This is HSJ’s new fortnightly briefing covering quality, performance and finances in the mental health sector.

Feedback and comments are welcome, so please feel free to email me in confidence.

Workforce woes

I’ve written before about how workforce and funding are the two main worries facing the sector.

But there is a palpable shift in dialogue among sector leaders suggesting workforce is quickly replacing money as the foremost of the two. This is supported by a survey from NHS Providers which found fewer than one in three mental health chairs and chief executives are confident they have enough staff to deliver existing services let alone extending or creating new services. In particular, trusts are struggling to recruit enough mental health nurses and psychiatrists.

The Care Quality Commission has also flagged up ward staffing levels as a national safety concern in its first report based on its comprehensive inspections of every specialist NHS and independent mental health provider.

The Mental Health Forward View implementation plan sets out a clear trajectory in raising investment for the sector. While there are still fears not all of it will reach the frontline, the direction of travel is at least right.

However, the CQC’s report, and recent figures from the NHS Digital show that the same cannot be said for workforce, with the number of psychiatrists and psychiatric nurses both having falling in recent years.

This is extremely worrying for the sector, especially after the revelation national mental health director Claire Murdoch made to HSJ last month that the sector needs more than the 10,000 new staff that prime minister Theresa May has promised if it is going to fully implement its plans.

With 20,000 vacancies to fill there is no question a monumental recruitment drive is needed to make sure the sector has the staff it needs to drive forward these changes and Brexit will make it even harder.

The centre is already grappling with this conundrum. The Health Education England mental health workforce strategy is already more than seven months overdue because the original drafts did not adequately address the staffing problems. The Royal College of Psychiatrists wants to see HEE plan for an additional 1,000 consultant psychiatrists, but the most pressing question is where will these come from?

There are three problems which the strategy needs to address:

  • How to attract more medical and nursing trainees into the sector.
  • How to keep people working in the sector and reduce high attrition rates.
  • How to expand the workforce when training new staff could take decades.

The whole sector will have its fingers crossed the strategy addresses these profound challenges, but there will be no quick fix.

Mental health at the crossroads

The CQC’s new report gives the mental health sector much to be cheerful about. But it also paints a stark picture of the difference in quality provided by different organisations.

The biggest concerns were around safety, with 40 per cent of NHS core services and 39 per cent of independent core services were rated requires improvement or inadequate for safety.

Concerns raised by the watchdog were poor physical environments on many wards, staff shortages and staff not managing medicines safely.

Poor physical environments and staffing shortages are concerns which have been raised again and again about mental health services. This is going to take time, and upgrading some extremely dated estate – which includes listed old asylum buildings – is not going to be cheap.

So it was very positive this week to see mental health services getting a good slice of the £325m of extra capital funding that was pledged to the NHS in the spring budget. But parity of esteem purists will point out that mental health only makes up four of the 15 schemes getting some cash. While a good first step, much more will be needed to bring the mental health sector’s estate fully into the 21st century.

The safety and quality fears highlighted in the CQC’s report led to deputy chief inspector and lead for mental health Paul Lelliot to say the sector is at a crossroads. On the one hand, a future where patients have easy access to care which is close to home. On the other, services rooted in the past, using over-restrictive practices and not tailored to patient’s needs.

Exercising restraint

The CQC has also pledged to strengthen its policy over the use of restraint in mental health services.

This has been sparked by the watchdog’s concern over the great variation across the country in how often staff physically restrain patients whose behaviour they find challenging.

The CQC vowed to further strengthen its assessment of how and how often services use physical restraint and ”send a clear message to providers that we will be subjecting services where staff frequently resort to restrictive interventions to much tougher scrutiny”.

Many trusts have been stung by the CQC on their use of restraint, with it being a common theme in their inspection reports.

But there is no indication yet of what the regulator will toughen up on, nor how it will send its “clear message”.