The shortage of mental health nurses has consequences for the mix of care and skills

The ‘mental health 360’ report from the King’s Fund has warned that the increase in the number of mental health nurses in recent years has been “insufficient to meet demand”.

“Nurses provide the vast majority of mental health care and play a central role in improving patient outcomes”

Stefan Jones

Furthermore, the increase in the number of nurses has mainly taken place in community services, which is in line with national priorities to move more care out of hospitals.

However, the King’s Fund report warned that “the number of nurses in inpatient settings has fallen to levels that are impacting the quality of care”.

It also revealed a changing skill mix in mental health: more support staff and fewer registered nurses.

In 2012-2013, the skill mix on adult acute mental health units was 60% registered nursing staff and 40% support staff – by 2022-2023 this situation was reversed.

“Changes in the experience level of staff and the skills mix of services have raised concerns about the ability to provide safe and effective care,” the report said.

Across all contexts, the report found that the number of mental health nurses increased overall, but this follows a substantial decline between 2010 and 2017.

As a result, the number of mental health nurses – who make up the majority of the mental health workforce – is only now recovering to 2010 levels.

As of September 2023, there were still 13,300 vacancies for nurses in NHS mental health services in England.

Across all regions, the mental health vacancy rate is higher than that in the NHS overall, the report shows.

The NHS Long Term Workforce Plan is seeking to address the gaps, with the ambition to increase mental health nursing training places by 13% by 2025-26 and by 93% by 2031-32.

However, as applications to study nursing decline, there are concerns about how these plans will be achieved.

Elsewhere in the report, the King’s Fund notes that the demand for mental health care has increased.

Compared to April 2016, the number of people in contact with secondary mental health services has increased by 59%, and referrals to NHS Talking Therapies have increased by 44%.

Services with waiting times – talking therapies and early psychosis intervention – have consistently met these since 2017 and have led to better access for patients.

However, for other services where there are no targets, the King’s Fund said access was varied, and there were also gaps in services, which could have caused some people to miss out on care.

For example, the report raised concerns about a lack of options for people whose conditions are too complex for talking therapies but do not meet the threshold for specialist secondary mental health care.

These service gaps exist despite investment in mental health services in England having increased since 2017-18, in line with government commitments.

The report also warned that “the overall quality of care has deteriorated” and that there was “substantial and unwarranted variation in the quality of care between providers and services”.

It reported a decline in mental health services rated ‘good’ or ‘excellent’ between 2022 and 2023.

And in the 2022 NHS Staff Survey, the proportion of mental health staff who reported being satisfied with the standard of care in their organization fell to the lowest level in five years (63%).

There were also “inequalities in access to care that vary according to socio-demographic characteristics,” the King’s Fund report said.

For example, it said that people from certain ethnic minority groups had poorer access to talking therapies compared to people of white British heritage.

Elderly and disabled people were also underrepresented in talking therapies, relative to population needs.

Ethnic inequality in the use of the Mental Health Act also remained a problem.

In 2022-2023, detention rates for people who identify as ‘black or black British’ were three and a half times higher than the rate for people who identify as ‘white’.

Stefan Jones

Commenting on the study’s findings, Stephen Jones, the Royal College of Nursing’s professional lead on mental health, expressed concern about the identified nursing shortage.

He warned: “Experienced staff are being pushed out by difficult working conditions and low pay, leaving new recruits with little time to find their way or learn from those with vital clinical experience – when this happens, patient care suffers.”

He said the decline in nursing student applications “should ring alarm bells in government and across the health and care sector”.

“Nurses provide the vast majority of mental health care and play a central role in improving patient outcomes,” he added.

“Ministers can recognize this by making a fair pay offer, together with an emergency package of measures in the budget to support nurse recruitment.”

Saffron Cordery, deputy director of NHS Providers, also said the report showed trusts needed ‘more long-term support’ from the government for mental health services.

“For years, mental health services have been deprived of adequate capital investment that is essential to provide high-quality care in the right environments for the well-being of patients and staff,” she added.

“The report recognizes that the sector has made progress in expanding services and improving access.

“Mental health must be more of a national priority and backed by the right funding and support to make significant further progress in improving access and quality of services.”

The Department of Health and Social Care has been approached for comment.