Admission and discharge criteria
Concerns about admission criteria were raised at several meetings that we had with CAMHS staff during this programme.Staff were also concerned about discharge planning and continuity and consistency of care. Services are aware that work to standardise admission criteria and models of care across all regional in-patient units is being undertaken and this was generally welcomed and seen as overdue.
When we visited none of the NHS specialist units were able to produce a set of written admission criteria or an admission policy.It appears that decisions are made on a case by case basis following assessment by members of the multidisciplinary team.Whilst this has the benefit of enabling admission of complex cases for assessment there is considerable merit to having clear admission criteria which is understood by referrers.
We were told on a number of occasions that a young person who was being, or had been, treated on an adult ward, had not been referred to the regional specialist unit because staff believed the referral would be unsuccessful. This appeared to be based on a mix of past experience and a lack of transparency about both the referral criteria and admission policy.
Each of these specialist NHS units had a waiting list . Units were however unable to provide accurate information on waiting times for admission.
Admissions
Twenty-five of the young people whose care we examined, had been assessed by CAMH services before admission. All of those admitted to the specialist unit had been assessed prior to admission.
The length of time between the decision to admit a young person and a bed becoming available varied considerably according to the setting. 32 case files recorded that this period was less than seven days. For those admitted to an adult ward, most were admitted within two days of the decision to admit, but two-thirds had not had a CAMHS assessment.While a majority of those admitted to a specialist unit were admitted within one week of the decision to admit, a smaller number waited between two weeks, and, in one case, five months.
It may be that the "necessary" relative delay in admission to the specialist units ( to allow full CAMHS assessment) compounds the low expectation of referral outcome that we encountered in some non-specialist settings, and this again highlights the need to for services toput standardised admission policies in place.
More than one third of the young people we visited had had previous admissions to hospital for care and treatment in relation to their mental health needs.
For some of these young people admission patterns reflected recurrent crises, often accompanied by self-harming behaviours, in circumstances where appropriate emergency social care accommodation might have been a more appropriate alternative to hospital admission.At some of our meetings CAMHS teams reported a need for appropriate emergency social care. In other cases, this reflected the challenge of caring for a young person with a particularly complex or treatment resistant mental illness, and sometimes highlighted the difficulty in accessing an appropriate setting for a young person with particular complex needs.
The reason most commonly given for admission to adult ward was "no adolescent beds available". In a small number of cases, the local NHS Board policy is to treat any young person over the age of 16 and not in full time education, in adult services. In one case, the parents did not want their child admitted to the adolescent unit because of the distance. Our wider monitoring work has identified this as an issue in other cases.
Care plans were evident in 32 of the case records we reviewed. However the quality and detail of these varied widely, as did review dates.In a further two cases care plans were not applicable as discharge took place within 11 hours. In most cases there was clear evidence of participation by the young person or of efforts to engage him or her in the care and treatment planning process.No particular model appeared to be used in any setting, but, in the non-specialist units review meetings tended to involve medical and nursing staff only. In the specialist units, reviews were more likely to be multi-disciplinary and multi-agency, with input from, for example, parents, psychology, pharmacy and social work.
All the young people we saw had contact with relevant professionals involved in their care at least once a week.The nature of the contact, for example whether this was one to one or in meetings was not always clear from records.
For around two thirds of young people, there were no documented family sessions. Documented family sessions most often took place when the young person was in a specialist unit.In a small number of cases, letters could be found inviting family to sessions but, no documentation could be found to confirm they had actually taken place.
We found no issues were with access to psychology, apart from for one young person whose care had been transferred to adult services at the age of 16, and who could not access psychology services.
The level of involvement of community CAMHS and local social work services varied widely. Some units make considerable efforts to overcome the challenge of serving a wide geographical area, for example using teleconferencing to involve community partners from the young person's home area.
For 16 of the young people whose care we looked at, there was no evidence on file to suggest that local CAMH Services remained involved in the young person's care during admission to hospital (one young person aged 17 had been discharged from CAMHS to Adult services at the age of 16).
Eighteen young people had social workers or mental health officers (MHO) allocated to their case.Of those who were detained under mental health legislation, half had both a Mental Health Officer and Social Worker.Seven out of 21 young people who were informal had allocated social workers.
Access to local social work services varies greatly between local authorities, and, especially where distances involved are great, MHO duties are often picked up by unit social workers. While this is a reasonable arrangement, it would be good practice for there to be anofficer within the young person's local social work department, identified from the outset, to ensure appropriate involvement in discharge planning and access to services, without delay, when care of the young person returns to local services.
The length of each young person's admission to in-patient care varied greatly. Although most admissions were less than six months in duration, one specialist unit reported that half of the young people in the unit had been there more than one year.
From the records we examined it was difficult to find any systematic process for agreeing the goals of individual admission between the in-patient unit, the local CAMHS team, the young person and his or her family. Community CAMH services identified this as a concern, particularly when a young person stayed in the specialist unit for a very long period of time and especially if they had another patient who was, in their opinion, in greater need of in-patient care.
Discharge planning
We found evidence on file of clear discharge care planning, or at least tentative plans, for only eight of the individuals we visited. No discharge planning protocols were in evidence. As there will always be multiple teams and agencies involved when a young person has been admitted to a regional specialist unit, it is a matter of some concern that there did not appear to be robust systems in place to ensure that all necessary parties were identified and able to be brought into discharge planning from the earliest agreed stage. As discussed above, the geographical distance may be an issue for bringing parties together, which highlights the need for agreed roles, responsibilities and effective communication.
Recommendation
Clear and consistent admission and discharge criteria for all the specialist in-patient facilities need to be agreed and widely circulated to ensure equity of access to specialist in-patient facilities across Scotland. The National In-patient Forum has started a piece of work to develop agreed and consistent criteria for the three in-patient units, for admissions and discharge planning, and we would hope that this work is completed in the near future.
