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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