Child and Adolescent Mental Health Services: inpatient report

A4.18 Impacts on services, clinicians and their other patients

The impact on children and young people themselves and their families of the current situation has been illustrated throughout this report. In addition to this and the financial costs to Health Boards and NHS Scotland, a high cost in terms of impact on services, clinicians and their other patient was apparent.

Impacts on services, clinicians and their other patients – summary

• Each admission a 'special arrangement'
• Clinicians anxious about patients inadequately managed in community
• Time consuming and stressful for clinicians, who often felt isolated and unsupported
• LD CAMH psychiatrists retaining responsibility for inpatients over long periods – not expected of other community-based psychiatrists
• Many additional unpaid hours worked over long periods
• Impact on time available for care of other patients in community
• Inpatient teams 'cobbled together' for individual patients, building up working relationships 'from scratch'
• Some serious staff injuries
• Inpatient nurses often anxious due to inexperience
• ALD patients lost access to inpatient care and facilities

A4.18.1 Impact of pre-admission issues

Managing patients at home or in alternative placements while arranging admission (see Section 4.7) could be extremely time-consuming and stressful for clinicians. Without access to support from intensive services, out-patient psychiatrists and other clinicians attempted to provide intensive input themselves, monitoring mental state, titrating and monitoring medication and attempting to manage risk. Community nurses (often from adult LD services due to lack of expertise/capacity in CAMHS) were sometimes 'drafted in'. Complex and time consuming liaison with other agencies and potential inpatient units was required. Where there was no local specialist LD CAMH team, CAMH psychiatrists, pediatricians and others struggled to manage these complex cases and often felt isolated and unsupported.

A severely mentally unwell young person had to be managed for weeks at home by their family and LD CAMH psychiatrist, when an YPU had considered the patient unmanageable in their unit. The psychiatrist visited the house 4 times a week over 2 months, including carrying out blood tests at home.

Finding a bed could be difficult when a mainstream YPU bed was required. However, where a more specialist unit was ideally required, trying to arrange admission to either an inappropriate unit locally or a specialist unit in England was far harder. Admissions were often preceded by prolonged and time-consuming negotiations between clinicians and managers from the various services. A lack of clear lines of management responsibility for children and young people with learning disability within some Health Boards meant a lack of management 'ownership', leaving clinicians unsupported. Looked-after children and young people, particularly those residing out of their home Health Board area were disproportionately affected in these situations.

A young person from one Health Board went to residential school in another and when this broke down moved to care placement in a third. A lack of ownership of their mental health care and lengthy debate and discussion ensued. Eventually the CAMH psychiatrist from the second Health Board had to travel to the third to detain the patient who was admitted to an YPU in a fourth Health Board. Even that eventual placement was not appropriate as the patient required an LD CAMH individualised setting. Significant senior clinician time was spent on these arrangements, to the detriment of their usual work.

Each admission became a special arrangement, adding to the stress for all concerned. Clinicians described a lot of uncertainty, 'trying to work out what to do', phoning around, organising and attending multiagency meetings. Psychiatrists who were not LD CAMH specialists particularly struggled, having no experience of the types of units available or required. Experienced LD CAMH consultant psychiatrists reported having to 'beg' adult LD colleagues to help them arrange a bed. Where admissions to England were arranged, clinicians also had to learn about referral processes, funding via Health Boards and/or NHS Scotland and cross-border Mental Health Act arrangements.

A psychiatrist described a patient with severe learning disability and extremely high levels of distress who should have been admitted 5 weeks earlier had a suitable facility been available. After weeks of trying to manage in the community, it was clear that the situation at home was completely untenable, but it took the psychiatrist nearly 8 hours of phone calls to secure a bed, even to an inappropriate adult LD hospital. This included finding an out of area bed, agreeing funding from the home Health Board and securing emergency alterations of the registration of the facility to allow a person under age 18 to be admitted.

When admission was the only option, it was stressful having to advise uncertain families to accept this, particularly when clinicians themselves were not confident about the expertise in an available unit.

A4.18.2 Impact of admissions to Scottish wards

A4.18.2 (i) Adult wards

LD CAMH or CAMH psychiatrists usually had to continue to be the 'Responsible Medical Officer' ( RMO) for their patient during admissions to adult LD and adult mental health wards. Additional paid sessions for this work were rare, more often doctors worked many extra hours in their own time, with significant and prolonged impact on clinicians' personal lives. There was inevitably also an effect on time available for care of their other patients. Where nurses from Intensive CAMH or LD CAMH services had to work into the ward to support admissions, they were also unable/very limited in their ability to provide their usual services, risking escalation of other patients' problems.

The time required to support these complex admissions was substantial, e.g. for reviewing the patient, attending weekly team meetings, overseeing the use of the Mental Health Act and regularly liaising with staff and families. For relatively brief admission to adult mental health wards, CAMH clinicians could spend up to half of their working week in a ward supporting an admission. One CAMH psychiatrist described this as now happening routinely as 'part of the job'.

During the admission of a young person with severe learning disability, there was impact on the care of other CAMHS patients, as at that time there was very little protected time for crisis work within the CAMH service. The CAMH team visited the ward and gave direct nursing care. More input was needed than for other young people without learning disability who went onto the adult ward, due to the severity of the learning disability and communication problems.

For longer admissions (often to adult LD wards), more than a whole day a week of Consultant Psychiatry time was usually required in the first months of an admission, and at least half a day a week for ongoing care. Wards were often at a distance from their usual base. For example, to support an admission a consultant LD CAMH psychiatrist visited a ward 3 days a week and other colleagues 2 days a week over a 7 week period. For another patient, a psychiatrist visited a ward twice a week for over a year at a considerable distance from base.

It was time-consuming and stressful for psychiatrists being RMO, working with unfamiliar teams who were anxious and inexperienced in working with this patient group. Relationships and effective joint working had to be built up with staff groups, often from scratch for each admission.

There were prolonged negotiations with a family over where was most suitable for their young person. A local team had to be 'cobbled together' to support a local admission of a very complex young person. This was inevitably time consuming and difficult for staff who did not usually work together. The huge local input over months was unsustainable as it had a massive impact on other clinical work and ultimately little progress was made.

Admissions of children and young people to adult LD wards had an inevitable knock-on effect on services for adult patients. Beds and day facilities for adult patients were restricted for months or years on end. More adults than usual who required admission had to be maintained at home or admitted to inappropriate AMH wards. Adult inpatients were distressed by noise and activity levels in the ward where children and young people with highly disturbed behaviour were managed. Some were directly at risk from or upset by the behaviour of young patients. A small number of young people made a very serious impact on other patients, ward function and the physical facility, e.g. due to highly destructive behaviour and/or frequent serious physical assaults on staff and occasionally other patients.

Providing 1:1 or higher staff levels or developing core consistent staff teams around individual young people was complex and expensive to arrange, impacting on staffing levels and care of other patients. Adult in-patients had less access to their own usual activities, e.g. forensic patients not being allowed into the area used for joint activities with non-forensic patients due to the presence of a young person.

Admissions of children and young people with learning disability to adult mental health wards also sometimes had an impact on adult LD services, with adult LD nurses brought in to support admissions of young people to adult mental health wards or IPCUs.

Adult LD psychiatrists commented that there was always tension among ward staff when children and young people were on their wards. The responsible consultant psychiatrist often felt more confident, either being an LD CAMH psychiatrist working into the ward, or an adult psychiatrist getting consultation support from CAMH psychiatry colleagues. However, nursing staff did not often get similar support. Staff on AMH wards who lacked confidence could also become very anxious about their ability to manage patients so different from their usual patient group. On both types of ward, staff were generally apprehensive, concerned about whether they are doing things correctly, sometimes contributing to risk adverse and overly restrictive management.

Serious injuries were sustained by a number of adult LD nurses. This led to further depletion of staff due to sick leave and in one case contributed to severe impairment of the functioning of an entire ward. Some staff reportedly still felt traumatised several years after such admissions and fearful of another similar situation arising. Health and visiting care staff were distressed and anxious about needing to nurse some young people in highly restrictive settings due to lack of suitable alternatives. Multiple repairs and costly adaptations to ward facilities were required.

A4.18.2 (ii) Age-appropriate admissions

Community CAMH psychiatrists did not generally retain RMO responsibility for patients admitted to YPUs. However, LD CAMH psychiatrists needed to provide high levels of input for the majority of their patients. It was not uncommon for LD CAMH psychiatrists and nurse therapists to visit an YPU 2-3 times a week or even more for up to a year to support admissions. Community clinicians for patients without learning disability would generally only be expected to visit for ward reviews once every 4-6 weeks. When an LD CAMH ITS became a patient's inpatient team in a segregated area of an YPU, this hugely reduced their capacity for work with other young people in the community.

Clinicians did not report much impact on other YPU patients in the survey, but one commented on others being upset by a patient's noise and level of distress. Some YPU staff injuries were reported.

Generally less active and intensive input was required from community clinicians to support admissions of children with learning disability and/or autism spectrum disorder to the National Child Psychiatry Inpatient Unit compared to other units. Appropriate attendance at regular meetings was required for liaison and discharge planning.

Psychiatrists noted how generous their local pediatric wards could be in allowing admission for mental health reasons, but that they needed to be heavily supported. Community CAMH, LD CAMH or pediatric liaison psychiatry teams supporting these admissions could find it time consuming, impacting on care of other patients.

A4.18.3 Admissions to English specialist units

Where a specialist NHS LD CAMH inpatient unit was used, local clinicians knew the service and had good working relationships with the consultant psychiatrist, time taken on liaison was limited, e.g. telephone calls and a day every 3 months attending multidisciplinary review meetings. In other cases where there was concern or uncertainty about care provided, psychiatrists visited more frequently, even at great distances to ensure that assessment and treatment was appropriate.

A4.18.4 Patients not admitted when required

High levels of intervention from CAMH, LD CAMH or adult LD clinicians to manage patients where admission was required but not possible have been described in Section 4.15. This was also time-consuming with impact on clinicians' care of other patients and personal life for similar reasons to those described above. A number of situations were described where there was single-handed input from LD CAMH psychiatrists where children and young people with learning disability were excluded from local CAMH ITS (intensive treatment service) provision. Examples were given of very high levels of input, such as those below.

An LD CAMH consultant psychiatrist provided daily visits of 2 hours including travel time over a 4 week period to support a young person with learning disability and mental illness at home. This was done unpaid and out of working hours to limit the impact on other patients, with considerable impact on the clinician's personal life, including paying additional childcare fees.

A CAMH consultant psychiatrist gave at least ½ day a week over a number of months to a child with severe learning disability and autism spectrum disorder who required a hospital admission that was not available. This level was not adequate for the needs of the child but no more was possible within local service provision. Adult LD nurses were drawn away from their usual work to provide intensive input into the family home but this was not successful.

Psychiatrists described being extremely anxious, sometimes for months on end when managing very unwell patients in high risk situations at home, when they should have been in hospital. Professionals from across agencies felt helpless due to an inability to offer appropriate responses to the children and young people and families they worked with.