NHS mental health trusts are struggling to staff services on a daily basis, with some regularly resorting to using healthcare assistants in place of registered nurses, a new report by a think-tank has found.
The King’s Fund think-tank said the lack of available mental health staff nationally – in particular nurses – “continues to undermine” work to ensure safe staffing levels.
“In several cases trust boards note that insufficient availability of temporary staff meant that services remained understaffed”
King’s Fund report
The organisation analysed workforce statistics for the NHS in England since 2009 and looked at board papers from eight mental health trusts over six months from January 2016.
It also analysed annual financial accounts of NHS mental health, acute and specialist provider trusts, plus reviewed Care Quality Commission inspection reports on all 54 NHS mental health trusts in England.
It reiterated the previously reported 13% decline in full-time equivalent NHS mental health nurses between September 2009 and August 2017. But its analysis also found this reduction was having the most impact on mental health nurses working in inpatient services.
The number of nurses in this setting – defined by NHS Digital as working in “other psychiatry” roles – has reduced by almost 25% over the period, from just under 26,000 to around 19,000, said the report.
“The overall spending gap between mental health and acute trusts has widened because funding has focused on relieving hospitals”
While the number of mental health nurses working in the community slightly increased over this time, this was not enough to offset the overall reduction, added the report, called Funding and staffing of NHS mental health providers: still waiting for parity.
The analysis also revealed that while the number of inpatient NHS mental health nurses has decreased, the number of nursing assistants employed in this setting had stayed the same – until a small increase since 2014.
This has meant that, since May 2016, the number of support staff employed has been higher than the number of registered nurses in NHS inpatient settings.
Its review of board papers revealed all eight trusts were reliant on bank and agency workers to meet mental health safe staffing requirements.
At one mental health trust, nearly a third of shifts in a month were filled by temporary staff at the same time as nearly a quarter of registered nurses in post being newly registered.
In addition, the extent to which temporary staff are able to fill staffing gaps at trusts was not clear, said the think-tank.
“In several cases trust boards note that insufficient availability of temporary staff meant that services remained understaffed,” said the report.
It found half of the trusts often needed to go beyond planned levels “in order to meet the needs of patients”. In some cases this meant individual shifts had 300% more staff than was originally expected.
“Growing staff shortages are affecting the quality and safety of care”
But the think-tank’s analysis highlighted this was sometimes achieved by substituting staff groups.
“Although this measure is often framed as part of an escalation plan for staffing inpatient wards, the regularity by which it was reported suggests it represented routine rather than exceptional practice throughout the period we reviewed,” said the report.
In the group of eight trusts it looked at, this was predominantly occurring where support workers were used in place of registered nurses, it said.
The think-tank noted that some organisations were looking to new roles as part of work to transform services. However, it warned they “are not immune from the pressures and challenges facing other workforce roles”.
It referred to one trust where the development of a new support role in the community had to be abandoned due to concerns about high caseloads among clinical staff, high turnover of staff in the new post, and poor clinical oversight of the new role.
More widely the organisation’s analysis of CQC reports found problems with the staffing were a contributing factor to the safety of the care provided in over half of mental health trusts.
Meanwhile, its review of operating income across all mental health trusts found around 40% saw a reduction in their budgets between 2012 and 2015 - compared with 13% to 27% of acute trusts.
In 2016-17 this improved and 84% of mental health trusts received an increase in funding in cash terms – but this was still worse than acute trusts, which saw 94% receive an increase.
Helen Gilburt, report author and fellow in health policy at the King’s Fund, said: “While the great majority of local clinical commissioning groups have met their commitments to raise spending on mental health, the overall spending gap between mental health trusts and acute and specialist trusts has widened because national funding has focused on relieving pressure on acute hospitals.”
“Parity of esteem between mental and physical health will never be achieved unless there are enough mental health nurses”
She added: “Despite the commitment of national leaders, the funding gap between mental health and acute NHS services is continuing to widen, while growing staff shortages are affecting the quality and safety of care.”
The Royal College of Nursing said the report was “worrying” and that ambition for mental and physical health to be treated the same would not be achieved unless there were enough mental health nurses.
Catherine Gamble, RCN professional lead for mental health, said: “Parity of esteem between mental and physical health will never be achieved unless there are enough mental health nurses to support recovery and care properly for people with mental health problems.”
NHS Providers deputy chief executive Saffron Cordery said that despite increased income for mental health trusts, more investment was needed.
“Services face rapidly rising demand, with over 70% of mental health leaders telling us last year they expect demand to rise further,” she said.
“Over 70% of mental health leaders [told] us last year they expect demand to rise further”
A spokeswoman for the Department of Health and Social Care said: “This government is absolutely committed to improving mental health care in this country.
“As this report makes clear — funding into mental health has increased substantially. In 2016-17 the proportion of investment spent by CCGs on mental health actually increased by 6.7%, and plans are in place to maintain significant increases to 2020-21.”
“We are also creating 21,000 new posts by 2021 to ensure we have the right staff to deliver high quality care,” she added.