Care and treatment of children and young people under 18
Our interest in these figures
Monitoring the admission of young people to non-specialist settings such as adult and paediatric wards, for the treatment of mental illness has been one of our monitoring priorities since the Mental Health (Care & Treatment) Act 2003 came into force. We have raised concerns about the number of admissions for several years, and in Delivering for Mental Health published in 2006 the Scottish Government made a commitment to reduce the number of admissions of children and young people to adult beds by 50% by 2009.
In our monitoring of the admissions of young people under-18 years old across Scotland we look to confirm whether NHS Boards are managing to fulfil their legal duty to provide age appropriate services and accommodation. We expect to be notified of all formal and informal admissions to non specialist facilities. We have continued to ask Responsible Medical Officers (RMOs) to provide us with more detailed information once we have been notified of an admission.
Monitoring admissions of children and young people to non-specialist facilities will remain a priority for us in the coming year.
What we found
The figures in the table above show that in 2008-09 we were notified of 149 admissions, involving 138 young people under the age of 18 to non specialist wards.
Although this figure is lower than the figure for 2006-07 (when we were notified of 186 admissions), there is an increase in the number of admissions compared to 2007-08. We are concerned about this. This increase would suggest that NHS Boards are going to experience some difficulties achieving the specific commitment in Delivering for Mental Health to reduce the number of admissions by 50% by 2009.
Our interest in these figures
Our view is that when a young person needs in-patient treatment their particular clinical needs should be paramount. In comparing admissions to non-specialist facilities by NHS Board area we are looking to see whether there have been significant changes in the number of admissions within a specific area compared to figures from the previous year.
The 2003 Act is clear that the specific duty on NHS Boards to provide sufficient services for young people continues to their 18th birthday. We are aware that children and adolescent mental health (CAMH) services are configured differently and have different eligibility criteria in different areas. We are also aware that CAMH services are making strenuous efforts to admit under-16s to specialist facilities.
What we found
Figures in the table above compare admissions in 2007-08 and 2008-09 by NHS Board area. Comparison over these 2 years shows that in Fife, Forth Valley, Lanarkshire, Lothian and Tayside, there were fewer admissions this year than last year. However, there has been a significant increase in admissions in Grampian, Ayrshire and Arran, Highland, and in Greater Glasgow and Clyde. We are aware that in Greater Glasgow and Clyde the process of commissioning and building the new unit for young people may have influenced the number of admissions and that work is being undertaken to analyse the admission of young people to adult wards. We will be sharing information to assist this work, and also to clarify that we have been notified appropriately about all relevant admissions in this area.
Figure: Admissions of young people to non-specialist wards by gender three year trend
Our interest in these figures
Our analysis of non-specialist admissions identified an overall increase of admissions for young people to non-specialist wards. However we found that the number of admissions for young men has gone up, while admissions of young women have decreased. About half of the non-specialist admissions of young ment were for males aged 17.
What we found
This data shows that mental health services are treating young men and women differently. Possible reasons are that girls are admitted on an arranged basis, often for treatment for eating disorders, whereas boys are more likely to need urgent admission for other mental health problems when arranging a specialist placement is more difficult. There may be a tendency to regard 17-year-old males as less suitable for an adolescent mental health ward. The Scottish Government and specialist services for adolescents need to examine this finding and ensure that they do not discriminate on the basis of gender.
Our interest in these figures
When a young person is admitted to a non-specialist ward it is important that NHS Boards fulfil their duties to provide appropriate services. To enable us to monitor how this duty is being fulfilled we continue to ask RMOs to provide us with more detailed information once we have been notified of an admission, and some of the information we request is summarised in the table above.
We specifically want to see whether specialist CAMH service input is available, to ensure that appropriate care and treatment is being provided to the young person, and that relevant guidance and support is available for staff in non-specialist units who will rarely have experience of providing treatment and support to young people.
What we found
In 37% of admissions the RMO at the point of admission was a child and adolescent specialist. In 35% of admissions nurses with experience in the field were available to work directly with the young person and in 56% of admissions nurses with relevant specialist experience were available to provide advice to ward staff.
When compared with information collected last year this shows that the number of cases where the RMO at admission is a child and adolescent specialist continues to increase, but that the availability of nursing staff with relevant experience, either to work directly with the young person or to provide advice to ward staff, has decreased since 2007-08.
We have just completed a themed visit programme to CAMH services across Scotland. There will be further discussion in the national report, with reference to the information we gathered about local protocols for the management of admissions and about CAMHS input, when the report from this programme is published later this year.
Our interest in these figures
We receive information on monitoring forms about social work input. Many young people admitted to a non-specialist facility will have had no prior involvement with social work, but our expectation would be that if social work input is felt to be necessary at the time when an admission is being considered, or after admission, then there should be clear local arrangements in place to secure that input.
What we found
Compared to the figures for 2007-08 fewer young people had an allocated social worker at the time of admission ( 44% compared to 52% in 2007/8). However a higher proportion of young people had access to a social worker after admission, according to the monitoring information we received (42% compared to 31%) and there has been a reduction in the number of young people who had no allocated social worker when admitted, and no access to a worker during the admission. We would hope this indicates that more integrated approaches to provide care and support when young people become in-patients are developing across the country, and again we will focus on this issue further in the national themed visit report to be published shortly, following our recent meetings with CAMH services across Scotland.
Our interest in these figures
We ask for specific information about the supervision arrangements for young people admitted to non-specialist facilities to enable us to monitor whether the need for heightened observation is being carefully considered, and also so that we can arrange to visit any young person, if they are particularly vulnerable, to look at the care and support arrangements in place.
We would expect any issues about the safety and security of young people who may be vulnerable in non-specialist settings to be assessed and addressed by services. We have also previously highlighted the lack of an intensive psychiatric care unit (IPCU) for young people, and the situation with regard to this has not changed in the last year.
What we found
Significantly more young people were accommodated in single rooms throughout the admission than in the previous year, and we welcome this. A slightly higher number were nursed under constant observation and more were transferred to an IPCU or locked ward compared to last year, and one young person was admitted to the State Hospital in this period. There may be a number of reasons why constant observation or transfer to an IPCU were felt to be necessary, and this will probably reflect clinicians' views that young people can be vulnerable, and that risks and vulnerability are being carefully assessed during admissions.
Our interest in these figures
We ask for further information about access to other provisions to give us a clearer picture of how NHS Boards are fulfilling their duty to provide age appropriate services. Because a large proportion of admissions are for very short periods of time access to appropriate recreational activities and education may not be significant issues for many young people.
We want to know if independent advocacy services are readily available, given the important role advocacy can play in ensuring any patient's views are heard.
We also want to know how many young people with a learning disability are admitted to non-specialist facilities, because of the ongoing concerns about the lack of appropriate services for young people who have a significant learning disability and require in-patient admission for assessment and/or treatment, particularly where there are significant problems with challenging behaviour.
What we found
There has been a reduction in the number of young people who were reported as having access to age appropriate activities. In very few cases was access to education discussed. Again this may not have been appropriate if an admission was for a short period of time, but it is certainly the case that in the absence of specialist CAMHS or social work input, staff in adult wards will not know how to access continuing education services if this is appropriate while the young person is in hospital.
The overall number of young people reported as having had access to advocacy is exactly the same as last year, but it is concerning that almost a third of young people admitted were reported as not having access to advocacy during their admission.
Although the number of young people with a learning disability involved in these admissions is small, and has fallen from the previous year, it remains concerning that there is no specialist in-patient provision for this group. We are aware that in specific cases the admission of a young person to an adult facility has had a very considerable impact on adult patients in a ward, because of the intensive care and support which has had to be provided to meet the care needs of the young person.
Our interest in these figures
Monitoring the admission of young people to non specialist settings such as adult and paediatric wards, for the treatment of mental illness has been a priority for us since the 2003 Act came into force. We are interested in the figures for the age and gender of young people admitted, because they can indicate whether there are any trends, evident over a period of time, with regard to the admission of young people, and can suggest where services should be giving careful thought to arrangements in place to meet needs, or where there may be specific issues to address.
What we found
As was the case in the previous two years there were more 17 year olds admitted than any other age group, with 115 (77%) of admissions involving young people aged 16 to 17. This figure is fairly consistent with figures from the previous two years.
What is striking with the age and gender figures for 2008-09 is the shift in balance between the number of young males and females admitted. The trend over the past three years has been for the number of female admissions to non-specialist facilities to fall and the number of male admissions to rise, particularly in the 17 year old age group. In 2006-07 almost exactly the same number of young women and men age 17 were admitted. In 2008-09 90% more young men age 17 were admitted than young women. We are not sure why this is happening and will look at the figures for admissions to specialist facilities, to see if young women are more likely to be admitted to these in-patient facilities than young men.
We would also want to undertake a retrospective study of admissions over a specific period of time to try to establish if there are specific reasons why there has been such a marked shift in the in the gender ratio of young people admitted to non-specialist facilities.
Annual reports
- directors introduction
- overview of the Mental Health (Care & Treatment) (Scotland) Act 2003 introduction
- new orders granted in 2008-09
- total numbers of 2003 Act orders in existence
- monitoring our priority areas
- monitoring of priority areas
- overrides of advance statements
- community based compulsory treatment
services for young people
- additional findings from our monitoring of mental health law
- our overview of the use of the Adults with Incapacity (Scotland) Act 2000