The shortage of registered mental health nurses “is a systemic issue which requires longer-term national workforce planning”, the Care Quality Commission (CQC) has said.
In a report published today on how services apply the Mental Health Act 1983 (MHA), the regulator reported serious concerns of “chronic” nurse shortages causing a threat to both staff and patient safety.
“Mental health services and staff are at breaking point”
The Monitoring the Mental Health Act (MHA) report 2021-22 laid out the CQC’s findings from its engagement with people subject to the MHA and a review of services which are registered to assess, treat and care for people detained using the MHA.
The data in the report is based on findings from the CQC’s monitoring reviews in 2021-22.
It carried out 609 MHA monitoring reviews, where 466 wards had an on-site visit and 143 wards had a remote review.
In addition, CQC interviewed 2,667 patients and 726 carers and handled 2,434 complaints and contacts from patients and others raising issues concerning the MHA.
“Workforce issues and staffing shortages remain the greatest challenge for the mental health sector,” the CQC report found.
Understaffing was identified as having affected the safety of both patients and staff.
In some services, nurses working over a weekend were expected to provide therapeutic activities “on top of their usual nursing tasks”, as occupational therapists or activity coordinators were only available during the weekday.
It also noted that a lack of therapeutic interventions had led to “an increased risk of violence and aggression on the wards”.
In a review of an acute ward for men and women, the CQC reported: “Patients told us that low staffing levels affected their access to regular named nursing sessions, supported activities and accessing the external areas.
“Staff were sometimes too busy to support access to the garden.”
The report warned that chronic staff shortages had made it difficult for nurses “to give their full attention to their tasks”. It had also led to challenges around their ability to respond to incidents.
In a report from a children and young people’s (CYP) mental health ward, the CQC said: “Both registered nurses had to stop doing essential tasks on several occasions due to the need to reprioritise.”
Meanwhile another observation said: “Registered nurses and the specialist nurse spent significant periods of time trying to juggle staff rotas to cover gaps and observations on the ward.”
Services had been forced to seek out solutions to chronic understaffing, such as deploying ward managers, matrons and other professionals to cover nursing shifts.
As a consequence this led to staff taking on responsibilities “they may not be able to carry out safely”.
CQC director of mental health, Chris Dzikiti, said: “Mental health services and staff are at breaking point, with staffing shortages affecting people’s care and putting safety at risk.”
He added: “While providers are attempting to put in place measures to mitigate staffing issues, the shortage of qualified mental health nurses is a systemic issue which requires longer-term national workforce planning.”
The report described how gaps in community care were adding to the pressure on mental health inpatient services, as bed availability in many services was “running close to or above capacity”.
It said: “While some services are managing to accommodate patients without extended delays, many others are struggling to provide a bed, leading to people being cared for in inappropriate environments.”
The report raised particular concern about the impact this was having on CYP mental health services, noting that the rising demand had increased the risk of children ending up in general children’s wards or adult psychiatric wards.
Delays in accessing eating disorder services were also a concern. The report noted that some CYP mental health units were struggling with the increasing number of patients with eating disorders, who also have “higher levels of distress and clinical need”.
Nursing Times reported in October that the exponential rise in the number of CYP seeking help for eating disorders was having an impact on the nursing workforce, who felt that they were not able to support CYP properly due to demand far outstripping supply.
Good care from nursing staff was also observed by the CQC where patients had been detained under the MHA.
Notably the report praised “very good practice” where nurses had support patients “to have a voice in the running of services”.
At two low secure wards in Milton Keynes, the regulator had said: “Patients told us that staff involved them in decisions about their care.
“They said that their key nurses review their care plans with them every four weeks. There was evidence of patients’ views and how they had been considered in care plans and the minutes of individual patient reviews.”
This good practice was also identified at Nottinghamshire Healthcare NHS Foundation Trust, in a report which described how patients “were able to name their named nurse” and said the nurse spent time with them.
However, the report stressed that change is needed to resolve longstanding inequalities, calling for “urgent action” to tackle disproportionate use of sectioning and restrictive community treatment orders on Black people and people from other ethnic minority groups.
“The NHS is on life support and without proper pay and funding it may not survive”
Mr Dzikiti said: “It is not acceptable that people from Black and some ethnic minority groups are subject to disproportionate use of sectioning and restrictive community treatment orders – providers should be asking themselves what they are doing to actively challenge this.”
He added: “We welcome recent funding commitments for the system and recognise work that is underway at a national level to build racial equality into mental health services and the government funded pilots testing culturally appropriate advocacy.
“There is an also opportunity to drive change at a local level with the involvement of integrated care systems, so the issues can be acted on jointly.”
Mr Dzikiti said that the CQC “will continue to monitor the use of the Mental Health Act in services and report when appropriate”.
Responding to the findings in the report, Dave Munday, lead professional officer for mental health at Unite, told Nursing Times that he welcomed the comments from Mr Dzikiti.
He said that Unite “wholeheartedly agrees that mental health services and staff are at breaking point” and that the union would join in demanding longer-term national workforce planning in mental health nursing.
Mr Munday said: “The NHS is on life support and without proper pay and funding it may not survive.
“That’s why NHS workers are standing up – they know that decent pay is essential to the service’s future.”
He added: “We know that austerity did so much damage to mental health services and to the people that desperately need to access them.”
“To set course on austerity again is deeply devastating and the wrong approach,” he warned.