Mapping the UK renal psychosocial workforce: the first comprehensive workforce survey

Table 1 shows the identified staffing levels in adult and paediatric services as per July 2017 across 84 renal units in the UK, a complete list of identified psychosocial staffing per parent unit can be found in Additional file 1. It was observed that some of the units employed non-traditional members of psychosocial staff, such as a cultural and health liaison officer. Three units contracted external companies, namely Auriga and Citizens Advice Bureau (CAB), to provide patients with welfare and benefits advice. The four main providers of psychosocial services in the nephrology setting were identified as social workers (35.6, 95% confidence interval [CI] =28.8, 42.8), psychologists (34%, CI = 27.3, 41.2), counsellors/psychotherapists (15.7%, CI = 10.5, 20.7) and youth workers (5.2%, CI = 2.1, 8.4). Of these four types of professionals, 12.4% worked in paediatric services, whereas only 1.5% of the entire RRT population is under 18 years of age. The numbers of psychosocial staff available to renal patients in a unit varied from zero to seven (Mdn = 2.37, IQR = 1–3.75). Twelve units (14.3%, CI = 7.6, 23.6) had no renal dedicated psychosocial service and sixteen units (19.1%, CI = 11.3, 29.1) had one member of psychosocial staff available to patients. In the other units, different members of staff worked together in varying combinations.

Table 2 shows the median and dispersion of adult patients per 1 WTE staff per unit, for psychologists, social workers and counsellors/psychotherapists. Dialysis patients include all dialysis modalities and RRT also includes transplant patients. In addition, the table shows the proportion of units that meet the benchmark ratios as recommended in the 2002 workforce report [25]. There are no units that meet the social work requirements, which means that the psychology requirement for all units is 1 WTE per 500 RRT patients. Only four units meet this requirement, three of which are in Wales. Some units that employ psychologists also offer a counselling service. Taking the counselling and psychology provision together would mean that one additional unit has a provision of 1 WTE psychologist and counsellor for less than 500 RRT patients. It is however not specified in the 2002 recommendations how the presence of counselling services in a unit affect the psychology requirements.

Notable variations exist between the staff to dialysis patient ratios across different units. For social work, the unit with the best staff ratio per dialysis patient had a ratio of 104, exceeding the benchmark with 48%. This was 165 for psychology and 171 for counselling. The worst ratio for social work was 1895. This was 4430 for psychology and 7390 for counselling. Figure 1 shows the variation in dialysis patient-to-staff ratios per profession. Ratios for RRT patients showed similar variations. Figure 2 provides an overview of the different ratios across all units that have psychology and/or social work provision.

Differences in median ratios for adult psychology and social work services across the four UK countries have been observed (Table 3). No renal counsellors/psychotherapists were identified in Wales and Scotland, in Northern-Ireland one unit was found to employ a counsellor. Most renal units in Scotland (5 out of 9) do not have any renal dedicated psychosocial staff, but instead operate a general model of psychosocial service provision. Ratios for psychology and social work services were the lowest in Wales.

The ratios for number of ERF patients per 1 WTE staff in paediatric services are summarized in Table 4. The ratios in paediatric services were substantially lower than in adult services, which means that even though there are far fewer children with ERF than adults on RRT, relatively more staff is employed in paediatric units. The 2002 recommendations for paediatric services were based on WTE staff per million population of the entire region that a hospital served [25] and not on the number of renal patients in paediatric services. For that reason, it could not be usefully determined whether the found ratios met the set requirements.

As previously stated, the 2002 workforce report only provided complete information on workforce data for renal social workers and psychologists. Therefore, changes in the workforce since 2002 can be reported for renal psychologists and social workers only. The total WTE of renal psychologists has increased with 1088%, from 2.5 to 27.2 WTE. Instead, the adult social worker WTE has decreased with 19%, from 55 to 44.6 WTE. The percentage of adult units without social worker input has increased with 252.1%, from 14 to 49.3%. In addition, the results show that in 2017, 29.6% of units had no psychology or social work support available. Only four units (4.7%, CI = 1.3, 11.7) provided adequate psychology provision and for all units the social work provision was inadequate. The 2002 workforce report did not offer any data on adequacy of provision to compare against.

Taken together, the adult workforce of these psychosocial professions has increased with almost 25% over the past 15 years. However, over the same time, the RRT population has increased with over 50%. Table 5 shows a comparison of overall adult staff to patient ratios, including units without psychosocial services.

Paediatric renal psychology and social work services have decreased with 20.6% over the last 15 years. Psychology provision decreased with 6.6%, from 6.1 to 5.7 WTE and social work services decreased with 28.9% from 10.4 to 7.4 WTE. In 2002, it was reported that three paediatric units (21.4%) did not have social work input and six units (43%) had no psychology input. Now, the number of paediatric units without social work input has increased with 66.7%, to five units (35.7%). Instead, the number of units without psychology input has decreased with 66.7%, to two units (14.2%). All paediatric units have at least one social worker or psychologist present, even though in one of the units the psychosocial service is made up of a psychologist who works less than 0.1 WTE on renal services.

The results show a great variety in models and availability of psychosocial services within the 84 renal units and UK countries, with Wales reporting the best staff-to-patient ratios. These findings suggest that a general service provision model for renal psychosocial care in the UK is lacking. Guidelines that state patients must ‘have access to’ psychosocial services [21‐23] hardly seem strict or specific enough. This suggests renal units do not have to employ staff to provide these services, nor do they clarify the type and number of staff that should be accessible. At a very pragmatic level, adequacy of staffing ultimately determines whether guidelines issued to improve care and safety are implemented [29]. However, sufficient consideration of staffing levels and how they may be a factor in suboptimal care seems to have been overlooked when drafting these documents.

The recommendations as set out in the 2002 report provided guidance for the provision of social work and psychology. An update of these recommendations should be considered, since it is currently unclear how the presence of counselling and youth services in a unit affects the social work and psychology requirements. Moreover, a recommendation for paediatric services based on the number of children with ERF is lacking. Even though the recommendations for social work are similar to those in Australia and the USA, the evidence base for these benchmarks has been questioned [2, 29]. To inform the development of future recommendations, it is useful to explore and compare recommended levels of provision in other physical health specialities in which psychosocial workforce planning has evolved. In paediatric and adult cystic fibrosis (CF), the care standards require 1 WTE psychologist and 1 WTE social worker per 150 patients [30]. This model involves providing all patients with routine psychosocial care and not stratifying on the basis of psychosocial need. The recommended levels for social work provision are broadly similar in both CF and RRT, but the recommendations for psychology services differ quite considerably. These seem to be more in line with those in cancer care, where NICE estimates that 15% of patients will need level 3 (counsellor/psychologist) support and 10% will need level 4 (psychologist/psychiatrist) intervention [31]. This has led to the development and application of a cancer care model for psychological provision across London [32], which suggests a maximum yearly caseload of 150 patients per full-time level 3/4 worker. It should be noted that this oncology model is for psychological intervention only and not social work services. In 2014, these services appeared to be mostly provided by charity funded oncology social workers and social services [33]. Regardless of whether it is desirable that the help of charities is needed to provide access to social work, this suggests that the variety in psychosocial service provision is not limited to kidney care, but exists within care pathways across other long-term conditions. Applying the cancer care model to renal care would allow for the inclusion of counsellors/psychotherapists in the recommendations and the use of an acuity model; of every 600 RRT patients, 150 patients would require level 3/4 intervention. Sharing of psychosocial provision across other long-term conditions such as diabetes and oncology, may be a way this could be operationalised for smaller units, indeed in some areas this is already established practice. However, even though patients with chronic conditions seem to experience an impact of their disease in similar psychosocial areas, it cannot be assumed that the need for psychosocial services is the same in both CKD and oncology patients.

The above comparisons suggest that the renal recommended staffing levels from 2002 are in line with a social work provision model of providing support to all RRT patients and a psychological provision model of providing support to approximately 25% of the RRT population. However, these recommendations should also include pre-dialysis and palliative care work [25], which is now not clearly reflected in the recommendations based on RRT patients. The survey findings show that not one of the 84 renal units meet the requirements for psychology and social work services together, with average staff-to-patient ratios far exceeding the benchmarks. Based on the recommendations, the current staffing requirement for adequate adult renal social work would be 437.8 WTE and for psychology services this would then be 61.3 WTE. Given that the social work establishment currently is 44.6 WTE, it should be questioned how realistic these benchmarks are.

Although health systems and training of professionals vary across countries, studies from the USA [29] and Australia [2] show that the exceeding of social work benchmarks appears to be a consistent theme that fits within a wider, global shortage of the whole nephrology workforce [3]. In 2011, American renal social work benchmarks were exceeded in 10 out of 50 states. Apart from one state reporting a ratio of 1:425, the median ratio for other states exceeding the recommendations for dialysis patients was 1:150 [29]. In Australia, a recent study in Queensland showed a ratio of 1:191 dialysis patients, whereas one in Western Australia in 2007 calculated ratios of 1:322 [2]. Even though it should be noted that these countries seem to have less renal psychological provision than the UK, the overall UK renal social worker-to-dialysis patient ratio of 1:624 is considerably higher. Indeed, a lack of UK psychosocial service provision appears to be identified by this investigation. Yet, this cannot be concluded based on the current evidence, or lack thereof. Further research into psychosocial problems and need for services is required, to provide an evidence base to support and update 2002 staffing recommendations.

The comparison of the current workforce with the 2001 workforce shows that overall, the WTEs of psychologists and social workers have increased with 12.8%, thanks to the large (1088%) increase of adult psychology staff. Instead, paediatric psychosocial services and adult social work saw their workforce decreasing. The results show an interesting trend, namely that the combined psychology and counselling/psychotherapy workforce has become almost the same size as that of the social workers. Indeed, the increase of psychology services seems to have come at the cost of social work services. The 2002 report shows that traditionally, renal social workers provided psychosocial support for CKD patients, as still seems to be the case in the USA and Australia [2, 29]. The employment of renal psychologists and counsellors/psychotherapists is a relatively new and unique phenomenon in the UK, leading to the creation of new service provision models. Even though this shift could be a result of the increasing evidence on psychological problems and interventions with CKD patients – or possibly the lack of high-quality studies that could form an evidence base for renal social work – the reasons for units deciding to employ certain members of staff requires clearer understanding. However, with benchmarks for social work far exceeded, one can wonder if there is enough time for social workers to provide the complex case work activities that they are trained to do. Indeed, renal social workers in the USA have reported that high caseloads prevent them from providing adequate support and that, in their view, patients are being denied access to good quality services [34]. There is a need to investigate whether this is also the case in the UK, manifesting in an unmet need for support, or that patients access services through other routes if adequate dedicated provision of psychosocial care in their unit is lacking. It is unclear whether in these units the role of the nurses is expanded to include a certain level of psychosocial support, or whether patients access psychosocial services through the general hospital team or their GP. Moreover, the effectiveness of other models of service provision needs to be evaluated, to determine whether there is a difference in patient outcomes of services provided by renal dedicated staff or general staff.

As described above, the data collection process for this paper was complicated and time-consuming and it requires improvement to make it appropriate for regular, future psychosocial workforce audits. Namely, the BRS workforce survey (based on the SRA survey) was a large document that would take time to complete, which might explain the low response rates. In addition, if the psychosocial section of this larger survey contained no data, it was unclear whether this was because there was no staff available, or whether the section was not completed. Moreover, the contradictory information found between data from CDs and psychosocial staff could suggest that staff roles are not always clear. Also, the survey asked to list renal dedicated psychosocial staff and thus did not include general psychosocial services that patients might have access to. This might explain the differences in findings from a national survey into renal young adult transition services in 2016, which found a higher number of units having access to psychology or youth work services [35], than found in the current investigation. Intuitively, a renal dedicated psychosocial service is provided by any member of psychosocial staff, with time specifically allocated for renal patients, who is funded through the renal budget or a renal charity. Future workforce audits could include a question around funding streams of services, to increase understanding around different funding models of psychosocial care.

Instead, the questionnaire distributed through the psychosocial professional groups provided detailed information that was likely to be accurate, as it came directly from psychosocial staff. However, since the questionnaire was distributed through the professional networks there was a high possibility that it did not reach all members of psychosocial staff, especially those that are not members of the professional groups. Moreover, this questionnaire would not reach the units that do not have any psychosocial provision, therefore not allowing them to confirm their lack of services. The FOI requests proved useful for collecting data from units that did not initially respond, since hospitals have a legal obligation to reply to FOI requests within 20 working days [36]. The confirmation of final results by CDs was believed to increase the reliability of findings and did not show any indications of response bias. Namely, the CDs that did not confirm results were thought to have varying numbers of psychosocial staff available to their patients.

Through combining the learning from all different data collection methods used in this paper the following recommendation can be made: Future psychosocial workforce audits should use a simple electronic survey, asking about type, number, WTE and funding of psychosocial staff. This survey should be completed by psychosocial staff where available, but should be send to CDs of all units, either directly via email or via FOIs, to warrant a return if there is no psychosocial staff available.