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In December 2004 the Mental Health Act Commission published a report on 18 months of data collected from April 2002. Noble Lords will recall that I spoke about some of the worrying results from this report on an earlier occasion. I highlighted the
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The general level of over-representation of black and minority ethnic children and adolescents detained on adult wards is in stark contrast to their representation among those accessing informal care with specialist in-patient CAMHS units, where they made up only 3 per cent of reported admissions. Very few staff working on adult wards had received any specialist training in working with children or adolescents with mental health needs. On a number of visits staff expressed concerns over their lack of skills and knowledge for working with this client group. In some cases it was reported that they felt they could only offer containment until a more suitable placement became available.
There were often no arrangements for the continuation of young people’s education, even for those aged under 16 and of compulsory school age. Appropriate plans for the continuation of education during their hospital stay were in place for only about 10 per cent of the young patients visited, rising to just over 18 per cent for those under 16. Only one-third had access to a programme of activities appropriate to their age and abilities.
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In order to humanise those statistics, let me give your Lordships just a couple of example of patients whom the Mental Health Act Commission has met in the course of its work. Miss A was 16 years old and detained under Section 22 in an adult psychiatric care unit in central England. She had been initially admitted to an acute adult psychiatric ward as an informal patient having been transferred there from the local general hospital following an overdose. While on the acute ward, she was placed under Section 5(2) to prevent her from leaving until she was assessed for detention under Section 2 of the Mental Health Act.
She was then transferred to a mixed-sex adult psychiatric intensive care unit. Although staff had sought a more appropriate placement on an adolescent unit, none was available. Ward staff felt that they were providing merely containment. Although additional staff had been allocated to provide special observation in view of her vulnerability in an adult setting, they acknowledged that her special needs were not being met. Ward staff had not received any recent training in the care of adolescents and they had no access to a specialist child and adolescent psychiatrist for advice and guidance.
Miss A told Mental Health Act commissioners that, although she was generally happy with the care
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B was a 15 year-old Asian boy detained under Section 3 on an adult psychiatric intensive care unit. Three months before the Mental Health Act Commission met him, he had been transferred there from a nearby adolescent unit after having been assessed as requiring secure care as a result of his absconding, serious self-harm and suicide attempts. Secure care was not available under the local CAMHS service and, although he had been referred to an independent hospital out of the area that would have provided a specialist locked adolescent unit, no bed was available immediately.
Not all of the permanent staff on the ward had been police-checked and there was no access to a copy of the Children Act or the relevant guidance volumes on the ward. When he had been on the local adolescent unit, B had received daily education sessions. Since being transferred to the adult intensive treatment unit, he was being offered only two education sessions a week. Staff who had received no specialist training to work with adolescents were finding it difficult to cater for his needs or provide appropriate activities. They agreed that it was not a suitable environment for a 15 year-old boy for almost four months, but said that there was a serious lack of ITU beds available nationally for adolescents. I have no information on whether there were any cultural, religious, dietary or linguistic issues attended to for that young Asian boy.
I hope that those illustrations of how detained children and adolescents may be treated in adult services will help to emphasise the importance of the matters raised by noble Lords. I trust that the Minister will be persuaded to take urgent action on the matter.
Baroness Howells of St Davids: My amendment has been linked to Amendment No. 27. It is intended to ensure that children and young people under 18 receive services that meet their needs. I am obliged to all noble Lords who have spoken so eloquently, laying a foundation of appreciation in this Committee that children under the age of 18 should not be treated as though they were adults. Also listening to the debate is Kathryn Pugh, who comes from YoungMinds. She has been most supportive in drafting the amendment. I am sure that noble Lords would join me in expecting government, practitioners and parents to be united in ensuring that children get the best possible care to meet their needs.
Can we assume that primary care trusts will not hesitate to follow the code of practice and implement the guidance for independent advocacy immediately? National Standards for the Provision of Children’s Advocacy Services was published in 2002, informed by
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As the Committee discussed during the debate on principles, the establishment of guidance is no guarantee that what the Government regard as good practice will take place. We are all aware that financial pressures on national health trusts may prevent them purchasing services such as advocacy that are seen as a luxury rather than a basic right.
We owe it to our young people to afford them independent advocacy. It provides a safeguard against the improper use of powers to detain or to treat them. With an advocate present, a young person can be sure that someone independent of their parents, carers or clinicians will communicate their interests and ensure their right of appeal. We know that in a culturally mixed society not everyone is aware of his or her own rights under the law. In the amendment that clarifies the right of 16 and 17 year-olds to refuse treatment and not have that refusal overridden by their parents, we heard that despite guidance and case law, professionals responsible for treating young people are confused as to who or what should be permitted. How can we then expect a 14, 15, 16 or 17 year-old to understand what treatment under compulsion means for them, and to know their rights?
I illustrate this with the story of a young Asian girl, whom I will call S. She is 17, lives with her parents and was very depressed. She had self-harmed and taken overdoses, and was in regular contact with services. In one of her visits to mental health services, S talked about wanting to die. When asked if she was going to do anything to make this happen, she said she would if she got the opportunity. Due to concerns for her safety, she was admitted to hospital on a voluntary basis. This was a very daunting experience, as previously S had spent little time away from home.
S was admitted to an adult ward and was in a room with more than one adult, where a fellow patient threatened her. Although she found the environment intimidating and wanted to go home, it was recommended that she stay in hospital to be monitored. Staff did not understand the cultural difficulties she had on the ward, nor her difficulties in sharing a room, the inaccessibility of somewhere safe to pray and the lack of understanding of her dietary requirements. She was told that if she tried to leave she would be placed under section. S felt that nobody was explaining what this meant to her and that she continued to be in an unfamiliar environment with no, or little, support. She felt uncomfortable around certain members of staff, one even asking her if she felt it fair to put her parents through this.
A culturally competent advocate could have helped to improve the therapeutic alliance and helped staff to understand the importance of following her religious beliefs and of being in a private room. Her parents themselves would have been reassured to know that S had someone to whom she could relate, who both understood the system and was in her corner. Feeling more in control of the situation may have prevented S
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We have heard from other noble Lords about the over-representation of black and minority-ethnic patients on in-patient wards and under compulsion. I echo the remarks of those who have commented on the fear of many in the black community that reaching out to mental health services will mean being sectioned. I am positive that giving people the right to independent advocacy will go some way towards reassuring young people, their families and communities that their voices will be heard and their rights protected. I hope that this reassurance will help young people to seek help earlier before they reach a crisis, and that it may therefore even help to prevent admission.
It is ironic that the Mental Capacity Act 2005 enshrines a right to advocacy for people lacking capacity through the Independent Mental Capacity Advocacy Service, which is due to be implemented in April 2007. It is unacceptable for some patients who lack capacity to be awarded a statutory right to an advocate, while those who lack capacity and who are detained for their mental disorder do not have a similar statutory right to one. It is even more ironic when we consider that the Adoption and Children Act 2002 gives the right to advocacy to young people who are looked after by the state. Yet we do not guarantee young people with a mental health problem the right to such a service, despite their vulnerability.
The number we are talking about is small; according to the Mental Health Act Commission, it is about 260 young people a year, although we cannot estimate the number of young people who, as in the example I have just given, are threatened with detention and comply through fear. I and many others have welcomed the Government’s excellent policies to improve mental health services for children and young people, and I ask that the Government and this Committee regard the amendment as being within the spirit of the National Service Framework for Children and Every Child Matters and accept it as a logical and necessary addition to the 1983 Act.
Baroness Walmsley: On behalf of Members on these Benches, I support both the amendments, which would ensure that a child would be treated in an appropriate place after an appropriate assessment by a suitably qualified person and would have the necessary help to understand his rights and to express his views. This is a very laudable set of objectives and, although it would cost a little money in the short term, it would most certainly save the Government a great deal more money in the long term.
I hope the Minister will note that we are not trying to demonise adult wards, as the noble Earl, Lord Howe, said. Indeed, Amendment No. 27 would allow for 16 and 17 year-olds to be admitted to such a ward if the assessment determined that it would be in their interests and if the patient was happy with that. I must say at this point that references to the child’s best interests seem remarkably absent from the Bill.
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There seems to be nothing in the Bill about the duty of care to underage patients as children first and foremost—individuals who are different from adults in their needs, their level of vulnerability and their response to stressful situations. However, it is not beyond redemption, which we are seeking to achieve through the amendments. It is vital that children are treated in age-appropriate settings, partly because of the quality of treatment they will get there and partly because that treatment and that experience will colour their attitude to treatment later on. If they disengage from the process because of a bad experience when they are young, how will we get them to accept treatment voluntarily when they get older?
However, that is not the only reason. Child protection is a major factor. How can we countenance putting young people in situations where they can be abused, where illegal drugs are often widely and cheaply available on the ward, and where the staff are too busy to watch over them at all times? It is happening all the time. Here are some real examples given to Dr Cathy Street, research consultant to YoungMinds.
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A young woman was admitted at the age of 14 to an adolescent unit for self harm and attempted suicide. She was discharged, but continued to self harm, with regular visits to A&E. Eventually, she was placed under section at the age of 15. No bed was available in the adolescent unit, so she was taken to the adult ward, where she was placed on suicide watch. She was promised an advocate but no one came to visit her. She was discharged very suddenly, placed in a cab, and the driver was told to take her to the social services offices. The driver got lost, so the young woman directed him to a youth project she knew. Project workers at the group, who were horrified that she had been discharged so abruptly and so recently from suicide watch, called social services, which placed her with a foster family she had never met. She was finally readmitted to an adolescent unit, where it was recommended that she should receive long-term therapeutic care.
A young man, aged 15, was psychotic. The police were called to help with the admission, but, as no beds were available in a specialist unit, the police offered to keep him in a cell until a bed could be found. Fortunately, his mother refused to let this happen, so the young man was sedated for 24 hours while the arguments about where he should go raged on. He was admitted to the adult ward, which refused to keep him for more than 24 hours. Eventually, the PCT agreed to fund an independent place for six weeks, but no more. When he came home he still needed in-patient treatment, but it took nine months for him to be admitted to an adolescent unit.
My final example is a young man aged 15 who tried to kill himself by jumping in front of a car. He was admitted to A&E for 24 hours while staff looked for a bed, but the only place was on an adult ward,
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This is no way to treat young people, and I gather that it is all down to funding. Indeed, it is another example of a postcode lottery, since we know that the south of the country is much better provided with children and adolescent beds than the north. Something must be done to ensure that the number of child and adolescent beds per million of population recommended by the Royal College of Psychiatrists is available in all parts of the country. We also need more effort to provide services in the community to prevent the need for young people going into hospital at all.
We know that the Children’s Commissioner, Sir Albert Aynsley-Green, is very concerned about children going into adult units. He is about to publish a research report on the matter, which I understand makes horrifying reading. I have had time to read only the executive summary so far. There is evidence that children not only feel vulnerable to aggression and sexual harassment in adult wards, but also experience these things not infrequently.
In relation to the skills requirements under Amendment No. 27, why are we lagging behind Scotland, where the Mental Health Act 2003 specifies age-appropriate supervision by CAMHS specialists? Why is the National Service Framework for Children and Young People not being adhered to? Standard 9, paragraph 9.8, states:
“The different range and prevalence of serious disorders in childhood compared with adolescence means that services for these two broad age groups have to cater for a different range of needs, which need to be reflected in the specific skills of the staff working with them”.
That is clear, but it does not always happen.
Finally, Amendment No. 27 requires age-appropriate assessment by a CAMHS specialist, which seems only common sense in the light of what we have just heard. On Amendment No. 41 and advocacy, we are talking about very vulnerable young people who are not in their own homes. Children similar to those in public care in children’s homes or foster settings have a right to a dedicated social worker and someone who acts as an advocate. Why, then, do children in mental health settings not always receive the same right? The number of compulsorily detained children is small and organisations looking into the matter have calculated that the cost of providing this service to them would be less than £100,000 a year. If the service were extended to all children and adolescents in CAMHS units, which is desirable but not covered by this amendment, the cost would still be only about £1 million per year, a very small amount compared to the potential benefit. If the Government believe these figures are incorrect, I hope that the Minister will give us his calculations and tell us his source.
We should not be relying on a child’s parents to express his views and ensure he has all the information he needs to understand what is happening to him. Most parents are not equipped to do this, and what of the child who has no parents, or
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Baroness Masham of Ilton: I have a very brief speech. Throughout the National Health Service there have for many years been problems of accommodation for adolescents. It is difficult to treat adolescents with young children and babies in paediatric wards, and it is equally inappropriate to treat young people in adult wards, as has been said. I want to give noble Lords a few positive examples.
There is a splendid organisation called Body and Soul providing support for people with HIV and AIDS. In its work it has found that adolescents need their own space and help, away from children and adults. A hospice for children in Yorkshire has made a section for adolescents needing hospice care. It was so important for them to have their own accommodation with their age group. In young offender institutions, adolescents are now separated from the over-18s. It is even more important for young, mentally ill adolescents to have their own wards. Many of them have problems associated with puberty. Putting young people in adult wards with mentally ill adult patients could be to put them at risk. With so much emphasis placed these days on health and safety, who, can I ask the Minister, does the risk assessments for these young and vulnerable adults, especially given staff shortages in many hospitals at night? Why should mentally ill young people, who will have more problems than anyone else, not be treated in the same way as other groups such as the ones I have mentioned—and whose treatment I have found to be satisfactory?
Lord Carlile of Berriew: I apologise for speaking and thereby lengthening the debate at this stage of the evening, but in my view these amendments are among the most important to this Bill. They are consistent with the views of the joint scrutiny committee. It was our view that it was self-evident, as well as being a matter of evidence, that young people should be in age-appropriate facilities and that they should have doctors who are experienced in treating young people.
I want to reflect for a moment on my very close observations some 10 years ago of a young girl who went into a hospital suffering from serious depression and anorexia. On the advice of a reputable consultant—this was not in the countryside, but in London—she was sent to an adult unit. There she was treated heavily with drugs. After about four months, and as a result of parental demands made by parents who in the early stages were completely ignorant of the mental health sector, she was moved in a stupefied state to the adolescent unit at the Bethlem hospital, part of the Maudsley hospital. Some time later, the consultant who had professed expertise in treating that girl, though not a specialist CAMHS doctor, was suspended by the General Medical Council for sexual impropriety with a young female adult patient. The life of that girl was saved in the CAMHS unit at the Bethlem hospital because she was treated in an age-appropriate environment by highly specialist consultants with enormous skills.
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I can, if necessary, provide every detail of that story, having observed it at the closest quarters possible. It shows how dangerous it can be for anything other than the closest scrutiny—at an age-appropriate and place-appropriate level—to be put upon every single case involving a child. In many cases, teenagers who face the kind of situation I described are mature in some ways, but extremely immature in others. It emphasises the importance of them having age-appropriate treatment in all respects. The noble Lord, Lord Patel of Bradford, gave us a helpful catalogue in summary form—I am sure that it could have lasted for volumes, or hours—of other cases bearing out the example that I observed at such close quarters and was describing.
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