Covid increased mental health needs dramatically, for all sorts of reasons. The trauma of living with a pandemic itself, or with long Covid. Sitting at home without structure. People losing their role or identity because they’ve lost their jobs or businesses, or because time away made them realise how bad for them their job was. Becoming depressed or detached from their sanity because of a combination of things. Illicit drug use has increased. General wellbeing has declined.
It’s just massive, a perfect storm. And we’ve not got the resources or staffing in the Welsh mental health system to cope with it, even as referrals increase. The need has mushroomed but resources are shrinking, like some weird Alice in Wonderland experiment. Mental health is always the poor relative in health services anyway, forgotten or an afterthought. But now we’re nowhere close to being able to deliver as we need to. And it is not frontline staff’s fault, though we’re often blamed. As a result, we too now have increasing mental health vulnerabilities and needs that aren’t being met.
Retention is horrific, no one wants to do this anymore. I used to be proud to say I worked for the NHS, not all that long ago. Now if people ask what I do, I avoid answering the question. It’s partly because I can no longer take pride in what we’re able to achieve in mental health, and because I fear being attacked. I know I’m not alone in this. The general feeling and belief among the staff you talk to is that we’re being treated really poorly. There’s also a widespread perception that the Conservative Party is doing its level best to destroy what it can, with the aim of privatising healthcare.
So you’ll see something that’s really broken, if you look. The people who work within it are increasingly broken. And there are more people than ever for us to support who are ever more broken.
The sad thing about it is, if you speak to the staff, they really care about what they do. They want to keep doing it, but they’re burnt out. They’re seeing about 20% given to people who need 110%, which in itself burns them out. But that’s all that’s possible. You’re constantly fire-fighting. You can’t be proactive, let alone preventative. There’s no time for that.
When I first started in this profession, decades back now, in a North Wales mental hospital, there were people kept there for life for nothing. They’d been arrested then locked away, for things like petty theft, petty arson, or having an ‘illegitimate’ child. They’d become chronically institutionalised by the mental health system of the time and had nowhere else to be. They died there. It was both a wake up call and realisation of a calling for me.
I genuinely still love mental health service users with all my heart. Sadly, it no longer feels like a calling to work with them, though. It’s got nothing to do with them. It’s because I can do nearly nothing for them anymore, through no fault of theirs or mine. That’s the true craziness.
You’ve no longer got staff of my age or experience coming through the mental health system. You’ve got people qualified one or two years, who are still very much learning. You can’t retain or replace the experience there was. People are retiring or getting signed off with their own mental health issues: burnout, anxiety, and depression. It’s a loss of capacity of all kinds. You can’t just replace the clinical intuition that builds up in people over time.
I go in to people on the brink of tears most days, nowadays.
Loss of capacity
And you can’t plan ahead properly anymore, or do succession planning. How can you, when you don’t know what demand or supply will be in play a year from now? It used to be possible, but no more. It’s partly because ever more staff are developing the same issues as the people they’re trying to support, by being over-stretched and under-regarded. Mental health services are going to have to do what general health does, recruit from overseas. But that’s harder because of Brexit.
There’s something called streamlining, where there are agreements with universities about jobs for students after they graduate. There used to be a projection of around 30 each year, something like that. The last estimate I heard of was half a dozen or so. And again, they lack experience. They too will need some of the time and attention of existing staff, until they find their feet. So you’ve got one mental health nurse doing the job of three. Then newer people might not stay long, the atmosphere isn’t great and the workload is beyond. The money works out better in a supermarket, all things considered.
What they should mostly be doing is seeing the people in their existing caseloads, helping them into recovery or to regain their independence. These are patients in secondary care, who GPs can’t help. We also take on emergency or urgent referrals. There’s statutory guidance as to how quickly such referrals should be attended to, including seeing people for a routine assessment. This is on top of existing casework, remember. At the moment we can’t always meet statutory duties.
And there’s this new 111 Press 2 service, which has had a full launch despite being understaffed. People on those lines do a preliminary assessment – based on how much experience? – then may pass the callers onto us. So there’s yet another increase in referrals, without any additional resourcing to match it. When we’re already on our uppers.
The biggest thing that’s changed in my many years of work in the mental health sector is that wanting to do the job and doing it are no longer the same thing. My passion and desire to do it haven’t changed a bit. I love working with other staff and our patients as much as ever, but don’t feel I can anymore because it’s all broken. They’re not broken, it is. And it’s breaking us, too. Those who’ve never worked with the severely mentally ill might assume it’s proximity to that which causes burnout and other issues. But they’re the only thing left keeping me in.
I currently have to work until I’m 65, no matter what shape I’m in. There’s no recognition of or flexibility about that. There’s something that used to be called Mental Health Officer status, which allowed for early retirement. It was done away with long ago, for us. There’s still an equivalent for others, like police officers and firefighters. That’s another thing tipping staff over the edge, knowing that they have to keep going no matter what. Especially as what they earn goes less far, as for so many people now. I think it’s under review. But if there’s a pension penalty to allow earlier retirement, there’s no real change; it’s just turd-polishing.
If you were to ask me if the mental health teams I know should work with your loved one who has mental health issues, I would say a wholehearted yes. I know how dedicated and wonderful those people are. Would I be happy for your loved one to receive care from the system we’re currently in? I’d have to say no. Categorically. I’d rather take them home to care for them myself.
If the world flipped over suddenly, and I found myself as first minister or prime minister, what would I prioritise? I’d have to make sure the ministers in charge of health, including mental health, weren’t some hedge funder or something. I’d make sure they had a working knowledge of how the front line looks, feels, and operates. That they had actual inside experience. A porter would make a better health secretary. At least they know what’s actually going on. Then I’d be open, honest, and transparent about how and why it’s broken, and make sure it’s all properly resourced.
Mental health services aren’t healthy
Because what’s more important than health, mental and physical? But that would be hard to do now, the resourcing, as there are so few qualified staff. Building that takes time. There is actually a magic money tree when it suits the UK government, we’ve seen that. But there’s no enchanted orchard of healthcare experience. I’d make both short- and long-term commitments to resourcing and capacity. Rather than operating out of the desire not to want everyone who needs it to have access to high-quality, timely health care at every level.
Do you increase wages? I agreed with the strike and with ending it, and feel the increase was reasonable. But if you talk to nurses now, it’s not about the pay. Aside from being able to survive this cost of living crisis, this cost of profiteering crisis. It’s about the appalling terms and conditions they’re now expected to work under.
And to add insult to injury, we’re now maligned. Blamed for all manner of ills. It’s so bizarre that we were bring clapped and thanked and rainbowed just a few years ago. Some were given bin-bags as PPE. Nurses died. And now we’re vilified. By the press, by our own government. We know it says nothing about us, only about them, but of course it gets to you. Especially when unthinking people just fall for it. That’s why, like I said, I don’t admit to what I do for a living anymore, nor do others. We risk people having a go at us. We have it cushy, we always want more money, or how can we work in something so broken and not do anything? That sort of thing.
But that’s not in our gift, in our power. Believe me, we would if we could. We can’t change the fact that money hasn’t been given, or that staff capacity has been allowed to run down. But there’s this atmosphere of people, especially the government, somehow thinking it’s always our fault, never theirs. This infects the management, too. Middle managers have been pressured into caring about ‘footprints’, ‘lessons learned’, how they look on paper. Not front-line staff welfare. The recording of faults, when improvements are no longer really possible. A culture of finger-pointing.
Some of them used to work on the front lines themselves. But they’ve lost touch with that in a blizzard of bureaucracy. They’ve lost sight. I feel for them because it’s the pressure from even higher up, they’re literally caught in the middle. If you sat them down and asked them why they do the job they do, I don’t think they’d be able to answer. They’re so far removed from the reality of what it’s really like now. Don’t get me wrong, there are some terrific people in amongst all that. But they feel powerless to do anything, so they can’t look the situation directly in the eye.
People talk about how great it is that we save lives – or used to. But no one talks about what it’s like to take the decision whether to allow someone to go home, when they’ve said they’ll kill themselves if they do. We used to feel confident in such decision making, but that’s gone. Because the support for it isn’t there. There’s a flip-flop effect. You want to take a certain course of action, but can’t as you know the service can’t meet the needs of that person. And that the system no longer has your back when you take a decision with potentially serious consequences. And all that lack of support can increase the fallout tenfold!
It’s really good that people generally are talking about mental health more now, being more open about it. Light is a disinfectant. But of course, this means demand on the mental health system has increased. And we’ve never been less able to meet it. Resources haven’t been increased to reflect this positive change and its impacts. People who can afford it get a private assessment, but they’re not accepted at face value by the NHS, because there’s no standards governance there. For all we know they’re not worth the paper they’re written on. And the police increasingly don’t want to know about mental health matters; are both dismissive in their language and but try to buck-pass to us anyway.
Hearing someone, hearing them really properly, is a mental health intervention all by itself. We used to talk about the emotional labour of all this at work; about the frustration. But in a system this broken, when you know you’re this powerless, even that doesn’t make a damn bit of difference. So we don’t, now, really. We’d like you to, though. Please see us. Please hear us.
A. can’t really take all this anymore, but can’t retire, and needs to retrain. Can you help?
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