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Care and treatment of children and young people under 18

 

 Younger people admitted to non-specialist services 2009-10

 

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 Our interest in this

Monitoring the admission of young people to non-specialist settings (such as adult psychiatric and paediatric medical wards) for the treatment of mental illness has been one of our monitoring priorities since the Mental Health (Care and Treatment) Act 2003 was introduced.

We have raised concerns about the number of these admissions for several years. We were pleased therefore with the commitment in Delivering for Mental Health, published in 2006, to reduce the number of admissions of children and young people to adult beds by 50% by 2009. We commented in our annual report 2008-09 that, based on our findings for that year, NHS Boards were likely to experience some difficulties achieving this specific commitment.

In our monitoring of the admissions of young people under 18 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

In 2009-10 we were notified of 184 admissions, involving 147 young people. These figures compare with 149 notifications of admissions, involving 138 young people, in 2008-9.

We anticipated last year that NHS Boards would experience difficulties meeting the commitment to reduce admissions by 50% by 2009, as last year's figures had increased slightly compared to 2007-8. The figures for 2009-10 have increased again, and significantly more than they did in 2008-9. We are concerned about this and are also concerned about the number of repeat admissions of young people. The number of young people admitted has risen slightly, by 9, but the total number of admissions has risen by 35. One fifth of admissions involve young people who were admitted more than once in the year. 

A significantly higher proportion of young people were admitted more than once in 2009-10 compared to the previous three years, and we want to understand more clearly why this may be happening. We will be revising the monitoring form we use, to collect more helpful information about supports being provided when a young person is discharged following an admission. We hope this information will be useful in looking at the repeat admission figures in the future.

Admissions of young people to non-specialist wards by NHS Board

 

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Our interest in this

Our view is that when a young person needs in-patient treatment their individual 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. In this year's figures we are also identifying not only the number of admissions in each area but the number of young people involved. For comparison, we have looked at the figures for 2008-9 and identified the number of young people involved then.

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 child and adolescent (CAMH) services are configured differently and have different eligibility criteria in different areas. We have highlighted this issue in the on the themed visit report where we recommend that all NHS  Boards should provide CAMH services to young people up to their 18th birthday, unless clinical need indicates otherwise in a particular case. We are also aware that CAMH services are making strenuous efforts to admit under-16s to specialist facilities, and that work is currently in progress nationally to develop agreed criteria for the admission to and discharge from specialist in-patient units. We hope that when these admission criteria are in place this will impact on the numbers of admissions to non-specialist facilities.

What we found

In the majority of NHS Board areas the number of notifications has been static, or has reduced slightly. In Forth Valley there was a very small increase, and in Dumfries and Galloway the higher number of admissions actually related to a smaller number of young people i.e. a few young people were admitted several times. There have been more significant increases though in three board areas, in Ayrshire and Arran, Lanarkshire, and Lothian.

In Lothian all admissions, apart from one, involved young people aged 16-17. Looking more closely at the information we received, we can see that in almost 75% of cases the young person had self harmed or was voicing suicidal ideation. In only three cases were we advised that no CAMHS bed was available. In Lanarkshire the CAMH service at present is only involved with young people up to the age of 16. We think this probably influences the relatively high number of admissions to adult wards in this area. In Ayrshire and Arran the Mental Health Directorate has advised us that they were already aware of these increases and had undertaken work to identify factors involved. As in Lothian there is a growing problem of self harm, or voicing suicidal ideation, in the context of alcohol or drug misuse, and consideration is being given to developing an intensive service response. In Ayrshire and Arran there is also an acknowledged lack of alternative crisis social care placements and discussions are taking place with service partners around addressing difficulties in accessing places in the regional in-patient unit. We want to see progress in all these identified areas, to improve the access young people in Ayrshire and Arran have to age appropriate care and treatment.

 

Specialist healthcare for young people admitted to non-specialist wards

 

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Our interest in this

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. 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.

Our interest in this issue has been heightened as a result of the CAMHS themed visit we undertook last year.  We were made aware that access to specialist CAMH services when a young person is admitted to an adult ward varies across the country, with staff in several adult wards reporting a very limited access to CAMH support during admissions.

What we found

In 25% of admissions the responsible medical officer at the point of admission was a child and adolescent specialist. In 41% of admissions nurses with experience in the field were available to work directly with the young person and in 71% of admissions nurses with relevant experience were available to provide advice to ward staff.

This shows that, compared to last year, the availability of nursing staff with relevant experience to either work directly with the young person, or to provide advice to ward staff, has increased and we welcome this. The number of cases where the RMO at admission is a child and adolescent specialist has decreased. However, we are aware that in many cases specialist child and adolescent consultants are providing advice and support during admissions. This information may not be being captured consistently in our monitoring forms. We will therefore be asking specific questions about CAMH consultant input in individual cases as we introduce a revised monitoring form later this year. We would expect the information we report on next year to have more details about the level of CAMH consultant input into the care and treatment being provided when a young person is admitted. We hope that there is more significant input than the current available information suggests.

Social work provision for young people in non-specialist wards

 

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Our interest in this

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 to secure that input.

We also have an interest in the provision of services to looked after children. There is evidence that looked after children generally experience poorer mental health and there is now a national requirement that NHS Boards ensure that the health care needs of looked after children are assessed and met, including mental health needs. We would assume that any looked after young person admitted to a non-specialist facility will have an identified social worker.

What we found

Compared to the figures for 2008-09 more young people this year had an allocated social worker at the time of admission (49% compared to 44% in 2008-09).

A slightly higher number of young people had access to a social worker after admission (67 compared to 62 in 2008-09) but this represents a smaller proportion of the total than last year because of the higher overall number of admissions. There has been an overall reduction in the number and proportion of young people who had no social worker when admitted, and no access to a worker during admission.

We hope that this indicates that more integrated approaches to providing care and support are being developed across the country - both on admission and when individual discharge is being planned.  It is not acceptable that 13% of young people admitted to specialist ward had no access to a social worker.

Supervision of young people admitted to non-specialist wards 2009-10

 

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Our interest in this

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. We also use this information to help us decide if we want to arrange to visit a young person. We will arrange a visit if the young person is particularily vulnerable, to look at the care and support arrangements in place.

What we found

Fewer young people were transferred to an IPCU or locked ward compared to last year (14% compared to 17% in 2008-09).  Significantly more young people were accommodated in single rooms throughout the admission than in the previous year (137 compared to 112 in 2008-09) and we welcome this. A higher number were nursed under constant observation this year (105 compared to 87) and we would hope that this reflects a recognition that young people can be very vulnerable, particularily in an adult ward, and that risks and vulnerability are being carefully assessed during their admission.

We aim to gather more specific monitoring information as a result of our revised monitoring form, and will be asking for more details about how decisions are taken about observation levels in future. We will therefore have more information about the supervision of young people in non-specialist facilities in next year's report.

We are aware, from our visits to CAMH services this year that many NHS Boards either have an identified adult ward which will be used when a young person is admitted, or are considering such an arrangement. Such arrangements can be very helpful in ensuring that single rooms are available for admissions and that the physical environment in a ward is as suitable as possible for the needs of a young person. Where such arrangements are in place we expect staff will be more aware of how to access age appropriate support for young people.

 

Other care provision for young people in non-specialist wards 2009-10

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Our interest in this

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.

We want to know if independent advocacy services are readily available, given the important role advocacy can play in ensuring that 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 significant learning disabilities and require in-patient admission for assessment and/or treatment, particularily where there are significant problems with challenging behaviour.

What we found

The information provided indicates that slightly more young people are having access to age appropriate activities than in 2008-09 (51% compared to 49%), and significantly more had access to advocacy services (80% compared to 69%). We welcome this, although it is still concerning if all young people are not reported as having access to advocacy during their admission. We also understand that for many admissions, which are very brief, access to age appropriate recreational activities may not be relevant. We also appreciate that there may be a lack of clarity about what constitutes age appropriate recreational activities, and that this may be reflected in the information collected by our monitoring forms. Where beds have been designated in specific adult wards for the admission of young people we have seen examples of considerable attention being paid to providing age appropriate activities.

From the information provided, access to education was discussed more frequently in 2009-10 than in the previous year ( in 61 cases as opposed to 43 cases in 2008-09).  It may not have been appropriate to discuss access to education if an admission was for a very short period of time. We have concerns though that in certain situations it clearly would have been appropriate to consider issues about access to education when a young person was in a non-specialist facility. We have made a specific recommendation about this issue in our themed visit report . We remain concerned that, in the absence of specialist CAMHS or social work input, staff in adult wards will not know how to access education services should this be required.

We will also be starting to ask for more specific details about how this issue is being addressed so that we we receive better and more consistent information about education provision.

Age and gender of young people admitted to non-specialist wards 2009-10

 

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Our interest in this

We are interested in the figures for the age and gender of young people admitted because they can indicate whether there are any evident  long-term trends in the care and treatment of young people. These figures can suggest where services should be giving careful thought to the arrangements that are in place to meet needs, or whether there are specific issues to address in their services.

What we found

The data on the admission of young people to non-specialist wards over the previous three years has shown that mental health services have been treating young men and young women differently.  While the number of admissions of young men is increasing, admissions of young women are decreasing. We looked at some possible reasons for this in 2008-09 and suggested that young women may be more likely to be admitted on an arranged basis, often for treatment of eating disorders, whereas young men may be more likely to need urgent admission for other mental health problems.  We also suggested that there may be a tendency to regard 17 year old males as less suitable for an adolescent mental health ward.

As was the case in the previous three years,  more 17 year olds were admitted to non specialist wards than any other age group. 80% of these admissions involved young people aged 16 to 17. This figure is very consistent with figures from the previous three years (for example 77% of admissions in 2008-09 involved young people aged 16 or 17).

The trend over the previous three years has been for the number of female admissions to non-specialist facilities to fall and the number of male admissions to rise, particularily in the 17 year old age group. This trend has not continued in 2009-10, and the number of male and female admissions for 17 year olds is almost exactly equal, with more 16 year old young women than young men being admitted. It is not clear why this has happened this year and we will continue to look closely at admissions by gender to see if the reversal of the previous trend is maintained.