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

5 Conclusions

To conclude, staff currently working in services providing intensive levels of psychiatric care to young people are working extremely hard to adapt their practice and manage situations as safely as possibly. However, based on findings from this review, dedicated IPCU provision for young people is a necessary requirement to provide quality care moving forward.

Qualitative data (although as mentioned previously this is not recorded systemically and therefore caution must be taken) combined with the experience of NHS staff, outline that while young people can sometimes be transferred to an adult IPCU, those who are not accepted are managed within open wards. Staff experiences indicate the challenges that this brings, and the negative impact this can have on the wellbeing of the young person concerned, as well as on the other young people in the open unit. Those who are transferred to an adult IPCU often face seclusion to ensure safety from other patients, and do not have the same access to age-appropriate services (e.g. education, age-appropriate occupational therapy input). Based on the findings of this review, neither of these options appear fit for purpose.

Location is a key debating point for any new IPCU provision, particularly when considering the appropriateness of national or regional units. Discussions made clear the importance of considering the negative impact of removing a young person from their local region and community to receive further inpatient care, and suggested this should be minimised if possible. Also discussed was the challenge of transferring a patient, who is likely to be distressed, between services. Staff noted this can be challenging even between units on the same site, but factoring in travelling long distances, in appropriate vehicles, requires significant planning.

Location in terms of adjacencies to existing units is also an important aspect of the options appraisal. Appropriate adjacent inpatient units could provide staffing support, however it will be crucial to plan this in a way that is manageable for all units. Staffing required for an IPCU for young people requires specialised training and consultations highlighted the requirement for any staff working in this setting to be trained fully and given opportunity to maintain skills. In the likelihood of a new provision facilitating an out-of-hours service, consideration must be given to ensure appropriate consultant psychiatrist cover for this.

The number of beds required for this provision (whether in different regional settings, or a national unit) is difficult to infer from the data. Staff recognised that although quantitative data indicate a low number of admissions to IPCU, having to manage multiple patients who require IPCU over the same period of time is not unheard of. Although IPCU provision is intended to provide short term intensive input (a few weeks), occasionally patients can require a longer admission.

Consultations also considered where an IPCU would fit in current service structure. Primarily there would likely be a "Step up and Down" approach between IPCU and Open Young People's Units. With the development of the new National Secure Adolescent Inpatient Unit, IPCU could also act as a "bridge" between this service and Open Young People's Units.

5.1 Options Appraisal

The objectives identified in the options appraisal were developed drawing from the background literature and findings, as described in Sections 1 & 3. They were discussed within the review team and refined to take account of clinical considerations, and the priorities of young people and their families, as well as professional staff within the wider health and care system involved in supporting young people who require intensive psychiatric care. A weighting was assigned to each objective to indicative the relative importance for adolescent IPCU provision. The scoring was undertaken by two of the review team, again drawing on the findings of the review, including Section 4, but also the extensive clinical experience of the review lead. The options appraisal is thus not an "absolute" scientific measurement but rather an informed view. The thinking behind the weighting and scoring is described below.

• Provide age appropriate IPCU care - The Mental Welfare Commission have identified gaps in IPCU provision for young people: age appropriateness is therefore crucial to any future provision.
• Intensive (adolescent trained) nursing - This objective reflects the pressures in recruiting, training, and retaining nursing staff with adolescent intensive psychiatric experience, and that this requires different skills to nursing adults, and to nursing adolescents in open units. Adjacency to existing units may enable sharing staff across inpatient services and supports maintaining staff skill levels when patient demand is lower, although considerations must be taken to ensure existing units are staffed at a level that can support this.
• Full Multidisciplinary Team (MDT) staffing complement - Recognising pressures in recruiting, training, and retaining specialist MDT staff, with variation of scoring across options reflecting viability of potentially low part-time staffing given number of patients/beds vs adjacency to existing units with potential to share staff across. This includes considerations around out of hours staffing, consultant cover and job planning.
• Sufficient beds to meet likely demand - Available data indicates relatively low demand over any 12 month period, but with potential for peaks in demand that may exceed any new dedicated provision. Adjacent provision could support some flex across new IPCU provision and existing open units.
• SW support integrated & local SW links - National provision less likely to be able than regional provision to maintain strong links into social work services of the young person's home locality.
• Equality of access (travel minimised, gender appropriate) - Regional provision reduces impact of travel (for patient transfer and family access). Purpose built facilities reduce negative impact of vulnerable young people being exposed to risks from older patients.
• Family input integrated - Acknowledging that any intensive psychiatric care should use a family-centred approach, including planned visits of family/caregivers, and gathering information from families to inform safety planning, which can also enhance family members' relationship with the ward.
• Facilities are safe and appropriately secure - By the nature of their mental health care needs, young people referred are likely to present risk to themselves or others to a degree that cannot be managed safely in an open unit. Purpose built facilities are thus preferable.
• Fit for purpose: safe, secure, young people friendly, trauma informed care. IPCU provision must be designed in such a way that it is an environment in which young people can be comfortable, safe and secure. A low-stimulus environment to meet sensory needs would also be a requirement. Décor and facilities should be designed with young people at the centre.
• Access to meaningful activities (education, green space, exercise, arts) - Access to meaningful activities will be a requirement for any young person who is well enough to engage in them. While the expectation is admission to an IPCU should be short, recreational and educational facilities should be available and age appropriate. Being adjacent to an open unit could mean a broader range of activities.
• Capacity to adapt in case of emergency (fire, staff illness). Business continuity must be safely maintained in emergency situations.

Table 5 provides an overview of the options appraisal, including scoring and weighting of non-financial objectives in relation to options for adolescent IPCU provision. Option 1 (Regional purpose built adjacent units) score most highly. It should be stressed that this does not include economic considerations.

Recommendation 13) While it is difficult to infer from available data the number of beds that would be required, the review team recommend two beds per regional site are factored in to planning for the development of future adolescent intensive psychiatric provision.

Recommendation 14) On the basis of the findings of the review, and the outcome of the Options Appraisal, the review team suggest Regional purpose built adjacent units would best meet the requirements for adolescent intensive psychiatric provision in Scotland.