Memorandum submitted by the National Early Intervention Programme (MH 7)
As joint leads to the National Early Intervention in Psychosis Programme we write to urge you to consider very carefully the implications of the proposed new mental health bill now before you.
We think some of the proposals contained in this bill could have profoundly harmful consequences for young people experiencing their first episode of psychosis and their families. Indeed the specific concern of how the bill would adversely affect the state's duty of care towards children and young people has been recognised in the amendment that the House of Lords recently passed. We submit evidence in support of that amendment.
Q. Why should young people and children merit special concern?
A. This group are at particular risk of being legally detained into inpatient care.
Young people with their first episode of psychosis are more likely to experience a coercive entry to specialist mental health services than any other group of users of such services. Indeed it is almost the rule that for these young people their first experience of specialist help is in the setting of an in-patient unit, their stay often enforced through legal detention.
1. Inpatient rates: Studies of first episode psychosis consistently report admission rates to adult inpatient facilities of about 80% (eg Boeing et al, 2007 in a study specifically of under 18s)
2. Legal detention: approaching 40% of those in their first episode of illness are sectioned under the current act by community mental health teams
3. Young and black - a double whammy: the legal detention rate is even higher at over 50% for young black men (Morgan et al, 2005) reflecting their over representation in all mental health services.
Such a coercive early service experience breeds treatment reluctance and high service disengagement. This may explain why so many become lost to follow-up (50% within 12m) often only to re-emerge in further crisis, establishing a 'revolving door' pattern that all too often characterises these young peoples' future service use.
Q. Why is getting it right is so important for the under 18s?
A. Psychosis emerging in this young age group carries a poorer outlook for persistent illness and cumulative disability over a lifetime.
For 20% of adult sufferers, the onset of illness commenced aged 19 or less and for 5%, aged 15 or less. The majority of these young people have a relatively poorer outlook than those who are older at onset, leading to recurrent illness and markedly impaired social functioning (Hollis, 2003).
'She went from a children's service that didn't do psychosis to an adult service that didn't do young people'
Mother of a daughter with psychosis
One only needs visit an acute adult mental health ward to realise what a traumatic experience and inappropriate place to first experience care for a condition that will quite possible affect these young people and their families for the rest of their lives. So the very group most likely to need expert and appropriate care potentially for the rest of their lives are denied it by virtue of their age and the structure of present services over this key time of transition. It is quite simply a very bad start.
Q. Where does the current responsibility for providing care for the under18s lie?
A. PCTs have a duty of care for all under 18s in inpatient care.
PCTs have a duty of care to ensure that any in-patient under the age of 18 should be assessed by a Child & Adolescent Mental Health Service (CAMHS) professional, and that they receive in accordance with their particular needs. Furthermore if that young person is compulsorily detained under the mental health act then the assessment for compulsory treatment and subsequent supervision should be by a CAMHS professional (the only exception being if the situation is one of emergency).
Q. What evidence exists that PCTs and Mental Health Trusts are discharging their duty of care effectively for the under 18s
A. The Mental Health Act Commission have consistently voiced concerns about the treatment of detained children and adolescents within adult mental health facilities in its biennial reporting to the SoS.
A special report by the Mental Health Act Commission in 2003 listed many concerns alongside a series of recommendations. Issues noted included:
§ A survey of all relevant providers during the period 1999-2001 found that 62% of all children and young people under 18 admitted to inpatient care under the Act were placed on adult wards.
§ The majority of notifications were in respect of young people between 16-17 years of age with only 12.6% (34) being for children under 16 years.
§ For 16 and 17 year olds cared for on an adult ward only 13% had their care supervised by a specialist in child and adolescent psychiatry
Q. Specialist services provide early intervention to those aged 15 upwards with emerging psychosis
A. Most under 18s in England are still unable to access early intervention provision.
Despite being introduced as a policy priority in the National Service Framework (1999), half of England still lack any dedicated early intervention service (Tiffin et al 2007).
Indeed a quarter of those with EI services specifically exclude the under 16s (Pinfold et al 2007). The lack of CAMHS focus is reflected in the paucity of CAMHS professionals working in these teams (11% have dedicated part time CAMHS psychiatrists; 7% use part time CAMHS clinical psychologists; 5% employ qualified youth workers).
Q. Is there a continuing government commitment to improve services for young people with emerging psychosis?
A. EI is currently the most important NHS priority in mental health service development
From its emergence as a policy priority (refer to policy summary at end of this response), the incomplete service implementation of EI has been acknowledged prompting an EI Recovery Plan (Duncan Selbie Feb 2006). This has been further reinforced recently by the NHS Operating framework (section 2.19) and the Healthcare Commission as a new PCT commissioning target for 07/08.
This reaffirms the continuing government commitment towards improving the provision of EI services and links well with other policy initiatives for young people such as the children's NSF, Every Child Matters.
The mental health bill as it now stands will place practitioners and service providers in an unethical position where their legal power is not balanced by a parallel obligation to provide reasonable care and treatment in an age appropriate setting for these young people.
In considering this proposed legislation you should be aware that many PCTs and Mental Health Trusts have failed to implement government guidance that children should only be on adult wards by exception and where it is deemed appropriate.
This raises a fundamental question:
Q. How just is it that the state, through its various statutory organisations, can exercise such far-reaching legal powers whilst at the same time failing to discharge its responsibility to develop appropriate services for this vulnerable group of young people and their families?
This government has an excellent record of improving services for these young people, representing one of the most vulnerable, stigmatised and disadvantaged groups in our society. How sad it would be for these young people and their families if this record of government achievement and commitment were to be overturned by the perverse effects of a regressive mental health act.
Relevant Policy guidance: Department of Health, London.
2002 NHS Plan: Section 14.30 Early intervention in psychosis
§ Early intervention to reduce the period of untreated psychosis in young people can prevent initial problems, and improve long-term outcomes:
§ By 2004 all young people who experience a first episode of psychosis, such as schizophrenia, will receive the early and intensive support they need. This will benefit 7,500 young people each year
2003 CAMHS Target and Childrens' NSF
§ Comprehensive EI services by 2006
2006 Early Intervention Recovery Plan (Duncan Selbie Feb 2006)
§ Healthcare Commission: PCT commissioning target for 07/08
§ NHS operating framework 07/08: ...for the estimated 7,500 new cases each year of people needing early intervention. Recovery action on these issues will need to continue into 2007/08, so that patients receive the levels of care promised and we can be confident that comprehensive mental health services are in place in all areas.
§ NHS Institute for Improvement and Innovation 'Better Care Better Value Indicators': number of patients being served by EI services per weighted population (PCT)
Boeing L, et al (2007) Adolescent-onset psychosis: prevalence, needs and service provision British Journal of Psychiatry, 190, 18-26.
Morgan, C., Mallet, R., Hutchinson, G., et al (2005) Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission British Journal of Psychiatry, 186, 281-289
Mental Health Act Commission Review (2003) "Safeguarding Children and adolescents detained under the Mental Health Act 1983 on adult psychiatric Wards"
Pinfold P, Smith J, Shiers D. Audit of early intervention in psychosis service development in England in 2005. Psychiatr Bull 2007; 31: 7- 10.
Tiffin P A, Glover G, (2007) From commitment to reality: early intervention in psychosis services in England Early Intervention in Psychiatry 1 (1), 104-107