Crisis in mental health services

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On 25 January 2016 The Guardian exposed the collapse of NHS mental health services, citing figures from the NHS’s Health and Social Care Information centre showing that the number of registered mental health nurses (RMNs) working in psychiatry has decreased by 10.8% since 2010 as funding for the service has been slashed. The following day the paper revealed that the number of unexpected mental health patient deaths had risen by 21% over the last three years. This was inevitable given that mental health service budgets fell 8% in real terms under the last government. Claire Wilkinson reports on the crisis engulfing NHS mental health services.

Working on an acute psychiatric ward for the last four years, my experiences certainly correspond with this data. The North West mental health trust I work for is increasing its training and employment of Assistant Practitioners (APs), a relatively new role where a healthcare assistant is trained to take on many of the duties of a nurse while remaining unregistered in a professional capacity. APs are employed on a Band 4 in the NHS pay scale, whereas an entry-level RMN is employed on the more highly-paid Band 5. There is an obvious financial incentive for trusts to employ fewer RMNs and replace them with the cheaper APs, who are unable to progress past Band 4 or register with a professional body.

The reality of life working on an inpatient mental health ward is that staff of any Band are in perilously short supply, with our concept of what is and what is not an acceptable level of staffing changing month by month as we are forced to make do with fewer staff to look after the same number of patients, as well as to meet the ever-increasing requirements of the CQC inspectors.

Worsening this staffing crisis are the bed shortages. As The Guardian reports, beds in mental health services are in considerably higher demand now than they were in 2010. If any recovering psychiatric patient on my ward goes on overnight leave with their families, even though their bed is reserved and they are due to return to the ward the next morning, a new patient will be in that bed within the hour. There is always a long queue of patients waiting to be admitted. This places a considerable strain on other NHS services which may have to deal with mental health patients in crisis for days or even weeks before a psychiatric bed becomes available.

The decrease in RMNs is more dramatic on psychiatric wards (17%) than it is in the community (1%). It is usually RMNs who are newly qualified, younger and less experienced who take jobs on inpatient psychiatric wards, as these jobs are generally regarded as harder and more stressful than the higher paid roles in the community. After a few years working on an inpatient ward, most RMNs will want to progress and either become a deputy ward manager, or apply for a Band 6 job in the community. Both these avenues remove the RMN from actively working on the ward. This system is sustainable only if there is a stream of newly qualified (and cheaper) nurses to replace them. Over the last four years the wards I have worked on have always suffered from a shortage of qualified RMNs, forcing them to do many hours of overtime to ensure that the wards have at least one RMN on every shift. With the abolition of bursaries for nursing students, the number of newly-qualified RMNs looking for ward-based experience will plummet, and the shortage of ward-based RMNs will increase dramatically.

The rise in the number of patient deaths is clearly the consequence of falling staff numbers and intensifying pressure on working conditions. The three-year increase, from 1,412 annual unexpected mental health patient deaths to 1,713, represents an increase of 301 per year. The word ‘unexpected’ is deliberately neutral. But in reality, these figures represent mental health patients who have accessed services and whose conditions are supposedly being treated or managed whether in the community or on an inpatient ward. These patients are under the care of the NHS when they ‘unexpectedly’ die. The accurate word for these deaths would be ‘avoidable’. This is backed up by figures showing the 26% increase in suicide amongst mental health patients over the same period.

One very simple but effective method used on the wards to prevent suicides is to place patients on a higher level of ‘observations’. A suicidal patient may be put on a 1:1 observation, which means that they will have a member of staff with them at all times who is able to intervene to prevent any attempted suicide and, most importantly, to provide ongoing emotional support and reassurance. This method works, but requires a level of staffing that is becoming a distant memory. In my experience the dangerously short staffing levels on wards force RMNs to choose between keeping a patient at risk of suicide on a 1:1 or having enough staff to maintain the safety of the other patients on the ward. It can be that several patients may be at crisis point on the same ward at the same time meaning that several 1:1s may be necessary. An abundance of staff, whether RMNs or unqualified health care workers, is the most important requirement in keeping mental health services safe. But I have only ever witnessed an abundance of staff on any ward during an inspection or a visit by a chief executive, politician or celebrity, and this abundance disappears with the visitors.

Mental Health services were in crisis when I began working for the NHS four years ago. Now this crisis has worsened. Lives are at risk on a daily basis and the situation will worsen over the next few years as more staff are cut and skill levels reduced. Mental health patients are being neglected in spite of all the talk of ending the stigma surrounding mental health. We have to fight to change this.

Fight Racism! Fight Imperialism! 249 February/March 2016