Mental health units where experienced nurses bleed

The Health Services Safety Investigations Body (HSSIB) today has released the first of four planned reports in NHS and independent inpatient mental health units.

“The poor state of mental health care – much of which is not fit for purpose – is a cause for concern”

Saffron Cordery

This series of studies, first announced in 2023 by then Health and Human Services Secretary Steve Barclay, aims to identify safety issues in these environments and the factors causing them.

Today’s report focused on the “conditions” in which mental health hospital staff work and how these affect the provision of safe and therapeutic care.

It identified a range of issues relating to staffing, education and training, bias against certain patient groups, legacy and others, and made a range of recommendations.

HSSIB researchers found that staff turnover had a significant impact on the quality of care and training in inpatient mental health settings.

The report said registered mental health nurses with ‘limited’ experience were taking on supervisor roles as more experienced nurses had left.

The result was that junior employees did not always receive good quality supervision, the HSSIB found, which called for this to change.

The organization heard concerns that the NHS Long Term Workforce Plan was “potentially unachievable”, while it also fell short of setting targets for what was needed in mental health.

Some stakeholders interviewed for the report said government and NHS policies, particularly the workforce plan, were “too focused on recruitment and not retention”, and called for a re-evaluation of workforce planning in the mental health healthcare.

The HSSIB recommended that NHS England, together with the Department of Health and Social Care, royal colleges and other national bodies, would work to ‘identify and clarify’ continuing professional development needs for doctors, review and update the long-term workforce plan, and create a strategic plan to address mental health issues.

Some within nursing education also told the report that more clarity was needed around the role of the registered nurse in mental health.

In addition, concerns were raised that the number of registered nurses is being “diluted” due to the increase in the use of nurses and nurse health care assistants to fill grades on wards.

“Stakeholders said dilution affected the therapeutic engagement between registered nurses and patients,” the report said.

Registered adult nurses had been introduced to some mental health units, raising fears that they were being used to replace mental health nurses rather than working alongside them.

The HSSIB said there were providers who had “broadened” the mix of staff on wards in response to a “recognition of the benefits of multidisciplinary care”, but also as a result of a shortage of psychiatric nurses.

Overreliance on the Mental Health Optimal Staffing Tool (MHOST) was also investigated.

MHOST is a model created by The Shelford Group to help determine minimum staffing levels, with the intention that the results are a “guide” that is “triangulated based on professional judgment.”

However, the HSSIB found evidence that in some facilities physicians’ professional judgment about staffing needs was being “overruled” as they requested more staff than MHOST suggested.

In addition, the report referred to the fact that MHOST was developed based on data collected only between 2016 and 2018, and that its compliance would only create the conditions for a minimum safe level of care, and not for therapeutic care.

As a result, Shelford Group was instructed to update MHOST “regularly” and use new data to ensure it is up to date.

Meanwhile, the HSSIB heard that some registered inpatient care staff have been lost to community services, which have been expanded in recent years while the number of inpatient beds is being cut, due to the perception that this offers better career prospects, fewer restrictions and better work balance and private life. while also paying the same.

The report said: “Hospital nurse managers described that the move to community care had significantly affected their ability to staff wards and they felt there had been little national planning for this.”

Stefan Jones

Commenting on the publication, Stephen Jones, head of nursing at the Royal College of Nursing, said the HSSIB report showed that a ‘long-term failure to invest’ in nursing was having a ‘direct and deeply worrying’ impact on patients.

He said: “The high number of vacancies means that departments do not have enough specialist nurses, forcing services to turn to temporary staff, who are unfamiliar with patients’ needs. This can lead to inappropriate care being provided, putting both patients and staff at risk.

“Mental health patients deserve high-quality care, but a system under severe pressure is struggling to deliver it.

“The Government’s NHS reforms must include long-term, sustainable funding and targeted new investment to boost mental health recruitment.”

However, some positives regarding staffing levels were identified, including the fact that some services were growing “their own” nurses.

The report noted situations where staff had started working as healthcare assistants and progressed through nurse associate status to registration as nurses, with further opportunities for postgraduate education.

“Providers and staff were positive about this approach as it retained experienced staff who knew the work, the environment and the patients,” the HSSIB wrote.

“The barriers were the cost to the provider and the difficulty in freeing up staff to access development opportunities.”

The HSSIB has also investigated the treatment of transgender and non-binary patients, in response to concerns raised directly with the organisation.

During a visit to an inpatient hospital, researchers spoke with a trans woman who was admitted to a men’s ward. This happened, the healthcare provider told the HSSIB, due to the “complexity” of the patient’s circumstances.

The report notes that therapeutic care “should prevent patients from being placed in positions that could retraumatize them.”

“Mental health patients deserve high-quality care, but a system under severe pressure is struggling to deliver it”

Stefan Jones

Furthermore, the report heard there was “variation” in the level of care for transgender and non-binary people and some told the HSSIB they felt the national guidance was “outdated”.

The HSSIB recommended that NHS England develop new ‘guiding principles’ for inpatient mental health services to accommodate and better support all patients, including those who are non-binary and transgender.

Capital financing and the legacy of the NHS were also examined as part of the report.

The HSSIB found that mental health hospitals were struggling with “aging built environments” that in some cases could no longer meet the needs of patients.

It heard that some mental health providers had been unsuccessful in their bids for new builds or repairs under the New Hospital Program due to “limited funding” in the program and the need to prioritize reinforced aerated concrete hospitals (RAAC ).

As such, the Department of Health and Social Care was commissioned to assess the ‘capital requirements’ of inpatient mental health services across the country.

Speaking about the report, NHS Providers deputy chief executive Saffron Cordery said: “Trusts are working hard to deliver high-quality mental health services and manage risks to patient safety against a backdrop of rising demand and pressure on resources.

“However, this research makes clear how much more needs to be done nationally and locally to provide therapeutic mental health care for all patients across England.

“While there are improvements that individual trusts and services can make, HSSIB rightly recognizes that there are a range of issues outside the control of trusts, which hinder their ability to provide care to the consistently high standards they strive for for their patients. ”

Ms Cordery said the mental health system was under “relentless pressure” and agreed with the report’s findings that a shortage of staff and skills of mental health professionals was further impacting care.

She added: “The poor state of mental health care – much of which is not fit for purpose – is a cause for concern.

“It is vital that the government takes urgent action to ensure that all trusts have access to sufficient capital funding to halt the deterioration of their estates, reduce the backlog of repairs and provide high-quality care in a environment fit for the 21st century.”