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

3 Results

3.1 Regional clinician consultation

As described earlier, clinicians from adolescent inpatient units in three different Scottish regions were consulted to gather insight of current practice on how open units operate to provide more intensive care, and what provision would be most helpful for them in an ideal situation. The following sections outline the most prominent areas of discussion relevant to the review.

3.1.1 Young person's psychiatric "open" wards

3.1.1.1 Staffing

Clinicians outlined staffing in their adolescent psychiatric inpatient service for their region. Units adopt a multidisciplinary approach to staffing but primarily are run by a core Mental Health Nursing staff team, including Clinical Support Workers/Nursing Assistants, as well as domestic and administrative staff. Multidisciplinary input includes Consultant Psychiatrists, who also fulfil Responsible Medical Officer (RMO) duties, as well as Clinical Psychologists, Family Therapists, Occupational Therapists, Dieticians, Physiotherapists, Speech and Language Therapists and Art Therapists providing a varying number of sessions across the different units. The North region also has staff working in the role of Liaison Nurses to cover the different areas within the region.

The model of care in any IPCU provision will focus on a compassionate, young person and family-centred approach to care. It will be important to access information from the young person (as possible), their caregivers, and those looking after them in health, social care, education and third sector, prior to any planned admission. All staff will be guided in their care planning by the wishes of the young person on a What Matters to Me basis and an Advanced Statement as part of their rights as a young person subject to the Mental Health Act Scotland (2003).

3.1.1.2 Service design and facilities

Service design considerations include provision of a safe and secure environment for each young person admitted. A single en-suite room would be necessary for each young person. Each room and all facilities within the IPCU would be designed with consideration of meeting the needs of the young person, in the context of a setting that is as safe and ligature-free as possible. Safety considerations would be vital in provision of leisure activities for any patient.

Young people would need access to secure outdoor space for exercise, and there should be areas within the IPCU service for leisure and activities, planned visits of family, eating meals and snacks, and mixing with peers when this is safe. Appropriate educational facilities will be a requirement for any young person who is well enough to engage in them.

Design of internal and external spaces and activities provided should be compatible with the age range concerned. All areas should be furnished in a way that minimises risk of damage to self and others in the environment.

Consideration should be given to sensory issues, and specifically sensory overload, as part of the internal design of the service.

3.1.2 Patient profile for intensive psychiatric referral

The consultations discussed the situations that would prompt an individual to be considered for a referral to a more intensive service. Reference was made to the admission requirements as outlined in NAPICU guidance. Characteristics of this included "unmanageable levels of aggression", risk of absconding, a need for a low stimulus environment, and more intensive nursing support. In accordance with aforementioned guidance, patients must be detained under the Mental Health Act Scotland (2003).

3.1.2.1 Factors that could preclude referral to an IPCU

Factors were discussed that would preclude referral of a young person to an IPCU, and these reflect the guidance produced by NAPICU. However, staff from adolescent open wards and adult IPCUs identified that there is currently no formalised, detailed exclusion criteria for referrals. It was noted this has been considered in the past but would be a particularly complex task.

In terms of current options for a young person requiring IPCU input, factors indicative of vulnerability, such as patients under 16 years of age, those who have experienced trauma, or those with a significant learning disability, are unlikely to be accepted to an adult IPCU due to potential risk from adult patients in that ward.

When considering age, it is important to note that the age of young people admitted to current adult IPCU provision would likely differ if the service was set up for young people only. Concerns around admitting a younger patient (under 16) would potentially not be as prominent (although would still need to be considered on some level). An age-appropriate service would likely receive referrals for individuals who would currently be managed, with some difficulty in terms of environment, staffing and impact on self and others, in an open ward.

Those involved in the consultation expressed reluctance to admit individuals with particular diagnoses or conditions to an IPCU setting, even were an age appropriate IPCU available. Specifically mentioned were those with anorexia nervosa, as well as patients who have personality disorder as their sole diagnosis, or self-harm as their primary problem. It was felt the more restrictive measures of care in an IPCU would be to the detriment of such young people.

Participants noted that there can be a reluctance to admit adolescent females to an adult IPCU, especially if adults within the ward are prone to exhibiting behaviour that is inappropriate. This reflects the importance of not only age-appropriate care, but a service that is inclusive in supporting all young people, regardless of gender.

Recommendation 1) The review team wish to emphasise the importance of ensuring equality of access and recommend that an Equality Impact Assessment (EQIA) is undertaken as part of any future adolescent IPCU developments. It is crucial that steps are taken to provide for the needs of patients from different backgrounds (including BAME) and to ensure equality in relation to other protected characteristics.

Recommendation 2) Current service specifications, which were consulted for this report, do not specify standards for working with young people who are transgender or non-binary. Furthermore, a disproportionate number of young people who are LGBT+ are at risk of developing mental health problems (Plöderl & Tremblay, 2015). The review team therefore recommend that any future service providing intensive psychiatric care to young people take appropriate action to ensure comprehensive guidance is in place regarding supporting patients who are transgender or non-binary.

3.1.2.2 Distinction between Secure Service and IPCU patient profiles

Discussion highlighted the need for IPCU input not to be viewed or confused with services that are characterised to be secure:

"People get a bit confused about sometimes wanting to refer patients who just need a higher level of security as opposed to being something that can realistically add value to their care. So, we need to be really clear that it's about young people who do have a clear mental health difficulty that can be improved in some way by attending IPCU."

For more in-depth distinguishing factors between Secure Services and IPCU Services, see Section3.3, which outlines Secure Service design and admission criteria in detail.

3.1.3 Pathway

Drawing from all consultations it was clear that there is not necessarily one consistent pathway across Scotland for IPCU use by young people. There was, however, general understanding that IPCU care should be a short term treatment, and young people in particular should not remain in such a ward for any longer than necessary.

3.1.3.1 Referral

The process of referring a young person to IPCU service provision varies across different areas but also is dependent on whether the patient requires admission during an "out of hours" timeframe.

Often wards will require a referral form to be submitted to begin this process, an example used in the West of Scotland can be found in Appendix II. Other discussions indicated the difference between admitting a young person to an adult IPCU as opposed to admitting an adult; a young person's referral would be expected to be more consultant led, rather than nurse led.

Discussions outlined that once the IPCU had been made aware of the referral request, usual practice was for staff from the IPCU to visit the patient and staff in the referring service (usually an open psychiatric ward for young people). This was to assess suitability of the patient for an adult IPCU, and to build relationships with the staff who would be supporting the patient during the duration of stay, and the patient themselves.

Recommendation 3) Referrals to an Intensive Psychiatric Care service for young people should generally come from open adolescent inpatient psychiatrists, or be made by community child and adolescent psychiatrists in liaison with inpatient psychiatrists.

3.1.3.2 Admission procedures and transfers

Discussions turned to the procedures that are followed when young people are admitted to IPCUs. The specifics of this can vary across regions. In terms of RMO responsibility, one region outlined that this would remain with the RMO from the Young Person's Unit. Discussion with another region outlined that this approach varies across Health Boards. RMO responsibility can fall to the IPCU consultant but with input from a CAMHS consultant, and variation from this can arise based on whether the young person was admitted from the community or from the Young Person's Unit.

There was much discussion on transfers and ultimately how challenging this can be. This was particularly so when considerations are made to the levels of distress that a young person is experiencing, alongside what could potentially be a long journey out of their area. The consultations reflect that there can be complications even securing appropriate transport, and with the level of risk in transferring a young person who is not compliant, it is necessary to have a contingency plan in place. This review makes specific recommendations regarding this in relation to the review team's discussions with a representative from the Violence Reduction Service in GGC (Section 3.4).

Specific to the CAMHS population, the consultation addressed the importance of keeping family involved and informed. For example, ensuring parents and guardians have a full understanding of the reasoning of clinical staff when transferring their child to a more intensive environment. Even in instances where a transfer to an adult IPCU is deemed to be appropriate, distance between units can also be a significant barrier to access. Like many other considerations, there is a sense of a balancing act to ensure patients are only moved out of area away from their community if adult IPCU care is deemed to be absolutely necessary for the young person's care. This outlines the importance of admissions to IPCU remaining short, and that discharge planning is vital to a patient's transfer.

3.1.3.3 Discharge

The purpose of an IPCU provision is to provide short impactful nursing interventions to a person's care, anticipating the ideal length of time for any patient to be in this type of unit to be a few weeks, and as short as possible for a young person in this type of adult ward. Generally, clinicians taking part in the consultation agreed that planning for discharge should begin as soon as a young person is admitted to an adult IPCU, and even at the point of referral discussion.

Discussions outlined the importance of liaising with clinicians from the service that the young person is expected to be discharged to (usually the Young Person's Unit they were admitted from).

3.1.4 Current IPCU provision/practice

As services currently stand, consultations identified only two main formal options for adolescent patients who require an IPCU: either the young person is transferred to an adult IPCU or they remain in the Open Psychiatric Ward with additional input. It was highlighted that neither of these are ideal, as both carry risk. Caring for a young person requiring IPCU care in an Open Psychiatric Ward not only brings about significant risk to that young person, but also to the other young people in the ward. This impacts other patients both in terms of safety and in the way the environment may have to be adapted to ensure safety (for example the need for doors to be locked and items to be removed from general areas). A third, significantly less prominent option was to arrange a transfer to an adolescent IPCU in another part of the UK. As noted, in NHS England there are intensive psychiatric inpatient services for this age group. However, this also has disadvantages, not least travel and the distance from family. Admission to non-NHS secure care has also been considered for young people who require a secure environment for their care.

3.1.4.1 Adult IPCU - adolescent suitability

Admitting an adolescent patient to an adult IPCU means stepping up the level of care, clinical input, and additional nursing, but it can bring about a number of issues. One of the regional participants noted "It's providing a service to a young person that an adult IPCU isn't ideally set up for… it's a less than ideal situation".

3.1.4.1.1 Variation in ways of clinical working

Clinicians discussed that adult IPCUs are "developmentally wrong" for adolescent patients, given the lack of education facilities, and age-appropriate Occupational Therapy resource. The variation of approaches in providing clinical care to a child rather than an adult is significant.

With regards to psychiatric nursing care, staff working in IPCUs have a specific skillset that is continuously maintained by making use of core competencies of their role in such a specific nursing setting. Admitting a patient who is under the age of 18 to an adult ward (specifically a setting with intensive nursing practices), puts nursing staff in a position where they do not have the same level of competence as they would when working with an adult. "I think [Adult] IPCU nurses feel when there's a younger person in the unit that their skill set isn't quite right for that person in the unit."

To ease this process as much as possible, and to maintain consistent clinical responsibility, when an adolescent patient is transferred from an Open Psychiatric Ward to an adult IPCU, there is a requirement that nursing staff from the adolescent ward work with that patient in the adult IPCU. Although this is appropriate, it again is not an ideal situation, as it was discussed that there is a "difference in culture" being from two very different wards. It is also important to note that the RMO from the adolescent ward continues to provide RMO cover for adolescent patients when they reside in an adult IPCU.

Recommendation 4) NES should provide specific training for staff in intensive psychiatric care services, to cover nursing models, multi-disciplinary models of care, management of challenging behaviour, and risk to self and others in an intensive psychiatric care setting.

3.1.4.1.2 Adaptations for adolescents in an adult IPCU

For a young person to be nursed safely within an adult environment, a number of adaptations need to be made to the way of working. These can result in patients feeling isolated:

"There's difficulties in terms of protocols for young people being in an adult environment, whether that be an open adult ward or an IPCU in that they have to be on higher level observation, and that's about limiting any damaging contact they have with adult patients, so by that criteria alone they tend to be relatively isolated and not able to access all of [the] recreational activities."

This indicates the potential for negative impact on the wellbeing of young people who are placed in adult services, and suggests why staff do their best to support patients within an age-appropriate setting, wherever possible.

Subsequent feedback raised the additional option of an enhanced care bed adjacent to adult IPCU, with regional CAMHS unit input. This has the potential for 24/7 support to be available. It still presents the challenge of care being provided, but the young person remaining isolated.

3.1.4.2 Remaining in an open psychiatric ward

When young people who would require intensive psychiatric input cannot be admitted to an IPCU setting, staff within the open units simply do their best to manage challenging behaviour:

"We've also got some patients here just now that would qualify for an IPCU service if it was available, and really some complex nursing that has to be adapted, along with a pharmacology that has to be looked at, in order to try and keep some of these young people safe."

At one consultation, it was noted a conversation had started about how staff might be able to work in different environments to support the different type of nursing required. This could be a potential workaround to prevent use of adult IPCUs. This was, however, a very provisional conversation, and again is reflective of the efforts staff take to accommodate patients requiring this level of support.

3.1.4.3 Existing "workarounds": Intensive Nursing Suites or High Dependency Units

As discussed in the introduction, HDUs are developed at the discretion of the Open Psychiatric Ward they are a part of. While these can be planned additions to services, NHS Lothian Young Person's Unit (YPU) has developed what is informally known as the Intensive Nursing Suite (INS), as an addition to their service, and in response to challenges caused by gaps in services.

Discussion highlighted that all would wish a patient to only remain in a service that is not age appropriate for as little time as possible. Thus, while the INS does not act to fully replace IPCU provision, it does potentially prevent adolescent patients from requiring an adult ward (see data in Section 4). Co-location also enables short visits, negating the requirement for the transfer process. Further, as clinical responsibility remains with the YPU, they have control over bed usage.

Despite being co-located, the INS is separate enough from the main ward that staff need to be pulled from YPU staffing to provide two to one support and observation to the patient residing in the INS. There were concerns around this level of seclusion for a young person, and that if this continued for any length of time that there was a risk of the young person being "deskilled".

Recommendation 5) All least restrictive alternatives for care of a young person should be exhausted before admission to a psychiatric hospital is considered, and before admission to an Intensive Psychiatric Care Service is instigated.

3.1.5 Social care issues

Insight into current practice, workarounds, and issues are described in detail in our consultation with CSWOs (Section 3.5). In addition, the regional unit discussions indicated anecdotally that due to the number of children who are "looked after", involvement and good relationships with social work services would be vital to any service providing intensive psychiatric care:

"When I looked at the admissions to adult wards for under sixteens so many of them were kids who were in kinship care or accommodated by local authorities whose placements have broken down."

Subsequent feedback reflected this may highlight a gap in social care services. Young people in the community who do not have their needs via access to secure social care, can end up in a position where consideration is being given to an admission to an IPCU. Further details around the relationship between IPCU and social care is outlined in Section 3.5.

3.1.6 Communication

Discussions (including those with the developers of the Secure Inpatient Service) noted the importance of communication on a national network level. Clinicians talked about the National Inpatient Forum (NIF) as being used for communication previously. Consultation discussions noted the importance of this forum, or another network specifically for CAMHS inpatient services, to allow space for information sharing.

Recommendation 6) There should be a national steering group to allow economies of scale and consistency in service delivery if regional services are commissioned.

3.2 Young person data

As noted, due to circumstances within the Young Persons' Units, advocacy services have been unable to speak to patients in a capacity that would allow them to discuss the questionnaire as planned.

The review team also contacted The Quality Network for Inpatient CAMHS (QNIC) about accessing the views of young people previously collected as part of QNIC reviews, and contacted the Young Scot Health Panel (a group used by Scottish Government) with a view to gaining feedback on the consultation process. The review team have not been able to receive input from either organisation.

Recommendation 7) Future development of IPCU provision for young people should include consultation with organisations in the local community of the proposed site(s), as well as consultation with appropriate third sector/voluntary organisations.

Recommendation 8) Liaison with young people and carers is required before commissioning of any service is implemented to consider the views of those with lived experience. It is recommended that carers/young people are involved in any design of intensive psychiatric inpatient facilities.

3.3 National Secure Adolescent Inpatient Service

As indicated previously, three staff members involved in the setup and development of the National Secure Adolescent Inpatient Service (NSAIS) were consulted to provide insight into their own service, and the anticipated relationship between the NSAIS and current services, as well as any future young person IPCU provision. The most recent business case document (North Ayrshire and Arran Health and Social Care Partnership, 2019) provides a fuller picture of what the service will offer.

Consultations identified the NSAIS will be a 12-bed unit for individuals from the age of 12 to 18 years. Staffing will include psychiatrists, psychologists, nurses, nursing assistants, occupational therapists, occupational therapy assistants, speech and language therapists, dieticians and social workers as well as input from physiotherapists, art and music therapists and an advocacy service. Facilities include a seclusion suite and a fully operational school, which will be set up to provide 30 hours of education per week to patients, in accordance with North Ayrshire Council Policy.

3.3.1 Admission criteria

In terms of security, the NSAIS is expected to provide a medium secure physical environment, with procedural levels of security sitting somewhere between low and medium levels (implications of different levels of security are outlined by Crichton, 2009). Discussions recommended the importance of admission criteria to ensure individuals who access the service fully require this level of 24-hour psychiatric care and security.

"A lot of young people, although they're distressed, don't need 24-hour nursing care. They need 24-hour care, but they don't need a specialist mental health nurse."

A secure service would differ from an IPCU as it would offer more long-term care, rather than short intensive treatment. There would also be patients who have more serious levels of offences than would be expected to be in an IPCU.

Provisional criteria for admission to the NSAIS therefore is that patients would require help for a treatable mental illness (rather than distress), who are detained under the Mental Health Act Scotland (2003) and pose a risk that requires the level of security offered by a Secure Inpatient Service.

3.3.2 NSAIS Pathway

The NSAIS will not facilitate out of hours or emergency admissions and noted that referrals would be expected to be from other NHS Services. Procedure following referral would therefore be to assess the patient in their current NHS service (usually an inpatient ward). This process will include input from the patient and their family/carer, as well as members of the referring staff team. If the referral is not appropriate for the NSAIS, the team will offer guidance on how to manage the individual in their current setting. There is also guidance drawn up on a dispute resolution process to follow if required in these situations.

Although anticipated that the NSAIS will accommodate young people for longer term admissions, staff stressed that planning for discharge will begin as soon as the individual is assessed and accepted for admission. The team anticipated that a barrier to admission could be the beds not being available, therefore planning for placements after discharge is crucial to this process.

3.3.3 Relationship with IPCU

Currently, if a young person requires an increased level of security that their open psychiatric ward cannot facilitate, then they would potentially be admitted to an adult IPCU. This way of working has its drawbacks, as it offers a short-term solution, but in a service that is not age appropriate. With the development of the NSAIS, there will be the opportunity for a more appropriate longer-term solution to meet patients' needs.

There was a discussion of where an adolescent IPCU would then fit in. There was suggestion of a young person IPCU acting as part of a stepped approach. For example, an IPCU might be a suitable environment for a young person to be referred and assessed from, particularly if the IPCU facilitated out of hours or emergency admissions. Discussion with colleagues from the NSAIS indicated they felt it would be appropriate for a young persons' IPCU to be built adjacent to the NSAIS.

3.4 Discussion with Violence Reduction Service

This meeting was valuable to discuss recommendations with someone who has specific extensive knowledge and experience of reducing and managing high levels of violence risk in patients.

The Violence Reduction Service resource in NHSGGC works across all patient groups, and is split between providing training and clinical input. Training follows a public health approach aimed at minimising stress and distressed behaviour at a primary level, but also providing strategies at both secondary and tertiary levels. Clinically, the team provides behaviour and safety planning. Upon receiving a referral, the team spend time within the referring clinical service working with that staff team and patients. This health board wide way of working allows the Violence Reduction Service to continue working with a patient if they are moved to different units.

Specific to adolescents, there were several recommendations from this discussion the review team felt important to highlight, these are included in the following sections.

3.4.1 Activities should reflect what is appropriate and interesting to young people

At a primary level there was discussion that providing activities to reduce boredom is key to reducing the escalation of violence, aggression and self-harm. Emphasis was placed on the importance of ensuring activities are relevant to the adolescent patient group and not just what staff think is interesting. For example, open green spaces are important, but what is vital for adolescents is the opportunity to make use of this space for physical activity, rather than somewhere to sit and look at a garden. Using outdoor gym equipment in these areas, such as cross trainers, was suggested.

Recommendation 9) The planning and design of any intensive psychiatric care facility should consider the importance of a specific environment that is designed to meet patients' sensory needs in a way that will contribute to emotional regulation.

3.4.2 Recognise the value in peer support in an adolescent patient group

Young people often rely on peer support in the form of socialising, often communicating via their phones. However in secure environments patients can be separated from their belongings due to other risk issues.

A lack of socialisation can have a negative impact on the young person. With this in mind, it is vital to ensure that support is in place to provide any reassurance that the patients may seek out from their peer group in this way. It is also important to consider the value of open social spaces in the ward to provide opportunities for patients to engage with others, so peer support can occur more organically. "Discharge messages" from patients who have left the ward can promote feelings of hope for remaining patients and reduce risk of agitation.

3.4.3 Use technology to maintain communication with family

Maintaining contact with family is important due to the developmental need of adolescents. Particularly during the current COVID-19 pandemic, technology (video conferencing) can serve as an alternative when family visits are restricted. It is vital to ensure future provision is equipped with WiFi that can be used for this purpose. It is also important to gather information from families to inform safety planning. Validating the importance of a family member's input to this process will not only be helpful to care planning, but will also enhance the relationship that family members have with the ward.

3.4.4 Importance of relationship between staff and patients

The consultation confirmed the importance of engaging patients in the process of being admitted to hospital and recommended considering the "Safewards Model" as a way of building trusting relationships between staff and patients (Bowers, 2014). The discussion also emphasised the importance of staff who are able to mitigate giving bad news and the value of having these types of discussions in a manner that minimises distress.

3.4.4.1 Adult IPCU Clinical Exchange Group

The Clinical Exchange Group, established as a result of the Scottish Patient Safety Programme, is a NHSGGC based group with representatives from adult IPCUs, which aims to promote patient safety by reducing restrictive practice. The group is used to review complex cases, allows information and practice sharing sessions and is used as a platform for ensuring consistent ways of working across similar services. Future IPCU Services should be aware of this model for exchanging good practice.

3.4.5 Importance of management of individual levels of risk

When working with detained individuals where methods of restraint may be necessary, it is important for any approach to be the least restrictive possible. Managing individualised levels of risk must therefore take into account different risk factors: size of patients, previous trauma (e.g. to avoid triggers of abuse). Further details around managing individual levels of risk are detailed by NAPICU (2015).

3.4.6 Importance of planning when transferring patients between services

Risk management is vital in a process such as transporting patients who are detained and have the potential to become distressed. Specific recommendations were discussed for this process including the importance of having a management plan in place while recognising that this may need to be altered depending on the age of patient; notifying police in advance of the planned route of transfer; considering the type of vehicle (it was suggested that black cabs are often more suitable than ambulances); and knowing options for restraint that are appropriate. There are currently no formalised clinical governance guidelines for transporting patients.

Overall, the consultation with the Violence Reduction Service characterised that any service that requires violence reduction measures in place should ensure staff are trained in a values based approach that is the least restrictive possible for patients. Individual risk factors are vital to consider when completing risk assessments across all levels of secure care. There should be a process in place to ensure that these ways of working are being implemented and evidenced in practice.

Recommendation 10) IPCU service provision should be designed with violence reduction measures in mind when considering environmental and procedural planning. National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) guidelines should be instrumental in this. Violence Reduction Services should be consulted to provide training to staff working in any new intensive psychiatric care facility.

3.5 Discussion with Chief Social Work Officers

This consultation was useful for the review team to gain a sense of the involvement of social work when a young person is admitted to an inpatient psychiatric service, including IPCU provision.

3.5.1.1 Variation in Social Work involvement

There is real variation in the level of social work care that a young person receives. The discussion estimated that around 80% of patients requiring intensive psychiatric care will likely already have a named social worker assigned to them (known to be lower in specific illnesses like eating disorders), but not all of these individuals will have a package of care in place. There is no set "pathway" as such for social work involvement as this usually occurs on a case by case basis, and if admissions are running smoothly, there may be no requirement for social work during the admission. Indeed, social workers may only be notified of a patient's stay in hospital when they receive an invite to attend a discharge meeting. This variation can also lead to challenges - if social work input is required for a young person who is completely new to the service, then social work staff have no background information and often have to start from scratch to build a case file, which is not ideal at a potential time of crisis.

3.5.1.2 Requirement for a multi-agency, collaborative approach

The CSWOs in the discussion identified the need for a multidisciplinary approach when working with young people who require intensive psychiatric input. As mentioned briefly above, social work is often consulted only regarding specific patients, however it was noted that it can be helpful for social work to have a more general presence in inpatient services.

Recommendation 11) Exploration of care options with multi-agency partners as a team around the child should be in place before referral to an IPCU is made.

For example, having social workers attending relevant ward team meetings not only helps to build relationships with nursing staff, the consulting CSWOs expressed there are always problems to solve across services. The discussion expressed that there are anxieties from staff working across all services to support young people who require intensive psychiatric care, whether that be around forensic or CAMHS risk, and increased joint working from different agencies helps to share knowledge and provide reassurance. Joint working and pathways were suggested as being helpful to provide aftercare and ease transitioning processes for young people moving from child to adult services, in sharing information about other services that take referrals (e.g. admission criteria) and also in placing greater emphasis on care and compassion.

3.5.1.2.1 Example of good practice/specific workaround

The review team's attention was drawn to an example where current resources were used to support young people who required intensive psychiatric care in the community. In a more rural area, social work is making use of residential provisions for two to three young people and providing nursing and multi-agency input. Although this has been a move away from the traditional system, this provision has had a positive impact, and in one example has allowed children who previously had been in and out of hospital to now be in a position to safely access mainstream education. This model is particularly beneficial for services in more rural areas to access this level off care without young people being removed from their community.

The CSWOs reflected that this provision has been resource-intensive to set up, and that there is a need for staff in other residential services to receive specific training in mental health, in order to feel confident enough in their competence to deliver care in this way. Based on this use of resources, it is worth considering the current variability of intensive psychiatric care provision options.

3.5.1.3 Recommendations for the future, and potential gaps in service provision

Consulting CSWOs illustrated the benefit of a national resource in terms of concentration of specialist skills and therefore access to specialist care. However consultees felt there were drawbacks in terms of a national service model as this would mean that staff who have these skills would all be located in one place without an easy opportunity to spread knowledge to other parts of the country. A national unit would also mean that for patients not living in the area of the unit, there would be movement away from their support network in the form of friends and family, whereas a more regional approach would allow patients to remain close to local resources and community aftercare, allowing for better integration of services.

Discussion with CSWOs outlined some current gaps in service provision, for example, there was concern of young people being admitted to services that were not appropriate for them, as there is no other place for them to go. An individual presenting as a complex case with a high degree of risk can be referred to a secure service provision, whether a non-NHS secure unit or the developing NHS secure inpatient service, which may not be fully appropriate for their needs.

Other issues that were identified would not necessarily be solved by the development of a traditional adolescent IPCU. For example, young people with a learning disability would continue to have no direct provision available. The CSWOs also recognised that some young people who are experiencing episodic distress may not meet the criteria to be admitted to an IPCU if their illness is such that they do not cope well with restrictive measures, and other options would ideally need to be in place for these young people.

Recommendation 12) Even with the introduction of dedicated IPCU provision for young people, the review team anticipate there will remain a service gap for young people with a severe learning disability who are experiencing acute distress, and for whom a restrictive approach would not be appropriate. The review team wish to emphasise the importance of developing guidance for providing the correct support for these young people.