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National Mental Health Services Assessment: Final Report
6. WORKFORCE
6.1 The progressive move of services from hospital to community based settings has led to changes in the hospital inpatient population, the settings in which care takes place and the range of staff involved. People stay in hospital for a much shorter time and many people who used to be treated in hospital are now actively supported in the community. Those needing to be admitted to hospital therefore tend to have more complicated problems (50% have co-morbid substance misuse or alcohol problems) so that staff skills need to be developed. There is considerable overlap between the roles performed by professional groups within the range of care settings and in the skills the staff are expected to have.
6.2 The advent of the community-based
Compulsory Treatment Order under the Act will require additional skills and competencies, always underpinned by a therapeutic relationship based on ethical principles, including respect for the user's autonomy and respect for carers.
6.3 A service user should have access to:
skilled psychological interventions (from different staff groups, not just psychology)
social support, (including housing, opportunities for social activities and training or education)
medication when indicated
attention to alcohol problems and/or substance misuse
help to minimise the impact of personality related problems
support for recovery (including occupational opportunities)
evidence-based interventions to alleviate the effects of previous trauma
attention to their developmental needs (especially for young people and people with a learning disability)
6.4 In this complex system of care, the key to
who does what, when, why, who else needs to know and what was the outcome issues are best addressed within the developing integrated care pathways and managed clinical/care networks.
6.5 Workforce considerations are not only about numbers and training, but also about a service redesign approach with examination of service structure and practice and the increasing development of the voluntary sector. Redesign implies joint local determination of how best the available workforce resource can be used to the greatest advantage of both the user of services and the carer. Inter-professional relationships in front-line teams have sometimes been governed by the need to avoid overt conflict and by confusion about applying shared and specialist skills across different professions and agencies. There are still difficulties over, and imperfect understanding of, how to set up, focus, manage and evolve multi-disciplinary teams, let alone multi-agency variants. There is a need to foster flexible working practices to better meet the needs of service users whose problems do not fit neatly into the categories envisioned by professions a decade or more ago.
6.6 An urgent task is to identify core competencies for staff (building on the Department of Health's UK initiative).
94 This will help to clarify what is needed for joint training and what for specialist training, which would address some of these issues.
6.7 A related and relevant factor, raised several times during the Review Team visits, is the difficult issue of differential rates of pay for very similar work. Even within the same profession there are differentials: some Mental Health Officers get additional payments, some do not. The introduction of the new consultant and GP contracts, new training patterns for junior medical staff, and the impact of the Agenda for Change for non-medical professions are major drivers for discussion about service redesign. The European Working Time Directive, age structure in professions and demography provide other pressures.
6.8 The most obvious constraint on the further development of mental health services in Scotland is the shortage of appropriately trained and qualified staff, affecting health, social work and voluntary organisations. Even if large additional sums of money were made available recruitment would not be possible. The workforce for mental health services should be sought from a wider pool, with better retention and more purposeful training. Clarity is required about the approach to be adopted with regard to maximising the benefit for the patient from joint working with voluntary organisations, many of whose staff are well qualified and highly skilled. Without consistent better overall management of services, any impact of a larger and more skilled workforce may be lost.
6.9 With the current workforce shortage, services away from large urban centres are beginning to suffer a drain of staff to centralised locations which are more accessible and may be better resourced. Joint policies sensitive to local needs will be needed to counter this.
Staff groups for attention
6.10 The range of contacts and professional involvement will include, among others:
Consultant psychiatrists
Clinical (and other) psychologists
Registered mental health nurses
Allied health professionals, including dieticians, speech and language therapists, occupational therapists and physiotherapists
General Practitioners and other primary care workers
Social workers
Mental health officers
Pharmacists
Next steps
6.11 The forward development of the workforce supply issue requires action on at least two fronts:
The
longer term issue of shifting the trend towards training focused on explicit defined professional competencies and the dissolution of artificial (sometimes professionally driven) service boundaries; thus emphasising skills held in common, instead of increasing differentiation.
The
short term issue of making better use of the available workforce through service redesign to address staff shortages/recruitment/ training/retraining and working better with those who can be recruited.
Consultant psychiatrists
6.12 There are about 400 consultant psychiatrists in Scotland with around 8% of posts vacant.
93There is a UK wide shortage of consultant psychiatrists in general psychiatry and most specialties.
94 Given the numbers currently in training, and the age profile of existing consultants in Scotland the position is likely to deteriorate further. Given the length of training required, there is not going to be any early change for the better.
6.13 The 2003 Act makes provision for and gives powers and duties to 'approved medical practitioners' (AMPs) in relation to compulsory measures. AMPs are similar to 'section 20 doctors' under the 1984 Act. NHS boards, including The State Hospital, must maintain a list of medical practitioners who have the necessary qualifications and experience and have undertaken appropriate training. This is not limited to psychiatrists and it is hoped that more GPs will take on this responsibility, although there was little expression of interest shown during the Review visits.
6.14 The workforce implications of the contributions to be made by psychiatrists to the panels for Tribunals arising from the Mental Health (Care and Treatment) (Scotland) Act 2003, plus the need to appear before them, has been looked at by the Royal College of Psychiatrists and although it is hard to predict, between 18.2 and 28.5 whole time equivalents
95 were estimated as being necessary on top of the numbers of current vacancies. Much will depend on what the Tribunal procedures demand of clinicians, and the opportunity costs in terms of time and the diversion of effort. In addition, these calculations fail to take account of the impact of the European Working Time Directive which will be in force for consultants by the time the Act is implemented. Subsequent consideration by the Royal College of Psychiatrists suggests 30 whole time equivalents might be a better estimate of need.
6.15 At the time of writing, it is not clear what will be the impact of the new consultant contract. It gives an opportunity for the detailed re-evaluation of the tasks that can
only be undertaken by a consultant, and those that can be performed by other staff, which is implicit in the concept of service redesign.
6.16 The Royal College of Psychiatrists is looking at training, recruitment and retention issues.
Clinical psychologists
6.17 Training is now the responsibility of NHS Education for Scotland (NES). Work is in hand to:
increase the number of clinical psychologists (currently around 360 WTE (2002)
96
increase the numbers in training within the two existing schools
incorporate the existing group of assistant psychologists into an additional modular based training, leading to the DPhil over 5 years
initiate a year-long training leading to a diploma for graduate psychologists to enable them to work in the primary care environment
improve the training of other professionals by making places available to take modules on the 5 year course
consider how to retain the >25% of the workforce who will be eligible to retire in the next decade, and improve the working conditions of 1/3rd of the workforce who are part-time
move to a competency based training model
approach all Primary Care NHS Trust (PCT) Chief Executives to engage them in partnership with NES in taking this forward
6.18 There are increasing numbers of counselling and health psychologists, who also make valuable contributions to care.
Nursing
6.19 The net of pre-registration nursing recruitment is now cast much wider than the traditional school leaver group to incorporate mature students and alternative routes into the programme. Service redesign teams need to bear these in mind.
6.20 All entrants to pre-registration programmes must have the Nursing and Midwifery Council (NMC) minimum educational requirements, the equivalent of 5 points. This can be achieved in a variety of ways apart from the normal school educational attainment;
achievement of Scottish Vocational Qualification (SVQ) in Care at Level 3
specific pre-nursing Access programmes are provided by Further Education Colleges
Higher National Certificate (HNC) (non-NES endorsed pathway)
achievement of HNC Health Care (NES endorsed pathway)
6.21 In addition, National Education Scotland (NES) has commenced a mapping project to allow Accreditation of Prior Learning (APL) for appropriate SVQs against the new HNC Health Care (NES endorsed pathway) which will allow students to enter part way through the 1
st year of the pre-registration programme.
6.22 Pre-registration nurse education leading to registration in mental health nursing is provided from 7 universities across Scotland. Overall the Scottish Executive Health Department (SEHD) contracts for approximately 400-500 mental health students each year. Recruitment to mental health nursing programmes is slightly problematic with difficulty recruiting the required numbers. The Student Nurse Intake Planning (SNIP) process has recommended increased numbers of mental health students for the last 6 years (1997/98), but there has been an under-recruitment of approximately 10%.
6.23 There are 1200 to 1500 students undertaking pre-registration nurse training leading to first level registration in mental health nursing in any given year.
6.24 Child and Adolescent Mental Health Services - Napier University has also developed two Level 3 modules by flexible learning, which are proving very popular with a multidisciplinary audience. The uptake is Scotland-wide, and includes inpatient, outpatient and day care nurses, social work staff, independent sector providers, health visitors, school nurses, primary care workers, and allied health professionals. NHS Education for Scotland also has a multidisciplinary group developing CAMHS competencies, which will be set at 3 different levels and will lead to the development of suitable courses to meet the aforementioned levels of staff.
6.25 A commitment to improve the current position on recruitment and retention of nurses is being taken forward under the umbrella of
Facing the Future which is a national group chaired by the Minister for Health and Community Care. A particular focus has been in the areas of return to practice and the one year guarantee that ensures all newly qualified nurses gain employment in NHSScotland if they wish.
Allied health professions
6.26 The 5 allied health professions (AHPs) most associated with mental health services are art therapy, dietetics, occupational therapy, physiotherapy and speech and language therapy. In March 2003 there were 6043 AHPs (including support workers) employed in NHSScotland
97. Many AHPs have assistants supporting their work. Some of the professions are identified nationally and UK wide as shortage professions.
6.27 All AHPs are educated to degree level leading to state registration. Some of the professions offer post-graduate diplomas and MSc entry courses. Training standards and development are organised on a UK wide basis. Psychotherapeutic post-graduate qualifications (for example cognitive behaviour therapy, counselling, person centred therapy etc) are recognised by some of the therapy professions and required for some areas of specialist practice.
6.28 The Health Professions Council (HPC) is the regulatory body for all the allied health professions and registration gives the right to practice.
6.29 It is not clear what shortages there are within the current AHP workforce. There are several initiatives underway in Scotland to address recruitment and retention issues and the national workforce survey will provide some baseline information to inform future planning.
6.30 Occupational therapists will be members of mental health teams alongside other professionals such as speech and language therapists, physiotherapists and dieticians. All will have significant roles mainly with younger people, adults with learning disabilities and older people but the profile of each mental health team will vary between local health care systems according to the client group.
Primary care
6.31 The exact numbers of different professionals required to deliver mental health services in primary care settings is not known. However, mental health is a priority for primary care in several areas and insights on national needs may arise from local redesign of mental health services in primary care.
6.32 Opportunities for further development include:
GP education, including their role in operating provisions in the Act
education/training of other staff working in the community such as public health practitioners, community/practice nurses, midwives, staff in care homes and staff from voluntary groups/helplines, etc
availability of information about the care/referral routes
links to NHS out-of-hours services
Social workers
6.33 There are at present (2003) approximately 450 social work students in Scotland. The current professional qualification is the Diploma in Social Work (DipSW) but from 2004 the DipSW will be replaced by an honours degree qualification
98.
6.34 The Standards in Social Work Education (SISWE) set out what student social workers must achieve to gain the honours degree and to become professionally qualified. SISWE reflect the importance of core transferable knowledge and skills and integrated service delivery.
6.35 A pilot scheme is being developed to fast-track graduates through the DipSW course in 15-18 months rather than the usual 22-24 months.
6.36 The Scottish Social Services Council came into operation in October 2001. It has the duty of promoting high standards of conduct and practice among social services workers, and in their education and training. It will establish registers of key groups of social services staff and regulate the training and education of the workforce. In doing so it will determine the criteria for accreditation and re-accreditation and continuous professional development.
6.37 At present there are approximately 4,918 social workers and senior social workers (WTE as at December 2003
99) employed by local authorities in Scotland. Many are employed in the independent sector as well. The total social services workforce is thought to include around 100,000 staff.
Mental health officers
6.38 Mental Health Officers are professionally qualified social workers who have had two years post-qualification experience, are employed by local authorities, have successfully completed additional training established by the Scottish Social Services Council and who subsequently have been appointed by the Director of Social Work/Chief Social Work Officer to carry out specific duties under the Mental Health (Scotland) Act 1984 and Adults with Incapacity (Scotland) Act 2000. The requirements for training, approval and appointment are set out in Directions by Scottish Ministers. At present there are approximately 700 social workers who have been appointed to act as MHOs. Not all are using this qualification in practice because career progression usually means a person moves into a managerial role without direct client contact. This is discussed in more detail in the interim and locality reports.
6.39 Recruitment and retention of social workers and MHOs in particular is an acknowledged problem that is beginning to be addressed on a national level.
6.40 The Act places additional responsibilities on local authorities and the mental health officer service. The equivalent of an additional 50 or so full time MHOs will be required to meet these new responsibilities and 2.5m has been allocated in the local authority revenue settlement to increase the MHO establishment in 2004-05 and subsequent years
73.
6.41 The Scottish Executive commissioned research from the Scottish Development Centre on the capacity of the mental health officer service to meet existing and future statutory demand
100. This research examined service structures, supports and service models in place throughout Scotland and it is intended that the report will help local authorities in examining and redesigning existing MHO service structures. The development of National Service Standards for Mental Health Officer Services will also help to drive forward the development of MHO service structures to provide a more efficient and responsive service.
Pharmacists
6.42 Overall in pharmacy in Scotland there is thought to be around a 14% vacancy rate of hospital based pharmacists; the exact number of clinical pharmacists working within mental health as an area of special expertise is not known. Registration as a pharmacist takes five years, with a Masters degree in pharmacy followed by one year's practical training in community or hospital pharmacy.
6.43 Effective management of medication and its side-effects is a key factor in the treatment and long term success of the rehabilitation of people with a mental illness who require drug treatment. Side-effects such as weight gain or impotence can cause serious concerns and the pharmacist's knowledge and input can help doctors decide whether alternative drugs or approaches might be as effective, but with fewer side-effects.
6.44 The Review Team is aware that many hospital admissions are caused by preventable medicine-related problems. Patients, especially older people and those with chronic conditions, often receive treatment with 4 or more medicines (polypharmacy). These patients are more likely to develop side effects.
6.45 A lack of a systematic approach to the pharmaceutical care may lead to distress for the patients and their families, unnecessary hospital admissions and unnecessary cost. Clinical pharmacists can make a significant contribution to the management of psychiatric and other medicines and can help promote user compliance.
6.46 Some pharmacists are community based and integrated with their local community mental health team and outreach service, including the social and voluntary sectors. They provide information and advice to patients in drop-in centres and day-care centres, and can offer training on medication issues.
The English experience
6.47 Skills for Health was formed in April 2002 with the support of the four UK health departments, independent health sector, voluntary sector and staff organisations to create a new organisation to develop the skills of the workforce of the whole health sector through the competency framework for the services for various care groups, called the National Occupational Standards for UK. The
National Occupational Standards for Mental Health were published in June 2003
101. These Standards do not immediately assist in resolving the workforce problem but can be used as a tool for job descriptions and promote the use of a common language to describe competencies for the planning, delivery and evaluation of services. Department of Health (England) has since published their
Mental Health Services - Workforce Design and Development - Best Practice Guidance.
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