Next week I’ll be in London for this year’s Eileen Skellern and JPMHN Award evening, hearing Mick McKeown give his Making the most of militant and maverick tendencies for mental health nursing Skellern lecture and Patrick Callaghan deliver his Lifetime Achievement Award address. The day following, June 14th, I’ll be at Kingston/St George’s chairing the summer meeting of Mental Health Nurse Academics UK. One of the things we’ll we talking about is NHS England’s Interim People Plan, which looks to be prioritising mental health nursing as an occupational group in need of support. Here’s a short piece I wrote yesterday for the MHNAUK website, complete with a toxic-looking figure showing the decline in applications for nursing degrees:
The NHS needs more mental health nurses. The most recently available data on the size and composition of the workforce in NHS England, for February 2019, records a total of 36,290 mental health nurses. This compares to an NHS England mental health nursing workforce in September 2009 of 40,602.
Published on June 3rd 2019, the Interim NHS People Plan is about supporting the people needed to deliver NHS England’s Long Term Plan. Chapter 3 addresses nursing, this being the profession where the greatest shortages are found and where the most urgent and immediate action must be taken. Mental Health Nurse Academics UK welcomes the identification of mental health nursing as a priority group, and notes the Interim People Plan’s statement that what must now happen is:
[…] a detailed review across all branches of pre-registration nursing, including a strong focus on the steps needed in mental health and learning disability nursing to support growth in these areas.
The Plan echos Mental Health Nurse Academics UK’s view that undergraduate degree courses offer the best way to secure a future supply of nurses. It also reproduces a figure pointing to a sharp decline in applications for nursing and midwifery courses in England since the removal of bursary support (specifically, a 31% decrease between 2016 and 2018):
Extracted from Interim People Plan, p24
The Interim People Plan places an emphasis on what it refers to as ‘the offer’ made by the NHS to its staff. Mental health nursing needs a better offer if it is to improve the recruitment, retention and support of its current and future members. Mental Health Nurse Academics UK will be looking for concerted action in these areas.
My view is that this decline in applications was entirely foreseeable in the context of the removal of bursaries in England. As it happens, students of nursing and other health professions commencing their programmes of study in Welsh universities in Autumn 2019 can expect to be supported through the award of a bursary, in return for working for two years post-qualification in NHS Wales. That’s a good deal, in my book, and is something presented as part of the country’s wider #TrainWorkLive initiative. I’m not entirely sure how far this ‘Welsh offer’ (to borrow the language of the People Plan) is known throughout other parts of the UK: so I’m happy to give it a nudge here.
Mental health nursing is important and fulfilling work, and offers a fine and rewarding career. More people also need to be doing it. By way of background, last month Mental Health Nurse Academics UK (MHNAUK) submitted a response to Health Education England (HEE)’s Facing the Facts, Shaping the Futuredraft health and care workforce strategy for England to 2027. Contained in this HEE draft are figures on trends in the numbers of nurses, by field of practice, employed in NHS England over the period 2012 to 2017.
Growth/reduction in NHS employed nurses and midwives by field, 2012 to 2017 (extracted from Facing the Facts, Shaping the Future)
Obvious at a glance from this figure is the decline in both mental health and learning disability nursing numbers over time. Elsewhere HEE also describes a 14% mental health nursing vacancy rate.
Now, the Nursing Times reports a reduction for the second year in a row (£) in the numbers of applications for nursing degrees received via the Universities and Colleges Admissions Service (UCAS). Declining applications need to be viewed in the context of the removal of bursaries for students of nursing enrolling at English universities. In MHNAUK we have said, more than once, that we fear the loss of bursary support poses a particular threat to our field of practice. The same applies to learning disability nursing, where at least one degree programme closed last year (£).
With all this in mind this may be a good time to remind people of this useful page, hosted on the MHNAUK website, on joining the profession. As this says:
Forget all the stereotypes about straitjackets and Victorian asylums; modern mental health nursing focuses on helping and supporting people from all walks of life with a variety of ‘common’ mental health disorders (such as anxiety and depression) as well as more serious disorders such as drug and alcohol problems, suicidal feelings, psychosis, bipolar disorder and dementia. They also play a key role in promoting mental health and well-being among the public and preventing mental health problems occurring in the first place.
This helpful MHNAUK resource also includes suggestions for further reading, included in which are texts describing in detail many of the skills that mental health nurses routinely use and the context in which they go about their work. And, for any reader contemplating applying to any of the 60+ mental health nursing degree courses offered throughout the UK, do give some thought to our undergraduate nursing programmes here in the School of Healthcare Sciences at Cardiff University.
Yesterday the Nursing and Midwifery Council issued a press release reporting on a continued decline in the number of EU-qualified nurses and midwives joining the register, and a simultaneous increase in the number of EU-qualified nurses and midwives leaving. Behind the press release is a longer report, from which I have extracted two tables:
Meanwhile, UCAS (the Universities and Colleges Admissions Service) reports that applications for higher education programmes commencing in the 2017-18 academic year have declined across the board, but that it is nursing courses which have seen the sharpest fall. Applicants from England making at least one choice to study nursing dropped by 23% (to 33,810) in 2017.
The RCN, amongst others, has long been campaigning against persistent low pay for NHS nurses, arguing that a career which is so obviously poorly remunerated is no incentive to potential new recruits. Nor, for that matter, does it help efforts to retain existing staff. Previous reports from the RCN tell us that the UK’s nursing workforce is an ageing one.
Taken together, the loss of European nurses in the context of last year’s EU referendum, chronically poor workforce planning, a nursing profession which is getting older (and will therefore lose members to retirement), the loss of bursaries in England and continued low pay make for a toxic combination. But things can be done. Agreeing the future security of EU citizens in the UK would be a start, along with removing the NHS pay cap. Reintroducing bursaries might help rekindle UCAS applications. Better planning of future NHS staffing needs is long overdue. Nursing, of course, remains a mightily fulfilling career and I would hate to think that this (admittedly rather negative) post puts off anyone contemplating a move in this direction. But it also serves to highlight some of the serious challenges which lie ahead.
In a post on this site last year I drew attention to the (highly contested) decision by NICE to suspend its work on safe nurse staffing in inpatient mental health settings. Now, and with thanks to Shaun Lintern from the Health Service Journal (and to John Baker, who amongst mental health nurses has worked particularly hard to keep this issue alive), NICE’s evidence review in this area has just been published.
Here’s a quick summary. Seven research questions were asked in the review, with searches made of fifteen databases for evidence published since 1998. To be included, studies had to report on at least one of:
staffing in relation to outcomes;
staffing in relation to factors (such as service user factors, environmental factors);
staffing in relation to factors and outcomes.
Studies were eligible for inclusion if they reported findings from inpatient mental health areas serving people of any age. Outcomes of interest included serious incidents (e.g., self-harm, violence), delivery of nursing care (e.g., levels of contact) and other (e.g., nurse vacancy rates). Following a process of searching and sifting just 29 papers were finally included, and subject to quality appraisal. And the conclusions? Here they are, as extracted by John Baker with a call for action:
Working with the charity Rethink Mental Illness, and drawing on publicly available data, the RCN shows how (since 2010) the number of staffed mental health hospital beds across all four countries of the UK has reduced. The number of nurses working in NHS mental health services has also fallen, those remaining being revealed as an ageing group. Year on year, an increasing proportion is shown to be over the age of 50.
Here’s a chart showing reductions in the mental health nursing workforce, which I’ve extracted from page 16 of the report:
And, right at the front of the document, I see a clear case for investment contained in these recommendations which I reproduce word-for-word:
1) Governments must ensure there is equal
access to mental health services and that
the right treatment is available for people
when they need it.
2) Governments and NHS providers must
ensure that the commitment to parity of
esteem is directly reflected in the funding,
commissioning of services, workforce
planning, and patient outcomes.
3) Local commissioners and health boards
must make available enough local beds
to meet demand.
4) The principle of least restriction must
be embedded across all mental health
services. Detention under mental health
legislation should always be based on
clinical opinion and never be a result
of local failures to provide appropriate
care. Due to the significant increase in
detentions under the Mental Health Act
there should be a national objective set
to reduce detention rates in England.
5) There must be a consistent shift across
the UK from inpatient acute care to
community-based services which
recognises that prevention and early
intervention results in better outcomes,
reduces the pressure on acute services,
and reduces the overall cost to the NHS
in the long term.
6) Urgent action must be taken to address
the workforce shortages. Resources must
be committed to training and recruiting
enough mental health nurses who are able
to deliver specialist care in the changing
health and social care landscape.
7) NHS providers must invest in the current
mental health nursing workforce.
Band 6, 7 and 8 mental health nurses
should be developed to become advance
practitioners to deliver effective
recovery-led care in mental health
services.
8) There must be a sustainable and
long-term workforce planning strategy
which acknowledges the current
challenges facing the mental health
nursing workforce.
Whilst I was wandering around Cornwall last week (see photograph for evidence), The Lancet was busy publishing the latest paper from Professor Linda Aiken and her colleagues in the RN4CAST consortium. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study uses discharge data for 422,730 surgical patients in 300 hospitals in nine countries along with survey data from 26,516 practising nurses. That’s one big study. The abstract goes on to say:
Finding
An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031—1·106), and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886—0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients.
Interpretation
Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.
[NB: Not sure about odds ratio? Check out the relevant Wikipedia entry here.]
On the day the article was published in early online form the Council of Deans of Health here in the UK ran with this, The Conversation ran with this and The Guardian ran with this. The Lancet supplemented its article with this podcast.
The media interest reflects the scale of the study and the importance of its findings, which make a strong case for investment in nursing. A year ago, the International Journal of Nursing Studies published this special issue on the nursing workforce and outcomes, carrying a series of open access papers from the same RN4CAST team. There are other papers published elsewhere arising from this same study, and no doubt more to come.
What the RN4CAST researchers have not done is to have generated any data in psychiatric hospitals or involving mental health nurses. This is very reasonable, as theirs has been a complex-enough study ‘focused on general acute hospitals’, to quote from its published protocol. But it would be good to know more of the relationships across Europe between mental health nurse staffing and practitioner characteristics, organisational and management features and service user outcomes. Now there’s a challenge for someone.
Mental health nursing is important and fulfilling work, and offers a fine and rewarding career. More people also need to be doing it. By way of background, last month Mental Health Nurse Academics UK (MHNAUK) submitted 
Here’s a post to draw attention to the 
Whilst I was wandering around Cornwall last week (see photograph for evidence), The Lancet was busy publishing the latest paper from Professor Linda Aiken and her colleagues in the 
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