Mental health wards hemorrhaging experienced nurses

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

“The poor condition of the mental health estate – much of which is not fit for purpose – is a cause of concern”

Saffron Cordery

This series of investigations, first announced in 2023 by then-health and social care secretary Steve Barclay, aims to identify safety concerns in these settings and the factors driving them.

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

It found a spread of issues related to staffing, education and training, prejudice against certain patient groups, the estate and others and made a series of recommendations.

HSSIB investigators found that staff attrition was having a significant impact on the quality of care and training in inpatient mental health facilities.

The report said that registered mental health nurses with “limited” experience were taking on supervisor roles because more experienced nurses had left.

As a result, junior staff were not always getting good-quality supervision, found the HSSIB, which called for this to change.

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

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

The HSSIB recommended that NHS England, alongside the Department of Health and Social Care, royal colleges and other national bodies, work to “identify and clarify” the ongoing professional development needs for clinicians, review and update the long term workforce plan, and create a strategic plan to address mental health workforce issues.

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

As well as this, concerns were raised about registered nursing numbers being “diluted” due to the increase in the use of nursing associate and nursing healthcare assistants to fill out numbers on wards.

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

Registered adult nurses had been introduced onto some mental health wards, prompting worries that they were being used to replace mental health nurses rather than work alongside them.

The HSSIB said that there were providers which 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 mental heatlh nurses.

An overreliance of the Mental Health Optimal Staffing Tool (MHOST) was also investigated.

MHOST is a model which was created by The Shelford Group to aid with deciding minimum staffing levels with the intention of its outputs being a “guide” which is “triangulated with professional judgement”.

However, the HSSIB found evidence that, in some facilities, professional judgment by clinicians regarding workforce needs was being “overruled” because they were asking for more staff than MHOST suggested.

As well as this, the report referred to the fact that MHOST was developed using data only gathered between 2016 and 2018, and that adhering to it would only create the conditions for a minimum safe level of care, and not therapeutic care.

The Shelford Group was, as a result, told to update MHOST “on a regular basis” and use new data to ensure it is up to date.

Meanwhile, the HSSIB heard that some inpatient registered staff were being lost to community services, which have been expanding in recent years while inpatient beds are cut, because of a perception that it contained better career prospects, fewer restrictions, a better work-life balance while also paying the same.

The report read: “Hospital nursing 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.”

Responding to the publication, Royal College of Nursing head of nursing practice Stephen Jones 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: “High levels of vacancies mean wards do not have enough specialist nurses, forcing services to turn to temporary staff, unfamiliar with the needs of patients. This can result in inappropriate care being delivered, putting patients and staff alike at risk.

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

“The government’s NHS reforms must include long term, sustainable funding and dedicated new investment to boost recruitment into mental health nursing.”

Some positives regarding the workforce were identified, however, including the fact some services were “growing their own” nurses.

The report mentioned settings where staff had begun work as a healthcare assistant, and progressed through nursing associate status to registration as a nurse, with further opportunities for postgraduate education.

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

“The barriers were the cost to the provider and difficulties releasing staff to access development opportunities.”

The HSSIB also investigated, following concerns made directly to the organisation, the treatment of transgender and non-binary patients.

During a visit to one inpatient facility, investigators spoke with one trans woman who had been admitted to a male-only ward. This happened, the provider told the HSSIB, due to “complexity” in the patient’s circumstances.

The report observed that therapeutic care should “avoid putting patients in positions that may re-traumatise them”.

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

Stephen Jones

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

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

Capital funding and the NHS estate were also investigated as part of the report.

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

It heard that some mental health providers had been unsuccessful in their bids for new builds or fixes under the New Hospital Programme due to “limited funding” in the programme and the need to prioritise hospitals with reinforced aerated autoclave concrete (RAAC).

As such, the Department of Health and Social Care was told to asses the “capital requirements” of mental health inpatient services across the country.

NHS Providers deputy chief executive Saffron Cordery said of the report: “Trusts are working hard to provide high-quality mental health services and to manage risks to patient safety against a backdrop of soaring demand and resource pressures.

“This investigation lays bare however, how much more needs to be done nationally and locally to provide therapeutic mental health inpatient services for all patients across England.

“While there are improvements individual trusts and services can make, HSSIB rightly recognises that there are a range of issues beyond trusts’ control, which hinders their ability to provide care to the consistently high standards they aspire to for their patients.”

Ms Cordery said mental health services were under “relentless pressure” and agreed with the report’s findings that a shortfall in staff and skill mix of mental health professionals was further impacting care.

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

“It’s vital the government takes urgent action to ensure all trusts have access to sufficient capital funding to halt the deterioration of their estate, eradicate the repairs backlog and provide high-quality care in environments fit for the 21st century.”