Continuing their overarching theme ‘Our Nurses. Our Future’, the International Council of Nurses (ICN) has chosen to focus International Nurses Day 2024 on the economic power of care hoping to reshape perceptions and demonstrate how strategic investment in nursing can bring economic and societal benefits.
This builds on the ICN Charter for Change report launched on International Nurses Day 2023 which set out a series of commitments for governments and policy makers. QNIS has invited its Fellows to reflect on these policy actions and share their thoughts about the economic power of community nursing care.
The next blog in this series comes from Dr Linda Pollock, QNIS Fellow, Former QNIS Vice Chair and hugely experienced community nursing leader. Linda has huge experience in primary and community care and a particular expertise in mental health nursing. In this blog, Linda is focusing on the economic impact of mental health nursing.
#IND2024
#OurNursesOurFuture
My first job was in the Royal Infirmary of Edinburgh’s Poisons Unit where people were cared for and treated following instances of self-harm. These are now treated in A&E departments, but I cannot help but ask – what other mental health problems are tipping up there to be seen? Can data, and demands for mental health care there be quantified, and arguments made instead for dedicated facilities to ensure they are getting the right help in the right place? It may be that more community mental health nurses are needed to enable patients to make positive changes to their lives, support carers or allow them to stay at home? Investing in mental health resource, long term, will save money and be much cheaper than the current cost of £1000 to keep a patient overnight rather than £100 at home.
My staff nurse experience led me to train as a mental health nurse. I became 1 of only 4 Community Psychiatric Nurses in the City of Edinburgh when care in the community was seen as somewhat revolutionary, flowing against the tide. Thank goodness that perception has changed, and community mental health nursing has expanded out of all recognition now, with emergency response teams seen as the norm – focused on providing increased support to care for people at home wherever possible.
Let no-one query the benefits of the skills and expertise of psychiatric nurses – direct the doubters to do their own literature review and see the evidence for themselves
Before retiring, I worked for 6 years as an Independent Prison Monitor where I learned that 80% of crimes are linked to drug or alcohol abuse. I had first-hand experience of the poor mental and physical health of people in prison – many looked much older than their actual ages. A noteworthy number of the residents came from the least affluent areas in Scotland, had autism spectrum disorders, learning disabilities, and significant difficulties with literacy and numeracy, many returned repeatedly feeling safer in prison because they did not have the social support they needed in the community. And talking about social support there are an increasing number of older prisoners (over 55) who have committed historic crimes who have mental health needs and require help with their personal care while incarcerated.
The mental health picture has dramatically changed since the pandemic. It has left behind a mental health crisis across the whole population and particularly among the young. The number of children and young people with a probable mental health disorder rose from 1:9 before the coronavirus crisis to more than 1:5 last year. Almost ¼ of those aged 17-19 had a diagnosed problem. More than 1/5 of young women had an eating disorder, a 13-fold increase in five years. There have been big rises in anxiety, depression, self-harm, and tics.
When half of adult mental health problems emerge before the age of 15, and three quarters before the age of 18, we currently have a crisis with long term consequences. We need to be upskilling everyone who works with children to manage minor issues and differentiate between them and serious problems – it is crucial to teach children about good physical health and how to deal with stress. We need to avoid pathologizing ordinary anxiety and the normal challenges of growing up, but we also need to include timely intervention when children and young people require it. Society and social media generally need to be responsible about what they are bombarding our youth with.
Nurses working in Child & Adolescent Mental Health Services (CAMHS) are well placed to advise, support and intervene. Effective treatment for children alongside skilled support for parents, carers and families is essential. Early intervention is associated with better health outcomes and is more cost effective in the longer term. Apparently, mental health rather than physical illness is the main cause of long-term sickness in the workforce, and the full economic impact of mental illness according to the Royal College of Psychiatrists is about £118 billion per year, equivalent to 5% of GDP.
There has been a wealth of research done in Scotland on the benefits of dedicated mental health nursing input. The first doctorate – “A Study of the Psychiatric Nurse” – was published in 1961, and since then numerous, high-quality studies have been published demonstrating the value of specialist mental health interactions. Let no-one query the benefits of the skills and expertise of psychiatric nurses – direct the doubters to do their own literature review and see the evidence for themselves – the work done by Annie Altschul or Steve Tilley to mention but a few.
My time working in prison evidenced that there is a need to make a concerted effort to work with communities and vulnerable groups otherwise many seek solace in drugs and alcohol, and ultimately crime to fund their addictions. Over time, there has been a reduction in the availability of community nurses especially health visitors and school nurses, to deliver proven interventions which target at risk groups, and this means that families, not just prisoners, are damaged.
Research shows that community nurses can achieve behavioural change and sustainable health gains if, long term, their work is targeted in deprived areas (see the Chief Scientist’s Office Report (2000), on The Effectiveness of Public Health Nursing). QNIS has undertaken more recent evaluative research, assessing the impact on community nursing of its Complexity and Adversity Network programme. It has also run Catalysts for Change, and Creating Healthy Neighbourhood Projects. The benefits of such projects need to be embraced and adopted more widely i.e. funded across all Health Boards in Scotland. Such investment would make a big difference to the current mental health crisis.
Although the numbers of specialist mental health nurses on the ground have increased since I was a CPN, more mental health problems have emerged which are much more complex than in the past. These are compounded by the COVID pandemic, the cost-of-living crisis and, of course, the increased demands of an ageing population for social care which is obviously failing.
75 years on from the foundation of the NHS, social care is still an after-thought. The Institute of Fiscal Studies has found that a 31% reduction in social care was associated with an 18% increase in A&E admissions, and a 12.5% increase in readmissions within 7 days. Care homes are struggling to make ends meet, self-funders are cross-subsidising council funded places, and this impact is felt disproportionately in disadvantaged areas where there are care black spots. Nursing Directors (DNSs), since the pandemic, have taken an overview of quality of care in nursing homes and they are in a position to document details about how social care is failing older people with dementia, Parkinsons and the host of other mental health problems associated with ageing; they can collect information from community mental health nurses about how social isolation and loneliness is increasing pressures for care home placements, and they can produce options for alternative services that can be offered by mental health nurses to reduce such demands.
In the past, specific mental health grants were awarded by the government to increase the volume of support services to care for those struggling to live with mental health conditions and disabilities, this funding needs to happen again. It feels as if little has changed in terms of developing mental health community care or at least it seems like one step forward but two backwards. Community Mental Healthcare remains hugely underfunded, and the fight for more resources into Mental Health continues today, as evidenced by reports from Audit Scotland and the Mental Welfare Commission. A fairer and more sustainable social care system needs to be created.
Social Care needs to be fixed – successive governments have promised to do so but have not addressed funding of social care properly: it is still the poor relation of the health service. Derek Feeley has addressed social care with his proposals for a National Care Service (NCS) in Scotland; these have currently stalled, but setting up a NCS would help clarify and strengthen accountability of social care budget-holders, and importantly scale up results-generating interventions which keep the mentally ill out of inappropriate institutions and keep them at home.
The National Care Service needs to invest in staff (therefore improved outcomes), and create a culture which is community driven, truly integrated, and focused on the people receiving support (patients, families and their carers). To not do this is a false economy and far greater costs will otherwise just continue to pile up in the NHS instead.
Quoted figures are taken from Sylvester R (2023) The Times Health Commission: a report into the state of health and social care in Britain.
Dr Linda Pollock
QNIS Fellow
April 2024
