Scoping review of intensive psychiatric inpatient care provision for young people in Scotland: report

1 Background

1.1 The need for the review

Currently in NHS Scotland there is no direct inpatient service provision for adolescent patients who require intensive psychiatric input. This means patients are often referred to, or remain cared for, in services that do not fully fit their needs. This was highlighted by the Mental Welfare Commission in their Young Person Monitoring Report (2020), and Scottish Government subsequently commissioned a national review of Intensive Psychiatric Care Unit (IPCU) capacity that:

1. Is undertaken in partnership with Child and Adolescent Mental Health Services (CAMHS) regional leads.

2. Considers both local circumstances and overall national need.

3. Makes recommendations about whether additional IPCU facilities are required.

4. Develops a national pathway for access to IPCU services when required.

The review thus scoped out and sought feedback on the current position for young people from 12 up to 18 years who require intensive psychiatric support in Scotland. This has informed the development of options on how best to meet these needs when young people require this level of intensive input. The review has been led by Julie Metcalfe, Clinical Director of CAMHS in NHSGGC.

1.2 The importance of psychiatric care at all life stages

An overwhelming amount of evidence illustrates the importance of providing appropriate psychiatric care, when required, at all stages of life. The Adult Psychiatry Morbidity Survey (2007) outlined that almost 6% of individuals age 16 and older reported having attempted to take their own lives at some point in their life. Within the UK, 18,220 individuals with mental health problems completed suicide in the ten years from 2003-2013 (National Inquiry into Suicide and Homicide, 2015) and in 2013, 6,233 suicides were recorded in individuals aged 15 and over (Office for National Statistics, 2015). Of these 6,233 people, 22% were female and 78% were male, suggesting gender differences and possible inequalities with regards to access to mental health support in the UK.

1.3 Psychiatric care for young people seen by CAMHS

The latest NHS Digital (2020) follow-up study on the mental health of children and young people in England found 20% of 17-22 year-olds were identified as having a probable mental health disorder. Similar results were found in 11-16 year-olds, where 17.6% had a probable mental health disorder, an increase from 12.6% in 2017 in this same age range (NHS Digital, 2018). This steady change mirrors findings in Scotland, where an increase in peer problems and emotional problems in adolescents has been found over time (Black and Martin, 2015).

Considering the wider context of mental health problems, The Mental Health Foundation (2019) conducted a study of young people in Scotland and found 20% of young people feel they do not have a trusted adult that they could go to for support and advice, and 29% said that where they live has a negative impact on their mental health. This report outlined the risk factors associated with mental health disorders in this age group and stressed the importance of care that is both accessible and acceptable for this age group.

The Children and Young People's Mental Health Coalition (2015) highlighted the importance of promoting emotional health and wellbeing in an individual's childhood, as a means of positively impacting their later life, in terms of cognitive development, learning, and physical and mental health.

The mental health of children and young people is thus influenced by many factors, including any physical and neurological disabilities that may present at birth or in early childhood, as well as the social and economic circumstances in which the family lives (including homelessness, poverty, mental health difficulties or substance use in the adults who look after them, their LGBT status, and whether they are looked after outside their family of origin).

It is clear that the needs of children and young people in Scotland are best met by assessment of need at an early stage in life, with responses to these needs coming from the whole range of services in the community that contribute to children and young people's lives. The SHANARRI wellbeing indicators (Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible, and Included) provide a means of assessing children's needs across a range of domains (The Getting it Right for Every Child Team, 2017). Any additional support needs indicated through a SHANARRI assessment are best met by the agencies (statutory and third sector) involved in communities working to an integrated care plan based on Getting It Right For Every Child (GIRFEC).

This approach to meeting need applies just as much to looking after young people with major psychiatric difficulties as it does to children in early years. It is recognised that many young people who require access to intensive psychiatric care are likely to have a number of risk factors in their developmental profiles that can only be met by the approach described above. It is always best to intervene as early as possible in any developing psychiatric disorder, with the support of family and other agencies, to seek to circumvent need for the most intensive psychiatric care later in adolescence. Nonetheless, a small number of young people, usually in later adolescence, will require intensive psychiatric support for a period of time. It is also recognised that these young people will also require the support of statutory and voluntary agencies to help them move on and recover from any severe psychiatric disorder.

1.4 Intensive psychiatric care for young people

As noted above, in their 2018-2019 Young People Monitoring Report, the Mental Welfare Commission (2020) continued to recommend the current gap in IPCU service provision for adolescents be addressed. Research in terms of the efficacy of IPCUs is limited in relation to the adolescent patient group, however, a few papers have documented the benefit of both age appropriate and intensive services.

Currently in NHS Scotland, young people under 18 years who require Intensive Psychiatric Care in an inpatient setting are often admitted to adult IPCUs, or they are cared for, sometimes with difficulty, within existing open inpatient services. Duddu et al, (2016) evaluated the use of a psychiatric inpatient service for 16 and 17 year-olds, and emphasised the importance of age appropriate psychiatric care when working with young people. They outlined several issues with regards to caring for adolescents in adult psychiatric wards, with a specific emphasis on the difference in skills required by staff to manage younger patients.

Specifically in Scotland, NHS Lothian previously redesigned their CAMH Services to develop an Intensive Treatment Service for young people up to 18 years within the community. The aim was to reduce admissions to inpatient services (Duffy and Skeldon, 2013). Although there was an increase in admissions to the young person's open ward, admissions became shorter, and findings suggested a significant reduction in admissions of young people to adult psychiatric wards. This service has successfully managed to minimise the need for placing young people in a ward not fit for their age group. It is important to recognise, however, that there are occasions where inpatient admissions of adolescents to adult mental health facilities occur as the 'least worst' option within this patient group. However, there is clear consensus that admissions for young people should be to inpatient facilities that are designed to meet their developmental needs, with a staff group trained in working with young people with psychiatric disorders.

1.5 Service specifications for Tier 4 and IPCU provision

Intensive psychiatric care is integrated into services in NHS England and can take different forms in terms of step-up/step down care pathways (NHS England, 2018). It is important to take note of the roles of the range of inpatient units to better understand the differences between these services and IPCUs so that appropriate referral pathways to and from services can be managed.

1.5.1 Levels of security in inpatient settings

The NHS England Service Specification notes Tier 4 inpatient CAMH Services "offer care at four levels to support the effective management of differing nature of risk presented by children and young people under 18". The specification outlines the variance of security levels in inpatient units, as follows:

• Medium secure units, the highest security setting that an under 18 year-old can be placed in. This is characterised by high levels of relational and procedural security, and stringent levels of physical security. Individuals placed in medium secure care will include young people who have a mental or neurodevelopmental disorder that poses a risk of harm to others, or who have committed grave crimes.
• Low secure units, young people admitted to these units are either forensic in presentation and pose a risk of harm to others, or are non-forensic but exhibit behaviour that is challenging as well as posing a risk of self-harm and being vulnerable.
• For Psychiatric Intensive Care Units levels of physical, relational, and procedural security should be similar to those in low secure units.
• For general adolescent inpatient services care is provided without the need for enhanced physical or procedural security measures.

Both low and medium secure units are set up for patients to have longer stays in the ward - as long as several months to a year in duration.

Development is currently underway for the National Secure Adolescent Inpatient Service (NSAIS), a unit which will be the first of its kind to provide medium secure care in NHS Scotland, located in NHS Ayrshire & Arran. The most recent copy of the business case indicates the Unit will open in 2022.

1.5.2 High Dependency Units

A separate NHS England specification stresses the importance of drawing a distinction between PICU and inpatient services, particularly High Dependency Units (HDUs) (NHS England, No date). The service specification outlines that HDUs are not stand alone units, but are instead areas within some CAMHS non-secure services that exist to provide care for young people whose behaviour particularly challenges the service. These units remain the clinical responsibility of the open unit in which they exist, and are not a separate service commissioned by NHS England, therefore capacity for these units varies across services.

1.5.3 Considerations for IPCUs or PICUs

The NHS England Tier 4 CAMHS PICU service specification (2018) details that patients are admitted on the grounds that they are experiencing a "short term behavioural disturbance" that requires more specialist input than what is available in open inpatient provision, and any adjacent HDUs. There is the expectation that admission should not exceed 8 weeks in duration. Recreational and educational facilities should therefore be available, and be age appropriate, but will differ to that of open wards due to the short-term nature of admissions.

The Quality Network for Psychiatric Intensive Care Units (QNPICU) (2017) produced standards that advise on the requirements for providing care in an adult PICU that are currently used in NHS Scotland. Furthermore, individual Trusts have produced additional local guidance, and Appendix I includes a flowchart of the pathway followed for admission and discharge to adult PICUs in Southern Health NHS Foundation Trust. Guidance more specific to adolescents can be found in The National Association of Psychiatric Care and Low Secure Units (NAPICU), who in 2015 published the national minimum standards for PICUs for young people. This document outlines the requirements of a PICU in terms of referrals, treatment, discharge planning, and environmental factors. The review team recommend full consultation of this document when considering the development of an IPCU but key headings that provide insight into the individuality of this type of service when compared to previously mentioned services are discussed below.

1.5.3.1 NAPICU Admission Requirements

Key criteria and requirements that referrals should demonstrate in order to be admitted to a PICU should be clear and consistent, (as should exclusion criteria):

• Patients should be 12-18 years of age (up to the day of their 18^th birthday).
• Young people referred should be exhibiting behaviour that puts either themselves or others at risk (to a degree that cannot be managed safely in an open, acute service) as a result of mental health problems or a learning disability.
• Young people referred to a PICU should be detained under the Mental Health Act Scotland (2003).

It has also been recommended to have a process in place for when a referral does not meet the criteria for admission to a PICU. A referral form currently in use for admissions to an adult IPCU in NHS Greater Glasgow and Clyde (found in Appendix II) shows the details that are required to begin the referral and admission process.

1.5.3.2 NAPICU Service recommendations

In terms of length of admission, it is recommended that the patient's treatment plan anticipate an admission of no longer than 6 weeks in a PICU. Thorough pathways should be in place that plan multidisciplinary treatment, with joint working towards a collaborative goal. Anticipatory decision making regarding the discharge location of a patient should begin from the initial referral to a PICU. This process will allow for a review process in patients where there is a likelihood of a longer stay in order to re-evaluate the treatment plan.

On top of a patient's treatment plan, the NAPICU guidelines recommend that a range of therapeutic activities should be provided for young people within a PICU; the document goes into further detail of examples of these. Facilities and ward environment should take into account the level of risk and therefore level of security in this setting, this includes observation policies. NAPICU standards recommend consultation of standards produced by SIGN (Scottish Intercollegiate Guidelines Network) for further detail on this.