings,” it said. “Evidence to inform staffing decisions is lacking, resulting in an array of staffing policies and varying advice. Current staffing models are based mainly on the traditional dual (doctor–nurse), role-based model.
Exclusive: Regulator Monitor appoints Ruth May as nurse director
“This does not reflect the current workforce, and limits staffing decisions. In addition, mental health staffing provision varies widely between regions. While new roles and new staff will play an important role in mental health services in future, we need a clear plan for how the current workforce can meet the challenges ahead,” it added.
NHS Improvement’s director of nursing for imrovement Professor Mark Radford noted that within mental health there was “huge diversity” in the types of care models used, which meant a “one-size-fits-all” approach to staffing levels was not appropriate.
“One of the approaches in the document is about recognising the contribution of everybody in the multi-disciplinary team and giving some support to understanding how it is that the delivery and deployment of nursing time and expertise is best suited to different types of setting,” he told Nursing Times.
When asked by Nursing Times how problematic the lack of evidence for informing staffing decisions in mental health was and what should be done in its absence, he said there was a clear need to develop the evidence base.
”We were pleased that the evidence review team recongise there are some good examples out there that could be used as best practice but that we need to start to develop a more robust evidence review process and research generation exercise to ensure there is more there in the future,” he said.
Professor Radford acknowledged safe staffing decisions in mental health were currently “probably more weighted” on the use of professional judgement.
He stressed it was therefore even more important that the boards of mental health organisations understood patient outcomes in relation to staffing decisions.
Senior nurses appointed by national regulator
“Safe staffing has to be seen alongside the ouputs that are acheived for patients. Some of it may be related to access, some of it may be related to incidents, and also recovery. Boards should be sighted not just on a specific numbers of staff for the setting they are leading but also the outputs - to make sure they are delivering good care and also to recognise any issues that can be rapidly spotted and dealt with,” he said.
NHS Improvement executive chief nurse Dr Ruth May said: “[The guidance has] been designed in partnership with academic institutions and experts, to support a multi-professional approach to safe staffing to ensure we get the right staff, in the right place at the right time.
“It is now up to NHS staff, patients, managers and the public to let us know what they think to help us refine this work to better serve the NHS,” said Dr May, who is also deputy chief nursing officer for England.
The guidance is out for consultation until 28 April 2017.