opinion: COMMUNITY SPIRIT

Without much publicity, the report of the workforce action team (WAT) was published in mid-August. Since then, it has received little attention, partly because of the political and emotional events that have dominated all our communications, partly because the conclusions might have struggled to grab headlines at the best of times. But the subject is so important to mental healthcare it would be of great concern if it was considered anything less than top priority.

I have always wondered whether we think carefully enough about what we hope to achieve by reorganising services.

The challenge must be to place competent staff in the best possible place to treat and care for service users - seen for some decades as the community rather than hospital.

A model has emerged in England that places a lot of emphasis on specialist teams. But the workforce implications have been largely ignored.WAT at last brings some of these into the open, though still as questions rather than answers.

I recently visited a hospital in Europe. Staff had experienced problems with crisis admissions and planned more beds. After years of Anglo-Saxon education on the benefits of crisis teams as an alternative to admission, I wanted to advise reducing bed numbers. Then I discovered that a ward with 20 patients was staffed by two to three nurses on a shift, whereas a community crisis team would require about 10 multidisciplinary staff for 15 patients.

Workforce supply was such a problem that the idea of developing services which needed higher staff numbers was unrealistic.While not condoning ward staffing levels, or arguing that my scenario makes a case for beds, it does show the need for more sophisticated thinking than simply implementing service models on the strength of clinical benefits at equal cost.We are not left with much if we design superb models without the workforce to deliver them.

Ironically, the problem is not a shortage of money - though£300m does not seem overgenerous - but finding the workforce to pay the money to.

The mental health national service framework and the NHS plan represent at least an additional 8,000 staff, well within the budget. But any projected increase is optimistic when we are struggling to recruit psychiatrists, nurses and social workers.

Two solutions are possible:

concentrating on retention, and opening new entry routes. The WAT report mentions both.

Neither is straightforward. The existing workforce is ageing and needs large-scale retraining.

Large asylums with thousands of staff available for redeployment no longer exist. So we will have to rob Peter to pay Paul or, to use the jargon, set priorities.

To find out what this means, talk to managers who cannot staff admission wards because all their staff have fled to community teams, where they get more pay for less stressful work.

The pay incentives may have been appropriate when we needed to staff community teams, but they have now become perverse.

Skill mix is crucial, and implicitly many WAT recommendations deal with this.

Occupational standards, capabilities, non-professional workers and new training programmes all share the aim of shifting roles and preparing people for new styles of working.

The non-professional worker is creating great interest: we cannot afford to persist with existing professional boundaries and monopolies. Equally, believing that skills do not matter will not benefit patient care.

It may not be an issue whether a psychologist or an ex-train driver is offering you great counselling.

But does creating a two or threeyear training programme for 'unqualified' staff - including relevant attitudes, knowledge and skills - merely change a label? Are we reinventing a nurse with a different name?

The game will be occupational standards and capabilities, not professional qualifications - though this should not be a contradiction.

I do not believe that any amount of creativity will solve the shortfall.We will have to be parsimonious with our planning and start with realistic assumptions about workforce supply, designing services accordingly.

Models of care need to be judged on staff efficiency. I can imagine a scale to indicate quantity and quality of care by staff member.

The key factor to optimise this balance is training, where we will have to invest heavily.

The challenge is how to drive such a programme forward without obvious leadership, when it is contentious with professional bodies and training organisations.

If the WAT report achieves only recognition of these issues and triggers progress, it deserves to be remembered as a success.

Dr Matt Muijen is director of the Sainsbury Centre for Mental Health.