Child and Adolescent Mental Health Services: inpatient report

6. Full Recommendations

1. A bespoke national learning disability child and adolescent mental health inpatient unit, with 9 beds, located in Scotland, for children and young people with more severe levels of learning disability, complexity and challenging behaviour.

• A minimum number of 9 beds is initially required, to include 3 robust, individualised environments
• It will be for children and young people with more severe levels of learning disability, complexity and challenging behavior whose needs cannot be met in the existing Scottish child and adolescent inpatient mental health units
• The recommended bed numbers assumes that adolescents with mild learning disability and/or autism spectrum disorder who need secure inpatient mental health care will be accommodated within the proposed Scottish secure/forensic adolescent mental health inpatient unit.
• Accommodation should be available on-site for families and carers
• Advocacy for children and young people should be provided
• Family support services should be provided
• The service specification should be informed by information gathered by this study, and the NHS England LD CAMHS inpatient service specification

Options appraisal of the location should take into account:

• Access to specialist pediatric support, including pediatric neurology
• Need for co-location with adult learning disability wards for nursing support and back-up
• Consideration of co-location with any Scottish secure forensic adolescent mental health inpatient unit to share expertise and make joint use of facilities such as safe outdoor space, sporting, educational and therapeutic spaces
• The site should have capacity for expansion, given that recommendations for bed numbers are minimum estimates of need and the possibility that development of community LD CAMH services may uncover further hidden need.

There should be broad stakeholder involvement in the planning and development of a unit, its referral criteria, and pathways in and out and service specification. Stakeholders should include:

• Children, young people, families and carers
• CAMHS, LD CAMHS, adult LD, child health/pediatrics
• Local authority social care and education partners
• Third sector organisations

The unit should develop and support local community LD CAMH services with:

• Clear pathways in and out of the unit
• Telemedicine links for consultation advice on complex outpatients and for inpatient review/planning meetings
• An ability for staff to travel to assess and advise on the management of complex children and young people who may or may not ultimately require admission

Referral criteria, role and remit should be clearly set out in relation to the regional YPUs, National Children's Psychiatry Inpatient Unit, Adult LD wards and any young person's Secure forensic mental health inpatient unit.

Close links with the regional YPUs and the National Child Psychiatry Inpatient Unit should be maintained, with sharing of expertise and joint working to best meet the needs of all children and young people.

Consideration should be given to the development of a specialist interim social care/education facility located near to the inpatient unit:

• For children and young people no longer requiring hospital care, but whose local authorities need time and support to commission bespoke local care packages
• This facility and the inpatient unit could share staff and skills to benefit of the children and young people
• Revenue costs should be borne by the home health and social care partnerships of the temporary residents
• Discharge planning must be part of the entry criteria.

2. A national clinical network to support development of the unit and community services, linking with multiagency partners across Scotland.

The current LD CAMHS Scotland Network should be developed into a more formal funded network.

The Network will:

• Support the development of a unit, its role, remit and service specification
• Work with NES to take forward training and workforce planning, to ensure ongoing sufficient trained staff for the unit and community services
• Be based in the unit once open, to support links with local services across Scotland, encourage patient flow and have an ongoing role in community service development
• Develop links with multiagency partners nationally to encourage collaborative strategic service planning.

3. Improvements in access to the four existing Scottish child and adolescent mental health inpatient units for children and young people with autism spectrum disorder and those with milder degrees of learning disability and less complex needs.

• Children and young people with autism spectrum disorder (without learning disability) and children and young people with mild learning disability should be treated on existing child and young person's mental health inpatient units, unless there is a need for security
• Staff need additional training and support in working with these children and young people
• Some children and young people with moderate learning disability may be treated on existing units, but may require additional support.

4. Additional training and support for staff at the four existing Scottish child and adolescent mental health inpatient units in order to improve outcomes for children and young people with autism spectrum disorder and those with milder degrees of learning disability who receive treatment in those units.

5. Development of the full range of community child and adolescent mental health services for children and young people with learning disability across Scotland.

Development must include early intervention, multidisciplinary outpatient teams and intensive community assessment/treatment services.

6. Health and Social Care Partnerships to review community provision for children and young people with a learning disability and/or autism spectrum disorder in order to maximise appropriate use of a bespoke mental health inpatient unit and work with any new unit to ensure appropriate referral pathways and discharge planning.

7. Health and Social Care Partnerships and NHS Scotland must create clear pathways and commissioning arrangements to existing facilities, including those outwith Scotland.

8. NHS National Specialist Services Division should continue to ensure that pathways to specialist services in England are available for the occasions where an admission to a unit outwith Scotland would be more clinically appropriate.

There needs to be clear guidance and commissioning agreements made for easier access to NHS England beds:

• Pending the development of a LD CAMH inpatient unit
• For the very small number of children and young people likely to still require specialist care in England in the future.