Mind over matter

Recruitment
and retention in the mental health service is reaching crisis point with costs
spiralling to pay for agency staff. Now HR professionals are being targeted by
a campaign urging them to use their experience to help reverse the trend.
Sophie Petit-Zeman reports

The
mental health workforce is in difficulties. Recently described by one nurse as
“a daily traumatic environment” many psychiatric wards are understaffed and
overstretched. Services lack the time and personnel to improve practice, leaving
permanent staff feeling hard-pressed and reluctant to stay.

In
turn, staff shortages lead to heavy use of locums and agency workers, which is
expensive and can destabilise teams.

Long
hours, excessive paperwork and heavy caseloads create further burdens,
discontent and low morale, unalleviated by the grim physical environments of
many mental health services.

In
1998, 14 per cent of consultant psychiatry posts were vacant or filled by
locums, and the number of unfilled posts had risen by 32 per cent since 1995.
More than a third of NHS trusts recently reported difficulties recruiting
psychiatrists, and staffing problems are worse in this than in any other
medical specialty.

In
mental health nursing, 2.1 per cent of posts are “hard to fill” and 85 per cent
of NHS trusts have general difficulties recruiting and retaining nurses.

Agency
staff are becoming commonplace – a transient workforce which often fails to
foster team spirit or much needed feelings of security among patients.

A
decline, over recent years, in newly qualified specialist mental health nurses
suggests that resolving the situation will present tough challenges.

There
is a well-documented dearth of clinical psychologists, acutely felt by the many
thousands of people on NHS waiting lists for “talking treatments”. It is
unclear whether the increased numbers of clinical psychologists expected to
enter training will have a significant impact on the shortfall.

Social
workers and occupational therapists (OTs) are also desperately needed. Vacancy
rates are above 10 per cent for full-time OTs across the NHS, and applications
for OT courses have fallen by 46 per cent in the past five years.

Juggling
conflicting demands

It
continues to be a predominantly female workforce, and much as we may hope otherwise,
women still often find themselves primarily responsible for juggling
conflicting demands of home, family and employment, putting much of the OT
population under extra pressure.

Recognising
the difficult state of staffing in this notorious “Cinderella” area of
healthcare, the Sainsbury Centre for Mental Health (SCMH) produced a report
last summer, Finding & Keeping, which considered the problems in depth.
SCMH recently launched a campaign to bring the reports’ findings to the urgent
attention of personnel and human resources managers and the document is already
being intensively used by the Workforce Action Team, a group set up to take
forward the aims of the Government’s National Service Framework for Mental
Health.

As
Dr Matt Muijen, director of the SCMH and a member of the action team, explains,
“A team subgroup, chaired by John Cox, president of the Royal College of
Psychiatrists, is looking at recruitment and retention, using Finding &
Keeping as a basis.” Muijen is determined that ways are found to bring staff
back into mental health care, and keep them in post, in rewarding and
fulfilling jobs.

Sir
Graham Hart KCB, former permanent secretary in the Department of Health,
chaired Finding & Keeping’s steering group and points out that “the cost of
implementing good human resources practice is small in comparison with the
possible benefits for staff and for patients”. This comment summarises not only
the philosophy of the report as a whole, but also the view of much of the
mental health sector. Many are pressing for improvements, while some are
already getting their working practices right.

The
recommendations of Finding & Keeping are fully in accord with the proposals
for reform set out last year by the DoH in A Health Service of all the Talents.
This document states, “We need to make sure that we plan and develop the NHS
workforce, and use our investment in it, to deliver the best, most effective,
care for patients. Because caring for people is what the NHS is all about.”

It
also recognises that “the NHS workforce needs to be transformed in order to
provide the sort of care which will be needed in the future”.

The
emphasis is placed on team working, flexible working to optimise skills and
talents, streamlined workforce planning and development stemming from the needs
of patients not professionals, maximising the contribution of all staff to
patient care by breaking down some of the barriers between the types of care
that can be provided only by doctors or nurses and modernising education and
training and expanding the workforce to meet future demands.

Why
the problem?

Workforce
planning in health and social care has never been easy, and changes in the
mental healthcare system, including, significantly, the gradual implementation
and development of community care have brought new challenges.

While
the problems catalogued in Finding & Keeping might alone be sufficient to
send staff running for the door, the disorientating rate of change in mental
health services over recent years also contributes heavily, and has not been
coupled with opportunities for staff development. Indeed, according to Muijen,
“Many staff feel that they are standing still in their careers, without
promotion opportunities or wider career development. Some staff have also lost
role clarity and feel that their jobs are poorly paid and low in status.”

It
would be unfair to lay the blame for this state of affairs solely at the door
of mental health service managers. Their task is a daunting and complex one,
and there is no standard training or preparation to help them juggle competing
demands and differing stakeholder perspectives. As mental health care becomes
increasingly multi-disciplinary and inter-agency, things can only get tougher.

What
can be done?

Organisations
clearly perform better when they have satisfied, committed staff. In many
environments, such success is measured in terms of profits and productivity.
Within mental health care, the benchmark of a “good organisation” is harder to
measure – people who use services need to feel safe and supported, be
well-treated and, hopefully, get better.

Workforce
problems cannot be solved simply by increasing recruitment – although this
would certainly help – and a wider vision is needed to boost the appeal of
working in mental health care.

According
to Muijen, “Action must be taken at two levels. In the immediate future,
changes can be made by identifying targeted solutions to specific problems. For
example, where wards are physically unpleasant, changing this could have a
significant impact on morale and hence drive improvements in staff performance
and retention.

“Taking
a broader perspective, a strategic framework is needed to ensure good
employment and management practices.”

Addressing
the first of these, Finding & Keeping contains a comprehensive “A to Z of
interventions to improve recruitment and retention”, with focused solutions to
specific problems.

HR
to take centre stage

It
also describes three main components of the broader strategic framework. Firstly,
HR needs to take centre stage, supported by high quality, professionally
trained HR managers knowledgeable about the ethos of mental health services and
familiar with professional relationships and skills.

This
recommendation may need to be supported by giving HR managers a formal
introduction to healthcare systems, perhaps through a new module in HR
training.

Secondly,
quality leadership and management of mental health services must be promoted,
which means addressing in parallel the tricky question of who should take such
a lead.

New
cross-disciplinary working practices do not make resolving this question
easier. Again, training will be fundamental to ensure that leaders are
attracted, retained and nurtured, and indeed that they can in turn identify and
nurture staff who can be led.

The
third part of the framework focuses on providing better support for mental
health staff and promoting their mental and physical well-being.

Many
of the areas that this would address overlap with those covered by strengthening
leadership and the HR function, but it needs to be actively kept at the top of
the agenda.

The
SCMH is not alone in calling attention to the crisis in the mental health
workforce and others are addressing the issue in interesting ways. The first
National Conference of Survivor Workers took place last month, sponsored by
Manchester Health Authority and the regional NHS Executive.

This
event looked broadly at the employment rights and well-being of people who have
used or “survived” mental health services, and highlighted the particular, and
peculiar, intolerance of health and social service employers to those with a
mental illness history.

Conference
coordinator Rose Snow explained, “Mental health services are ignoring or even
discriminating against a valuable workforce that’s on their doorstep.

“Service
users should not be given tokenist jobs as hospital janitors, but encouraged to
actively contribute their skills and experience within all levels of the mental
health and social care professions.”

Such
calls mirror stated government policy, where “ the patient is king” and as
Lionel Joyce, a former NHS trust chief executive who hid his mental illness for
many years while his career flourished, wrote recently, “The NHS wants to give
the customer what the customer wants. It wants to value the customer without
actually valuing the customer’s experience as a useful attribute in the
workforce.”

And
the figures highlight the importance of listening to him. As many as 50 per
cent of women of working age will suffer from depression. As the NHS workforce
is 70 per cent female, 35 per cent of the entire workforce will be affected.

Add
to this the quarter of working males who will suffer from depression, and a
total of 42.5 per cent of the workforce may have depression at some time, not
to mention other mental illness, experiences of which they might be encouraged
to bring constructively to their work.

While
acknowledging that discrimination against those with mental health problems in
the workplace may reflect a genuine concern for their well-being and a desire
to spare them stressful jobs (although arguably coloured by fears of disrupted
working patterns and reduced productivity), Joyce says, “If we worked on the
basis that most staff are likely to have an illness or disability during their
working career… the NHS would say to its staff, ‘When you become ill, we will
build in support and then use your experience as part of your personal profile
to help us improve our services’.

“It
would be a chance for the service to learn about its strengths and weaknesses
from personnel who now know both sides.”

Not
all staffing stories in the National Health Service are tales of woe. See
Success story against the odds – the university of ES3 at our website www.personneltoday.com/features

Contacts

Dr
Sophie Petit-Zeman is a consultant in public understanding of medicine and
science and former Biomedical Research Manager at the Mental Health Foundation.

Sainsbury
Centre for Mental Health
 www.sainsburycentre.org.uk
Finding & Keeping: Review of recruitment and retention in the mental health
workforce.  £15+£1.50 p&p; 020-7403
8790

Making
changes in the mental health workforce

Employers
need to:


Have efficient management information systems to monitor vacancies, turnover,
absence rates, use of agency staff, reasons for staff leaving and recruitment
effectiveness


Develop local strategies and action plans if they have significant recruitment
and retention problems


Optimise use of the mature workforce (aged 50 to 70 years)


Have sufficient numbers of professionally qualified HR staff


Promote continuing professional development for all staff


Enable management and leadership development where appropriate


Actively manage workloads to maximise patient contact


Appoint a leader responsible for simplification and integration of procedures
such as care planning and record-keeping


Develop and annually review and evaluate a workforce mental health promotion
strategy

The
Department of Health needs to:


Harvest the information collected by employers in (1) above to inform national
planning and policy development


Implement its policies on workforce planning set out in A Health Service of all
the Talents (see main text)


Review current pension arrangements to assess their impact on recruitment and
retention, especially in relation to mature staff

Adapted
from Finding & Keeping, Sainsbury Centre for Mental Health, 2000

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