It is at times tempting to ignore issues so complex that no simple solutions are available, and pray everything will turn out just fine. Future staffing of mental health services is just such a problem.
We are rightly preoccupied with a thorough review of mental health policy, and with planning major strategic changes to inadequate services. The document Modernising Mental Health Services: safe, sound and supportive prescribes much-needed crisis services, assertive outreach teams and additional safe 24-hour care. The forthcoming national service framework will probably add further detail and standards. The new style of services will have vast consequences for the workforce.
But there is a more worrying reality dawning: without a sufficient number of staff with the right skills, no modern or dependable mental health service is deliverable.Warning signs that we should not be complacent about the availability of such staff are everywhere. The existing workforce is ageing, and a high proportion of nurses and social workers are approaching retirement age. As many as 40 per cent of presently employed mental health nurses and social workers are entitled to take early retirement within the next five years or so.
Recruitment is a problem across the workforce. Among the medical specialties, it is most difficult to recruit and retain psychiatrists, with over 10 per cent of posts vacant. Intake of nursing students and applications to social work courses has declined significantly over the past few years.
Failures of recruitment and retention are the symptoms of a major supply problem, but there is no single disease to diagnose and treat. It is rather like depression, a complex interaction between body, mind and environment, with some aspects easy to remedy, others less so. An obvious factor is the stigma of mental illness and mental health services. It is hardly motivating to choose a career in a field that is perceived by the media as blundering from one disaster to the next, putting at risk not only the public but staff themselves.
It creates more pity than admiration to tell friends that one works in psychiatry. Once in the job, it is hard work, with large case-loads and constant pressure. Talking to clinical staff, it is worrying to hear consistent stories about lack of support and poor physical environment.
Taken in combination with the perceived poor pay of nurses, the other career options become hard to resist. And other options are there in plenty for the young school leaver with a couple of A-levels. The public sector no longer has a special attraction, based on the triad of altruism, a cosy job and security for life. The first factor is sadly no longer considered valid in a post-Thatcherite society, the second is recognised as untrue, and the third has lost much of its meaning in a constantly reorganised NHS with its associated redundancies.
Instead, the NHS is competing not only with other public sector employers like the police or education, but also with the private sector on terms such as status and salary. A lot is made of the fact that 7.5 per cent of nurses but 23 per cent of doctors are from minority ethnic backgrounds. I am not excluding discrimination playing its part in nursing, but I wonder whether high achievers from minority groups simply perceive nursing as beneath them, especially at a time when it is a sellers' market for well- qualified school leavers. All this means that simplistic solutions are not going to work. It is always tempting to blame it on government and poor central planning, but in fairness that is like blaming the ticket desk for poor sales of the latest box-office turkey.
So what approaches are realistic for mental health? First, it has to be realised that services need to be acceptable to both patients and staff. For example, the shifts necessary for 24-hour crisis services are difficult to sustain, especially for those with young families. However, neither patients nor staff want poorly designed and over-occupied inpatient units with high levels of aggression.
The greatest frustration of staff is that they are not involved in decisions relevant to their work pattern, and user involvement should be mirrored by staff involvement.This leads to the second point, which is career progression. Most would be willing to spend a period on an inpatient ward, provided there is a promise of a better future.
Some are even keen to continue jobs in hospital, but not at a lowly grade. After 10 years as a team leader of a community team even the best - especially the best - want progression. The only way forward is into management, which is frustrating for people who were motivated by personal contact with service users. I have seen many superb clinicians turn into very poor managers.
Extended grades are inevitable, and I did like the idea of a nurse consultant. What is wrong with paying some clinical nurses£35,000, since they may otherwise cost us a lot more as bad managers?
Finally, we have to accept that numbers of highly skilled staff will dwindle. We have to be imaginative about skill mix and roles. Nurse consultants will have to work with lower-grade nurses, in turn supervising larger numbers of community support workers.
Entry criteria for those workers could be relatively low, attracting people from a variety of backgrounds who need to be trained on the job. Pathways into nursing or social work could be opened for these people after a few years, in the process creating a workforce in tune with the community it serves.
This might even break through the stigma of mental illness and mental healthcare by achieving better integration into the local community. Yes, there will be a recruitment crisis, but it truly might pose challenges that could lead to exciting opportunities.