Nursing continues to be the most significant area of workforce shortage in the NHS. It is important to stress that, over the past 10 years, only adult nursing and children's nursing have seen modest increases in full-time equivalent numbers, while numbers in mental health and learning disability nursing are all lower than they were in June 2010.
Although the ongoing pandemic is exposing gaps in the overall NHS workforce, two reports, one from the Health Foundation (Buchan et al, 2020) and another from the Nuffield Trust (Palmer et al, 2020), warn of future difficulties in ensuring that there are sufficient numbers of mental health and learning disability nurses. Furthermore, the Health Foundation has revealed that in every English region there is a higher than average proportion of mental health nursing posts left unfilled.
Background
According to the Royal College of Nursing (RCN), the learning disability nurse workforce has plummeted by over 40% over the past decade (Launder, 2019). The data show that the number of learning disability nurses working for the NHS in England dropped from over 5500 in September 2009 to 3244 in February 2019 (Launder, 2019).
Similarly, in a survey conducted in England by the British Medical Association (BMA), the RCN and the Association of Clinical Psychologists (Hackett, 2020), 65% of the 390 mental health nurses polled reported a shortage of one or more nurses. These are not the only organisations that have raised concerns about nursing shortages within these smaller fields of practice. The independent charity, the Health Foundation, which has the objective of improving health care for the UK population, has suggested that staffing numbers in mental health and learning disability nursing especially are all lower than in June 2010.
Last year, the Health Foundation established the Research and Economic Analysis for the Long term Centre (REAL Centre) to share new evidence and data analysis, with the objective of assisting health and social care policymakers in considering the long-term implications of funding, design and delivery decisions. The REAL Centre's report (Buchan et al, 2020) reiterates concerns about nursing shortfalls in specific areas, which may lead to problems for the nation as it recovers from the impact of the COVID-19 pandemic. For many individuals with learning disability or mental health illness the ongoing pandemic has affected their quality of life and exacerbated symptoms.
The report from the Nuffield Trust (Palmer et al, 2020) specifically explores how the NHS can attract more people from a broad range of backgrounds to study mental health nursing and it makes a number of recommendations to improve recruitment and training for the mental health nursing workforce.
What has gone wrong?
In 2017, the Government lifted the cap on the number of nursing students entering university and replaced the fixed number of nursing bursaries with student loans, with the aim of attracting more nursing students into the university sector. However, this decision had unintended consequences and inadvertently resulted in dramatic falls in the number of people choosing to study mental health or learning disability nursing.
This was attributable in part to the demographics of potential students, namely that they tend to be older than those entering the adult and child fields of practice. Mature students, many of whom are retraining after careers elsewhere, are more risk averse than their younger counterparts and less willing to go into debt. A perfect storm, combining lower student numbers preparing to enter the professions with growing numbers of employees approaching retirement, is fuelling a workforce crisis in these fields of nursing (Browne et al, 2013).
A significant factor in the retirement element of this crisis is linked to employees who have mental health officer (MHO) status. Before 1995, any nurse working in the fields of mental health or learning disability had designated MHO status and could retire on full pension aged 55 years. The MHO status was a historical provision introduced to compensate staff members for the stresses of caring for patients with mental health illness or learning disability, but it was abolished in 1995. However, it still applies to a nurse who commenced training in either mental health or learning disability in 1994, who can still legally retire in 2024, with enhanced pension benefits to compensate for a shorter working span (BMA, 2020).
As a consequence of these interrelated factors, mental health and learning disability services in every health region have a higher than average proportion of unfilled nurse posts. Before Brexit, many health services were able to recruit registered nurses from abroad, but the Health Foundation report shows that international recruits account for only 7% of nurses in mental health trusts compared with 20% in acute NHS trusts. This is because, unlike the UK, which has historically developed a nursing register with several fields of practice, few other countries have specialised in mental health nurse education, making direct recruitment difficult. In context, although 88 UK universities offer nursing degrees, only 25 offer learning disability nursing courses.
Nearly 10 years ago, Gates (2011) warned that the learning disability workforce, and the specialty's education, career and leadership, needed to be urgently addressed. He argued that, unless efficient use was made of their knowledge and skills, it would be difficult to prevent a compromised workforce. Across the whole of the NHS nursing workforce, skill mix, ie the ratio between registered and non-registered nursing staff, is becoming diluted with the number of nursing support staff increasing at over twice the rate of growth in the number of registered nurses in the year to June 2020.
With the number of mental health nurses dropping by 8% over the past 10 years, coupled with the problems within learning disability nursing, the whole of the mental health workforce is in jeopardy. However, the Health Foundation report (Buchan et al, 2020) points out that, over the past year, there have been some increases in nursing numbers across all clinical areas, with numbers of those working in adult hospital nursing growing by 5.5%.
Nonetheless, the number working in learning disability nursing has grown by just 2% and in mental health by 3.8%. The current shortfall in these areas is now a major long-term and fundamental problem for the NHS as a whole. The short- and long-term effects of the pandemic on the mental health of individuals with existing conditions has brought the urgent need to deal with this workforce crisis into sharp focus. Furthermore the Health Foundation report (Buchan et al, 2020) shows that the impact of the pandemic is likely to increase demand for mental health services by at least 11% a year and lead to an additional 1.8 million referrals over the next 3 years.
Addressing workforce problems
The Health Foundation report (Buchan et al, 2020) is clear that achieving government targets for nursing staff, but especially in the learning disability and mental health fields, will need sustained investment and new initiatives to improve the retention of the current workforce. Effective post-Brexit measures to fast-track international recruitment to these fields will be necessary. As a caveat, the Health Foundation report (Buchan et al, 2020) argues that the overall government target of an extra 50 000 nursing positions by 2024–2025 will be insufficient to meet increased demand and enable the NHS to recover from the pandemic.
The Nuffield Trust report (Palmer et al, 2020) specifically looked at how the NHS can attract more people from a broad range of backgrounds to study mental health nursing, making the following recommendations:
The report also emphasises that the level and purpose of cost of living grants for these groups of potential students should be addressed as a matter of urgency and stresses the need to ensure there is a full range of routes into mental health nursing.
Conclusion
Despite these issues, both mental health and learning disability nursing offer the opportunity for a rewarding career. New and innovative routes into these fields of nursing practice are already being introduced, with new NHS trust-funded apprenticeship schemes and nursing-associate courses being available to existing healthcare support workers. The numbers of registered nursing associates increased from 1693 to 2707 between April and September 2020 (Nursing and Midwifery Council, 2020), with the number of new trainee nursing associate apprentices increasing to more 5346 in May 2020, up from 3651 in November 2018 (Nuffield Trust, 2020). In addition, NHS England is currently working on new plans to address some of the issues surrounding the supply of mental health and learning disability nurses.