PAC: Concerning pressures on NHS mental health staff causing vicious cycle of staff shortages

- Staff shortages holding back mental health services from improving and expanding

- Lack of definition on how to treat mental health services with equal priority as physical services – 12 years after goal was announced

The Public Accounts Committee has heard concerning evidence of increasing pressures on NHS mental health staff at a time of spiking demand. In a report published today, it warns that increased workload is leading to burnout for remaining staff, which contributes to a higher rate of staff turnover and a resulting vicious cycle of more staff shortages.

17,000 staff (12%) left the NHS mental health workforce in 2021-22, up from pre-pandemic levels of around 14,000 a year. Those citing work-life balance reasons for leaving increased from 4% in 2012-13 to 14% in 2021-22, and the percentage of days lost from the workforce due to psychiatric reasons doubled in a decade. NHS England told the PAC that, in common with all NHS staff, mental health problems are one of the biggest drivers of sickness among staff.

Staff shortages are holding back NHS mental health services as a whole from improving and expanding. The PAC calls on the NHS to address the fact that staff increases are being outpaced by the rise in demand for services. The NHS mental health workforce increased by 22% overall between 2016-17 and 2021-22, while referrals to these services increased by 44% over the same period. The PAC’s inquiry found that staff vacancy rates in acute inpatient mental health services are at approximately 20% or more.

Good data and information is necessary to manage and improve NHS services, as well as to deliver them impactfully and cost-effectively. The Government and NHS England (NHSE) acknowledged to the PAC that mental health services are lagging behind physical services in this area to a particularly concerning degree. Of 29 integrated care boards surveyed by the National Audit Office, only four said they had all or most of the data they needed to assess patient and user experiences, and none of them felt this in relation to patient outcomes.

Another area of particular concern for the PAC is a continuing lack of progress in the area of treating mental health services with equal priority as physical services – or ‘parity of esteem’. Despite the Government setting this ambition in 2011, and the PAC itself calling four years ago for a clear definition of how to measure progress to get there – a recommendation accepted at the time by the Government – there is still no such clear definition.

Dame Meg Hillier MP, Chair of the Committee, said: “The findings of our inquiry must serve as a warning to the Government that mental health is still in danger of not being treated with the same urgent priority as physical health. NHS mental health staff deal with some of the most challenging care needs there are. Staff in this space deserve not just our heartfelt gratitude for the job they do, but concrete support and training to work as part of well-staffed workplaces. Our report warns of a vicious cycle, in which staff shortages and morale both worsen in self-reinforcing parallel.

“The short-term actions being taken by the Government and NHS England to tackle ongoing pressure are welcome. But these numbers are still going in the wrong direction, as demand for care well outpaces the supply of staff to provide it. The Government must act to pull services out of this doom loop. Invaluable care for some of our most vulnerable cannot and must not be provided at the expense of the welfare of the workforce carrying it out.”

PAC report conclusions and recommendations 

Workforce shortages are constraining the improvement and expansion of NHS mental health services. Over the period 2016-17 to 2021-22, the NHS mental health workforce increased by 22% overall, although the increase varied greatly for different staff groups - higher for therapists and lower for doctors and nurses. Over the same period, referrals to the services increased by 44%, meaning that the increase in staff was outpaced by the rise in demand for services. The number of people with mental health needs is also increasing, for example, the proportion of 17–19-year-olds with a probable mental disorder more than doubled from 10% in 2017 to 26% in 2022. The Department and NHSE acknowledge that staff shortages remain the main constraint to improving and expanding services. We are also concerned about increasing pressures on staff, as evidenced by the rising number of staff sick days due to poor mental health and number of staff leaving. NHSE is taking short-term measures to try and help increase staff numbers, for example, through the introduction of new roles. For the longer term, NHSE emphasises the importance of continued funding for education and training pipelines as the current arrangements end by 2023-24. Given the immense challenges facing the workforce, we have been particularly concerned by the absence of the NHS’s long term workforce plan, which was eventually published on 30 June 2023. The plan predicts that demand for mental health services will grow faster than for other NHS services and confirms the particular challenge of expanding the mental health workforce.

Recommendation 1: In six months’ time, NHS England should write to the Committee setting out what targeted interventions are envisaged for the mental health sector under the plan to ensure it can get the doctors, nurses, therapists and other clinical and non-clinical staff that the service needs, and who will be responsible for delivering them.

Data and information for NHS mental health services still lags behind that for physical services. Service commissioners and providers need good data and information to manage and improve services, and this is also important to understand the impact and cost-effectiveness of services. Data on NHS mental health services have improved since 2015, and the NHS now regularly publishes data on service activity, spending and waiting times performance. But improvements to mental health data and information are taking longer than planned, with many service providers still not submitting data as required. The Department and NHSE acknowledge that data for mental health services still lag behind that for physical health. We are particularly concerned by the lack of data on patient outcomes and experiences, and poor data sharing, for example, between GPs and mental health trusts. Of 29 integrated care boards surveyed by the NAO, only four said they had all or most of the data they needed to assess patient and user experiences, and none of them felt this in relation to patient outcomes. When asked about the relative value for money and returns on investment, the Department and NHSE could not explain to us the cost effectiveness of their chosen interventions for mental health services.

Recommendation 2: In six months’ time the Department and NHS England should write to the Committee, setting out how they will:

• improve the quality and completeness of the data on mental health services, including cost of services and patient outcomes;
• ensure these data are shared appropriately to support integrated care systems to improve services locally, including tackling inequalities; and
• improve the evidence base on the cost-effectiveness of their investments, for example, on the roll out of mental health support teams in schools.

New integrated care boards and partnerships could struggle to prioritise mental health services and support, in the face of funding pressures and the need to reduce backlogs for physical health services. ICBs will be responsible for bringing forward many of the ambitious programmes for mental health services in their area, for example, ensuring data sharing across local NHS, local government and voluntary sector organisations, and workforce planning and deployment. Many of the challenges that ICBs have to address involve longstanding and unresolved issues and as the Department itself notes, “the proof will be in the pudding”. But we remain unconvinced that many of the ICBs, at this stage of their development, have the maturity, resources or capacity required to meet the high expectations placed on them for mental health services. This is particularly the case as ICBs tackle reducing backlogs for physical health services while under funding pressures. We are also concerned about the ability of NHSE, during a period of significant reorganisation, including a 30-40% planned reduction of central staffing, to support ICBs, hold them to account for performance, and challenge inconsistencies in local practices such as the patchy implementation of clinical guidance across local areas for people with eating disorders.

Recommendation 3: NHS England and the Department should evaluate how well the new integrated care boards and partnerships are supporting mental health services and how well their own support arrangements work to address variation between, and poorer performance in, local areas.

There is still no clear definition of the end goal of ‘parity of esteem’ 12 years after the government first set out its ambitions. From 2011, the government set out long-term ambitions to improve support and services for people with mental health problems and achieve ‘parity of esteem’ between mental health and physical health services. While the number of people accessing NHS funded mental services substantially increased from 3.6 million in 2016-17 to 4.5 million in 2021-22, as reported by the NAO, this still only equates to around one third of people with mental health needs, with an estimated eight million not accessing services. NHSE acknowledges that sizable treatment gaps will persist under the current planned rates of service expansion set for 2023-24. In our January 2019 report on mental health services for children and young people, we recommended that the Department should define clearly the criteria it would use to measure progress towards ‘parity of esteem’ – a recommendation accepted by government - and so are particularly concerned that there is still no detailed definition. Many stakeholders told us that a clear definition, objectives and roadmap are important to understand progress towards this end goal. NHSE would also welcome a definition, but the Department’s current position is not to specify one.

Recommendation 4: In its update to us in six months, the Department should also set out what achieving full ‘parity of esteem’ between mental and physical health services means in practice, for example, comprehensive access and waiting times standards and outcomes, timescales, funding and workforce requirements.

The Department and NHS England have still not committed to rolling out waiting times standards to all mental health services. From 2015, NHSE introduced specific waiting times standards for three service areas – talking therapy services, early intervention in psychosis services and eating disorder services for children and young people. Unlike the standards for physical health services, the current standards for mental health only apply to a limited number of service areas; they do not cover the bulk of core community and inpatient mental health services. In 2022, NHSE consulted on new waiting times standards for mental health services in the community and A&E, but it has not confirmed whether and when these will be implemented. NHSE says it has been improving data collection in preparation for the new standards over the last few years, but that is yet to agree with the Government on “trajectories for working towards meeting those standards”. Stakeholders we spoke to argued that the introduction of new standards would also provide the much needed impetus for providers to improve data, and so poor data was not a reason to delay standards being introduced.

Recommendation 5: In its update to us in six months, the Department and NHS England should set out their plan for implementing the new service standards.

Preventive and public health services for mental health have not had the same priority and focus on improvement as NHS mental health treatment services. Previous government strategies have emphasised the importance of preventive services for mental health and wellbeing, alongside treatment for mental illness. However, we, and many stakeholders, are concerned that preventive services have not been given the same priority and focus as NHS treatment services. From 2018-19 to 2022-23, the local authority public health grant had a real-terms reduction of 6%. The new ICSs will be a key mechanism for taking forward public health improvements and, while the Department and NHSE argue that “a fair amount of progress” has been made in promoting mental health over the last 10 to 15 years, they acknowledge that not all areas are fully mature in terms of preventive infrastructure. Given the range of social and economic factors that affect mental health, an effective preventive programme will require action from across government. In April 2022, government consulted on plans for a new 10-year cross-government strategy on mental health and wellbeing. However, many stakeholders have expressed their disappointment about the replacement of this by a planned five-year major conditions strategy from the Department, with mental health one of six conditions covered.

Recommendation 6: The Major Conditions Strategy must clearly set out how preventive and public health services for mental health will be improved and expanded, including how the right workforce will be secured