Admission to adult mental health wards for under 18's - adaptation for Scotland: guidance

Introduction

These best practice guidelines were developed in support of Action 19 of the Mental Health Strategy 2017-27:

Commission Lead Clinicians in CAMHS to help develop a protocol for admissions to non-specialist wards for young people with mental health problems

The guidelines seek also to support the implementation of section 23 of the Mental Health (Care and Treatment) (Scotland) Act 2003 (MHA) which states that:

S23. Provision of services and accommodation for certain patients under 18

A Health Board shall provide for any child or young person who—

a) is detained in hospital under Part 5 or 6 of this Act; or
b) has been admitted to hospital, whether voluntarily or not, for the purposes of receiving treatment for a mental disorder, such services and accommodation as are sufficient for the particular needs of that child or young person.

2) In this section, "child or young person" means a person under the age of 18 years.

When a young person under the age of 18 requires inpatient treatment, the needs of each individual young person are paramount and should be central to determining the care he or she receives. Section 23 places a duty on Health Boards to provide sufficient services and accommodation to meet the needs of young people under the age of 18 when they are admitted to hospital for treatment of their mental disorder.

For the purposes of this guidance non-specialist wards are defined as wards that have not been designed solely for the mental health care and treatment of young people under the age of 18. The most common non-specialist mental health wards to which young people are admitted are adult mental health.

In 2013 The Mental Welfare Commission for Scotland (MWCS) published guidance on the admission of young people to adult mental health wards. The aim of these standards is to develop that guidance further by incorporating elements adapted from accreditation standards developed by the Royal College of Psychiatrists in 2009 to enable adult mental health wards to demonstrate their ability to provide safe and appropriate care for young people under 18 who require admission.

When expanding on Section 23 of the MHA, the statutory guidance provided by the Code of Practice states that "whenever possible, it would be best practice to admit a child to a unit specialising in child and adolescent psychiatry" and that "a young patient should only be admitted to an adult ward in exceptional circumstances, for example, where no bed in a child or adolescent ward is immediately or directly available."

At times there may be no available alternatives to admission to a non-specialist ward and so such admissions may become necessary. When addressing the question of where a young person should be admitted, the needs of each individual child or young person should be regarded as paramount and it should be their needs, rather than constraints of services involved, that should guide the decision-making process.

In circumstances where there is no available specialist inpatient bed, a balance needs to be struck between the risks to the young person of failing to admit them and the potential adverse effects of the admission. Additionally, on rare occasions, it may be acceptable and appropriate for a young person to be cared for in an adult ward in preference to a specialist young person's unit. This decision will depend on the individual circumstances of the young person and factors that may influence this decision include the developmental maturity of the young person, their occupation and the nature of their mental health problems. It may also be the case that, on balance, an admission to an adult ward nearby may be preferable to an admission to a young person's unit far from home. Where an admission to a non-specialist bed does become unavoidable, however, every effort should be made to provide for the young person's needs as fully as possible including their ability to access age appropriate specialist care. In addition, when appropriate, every effort should be made to facilitate the young person's transfer to a specialist young person's unit as soon as possible. An agreement to admit a young person to an adult ward should never be seen as an acceptable alternative to the development of appropriate services.

If a child or young person is admitted to a non-specialist ward the MHA's Code of Practice emphasises the need of the clinical team to consider carefully the environment to which a young person is admitted and the impact that this might have on the young person. Considerations should include the potential risks to the young person in a ward environment designed for adults and a plan should be put in place to minimise such risks. This might include the allocation of a single room or special arrangements in relation to observation levels or monitoring of the young person while on the ward. The likely impact of other patient's behaviour, the potential availability of illicit substances and the avoidance of distressing experiences is also important to take into account and modification of visiting or smoking policies might be required. The Code of Practice recommends that nursing staff with experience of working with young people should be available to provide direct input into a young person's care as well as to support and guide ward staff. It recommends best practice would be for the RMO responsible for the child's care to be a child specialist and that hospital managers should advise the MWCS whenever a young person is admitted to a non-specialist ward.

Section 2(4) of the MHA states that any activity under the MHA undertaken in relation to a young person under 18 must be done so in manner that best secures the welfare of that individual child or young person. The Code of Practice outlines key aspects of this principle which includes taking into account the views and wishes of the child and the views of their carers; considering the carer's needs which are relevant to any activity under the MHA; providing sufficient information to the carer, when appropriate, to enable them to care for the patient; providing appropriate services to a child or young person where they are subject to compulsory powers under the MHA and acting under the MHA in a way that appears to involve the minimum restriction on the child or young person as is necessary under the circumstances. Section 278 of the Act requires that Health Boards take all reasonable steps to reduce any adverse effect on the relationship or contact between the child or individual with parental responsibilities if either individual are detained. Clinical staff should have an awareness of the young person's educational needs and sensitivity towards the needs of the families and to the complex issues that may exist for a young person around family involvement.

The original accreditation standards for England and Wales were subject to extensive consultation with young people, parents/carers, community and inpatient CAMHS professionals, inpatient adult mental health professionals, CAMHS and adult mental health service commissioners, mental health advocates, mental health lawyers, MHA implementation managers, CAMHS policy and strategy professionals from the Healthcare Commission (now the Care Quality Commission), Rethink and the National Patient Safety Agency (NPSA). In 2009 the standards were developed and piloted in 26 adult mental health wards across England - details on how the standards were developed, and the pilot findings and recommendations are available in the Royal College of Psychiatrists. AIMS – SC4Y: Safe and Appropriate care for young people on adult mental health wards. 2nd Edition, December 2009. In Scotland stakeholders and advisors were involved in the adaption of these standards for the Scottish context.

The standards cover the following eight topics:

1) Environment and facilities
2) Staffing and training
3) Assessment, admission, transfers and discharge
4) Care and treatment
5) Education and further learning
6) Information and advocacy
7) Consent and confidentiality
8) Other safeguards

The full set of standards is extensive and it is unlikely that any ward would meet all of them. To support their use in clinical governance activity, however, each standard has been categorised as follows:

Type 1: Failure to meet these standards would result in a significant threat to patient safety, rights or dignity and/or would breach the law;

Type 2: Standards that a ward in Scotland would be expected to meet;

Type 3: Standards than an excellent ward would meet or standards that are not the direct responsibility of the ward.