Monitoring the Mental Health Act in 2021 to 2022

Published: 1 December 2022 Page last updated: 22 March 2024


Staff shortages and the impact on patients

In last year’s Mental Health Act annual report we noted the impact of the COVID-19 pandemic on staff wellbeing and the knock-on effect this was having on staffing vacancies in the sector. As highlighted in our 2021/22 State of Care report, issues around workforce and staffing shortages remain the greatest challenge for the mental health sector.

During 2021/22, we have seen mental health services continuing to struggle with staffing levels. Staff sickness, including COVID-19 related sickness and self-isolation, have exacerbated difficulties posed by pre-existing staffing shortages.

Impact on patient care

Not having the right levels and skill mix of staff can affect services’ ability to provide safe and effective care and treatment that is in line with the guiding principles of the MHA Code of Practice.

Through our monitoring visits, both staff and patients have told us that a lack of staff means people are not receiving the level and quality of care they have a right to expect. In one service, staff told us they did not have enough staff and recognised that the care they provided could be better if they had time to develop relationships with patients.

The importance of therapeutic relationships was reflected in feedback from patients who told us they preferred the staff they knew and had developed relationships with. However, we heard that patients were not always able to build these relationships because of the high use of agency staff. In some services, such as eating disorder wards, patients told us that agency staff seemed unfamiliar with their ward type, and as a result could appear unprofessional or unfeeling when working with them.

In our feedback to the Health and Social Care Committee on workforce in July 2022, we emphasised that reliance on agency staff who do not have an ongoing therapeutic relationship with patients can increase the risk of services using excessive levels of restraint and seclusion. As we set out in our closed culture guidance, the use of restrictive practices including restraint and seclusion are both inherent risk factors and can be warning signs that closed cultures are developing.

This year, we have continued to hear about the impact of staffing shortages on patients’ access to therapeutic activities. This includes staff not having enough time to provide ward-based activities or one-to-one nursing, and patients’ leave being cancelled. Feedback from our MHA reviewers suggests that in some cases a lack of activities was also due to wards not putting these back in place following the COVID-19 pandemic. This lack of meaningful activities can affect patients’ recovery.

The availability of occupational therapists could affect what, if any, therapeutic activities were provided. In some services, occupational therapists or activity co-ordinators were only available during the weekday. This meant that on evenings and weekends it fell to nursing staff to provide these activities on top of their usual nursing tasks.

On some wards, we found that a lack of meaningful activities was in part due to vacancies in occupational therapy posts. On others, occupational therapy staff were being asked to help make up staffing numbers. While hospital managers in one service told us that this had helped in maintaining positive engagement with patients, having to cover nursing roles meant they were often not able to carry out their core role.

We have also seen the effect of staffing shortages on services’ ability to follow least restrictive practices. This includes, for example, people having limited access to garden areas, with some patients telling us they were regularly unable to get fresh air. A number of services told us that staffing numbers or skill mix could affect whether they are able to open garden doors. As we raise in our guidance on closed cultures, failing to allow people to have regular access to fresh air could be an indicator of people’s human rights being breached.

As highlighted in our last report, we continue to encourage services to challenge outdated, institutionalised and overly restrictive practices in favour of patient choice and a human-rights based approach. We have seen examples of services taking steps to make improvements, including reviewing blanket restrictions, exploring availability of ward activities, improving patient access to staff for support, and increasing staff training to support patients in distress.

Impact on patient safety

Through our monitoring activities we heard how staffing shortages, and the lack of therapeutic activities, could put people’s safety at risk. Patients told us that a lack of activities increased the risk of violence on the wards because people were bored. Staff shortages, and lack of appropriately trained staff, have also led to challenges around the ability of staff to respond to these incidents.

Pressures caused by understaffing are creating issues with observation checks. In some cases inexperienced staff are given tasks, such as constant observation, that may be inappropriate for their level of training and responsibility. In other cases, we heard that staff shortages had led to observation checks being missed because staff were too busy. In addition, we heard of patients being left isolated, leading to concerns for their safety.

In particular, staff shortages are having a negative effect on patients who need constant observation. Enhanced, continuous observation provides an opportunity for prolonged therapeutic engagement. However, it can be difficult and exhausting for both patients and staff. As a result, we were concerned to see staff carrying out constant observations of particular patients for long periods. On one ward, staff told us they could be observing the same patient for over 8 hours without breaks, which MHA reviewers felt could have an impact on the quality of care patients receive.

Understaffing makes it difficult for any member of staff to give their full attention to their tasks at any point in time. For example, at one mental health ward for children and young people, patients told us that they were waiting for staff support. We witnessed staff being pulled in multiple directions and having to continually reprioritise the tasks at hand. Consistent staff shortages can be an inherent risk factor in the development of closed cultures.

To address concerns related to understaffing, services told us about steps they were taking including, for example arranging training and support for staff, closer monitoring of staffing issues by managers, and more one-to-one protected time for patients and nurses. Other steps included employing additional activity co-ordinators and involving psychology staff in debriefs following incidents.

Staffing and staff welfare

A number of providers have told us about the actions they are taking to mitigate staffing resource issues. This includes employing ward managers, matrons and other professionals such as occupational therapists to substitute for nursing cover. In addition, we have heard of services moving substantive staff around hospital sites to provide cover, and staff working additional shifts. However, the juggling of staff cover across hospital sites can lead to periods of dangerous understaffing. For example, on one ward patients and staff told us how low staffing had led to staff working alone.

Hospital managers have told us about the challenges they face in managing staff shortages and skill mix. Agency nurses can earn substantially more than permanent NHS staff, and pay can be even higher for night shifts. This can affect the morale of permanent staff. For example, substantive staff in one unit told us that they felt that they had to work twice as hard for a much lower salary than agency staff, and that this potentially caused bad feeling.

It can also mean that it is difficult to ensure a mix of permanent and agency staff on night and day shifts. As a result, agency workers may not have the level of support and supervision they require. Many patients have told us that they dislike the fact that night-shift staff are largely unknown to them and that this makes them feel vulnerable. As stated in our guidance How CQC identifies and responds to closed cultures, we know that a high use of poorly inducted agency staff who do not know people’s needs can be a warning sign of a closed culture.

Some services are making additional efforts to ensure there are more permanent staff on night shifts so there is a better skill mix. Others have increased in-house training requirements as well as talking to staffing agencies about the training they provide.

We have also seen some services hiring staff from a limited pool of agency or bank staff to maintain continuity of staffing as much as possible. One provider told us that this has been made more difficult by changes to off-payroll working rules from April 2021 (IR35 legislation). This meant that block booked agency or bank staff were choosing not to continue to work at its hospital. Services are also looking at packages to offer staff for recruitment and retention, including recruiting from overseas.

Many services hold frequent safe staffing meetings to review staffing resources across units, to anticipate and request bank and agency cover in advance of need. Some services have a constant ‘dynamic’ staffing allocation, to expand and reduce teams to mirror the needs of patients on each ward.

Some services continue to maintain cohesive and stable teams. Good management and support of motivated staff is a key factor in this. The geographical location of units can be another factor. Some units have little staff turnover because staff are settled and happy where they live. Others are in areas that struggle to attract staff for reasons ranging from expensive costs of living in some local areas, to lack of amenities and housing stock in others. Services situated in commuting distance of other units offering London-weighted pay can also struggle to recruit. Units that report stable staffing appear most likely be valued by staff and patients.

However, many of the current measures to address staffing issues are not sustainable – the shortage of qualified mental health nurses is a systemic issue, which requires a system-wide response. These measures are also having a detrimental effect on staff wellbeing, with patients themselves telling us they were concerned about staff being overworked and exhausted.