Mental health nurse shortages affecting care and skill mix

The shortages of mental health nurses in hospital settings in England are impacting patient care and have led to a greater reliance on support staff, a new review has found.

The ‘mental health 360’ report by the King’s Fund has warned that increases in mental health nurse numbers seen over the last few years have been “insufficient to meet demand”.

“Nursing staff provide the vast majority of care in mental health services and are central to improving patient outcomes”

Stephen Jones

In addition, the rise in nurses has been mostly in community services, aligning 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 a level that impacts on the quality of care”.

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

In 2012-13, the skill mix on adult acute mental health wards was 60% registered nursing staff and 40% support staff – by 2022-23, this situation had reversed.

“Changes in the level of staff experience and skill mix of services have led to concerns about being able to provide safe and effective care,” stated the report.

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Across all settings, the report found that mental health nurse numbers were rising overall, but this follows a substantial decline between 2010 and 2017.

As result, the number of mental health nurses – who make up the largest proportion of the mental health workforce – is only now restoring to 2010 levels.

As of September 2023, there remained 13,300 nursing vacancies across NHS mental health services in England.

In all regions, vacancy rates in mental health services are higher than that in the NHS overall, found the report.

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

However, with applications to study nursing declining, there is concern about how these plans will be achieved.

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

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

In services where there are waiting time targets – talking therapies and psychosis early intervention – these have been consistently met since 2017 and have led to improved access for patients.

However, for other services where targets do not exist, the King’s Fund said there was varied access, and there were also service gaps that meant some people may be missing out on care.

For example, the report raised concern 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.

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These gaps in services are despite the fact that investment in mental health services in England has increased since 2017-18 in line with government commitments.

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

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

And in the 2022 NHS Staff Survey, the proportion of mental health staff reporting being happy with the standard of care in their organisation fell to its lowest level in five years (63%).

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

For example, it said people from some minority ethnic groups had poorer access to talking therapies compared with people of White British origin.

Older people and disabled people were also under-represented in talking therapies, relative to population need.

Ethnic inequalities in the use of the Mental Health Act also remained an issue.

In 2022-23, detention rates for people who identify as ‘Black or Black British’ were three-and-a-half times the rate for people who identify as ‘White’.

Royal College of Nursing professional lead for mental health, Stephen Jones

Stephen Jones

Commenting on the findings of the review, Royal College of Nursing professional lead for mental health, Stephen Jones, raised concern about the shortages of nurses identified.

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

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He said the decline in nursing student applicants should “sound alarm bells in government and across health and care”.

“Nursing staff provide the vast majority of care in mental health services and are central to improving patient outcomes,” he added.

“Ministers can recognise this by delivering a fair pay offer along with an emergency package of measures in the budget to support nurse recruitment.”

Also commenting, Saffron Cordery, deputy chief executive of NHS Providers, said the report showed that trusts needed “more, long-term” government support for mental health services.

“For years mental health services have been starved of adequate capital investment vital to provide high-quality care in the right settings for the good of patients and staff,” she added.

“The report acknowledges that the sector has made progress on 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 strides in improving access and the quality of services.”

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

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