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Mental healthcare – a service run ragged

Men meeting, mental health, groups discussion

Mental health staff face unmanageable workloads, depleted teams and poor access to training, BMA research finds – with government promises of new recruits sounding ever more hollow. Keith Cooper reports

Bold pledges to recruit vastly more members of staff, as a means of easing the pressure in mental healthcare, are often deployed with aplomb by politicians.

More than 10,000 extra would be recruited this year, said the Conservative manifesto in May 2017.

Its opponents back then believed it was based on ‘thin air’, they told the BBC. Two months later, the Government’s official plan, Stepping Forward to 2021, pushed the figure up to 19,000 additional staff.

Leap forward to 2019 for an even more ambitious scheme. The NHS England Mental Health Implementation Plan called for a further 27,000 staff, a mix of psychologists, psychiatrists, nurses, social and peer and other support staff, to make up the ‘multidisciplinary’ approach it envisioned. An influx of new staff into mental health would certainly help the patients who suffer the traumatic, sometimes tragic, consequences of shortfalls and those in the service who struggle to cope with ever-rising demand.

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However, such pledges, alongside parallel ones to improve services by funding the front line, are yet to make a significant mark, says BMA mental health policy lead and consultant psychiatrist Andrew Molodynski.

‘The opposite has happened,’ he adds. ‘There are longer waiting lists, increasing out-of-area placements, slimmed-down services that cannot cope with demand, and most worryingly, a rising suicide rate for the first time in decades.

‘Why, in the fifth-richest country in the world, do we allow this situation to continue and indeed worsen?’ (see 'Why do we allow our mental health services to be like this?' below).


‘Not on track’

So just how far have these pledges travelled in driving recruitment? Is ambition enough to improve care and conditions in the NHS?

The answer is a clear ‘no’, according to BMA analysis of workforce figures and a survey of more than 1,000 doctors, psychologists and mental-health nurses, carried out with the Royal College of Nursing and the Association of Clinical Psychologists UK.

The NHS is ‘not on track’ across multiple measures of workforce, its treatment of staff, and employers’ commitment to their wellbeing – an even more essential element, given the pressures.

Measuring Progress: Commitments to Support and Expand the Mental Health Workforce finds that many staff groups have stayed static in numbers or fallen during the past decade. The number of doctors, 9,000, has barely budged, despite the rhetoric, pledges and plans. More than 7,000 nurses, health visitors and midwives have left the NHS since 2009.

Vacancy rates for psychiatry posts in England have doubled since 2013 to nigh on one in 10. They’re even higher in clinical psychology and nursing. Meanwhile, work pressure on this diminishing and depleted workforce rises, according to figures.


Toll on staff

The effect on staff is revealed in the survey findings:

  • Almost seven out of 10 respondents work in teams with vital members of staff missing most or all of the time
  • Nearly half (47 per cent) of doctors work shifts in which they are down at least one medical colleague
  • Four in 10 found workloads ‘unmanageable’ or ‘mostly unmanageable’, according to respondents from all three professions
  • Half said access to training had worsened or greatly worsened
  • While positive improvements were reported by most working with multidisciplinary teams, many lacked access to the support staff they needed to take part fully.

The pressures on staff from all this takes an obvious toll.

A consultant psychiatrist, who asked not to be named, says he recently decided to quit his job after the struggle of running an inpatient service for years, caring for people who are acutely unwell.

‘Inpatient services are seen as the most expensive resource and the bottleneck in the service,’ he says.

‘The level of bureaucracy and scrutiny is relentless whenever something doesn’t go well. It inevitably results in another layer of process added on.’

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The desire, as a psychiatrist, to provide good patient care is constantly in tension with the need to take complete breaks from work, he adds.

‘It is difficult to get much sense of a break from work, certainly not enough of a consistent one. Nursing staff are probably hit more than doctors but nonetheless it does affect us as well.’


Can’t carry on

Manchester consultant child and adolescent psychiatrist Alison Dunkerley says she’s seen a ‘massive increase’ in demand for her services without any increase in resource.

‘It is sometimes really hard to recruit and retain staff,’ she says. ‘I am lucky enough to be able to retire soon. I never thought I would at 55.

'I actually enjoy my job in some ways but I’ve realised that I cannot carry on working the way I am.’

Royal College of Nursing professional lead for mental health Catherine Gamble says the survey shows staff are consistently held back by unfillable vacancies and the ‘e-rostering system’, which made agency work more attractive than full-time posts.

‘The clear majority of nursing staff felt the absence of one of their own on their last shifts. This hammers home the reality of the chronic workforce shortages that have plagued our profession,’ she adds.

‘Unless there is urgent investment in growing the nursing workforce the pressures will continue to grow to the point where it will no longer be possible to attract nurses to work in the NHS, and parity of esteem for physical and mental health remains a goal yet to be realised.’

Dr Molodynski calls for a ‘real parity’ in mental healthcare, a parity of resources, access, and outcomes – not just ‘esteem’.

The BMA has set out a series of recommendations to achieve real parity, including calls for extra ‘standards’ to keep tabs on access to services, a fairer share of resources, and a ‘realistic and measurable’ set of commitments on workforce.


Why do we allow our mental health services to be like this?

Andrew Molodynski

Mental health has been high on the political agenda for some years now, with bold promises from Government in recent times: more staff, more services, more funding, no patients being sent around the country for care, reduced waiting lists, fewer suicides. However, what we have seen outlined in this article and numerous academic and mainstream publications is essentially the opposite: longer waiting lists; increasing out-of-area placements; slimmed-down services that cannot cope with demand; and most worryingly a rising suicide rate for the first time in decades.

In microcosm, my own team (a general community team for people like you and I with mental health problems) has recently been audited as having 50 per cent too few staff. We knew that already. Will things be put right? Almost certainly not. If we were an oncology or paediatric team would they? Almost certainly yes.

Why, in the fifth-richest country in the world, a liberal democracy with a national health service ‘free at the point of use for all’, do we allow this situation to continue and indeed worsen? The reasons are not clear. The public is more supportive of the need to provide treatment for people suffering with mental health problems than ever, health workers are all aware of the need, and other services such as the police are crying out for things to improve.

Twenty years ago, there were similar calls for change, and these were answered – by a national service framework for mental health services and the necessary funding to enhance and transform services. It worked. We need something similar now.

The era of parity of esteem has seen a worsening of care standards overall. We at the BMA call loudly for real parity – parity of resources, access and outcomes.

If the Government will commit to achieving that over the period of the 10-year plan then their promises may come good and there will be fewer lives shattered or ended by the current shameful underinvestment. Fewer people languishing on wait lists for desperately needed therapy, fewer people being shipped around the country in the night for want of a bed, fewer children having their life chances ruined by waiting years (yes years) for treatment they need, fewer people taking the tragic final steps to end their lives because help and hope have gone.

Real parity, 25 per cent of NHS funding for mental health care across primary and secondary care, is not a choice – it’s a necessity.

Andrew Molodynski is the BMA consultants committee mental health lead


BMA recommendations on parity of resources, access and outcomes – what does it look like?

On funding: Clinical commissioning groups should double expenditure on mental healthcare. More should be spent on mental health wards, research, and in primary care and public health.

On access: Standards for access to services which are fully funded. Reviews of all trusts who place high numbers of patients in beds far from their homes.

On workforce: Realistic and measurable workforce goals. Targeted recruitment campaigns for the hardest-to-recruit sub-specialties, such as old-age psychiatry and learning-disability psychiatry.

On prevention: A cross-government body established to draw up a joint strategy on public mental health. National and local Government adopt a ‘mental-health in-all policy’; mental health impact assessments for all new policy proposals.

Read the BMA report




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