Mental Health Matters: Monday to Friday people

When the national director for mental health expressed her “shock” last week at ward managers’ lack of weekend working – linking such staffing patterns to potential gaps in detection of abuse and poor care – she ignited quite the debate.

Asked at the NHS Providers conference about recent reports into care scandals, Claire Murdoch said it was crucial to listen to frontline staff, who spent most of their time with patients, but added: “[It’s also] making sure your ward managers do work of a night and at the weekend.

“I’ve been a bit shocked to hear that we’ve moved with Agenda for Change and quite often ward managers are Monday to Friday people.”

It is understood Ms Murdoch is concerned managers are spending too much time on bureaucratic tasks, which typically happen during Monday to Friday shifts.

At her own organisation, Central and North West London Foundation Trust, there is a push for a 24/7 oversight of services. A paper prepared for the trust’s November board meeting, in response to “shocking” footage in documentaries such as BBC Panorama and Channel 4’s Dispatches, outlines areas of inpatient safety and quality CNWL wants to tackle.

It states trust bosses will “communicate clear expectation and permission to all ward managers/matrons to have full 24/7 oversight of services, with ward managers appropriately remunerated for working weekends/nights, and, as part of this, include visits to other wards on site as part of their shift”.

It also says the trust will commence with an immediate and sustained programme of out of hours, unplanned visits to all inpatient areas, and 24/7 services with the help of a mix of staff.

In her NHS Providers response, Ms Murdoch said she felt trusts need “our most senior folk across the seven-day period”, asking why shouldn’t leaders be making unannounced visits at two in the morning?

The inclusion of students, patients, and healthcare assistants in CNWL’s 24/7 working push also points to her belief, supported by research, that these groups are more likely to spot and signal abuse.

In a letter to all mental health providers following the Edenfield documentary, Ms Murdoch warned abuse is “grown and prevented locally”.

She added it could be tackled by staff taking accountability for theirs and others’ actions, and through oversight by senior clinicians and managers, alongside quality teams, local leaders and boards.

Funding and vacancies holding 24/7 back

However, various senior sources at mental health trusts across the country have told Mental Health Matters their organisations have limited ward manager coverage over weekends and at night.

Many have matrons or senior clinical nurses present, the latter sometimes on a duty basis, while wards are often given access to senior leadership as required.

Several trusts are working towards 24/7 models as a long-term ambition, but feel current funding and vacancy levels are preventing them from achieving it.

One trust leader told Mental Health Matters they felt NHS funding arrangements and national workforce shortages were preventing clinical managers from being scheduled on to all shifts. 

“We, like other NHS trusts, aspire to provide a full seven-day service model. However, this will need to be supported by both a continued increase in multi-year funding and sustained increases in the number of clinicians in training so that we achieve this long-held ambition,” they said.

Cost pressure has long been a factor for most trusts – not just mental health providers, although they do typically have smaller budgets – in ensuring managerial cover over weekends and at night.

Where staff are required to work to cover services in the evening, overnight, over weekends and on public holidays, the NHS Staff Council states they should receive unsocial hours payments or additional enhanced rates.

For weekends and after 8pm on weekdays, for those between bands four and nine, unsocial hours payments can equate to basic rate plus 60 per cent, according to NHS Employers. Many trusts say they struggle to pay their managers such premiums.

The debate over seven-day working and its impact on quality is not confined to mental healthcare, with one chief claiming some acute hospitals were turning into the “Marie Celeste” on Friday afternoons.

Another senior mental health source appeared to agree ward managers should not be caught up with bureaucratic tasks, adding such a manager sitting in the office “isn’t the answer” – they need to be “on the floor” and visible.

They said inspection and unannounced visits also help to establish the position of what is happening on wards.

However, they were also concerned that emphasis appears to have shifted from safety on inpatient wards to a debate about staffing models.

Safety reviews are ongoing across mental health trusts following Ms Murdoch’s September letter, while ministers are considering an inquiry.

One leader told Mental Health Matters they are more concerned about how senior colleagues review and monitor compassionate care, pointing out safe staffing levels are already set for each ward, and reviewed by boards regularly.

Meanwhile, some of the country’s largest trusts – such as Mersey Care FT – told Mental Health Matters they have managed to ensure a number of senior leaders on all shifts, including senior clinical and operational nurses in charge, alongside ward managers, 24 hours a day, seven days a week.

A DHSC spokeswoman said: “Anyone receiving treatment in a mental health ward should receive safe, effective care and be looked after with dignity and respect, and we expect Trusts to provide a high-quality service seven days a week to all patients on these wards.

“We’re investing an extra £2.3 billion per year in mental health services by 2024, which will deliver an additional 27,000 mental health professionals and give two million more people the help they need.

“There were 6,900 more mental health staff in June than at the same time last year and NHS England is providing an extra £10million funding to support mental health services throughout the winter to deal with record demand.”