Workforce

Connecting the dots: tackling mental health inequalities in Wales

This is the sixth chapter of the Health and Social Care Committee ‘Connecting the dots: tackling mental health inequalities in Wales’ report.

 

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On this page:

— Workforce

— Workforce planning

— Representativeness of the workforce

— Recruitment, retention and wellbeing

— Awareness and training

— Our view

— Report contents

 

 

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Workforce

Workforce planning

117. Specialist mental health staff are an important part of the picture, but addressing mental health inequalities requires viewing the workforce in its widest sense, including health services, social services, education, housing, public services, and the community and voluntary sectors. Participants in our workforce focus groups told us about the potential for other roles to support mental health services, including allied health professionals such as speech and language therapists and occupational therapists. They suggested that greater representation for allied health professions in leadership positions could inform the development of more effective pathways and services.[169]

118. Between February and March 2022, HEIW and Social Care Wales (“SCW”) consulted on a draft mental health workforce plan for health and social care. It highlighted recruitment challenges, high levels of vacancies and increasing workloads, and the need to grow the mental health workforce to keep pace with demand and address deficits in key professions in the specialist workforce.[170] The Royal College of Speech and Language Therapists described the workforce plan as “a real opportunity to remodel current provision and create sustainable services which ensure that all people in Wales can access appropriate mental health support”.[171]

119. The strategic mental health workforce plan for health and social care was published in November 2022.[172] Giving evidence to us in September 2022, before the plan’s publication, the Deputy Minister for MHW described it as a “very comprehensive and impressive document”. She said it identified work needed to tackle immediate pressures as well as longer-term planning for the future mental health workforce, including the different types of roles that may be needed and scope for greater involvement of the wider workforce including allied health professionals in the delivery of mental health services.[173] Tracey Breheny, the Welsh Government’s deputy director for mental health, substance misuse and vulnerable groups, explained that HEIW and SCW had graded elements of the plan according to “must do/could do” and identified associated costs.[174] The Deputy Minister for MHW said that she could not confirm that sufficient financial resources would be available to enable all elements of the plan to be implemented, as budget discussions within Welsh Government were ongoing.[175]

 

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Representativeness of the workforce

120. Many of those who contributed to our work have suggested that the mental health workforce, and the wider health workforce, are not sufficiently representative of the diverse communities they serve. Our advisory group suggested that one way to address this would be to provide training and support to neurodivergent people to help them enter the mental health workforce.

121. The Deputy Minister for MHW acknowledged that the workforce is not sufficiently representative. She told us that the HEIW and SCW workforce plan and training framework, together with the Welsh Government’s anti-racist action plan, would help make the mental health and health workforce more representative.[176] The strategic mental health workforce plan includes a commitment to improving data about the diversity of the mental health workforce, including information to be gathered via a broader survey of health and social care staff. It also states that the plan’s implementation will:

“…reflect strategic equality plans, taken forward with strong compassionate inclusive leadership ensuring a clear focus on engaging and addressing inequalities for people from differing socio-economic circumstances, including those who share the same protected characteristics and those who do not”.[177]

 

122. Similarly, the joint HEIW and SCW workforce strategy for health and social care published in October 2020 describes an ambition for a “workforce that is reflective of the population’s diversity, Welsh language and cultural identity”, as well as a focus on “exemplar employment practices with a clear focus on equality and diversity, employee voice and collective representation”.[178]

 

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Recruitment, retention and wellbeing

123. Recruitment and retention issues in the mental health workforce pre-date the COVID-19 pandemic, but staff are increasingly experiencing burnout, and attracting staff to train and work in mental health is challenging. The result is shortages, including specialist staff such as old age psychiatry[179] and child and adolescent mental health services.[180] The Royal College of Psychiatrists Wales said that “CAMHS services in Wales desperately need increased funding and staff”, and that staff and resources should be allocated equitably across Wales to “ensure we do not have regional discrepancy in access and mental health outcomes”.[181] It added that more needs to be done to attract people to work in mental health services, and suggested that this could include flexible or remote working opportunities, and making it easier for retired professionals or people with caring responsibilities to return to work.[182]

124. The Royal College of General Practitioners Wales called for investment in the primary care workforce, including GPs and social prescribers, as well as other professionals. It suggested that community pharmacists could play a greater role in supporting people experiencing lower-level mental health issues.[183] Similarly, the British Association for Counselling and Psychotherapy, which represents the counselling professions, described its members as “highly-trained yet underutilised”, noting that its recent workforce survey had identified additional capacity across its members amounting to “almost 10,000 client hours per week”.[184]

125. Efforts to recruit and train more staff were welcomed, but many of those contributing to our work emphasised the importance of staff retention and the role of staff wellbeing in this. Dr Julie Keely reported that many people were leaving the workforce due to physical or mental ill health, as well as the personal and professional impact of COVID-19 pressures.[185] Our workforce focus group participants emphasised that there are many positives to working in mental health services, but also highlighted the challenging, and sometime traumatic, working environment, as well as other factors including the rising costs of living and issues with pay structures:

“With regards to the mental health and wellbeing needs of the workforce itself. I think a lot of it is fairly straightforward stuff. Decent pay and decent working conditions. Specific services like counselling and wellbeing services have their place, but they shouldn't be used as a sticking plaster for not having a well-functioning, well-supported workplace. It's no good sending somebody working in a toxic workplace to a counselling service”.[186]

 

126. HEIW and SCW’s mental health workforce plan highlights the impact working in mental health services, especially acute and specialist services, can have on staff wellbeing, for example when dealing with cases of suicide, homicide, or coroner’s inquests. [187] The Deputy Minister for MHW emphasised the “strong focus” on wellbeing in the workforce plan, and added that workforce wellbeing was already a priority for the Welsh Government, including programmes such as Canopi, Healthy Working Wales, and Time to Change.[188]

 

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Awareness and training

127. The need for greater equality awareness and mental health training among frontline staff across public services has been consistently highlighted. For example, Cymorth Cymru noted that people who are homeless and experience a mental health crisis may be more likely to come into contact with the police, social workers and housing officers rather than GPs or mental health services. It cautioned that unless services are trained to respond to trauma or mental health crises, people could be dismissed or detained which could delay or prevent access to mental health treatment and support.[189]

128. In particular, GPs were identified as a key professional group where improved awareness and training in relation to mental health and equality issues is needed. GPs are often the first port of call for people who are experiencing a mental health issue, or who attend GP services for physical health issues but who may have hidden mental health issues manifesting as physical symptoms.[190] We heard evidence that older people and people from racialised communities are less likely than other age groups to be referred by GPs to appropriate mental health services.[191] Participants in our lived experience focus groups identified particular barriers in accessing GP services, with participants highlighting a lack of understanding or training for receptionists and other frontline staff in GP surgeries, as well as a lack of training for GPs themselves:

“Getting to the front line to GPs is difficult. Getting past the receptionist or front line staff is so hard. Front line staff that just can’t communicate with you and that is particularly common with autistic people.”[192]

 

129. Other issues raised included:

• Insufficient neurodiversity awareness and understanding among the healthcare and wider workforce including schools. In addition to general training, role-specific training may be needed, for example for teaching staff. Neurodivergent people told us the focus should be on:
  
  “…how to support and help people, and developing positive, constructive and helpful attitudes and cultures. For example, it could include how to communicate effectively, what language and terminology is appropriate, how to adapt or tailor services and support to meet neurodiverse people’s needs, and how to ensure that services and support enable neurodiverse people rather than ‘disabling’ them”.[193]

• Disability awareness training is needed to give clinicians and others working with disabled people a better understanding of their needs (i.e. not just training about conditions).
• A lack of cultural awareness or competence among the mental health and other health service and public service workforce.
• A need for more understanding of trauma, and the implementation of trauma-informed approaches. Such approaches could be beneficial for health and social care services, but also other settings such as emergency services and in the criminal justice system.
• Training gaps in relation to the mental health and other needs of specific groups or communities, including older people, people with sensory impairment or loss, people diagnosed with personality disorders, unpaid carers, and people experiencing grief. Gaps were also identified in relation to women’s health issues and suicide prevention awareness.

130. Workforce representatives recognised the need for training, but described workforce pressures and a lack of protected time to undertake training as significant barriers.[194] Lisa Turnbull of the RCN said:

“Very often, there is excellent education available on, say, learning disabilities and dementia or specific cultural issues or linguistic issues, and people know that they're in need of it and want to access it. But if you're talking about coming home after a 12 or 14-hour shift and then you've got caring responsibilities, when precisely are we expecting people to do this? So, once again, it's a really high expectation on these people, and yet not necessarily rewarded or recognised or given the opportunity to actually reach that level, just criticised when they don't.”[195]

 

131. The Deputy Minister for MHW acknowledged the Welsh Government had a leadership role in this regard, and committed to ensuring that equality, diversity and inclusion were “core topics and areas of focus for all our leaders”. She added that the Welsh Government was working with Diverse Cymru and other partners to make sure cultural competency training was available. However, she said that ensuring there were mechanisms in place for staff to undertake training was a matter for employers.[196]

 

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Our view

132. Issues relating to recruitment, retention and training gaps in the mental health and wider workforce pre-date the COVID-19 pandemic. However, they have been exacerbated, and staff are experiencing increased burnout in addition to the impact of rising costs of living. Further action is needed to improve and sustain staff wellbeing, including a greater focus on workplace culture and the wider causes of poor mental wellbeing among the workforce. To this end, we welcome the focus on workforce wellbeing in the mental health workforce plan, and the Deputy Minister’s confirmation that workforce wellbeing continues to be a Welsh Government priority.

133. As with all plans, the impact will be in the implementation. In the context of budgetary constraints there may be difficult choices to make in order to balance tackling immediate workforce pressures with developing a mental health workforce that is fit for the future and properly equipped to meet individuals’ diverse needs.

134. We need to build the capacity of the mental health and wider public service workforce to meet the needs of diverse communities more effectively. This will require a more diverse workforce that better reflects the communities it serves, improved equality awareness and training, and the removal of barriers that prevent staff from accessing training opportunities.

135. We also agree with our advisory group that training and support should be provided to people with lived experience to enable them to enter the mental health workforce. This should include neurodivergent people, as well as other groups identified as being underrepresented in the workforce.

 

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Table of Contents

— Chair's foreword

— Recommendations

— Summary

— Introduction

— Mental health inequalities

— Person-centred services

— Mental health is 'made' in communities

— Social prescribing

— Workforce

— Coordinated cross-government action

— Reform of the Mental Health Act 1983

— Annex: Mental health and emotional support