A former chief nurse has told an inquiry into mental health inpatient deaths that more resources must be put into the registered nursing workforce to improve patient care.
On 8 May, registered nurse Maria Nelligan and consultant psychiatrist Dr Ian Davidson appeared before the Lampard Inquiry as expert witnesses to provide contextual evidence on the state of mental health inpatient care.
“A lot of registered nurses have moved from inpatient areas to community teams… the terms and conditions are better in community teams”
Maria Nelligan
The inquiry, chaired by Baroness Kate Lampard, is looking into the deaths of at least 2,000 mental health inpatients under the care of various providers in Essex between January 2000 and the end of 2023.
Ms Nelligan and Dr Davidson had both submitted written reports on the national picture of mental health inpatient care in 2000-2023, focusing on how things improved or degraded, and how standards or norms shifted.
At the inquiry, the two experts were questioned on these reports, and other background evidence, by barrister Thomas Coke-Smyth, who serves as counsel to the inquiry.
Ms Nelligan, now retired but still on the register as a learning disability nurse, has previously been the chief nurse for mental health trusts including Greater Manchester Mental Health NHS Foundation Trust and Lancashire and South Cumbria NHS Foundation Trust.
Mr Coke-Smyth asked her about nurse staff shortages in mental health inpatient wards, noting that in her report she had written about an “increasing reliance” on healthcare support workers.
She told the inquiry that, in the period being covered by the inquiry, many mental health nurses were opting to work in services outside the NHS after qualifying.
“Registered nurses were not all coming into the NHS, and a lot of those registered nurses were going into the private sector and other areas,” she said.
“Therefore, the gaps needed to be filled by other practitioners; in this case, healthcare support workers. That would include also your assistant practitioners and later, nursing associates.
“There was also a period of time where there was an emphasis on reducing costs and healthcare support workers are cheaper than registered nurses. That was also a factor that came in during that period of time, and that informs some workforce plans as well.”
Ms Nelligan also said experienced mental health nurses were being lost from wards because of poor progression.
She explained that there were far more opportunities to move up a band in community mental health nursing.
“Over time, wards have now become quite complex areas to work in,” she said, continuing: “A lot of registered nurses have moved from inpatient areas to community teams… the terms and conditions are better in community teams.
“So, the majority of registered nurses on a ward would be a band 5, which is entry level remuneration, [whereas] in community teams, it’s the next level up, so that’s one factor for people moving… there’s a lack of career progression working on a ward.”
As well as this, Ms Nelligan said the “distressing” and “complex” nature of ward work further impacted on attrition and staff turnover.
She added: “It’s still an issue… with the more experienced registered nurses leaving to go work in the community, more junior registered nurses are on the wards, and they’re still finding their feet and developing their skills.
“That then dilutes what the nursing team are able to deliver to patients.”
“You will improve the morale of the clinical team and the outcomes can be better for everybody”
Maria Nelligan
Similarly, Mr Coke-Smyth asked the former chief nurse about the impact of heightened demand and nurse shortages on the ability of nursing staff to deliver one-to-one care for mental health inpatients.
Ms Nelligan said that interventions that could only be carried out by a registered nurse, as opposed to a support worker, such as one-to-one care and supervision of junior staff, were most likely to be dropped when pressures were high.
“The nurse in charge of that shift will have to make a decision about what things are going to continue as planned on the ward,” she said.
“Bearing in mind, there will be things that are not planned that will happen on the ward, like an admission might come in, there might be a disturbance, there might be an aggressive outbreak.
“As well as responding to reactive things that happen on the ward, the nurse also needs to decide what work that was planned for that shift is going to have to be postponed, and that can include supervision…”
Ms Nelligan also spoke about the various interventions and policy changes that had been implemented over the years on staffing, such as the NHS England National Quality Board guidance on safe staffing, published in 2016, a 2019 staffing tool funded by Health Education England and others.
She said these helped to stimulate investment from NHS trusts in charge of inpatient mental health wards, and otherwise address some of the key issues.
However, Ms Nelligan said the issues of staff shortages and high vacancy rates in mental health remained.
In Ms Nelligan’s report to the inquiry, she wrote about the current National Institute for Clinical Excellence (NICE), Care Quality Commission (CQC) and other guidance on minimum staffing, and how it would be “preferable” to always have at least three registered nurses on shift in most mental health inpatient wards.
Mr Coke-Smyth asked Ms Nelligan how “practicable or achievable” this would be.
The nurse said: “First of all, there has to be an acceptance that that is a good thing to do, and there has to be the resources available to meet that.
“The next thing is getting the registered nurses to fill the posts… if you increase the [numbers of]… and the retention of registered nurses on the wards, you will improve the quality of care provided to patients.
“You will improve the morale of the clinical team and the outcomes can be better for everybody.”
The inquiry continues.
