Children's and adolescents' mental health and CAMHS - Health Committee Contents


5  Inpatient CAMHS services (Tier 4)

121. Inpatient Tier 4 services are inpatient services for the most unwell children and young people whose mental health problems cannot be managed on an outpatient basis. Our submissions have described difficulties in accessing inpatient care for children and young people who have been assessed as requiring admission to hospital, with, in many cases, no beds being immediately available. When this happens, alternative arrangements have to be made to care for the child or young person until a CAMHS Tier 4 bed becomes available, which can often give rise to dangerous situations, as shown in the following stark examples from the Royal College of Psychiatrists:

    'Bipolar high risk patient had to be managed by parents at home went missing for a week because they couldn't look after her'

    'Anorexia patient lost further 10% body weight waiting for bed'

    'Risky situations arose in acute paediatric ward when numerous patients with mental health difficulties on ward at same time and 'ganged up' to confront nursing staff. Indirectly related to nursing staff not having training or skills to manage mental health needs of these patients.'

    'paed bed bay unsafe w access to glass, ligature points and barricading possibilities. Attempted ligature. Restraint by 5 man hosp security team and IM tranquillisation [age 14]. Another, police involved and prolonged handcuffs also age 14'

    'Young person (aged 15) on Section 136 in the police cell. It took 18 hours for the police surgeon to see her and then when the psychiatrist saw her it was not until 38 hours after admission to the cells that a bed was found for a section 2 in a distant city'

    'Admission to adult ward while awaiting bed has resulted in adverse experiences for some YP despite best attempts to provide appropriate care e.g. witnessing successful suicide attempt, assaulted by adult patient.'[158]

122. Inappropriate admission of young people to acute paediatric wards was raised as a problem by many of those submitting evidence, including Birmingham Children's Hospital NHS FT:

    Currently there are 4 Birmingham young people on paediatric wards awaiting a Tier 4 bed. We understand there are a further 14 across the region waiting for beds. These are the young people at most risk of suicide and we believe the current level of risk in the system is unacceptable.[159]

123. Worcester County Council state that "first and foremost, the most serious current issue in Worcestershire is the risk to children and young people's safety as a result of the national crisis in access to CAMHS Tier 4 in-patient facilities":

    The growing problem manifested itself over the last few months when our Acute Hospitals Trust raised major safety concerns when several CAMHS patients were kept inappropriately in an acute paediatric ward whilst waiting for a Tier 4 bed.[160]

124. An alternative to an inappropriate admission to a paediatric ward is for a child or young person to receive more intensive CAMHS support in the community whilst awaiting a bed, but this too can lead to unsafe situations:

    Other children and young people have been supported intensively in the community for long periods whilst on the waiting list for a Tier 4 bed. The longest delay to date has been 4 weeks, but CAMHS have recently been told that a child on the waiting list will have to wait for 6-8 weeks for a bed. This puts tremendous strain on the child, their family and the clinicians caring for them, who have to try to manage the child's condition and the significant risks to their safety that result from the lack of an appropriate safe clinical environment for their treatment.

    The Worcestershire health economy is being forced to make less than ideal provision for these children and young people who are not receiving the right care in the right place at the right time and we are very well aware that at any point we could be faced with a child death that could have been prevented if there had been ready access to Tier 4 in-patient care. [161]

125. Another outcome of the absence of appropriate CAMHS Tier 4 beds may be the inappropriate admission of children and young people to adult mental health wards. Data published in March by the HSCIC reveals that the number of children and young people being treated in adult mental health facilities is rising:

    In 2011-2012, 357 under-18s were treated on adult mental health wards in England, which went down to 219 in 2012-13. However, between April and November 2013 alone, the figure reached 250.[162]

126. Finally, if suitable inpatient beds are not available locally, children and young people may have to be admitted to a CAMHS Tier 4 bed elsewhere in England, which in some cases may be hundreds of miles from their homes:

    There have been occasions, and they seem to be increasing, when no Tier 4 bed was available in either private or NHS units across the country or the closest bed to London was in Edinburgh[163]

    An audit over 5 months in 2012 showed that … Children travelled to London, Birmingham, Berkshire, Norfolk - all hundreds of miles away … Over the past year, this trend has continued. The distances involved are frequently more than those highlighted in the media recently, with Cornish youngsters being admitted to units in the private sector, which the local CAMHS have no links to, and often staying there for several months.[164]

127. This causes great difficulties for families and friends visiting, and can also lead to longer stays in hospital as there are no links with local community CAMHS services to facilitate a swift discharge back home.

    This has led to financial and emotional hardship for families, increased lengths of stay and challenges in providing optimal treatment.[165]

128. This is not just a problem in rural areas, or areas that have limited CAMHS provision within their own region. A witness from Birmingham told us that although they in fact have sufficient local Tier 4 capacity to meet the needs of children and young people in their area, this capacity is now frequently being filled by children and young people from other parts of the country, forcing them to admit their children to units in other areas:

    We are a net importer of patients from other regions. As a result, some completely ridiculous things happen. Recently, for example, we had a 15?year?old girl who came from Birmingham as a new presentation and she had to go to Newcastle for a bed, while at the same time we had someone from Newcastle being admitted to one of our beds. The lack of co?ordination is completely outrageous.[166]

Use of police cells

129. A separate but related issue concerns the use of police cells for the accommodation of children and young people under Section 136 of the Mental Health Act. Section 136 give the police a power to remove from a public place any person an officer believes is suffering from mental disorder and who may cause harm to themselves or another and take them to a designated place of safety for assessment under the Act.[167] People who have been detained by the police under Section 136 of the Mental Health Act must be taken immediately to a safe place where a mental health assessment can be undertaken. This should be a 'health-based place of safety', located in a mental health hospital or an emergency department at a general hospital. They should only be taken to a police station in exceptional circumstances.[168]

130. Growing concern about people in crisis being taken to police cells instead of health based places of safety has prompted the Government to state that each local area, as part of its own Mental Health Crisis Declaration, should commit to reducing the use of police stations as places of safety.[169] This will be monitored by the Department of Health, with the expectation that the use of police cells as places of safety should fall rapidly, dropping below 50% of the 2011/12 figure by 2014/15.[170] With regard to children and young people specifically, the Crisis Care Concordat specifies that local protocols should ensure that police custody should "never" be used as a place of safety "except in very exceptional circumstances."[171]

131. However, figures from the Association of Chief Police Officers estimate that, in 2012/13, 580 children and young people under the age of 18 were detained under Section 136. Of those, it is estimated that 263 (45%) were taken to police custody. The CQC believes that the restrictions on access for young people to health-based places of safety in some areas are a key reason for this. A recent survey carried out by the CQC as part of its thematic review of mental health crisis care found that, while all but one upper tier local authority (county or municipal borough) area is served by a health-based place of safety, over 20% of these areas are not served by a place of safety which accepts young people under the age of 16. CQC found that 35% of the 161 health-based places of safety do not accept young people under the age of 16, and 17% do not accept young people aged 16-17.[172]

132. Young people who we met with described being held in police cells as a hugely frightening and negative experience, and others argued that there was a need for police officers to be better trained in understanding and managing young people with mental health problems. Research from the Howard League estimates that nearly 74% of mental health trusts do not provide a specialised place of safety for children:

    There are only 161 places of safety in England, many of which can only accommodate one person at any one time and a third of these places do not take under-16s. Therefore not only is there a severe lack of facilities and accommodation available but many of these facilities do not accept children and young people. Many trusts are refusing to admit children into their places of safety, arguing they are not age appropriate. This means adults may be held in a specialist facility but a police cell is used as a default place of safety for children. [173]

133. They go on to argue that:

    Under no circumstances should a child experiencing a mental health crisis be taken to a police station. A commitment to public safety means treating these children as vulnerable children, making sure they get the help they need, and not locking them away in a police cell. Resources need to be prioritised and in place to receive children under section 136 in specialised health-based settings to be able to assess these children quickly. Better still would be the removal of police stations as a place of safety under the Mental Health Act at least for children.[174]

134. Drawing on a survey of their membership, the Royal College of Psychiatrists reported that:

    Faculty members reported very variable experiences of S136 for children and young people. The majority reported an increase in the use of S136, including one who reported a 6 year old detained under S136. Several experienced consultants commented on the relatively recent use of S136 with the under 18s. Some described arrangements for young people, with young people admitted to adult 136 suites where staff are now enhanced CRB checked and able to manage under 18s. Others described unsatisfactory arrangements such as places of safety located in council offices or children and young people being held in Police cells for extended periods of time.[175]

135. Oxford Health NHS Foundation Trust provided details of the collaborative work they have done with the police service and local adult mental health services:

    Oxford Health NHS FT have worked with Police colleagues across all counties in which we work to ensure appropriate care for young people. For example the joint work we have done with police in Swindon, Wiltshire and BaNES to implement a policy to ensure police officers can get quick advice from CAMHS about young people they have concerns about. This has reduced use of section 136 in Swindon and Wiltshire and ensured YP get the correct assessments at the right level and kept children out of police cells.

    Oxford Health NHS FT does not provide adult mental health services in Swindon Wiltshire and BaNES and so it has been particularly important to work with commissioner's adult provider (Avon and Wiltshire Partnership NHS Trust), to get access to 136 suites for under 18s who do get detained under sec 136 in that area to ensure such children are not detained inappropriately in police cells. Where the Trust provides Adult Mental Health Services (Oxfordshire and Buckinghamshire) this has been managed in house.[176]

136. The Crisis Care Concordat was launched by Government in February 2014, with the aim of improving crisis care in mental health:

    Our Mental Health Crisis Care Concordat, launched on 18 February, makes it clear that all services should work together to minimise the chance of young people with mental illness ending up in a police cell. The Concordat builds on the objective we have given the NHS in the Mandate that every community should have plans to ensure no-one in crisis will be turned away. Unless there are specific arrangements in place with CAMHS, a local place of safety should be used, and the fact that such a unit might be attached to an adult ward should not preclude its use for this purpose.[177]

137. However, we saw little evidence that it has yet made an impact on crisis care for children and young people, with few references to it in the written evidence we received from commissioners and providers. One witness, when asked if she felt confident that progress was going to be made with the Crisis Care Concordat, replied that, although she was about to attend a meeting about implementing it, she still did not feel confident about its impact. [178]

Reasons for problems with Tier 4 access

138. The submissions received by this inquiry suggest that a range of factors may be contributing to the current difficulties in accessing beds. In a survey carried out by the Royal College of Psychiatrists, over 40% of respondents believed that each of the following issues were significant:

    Increase in referrals, decreased capacity of social care, decreased inpatient capacity, decreased community CAMHS capacity, changes in commissioning arrangements, change in clinical need /complexity of cases.[179]

139. In oral evidence, witnesses highlighted rising demand, new commissioning arrangements disrupting local networks that had previously worked to minimise the need for admissions, and reductions in some of the wider support systems that previously enabled young people with mental health problems to be managed in the community.[180] They also pointed out pre-existing problems with the distribution of Tier 4 services around the country.[181] John Rouse argued that current problems have their history in the previous commissioning system, where PCTs were variable in their approach to commissioning inpatient care:

    The point about "This has never been got right" is really important, because the system we had before 1 April 2013 had different but equal problems. One of the reasons why we are in the situation we are, in terms of tier 4 beds and disparate geography, is because PCTs took very different approaches to those responsibilities. Some really got their act together, formed regional groupings and worked with their strategic health authority; places like the west midlands and the north-west had really good strategies and adequate beds, part of which are now filled from other parts of the country. Other PCTs did their own thing, did not make proper provision, and in those areas we have insufficient beds. At the very least, by bringing that all together under NHS England, we can see the problem as a whole piece and plan on a national basis, working through the 10 area teams.[182]

140. Since April 2013, Tier 4 inpatient services have been commissioned on a national basis by NHS England. Following its review of Tier 4 services, NHS England has announced 50 new beds will be commissioned, to add to the 1,264 currently available in England.[183] The Minister was clear that "there have to be beds available for those who need them, and they should not be, unless it is a particular specialty, a long way away from home."[184] He went on to say that NHS England plans for each area to be "self-contained" in respect to access to beds, "so that each area can be confident that they have the beds for children and young people in their area and we end this unacceptable shunting of people around the country."[185] However, the NHS England review does not provide a conclusive answer on the reasons for the current problems, nor on whether there are sufficient beds:

    Commissioners were requested to offer a view about whether "in theory" there were sufficient beds to meet local demand both before and after April 2013. Responses were mixed; some said theoretically there were sufficient beds locally and others had a clear view that there were not, whilst some described a mixed picture across their geography. Most noted an increase in demand since April 2013 and therefore a current insufficiency of beds.

    It appears that the current difficulties being experienced are the consequence of a range of factors which adversely affect capacity. It is therefore impossible to conclude definitively whether the current level of bed provision is sufficient to meet the need. Variations in practice around admission protocols, approvals, availability of intensive community services and management of delayed discharges compound the picture as do bed closures and staffing problems. Some controls that were in place pre-April 2013 have been discontinued. Equally however, difficulties that were previously experienced at a local level are now seen nationally for the first time.[186]

Quality

141. NHS England note in their written submission that they and the Care Quality Commission (CQC) had closed admission to some Tier 4 units as a result of quality concerns, and on occasions units were closing to admission due to staff shortages.[187] When the Committee met with young people, some described their negative experiences in Tier 4 services, which included lack of choice of treatment and of carers, feelings of isolation, a sense of 'blame' for being there, and difficulties making the transition out of hospital.

142. In the written evidence received by the Committee from individual parents, carers and service users, about a quarter of submissions referred to inpatient care, and of these, a mixture of concern and praise were noted. Some of these highly praised specialised inpatient care for the difference it had made to their lives. For example, one adolescent and her parents were highly impressed at the care and support she had received in a specialised unit, including the treatment itself, the manner of the staff, the environment and the support of a charity to enable the parents to stay near the unit at the weekends free of charge. However, both the adolescent and her parents had been deeply concerned at the insensitive and abrupt manner in which discharge was handled and the lack of continuity of care, which was reflected in submissions by other parents and carers.[188]

143. A few parents and carers raised concerns about the lack of inpatient care locally, making it difficult and expensive for family to visit and support the child, and leading to a lack of continuity of care. One parent raised serious concerns about the practices of a particular residential unit to which his daughter had been admitted under section following extreme self-harm and a suicide attempt. [189]

144. NYAS is a charity providing advocacy services for young people. NYAS make the following observations about the quality of care in Tier 4 inpatient units based on their work with young people:

    The calibre of staff therefore is critical. Children and young people often talk to advocates about issues with staff rather than complain about what is happening. We have examples from young people which include asking the advocate to support them to raise concerns about staff attitudes which they were experiencing as punitive. In one case NYAS contributed to a resignation after which the young people reported that they were experiencing a more open and responsible culture and one in which they had more trust and confidence.

    The role of unit staff is critical in affecting a positive culture. Across all tier 4 advocacy services, attitudes of staff and in particular bank staff and staff working at night are a feature of concerns raised. In one setting, young people reported to the NYAS advocate the noise being made by night staff behaving irresponsibly which affected the sleep of young people on numerous occasions. Young people often feel that they wait too long for someone to talk to them. Decisions which should be discussed and agreed with young people sometimes are not. We have examples of a points system being introduced for the tidiest bedroom with a score board visible for all staff. Another example involved young people writing on the board outside their room what time they wanted to be woken up the following morning. If one young person failed to awake at the specified time, all young people would be woken up an hour earlier the next day as a result. It is also a concern that staff are unaware of the rights of children and young people. Effective training is essential for all staff about how to communicate with children and young people, how to treat them with dignity and respect even when their behaviour is challenging. They need to be aware of the rights and entitlements which includes the legislative framework.

    Food and the quality of it is a recurring theme across all the tier 4 services in which NYAS provides an advocacy service.

    It is critical to the recovery of children and young people that tier 4 settings do not fall back into institutionalising the staff and the patients. Responses from tier 4 managers of these settings to issues raised by advocates on behalf of children and young people is constructive but the actions they need to make take a long time.

    We also have positive feedback from children and young people about their experiences of tier 4 settings, including having a say in the décor of the unit.[190]

Commissioning inpatient CAMHS services (Tier 4)

145. In April 2013, NHS England took over commissioning of Tier 4 inpatient services. Fifteen months later, in July 2014, they published a review of inpatient services, and announced the commissioning of 50 extra inpatient beds, with further beds moved according to need.[191] As mentioned in the previous chapter, the move to national commissioning replaced the system of local commissioning by PCTs, which had reportedly led to geographical variation, as described by this provider organisation:

    In the past these services were patchy and there was considerable variation across the country with some areas having little or no access to beds. As a result, the move to national commissioning seemed like a good idea…[192]

146. Some written evidence we received was positive about the new commissioning arrangements:

    The structure of NHS England with a single Account Manager and supporting Local Area Teams works extremely well. This is the most cohesive commissioning and management structure that the NHS has had. As an independent sector operator, Alpha Hospitals has found working with NHS England to be hugely supportive. NHS England drives tangible improvements in the quality of care that they commission. They get to know services inside out and work in total partnership with services to drive forward the patient experience and the quality of the service.[193]

147. Even some witnesses who were critical about how the new arrangements were working remained supportive in principle of national involvement in commissioning.[194] However, our evidence highlighted a number of problems with NHS England's commissioning. Central and North West London NHS Foundation Trust raised the following issues:

    We have received no communication regarding access and discharge arrangements since the move to National Commissioning. We co-ordinate the North West London Out of Hours Emergency CAMHS response which makes this particularly concerning … We have been unable to engage NHS England in discussions regarding the current lack of in-patient beds and have therefore no agreed contingency plans to manage this. We have been left to negotiate with our local paediatric and adult ward bed managers with no support from the responsible commissioners … We are being asked for data regarding admissions and discharge data by local CCGs/CSU because it is not forthcoming from NHS England …No analysis of trends (and therefore barriers/problems) is being undertaken (or if it is then it is not being shared) to support understanding, planning and solutions.

    This is all having a significant impact on our ability to meet the needs of our service users and deliver our contracted services effectively and safely. Prior to the move to NHS England local CAMHS commissioners played a significant role in supporting and brokering partnerships between health, education and social care services to support discharge and avoid delays. This support is no longer available and this may go some way to explaining the huge problems we now face in accessing appropriate in-patient beds.[195]

148. Steve Buckerfield of North West London Commissioning Support Unit also described difficulties in collaborating with NHS England:

    That is probably not because they are unwilling but because they are currently too consumed with their own process. They explain they are still trying to find the contracts, and they do not understand how it works with their area teams and specialist teams. You remain sympathetic, but then you go back and they will not tell me who is in hospital. I used to know all the children who were in hospital; now I don't—they tell me to go and ask my provider. That lack of exchange of information with clinical commissioning groups is ridiculous. That is the bad side, I would say, and the answer is to force people to collaborate.[196]

149. Barnet, Enfield and Haringey Mental Health Trust put it in strong terms:

    A considerable amount of clinical time is also being spent trying to track down beds as there does not seem to be any centralised information available …. For the Tier 4 situation to be alleviated, it is vital that NHS England take control of the inpatient commissioning process. There needs to be a centralised structure where the use of beds is approved, as was previously the case with local commissioners, but also monitors the bed availability and can advise the closest bed to the requestor.[197]

150. Dr Diwakar of Birmingham Children's Hospital NHS Foundation Trust told us that in his view, the lack of effective national co-ordination of inpatient beds, which led to children being transported across the country, was 'completely outrageous'[198] Dr Diwakar also felt that in his view, there is insufficient co-ordination of the bed-finding and admission process by NHS England, and described paediatric intensive care as an example of a similar, highly specialised service which is better co-ordinated, with a single number that clinicians can call:

    Families need to know what they have a right to expect, who is responsible for delivering it and what they can do if they don't get it. What I am not seeing at a national level for tier 4 is somebody who says, "It is my responsibility to get your young person admitted to the nearest tier 4 bed that can meet your needs." ….If I take the example of paediatric intensive care … again you do get periods where the service is overwhelmed and children have to be transported across the country. But certainly what happens in the west midlands is that there is a single number that you can ring if you are a paediatrician wanting an intensive care bed … there is a service that is extremely responsive to the needs of children who are critically ill. I think we should aim to get the tier 4 service into exactly the same state, where there is central co­ordination either at a regional or national level which allows families to know that there is a single person or team who is responsible for finding the most appropriate placement and you can give them a name so that they have an identity.[199]

151. The press release accompanying the NHS England review notes "weaknesses in commissioning and case management"[200]; further detail is provided in the review report:

    Whilst the new commissioning responsibilities since April 2013 have been perceived by some as the cause of recent difficulties, there are other factors around past variation in practice and provision which have significantly influenced the situation. Arrangements that may have been in place by previous commissioners to manage demand largely disappeared on 1 April 2013. There were few if any posts in specialised area teams to place, manage or monitor the use of CAMHS Tier 4 in the first 6 months from April 2013 (now some case managers in place temporarily). Specialised area teams inherited an arrangement whereby their CAMHS Tier 3 providers could place young people anywhere there was a bed available, without nationally agreed access criteria or funding flow arrangements being in place.

    Areas which had previously worked to ensure sufficient capacity was available to them have expressed concern that the capacity in their area is now being used by other areas, for a variety of reasons, including insufficient provision elsewhere and lack of robust access assessment (which includes consideration of safe/effective alternatives to admission). This in turn impacts upon their ability to access local capacity for local young people. Thus the effects of shortfalls in provision in some areas are now over-spilling. The system put in place for commissioners to notify each other of a placement being made out of area was reliant on providers notifying commissioners of out of hour's placement. This was not universally adhered to. Information systems to track patients were not in place. They have since been developed although implementation is hampered by capacity …

    … In addition, where there were excellent local commissioner and specialised commissioner relationships previously in place these have been affected due to changes in personnel, capacity and/or understanding of responsibilities. This situation needs to be addressed.[201]

152. NHS England report that they are now planning to recruit 10-20 new case managers to ensure that young people receive appropriate levels of care.[202] Kath Murphy told the Committee that "over the years we have found that having case managers, particularly in specialised commissioning, is very effective, because it keeps track of individuals"[203]

Education for children in inpatient CAMHS

153. A specific issue raised by young people the Committee met was that of poor educational provision in Tier 4 services, and the wider impact of mental health problems on young people's education. Young people argued that there was not enough time spent on education in Tier 4 inpatient units, and also that the quality of it was poor. This issue was also raised by NYAS: "Education, activities and the quality of them are not consistent. This makes a return to community education harder for some."[204]

154. There is limited information available on education provision in inpatient CAMHS services, although in November 2013, OFSTED published a special report of an inspection of education provision for children and young people who do not, or cannot, attend full-time school education in the usual way, including, amongst other groups, those who have mental health needs and access Child and Adolescent Mental Health Services (CAMHS). The report, based on a sample of 15 local authorities, concluded that:

    In too many of the local areas visited, provision was not flexible enough so that some children and young people had only a few hours of education each week. For example, those with the most significant mental health needs frequently had effective, full-time education in hospital or healthcare settings, but such provision was less frequent for those using community mental health services. Ofsted does not routinely inspect some of the education provision visited for this survey, because it is run as a local authority service or a health service rather than as a school.[205]

155. We raised this issue with the Minister, and he told us that "it is something that clearly has to change. You have identified a real problem".[206] However, representatives from NHS England suggested that even though they commissioned Tier 4 services, the education delivered to children within those services was not their responsibility:

    It is an issue that has been raised, and it is my understanding—I am happy to be corrected—that it is education's responsibility to be providing education in those units, so we expect those units to discuss improving provision with the local education authority … I cannot respond on the local education authority not putting the education in. We can pursue it with that provider, but we need the area teams to pursue it. That is very much a local education authority responsibility.[207]

156. In a follow up response to our evidence session, the Minister stated that NHS England would, in fact, now be conducting further work in this area:

    NHS England are liaising with OFSTED to identify Child and Adolescent Mental Health Services (CAMHS) in which educational provision has been identified as requiring improvement, or as inadequate. NHS England will be asking its Area Teams to engage at local level to understand the underlying issues in each case. This will include seeking to understand the working relationship both with the educational providers and with the Local Authorities that commission them. NHS England will be asking whether there are other ways in which it can use its influence as a CAMHS commissioner to facilitate the improvement of educational provision.[208]

157. We also asked the Secretary of State for Education for her view on this:

    We recognise there are concerns around education provision and standards in Tier 4 CAMHS. Provision is made in a range of different ways. This can be necessary to provide for children with very specific circumstances, but can affect funding, commissioning and accountability for quality. We are working on with the Department of Health and NHS England to get better information on how provision is made and to identify whether further specific action is needed.

    In terms of quality, Ofsted inspects hospital education when it is provided by a 'hospital school' and all registered alternative provision. But we know that in some smaller medical units, such as Tier 4 CAMHS provision, the education may be through an individually commissioned arrangement rather than a hospital school and hence not inspected by Ofsted. This is a particular area where we recognise we need better information to inform future activity.[209]

Conclusions and recommendations

158. It is clear that there are major problems with access to Tier 4 inpatient services, with children and young people's safety being compromised while they wait, suffering from severe mental health problems, for an inpatient bed to become available. In some cases they will need to wait at home, in other cases in a general paediatric ward, or even in some instances in an adult psychiatric ward or a police cell. Often when beds are found they may be in distant parts of the country, making contact with family and friends difficult, and leading to longer stays.

159. Linked to this, the Committee is particularly concerned about the wholly unacceptable practice of taking children and young people detained under s136 of the Mental Health Act to police cells, which still persists, with very few mental health trusts providing a dedicated place of safety for children and young people.

160. It is wholly unacceptable that so many children and young people suffering a mental health crisis face detention under s136 of the Mental Health Act in police cells rather than in an appropriate place of safety. Such a situation would be unthinkable for children experiencing a crisis in their physical health because of a lack of an appropriate hospital bed and it should be regarded as a 'never event' for those in mental health crisis. In responding to this report we expect the Department of Health to be explicit in setting out how this practice will be eradicated.

161. Alongside problems with access to inpatient services, we also heard from young people and their parents, as well as those who work with them, of quality concerns in some inpatient services; NHS England reported that over the past year some inpatient services have in fact been closed owing to quality concerns.

162. Written submissions to this inquiry have described a situation where despite the move to national commissioning over a year ago, NHS England has yet to 'take control' of the inpatient commissioning process, with poor planning, lack of co-ordination, and inadequate communication with local providers and commissioners. While many of the difficulties NHS England is now seeking to address may be a legacy from previous arrangements, it has not, in our view, sufficiently prioritised these problems. We note that in addition to the new capacity that is being funded, NHS England is recruiting more case managers to give them better control over the commissioning process, but we are disappointed that during its first year as a commissioner of inpatient services, many of the perceived benefits of national planning have not been realised, and NHS England has instead presided over a system which has resulted in children being sent hundreds of miles to access care. We intend to review NHS England's progress addressing these problems early in 2015.

163. As a first step in improving its commissioning of Tier 4 services, we recommend that NHS England should introduce a centralised inquiry system for referrers and patients, of the type that is already in operation for paediatric intensive care services.

164. NHS England has announced 50 extra inpatient CAMHS beds, but by its own admission, it is not clear how many beds are needed to provide sufficient Tier 4 capacity. It is essential that the extra beds are commissioned in the areas which need them most, and are supported by an improved system of case management. We will seek an update on progress in this in six months.

165. As well as the well-publicised concerns relating to access to inpatient services, the young people we met with who had experience of inpatient CAMHS services gave us insight into a further problem, relating to the quality of education children and young people receive when they are being treated in inpatient units. We were very surprised when NHS England, which is responsible for commissioning inpatient services, stated that this was not its responsibility; since then, it appears that both NHS England and the DFE are taking steps to investigate this further.

166. We believe that education is crucial to protecting the life chances of the especially vulnerable young people who need inpatient treatment for mental health problems, particularly as in some cases these admissions may last many months. It is essential that clear standards are set for the quality of education provision in inpatient units, and that there is clear accountability and ownership for ensuring that these standards are upheld. As a first step towards this, we recommend that OFSTED, DFE and NHS England conduct a full audit of educational provision within inpatient units as a matter of urgency.


158   The Royal College of Psychiatrists (CMH0173) Annex B, pp33-34 Back

159   Birmingham Children's Hospital NHS Foundation Trust (CMH0130) para 8 Back

160   Worcester County Council (CMH0160), para 3 Back

161   Worcester County Council (CMH0160), para 4 Back

162   'Children admitted to adult mental health wards 'rising', BBC news website, 11 March 2014 (accessed October 2014)  Back

163   Barnet Child & Adolescent Mental Health Service (CMH0142) para 4.1 Back

164   Cornwall Partnership Foundation NHS Trust (CMH0189) p5 Back

165   Cornwall Partnership Foundation NHS Trust (CMH0189) p5 Back

166   Q156 Back

167   HM Government, Crisis Care Concordat, February 2014, p22 Back

168   New map of health-based places of safety for people experiencing a mental health crisis reveals restrictions in access for young people, CQC news release, 16 April 2014 (accessed October 2014) Back

169   HM Government, Crisis Care Concordat, February 2014, pp10-11 Back

170   HM Government, Crisis Care Concordat, February 2014, p24 Back

171   HM Government, Crisis Care Concordat, February 2014, p24 Back

172   New map of health-based places of safety for people experiencing a mental health crisis reveals restrictions in access for young people, CQC news release, 16 April 2014 (accessed October 2014) Back

173   Howard League (CMH0232) p4 Back

174   Howard League (CMH0232) p5 Back

175   The Royal College of Psychiatrists (CMH0173) para 35 Back

176   Oxford Health NHS Foundation Trust (CMH0230) para 42-43 Back

177   Department of Health (CMH0154) para 34 Back

178   Q167 Back

179   The Royal College of Psychiatrists (CMH0173), para 14, reasons listed in order beginning with the factor that most respondents indicated Back

180   Q11  Back

181   Q11; Q155  Back

182   Q360 Back

183   NHS England takes action to improve access to specialised mental health services for children and young people, NHS England media release, 10 July 2014 Back

184   Q341 Back

185   Q349 Back

186   NHS England, Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report, 10 July 2014 p86 - 87 Back

187   NHS England (CMH0193) para 8 Back

188   Personal experiences of CAMHS, written evidence, p9  Back

189   Personal experiences of CAMHS, written evidence, p10 Back

190   NYAS (CMH0081) pp3-5 Back

191   NHS England takes action to improve access to specialised mental health services for children and young people, NHS England media release, 10 July 2014 Back

192   Barnet Child & Adolescent Mental Health Service (CMH0142), para 4.1 Back

193   Alpha Hospitals Ltd (CMH0068), para 4i Back

194   Steve Buckerfield, Q255; Dr Diwakar, Q161 Back

195   Central and North West London NHS Foundation Trust (CMH0132) pp3-4 Back

196   Q255 Back

197   Barnet Child & Adolescent Mental Health Service (CMH0142), para 4.1-4.2  Back

198   Q156 Back

199   Qq 164-165 Back

200   NHS England takes action to improve access to specialised mental health services for children and young people, NHS England media release, 10 July 2014 Back

201   NHS England, Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report, 10 July 2014, pp 20-21 Back

202   NHS England takes action to improve access to specialised mental health services for children and young people, NHS England media release, 10 July 2014 Back

203   Q374 Back

204   NYAS (CMH0081)p4 Back

205   OFSTED, Pupils Missing Out on Education: Low aspirations, little access, limited achievement, November 2013, p8 Back

206   Q395 Back

207   Qq 394-95 Back

208   Written evidence submitted by Rt. Hon Norman Lamb MP, Minister of State for Care and Support (CMH0234) pp1-2 Back

209   Department for Education (CMH0236) p 3 Back


 
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© Parliamentary copyright 2014
Prepared 5 November 2014