Dawn Rees
The Rees Consultancy Ltd
2 Warrens Way
Tacolneston
Norfolk NR16 1DH
23rd June 2014
Dear Dawn,
Re: Review of CAMHS acute pathway including inpatient services (for Northern
Ireland HSCB)
As the Child & Adolescent Faculty of the Royal College of Psychiatrists in Northern Ireland,
we represent the views of Consultant Child and Adolescent Psychiatrists, Speciality Doctors
and Senior Trainees in the region. We welcome the opportunity to share the reported
opinions and concerns about recent and possible future changes to acute CAMHS in
Northern Ireland, particularly the nature and function of the inpatient units.
The College believe that this review is timely because the context in which acute CAMHS
must be delivered is changing fundamentally. Healthcare policy has emphasised the
economic imperative for a “shift to the left” i.e. with healthcare needs being met through
community-based rather than hospital services. Increased regulatory scrutiny has meant that
some historical practices, such as admissions of older adolescents to adult beds, are no
longer acceptable. Human rights legislation demands that all possible alternatives to hospital
admission must be considered. It seems that young people who are admitted to hospital are
more likely to be admitted under the provisions of our mental health order and this may be
partly due to the Interim Deprivation of Liberty Safeguards issued by the Department of
Health, Social Services and Public Safety in 2010. The College believe that the impact of the
expected introduction of capacity legislation, and the retention of enhanced mental health
legislation for under-16’s, should be carefully monitored.
Increasingly, specialist CAMHS care is driven by responding to risk. There is an expectation
that the mental health needs of children and young people will be met through an “acute”
medical model, when a more nuanced understanding of social and cultural factors should be
acknowledged. The regional assessment tools in use within CAMHS focus on quantifying
risk rather than meeting needs. The FACE risk assessment tool lacks validity and
consistency and has sometimes become a replacement for, rather than a compliment to,
clinical judgement.
All this means that we must find ways of managing higher levels of complexity in the
community, at a time when public scrutiny and expectation is increasing exponentially. The
influences on current patterns of bed use within the inpatient units are multifactorial and are
probably reflective of a response to external pressures and changing contexts as much as a
reflection of actual need within the population.
In 2012 the model for CAMHS commissioning changed from the more widely understood
tiered model to a “Stepped Care” one. At the time the College highlighted that, whilst this
framework might allow for the development of more efficient services that can be more easily
measured in terms of short term outcome, it would not necessarily allow for the considered
long-term planning and evolution of more effective and comprehensive services overall. This
problem is compounded by lack of clarity around how CAMHS services have been
commissioned historically. There is a tendency towards circular arguments between
commissioners and providers as to which services were, or were not, included in historically
funding arrangements e.g. services for under-5’s.
There is a widely held (although debated) view that, whilst demand on mental health
services in terms of numbers of referrals has stayed relatively constant over recent years,
those who do seek help are presenting with more complex needs and greater expectations
from services.
In this context, the provision of acute care is being reframed, with short-term assessment
and crisis resolution becoming the predominant model at Steps 4 and 5 of the CAMHS
model. This is concerning to the College. Resources have largely been focussed on
managing short-term risk. In terms of the inpatient units, this changing ethos has been
evidenced through developments such as the admission of under-12’s being deemed
“undesirable” and some beds being “managed” so that only emergency rather than planned
admissions are being accepted. Clinicians have sensed a drive for increased turnover within
the inpatient units. This is not always appropriate and depends on the development of more
robust step-up and step-down pathways, with better planned and resourced community
services. There will always be a cohort of young people who will benefit from planned and /
or longer-term admissions. Specialist CAMHS continues to operate with a legacy of chronic
under-funding, we receive a much lower percentage of the total mental health budget than
elsewhere in the U.K.
The development of crisis assessment teams has been very positive, but we should ensure
they do not become the only pathway to inpatient care or necessarily the main focus of new
or re-investment. CAMHS must be adequately resourced at all steps / tiers to ensure
services are comprehensive and future-proof.
The College would welcome further scrutiny as to whether crisis / intensive treatment teams
function differently according to their geographical location. There is a sense that
adolescents presenting with high-risk behaviours (e.g. acute suicidality alongside altered
mental state due to drug use and / or social care concerns) are more likely to be admitted if
they present in the Greater Belfast area, whereas in more remote areas such cases would
be managed locally. Some senior clinicians believe that there is a need for smaller inpatient
facilities in areas distant from Belfast; certainly our transport and technology systems are not
conducive to family and community life being protected during times of inpatient treatment
for those young people coming from more remote, rural regions. The College also believe
that careful consideration should be given to the need for increased numbers of social care
beds that offer a high level of support or secure care. There is a concern that often young
people are admitted to mental health units at times of crisis because it is not safe for them to
remain in the community. Care pathways should be developed which allow careful
multiagency planning and cooperation and the resource implications of this should be fully
considered.
Community-based CAMHS clinicians have noticed increasing difficulty in accessing planned
admissions and there is also a sense of their decreased confidence in the value of seeking
admission for young people being managed in outpatient CAMHS. It seems that most
admissions are of older adolescents with complex, intractable difficulties and these
admissions happen in an unplanned way. Outpatient treatment may not have been
optimised, assessment and treatment goals are less clear and discharge planning is difficult
(leading to increased length of stay). Demands on the staff team have increased, and this
appears to have had a negative impact on staff-turnover.
Clinicians are also aware that various review bodies (RQIA, QNIC etc.) have highlighted
concerns about the units, which may make people less likely to seek admission because of
concerns about the quality of experience or outcome. Others believe themselves that the
unit has become a less suitable environment for younger or more vulnerable clients,
because of the range of behaviours they may witness and emulate.
Despite all the issues outlined above, bed occupancy levels in Beechcroft have been
variously reported at 80% to 110%. The figure of 80% represents actual numbers of beds in
use at midnight i.e. not including beds held for young people on leave, so 110% might be a
more accurate representation of demand. We have previously sought reassurance from the
commissioners that the overall bed compliment will not be reduced. The College document,
“Building and Sustaining Specialist CAMHS” suggests a need for 43-72 mainstream CAMHS
beds and 11-15 I.D. CAMHS beds across the region. Those beds should run at 85%
maximum average occupancy. Whilst the majority of these beds should be for adolescents,
the College recognises a clear need for specialist beds for children under-13. These figures
are intended to be a general guide for service-planners in the U.K. In Northern Ireland the
under-18 population is 27-32% greater than other UK regions.
The College would strongly challenge any view that the need for beds has been reduced
because crisis teams have been established. There is a need for Step 5 CAMHS to
contribute to the overall management of cases that present longer-term complexity and risk,
sometimes by intervening early. Whilst we agree with commissioners that “acute” should not
always be defined by the presence of a bed, neither should it always be defined as
responding to high risk, crisis presentations. Often clinicians may seek admission to address
specific diagnostic questions or to optimise complex treatment regimes. On occasions, they
admissions of younger children and / or families will be beneficial and admission to a
suitable unit should be easily achievable.
In terms of intellectual disability services specifically, the Iveagh Unit has had to operate in a
context of entirely inadequate community services. Children and young people with
intellectual disability have very limited access to specialist, multidisciplinary, therapeutic
CAMHS. In some trust areas there are no specialist residential provisions for those young
people who are able to live at home. The pattern is of late, complex presentations to
inpatient services with very limited options to support a planned discharge, which leads to
the phenomena of “bed-blocking”. For Iveagh to be able to function efficiently there will need
to be a significant increase in community-based services.
The College advocate the need for better training and development pathways for CAMHS
practitioners and the need to ensure better retention of experienced practitioners, with less
reliance on use of staff on short-term contracts. The inpatients unit need to retain a cohort of
staff with particular expertise in meeting the therapeutic needs of young people in in-patient
care. To achieve this there needs to be improved pathways for training and career
progression.
The College are particularly concerned about the limited involvement to date of senior
clinicians in discussions about changes to the inpatient units. They have had limited
opportunity to influence decisions which have been taken or proposed. We want to see more
robust engagement of clinicians in the planning of acute / inpatient services. The importance
of clinical leadership should be recognised at a strategic level. The experience of both
inpatient and community-based Consultants will be valuable in helping to shape services
that are truly responsive to the needs of the population.
We believe there is a role for improved shared decision-making and joint-working between
community- and hospital-based services, both in terms of general service panning and with
regard to individual case management. The interface between hospital and community
should not be mediated via crisis teams alone, the College feel strongly that it should be
possible to plan admissions for children and young people who are being managed longterm at Step 3 and who require a more specialist assessment. There should be clear
pathways which allow psychiatrists working in community teams to participate in
collaborative admission and discharge planning processes and there may need to be
separate pathways for crisis and planned admissions. Community clinicians need to be able
to rely on timely admissions when these become necessary. Given the demands on
clinician’s time and geographical considerations, the system should be responsive, flexible
and easy-to-negotiate. Much of this could be achieved through out-reach / in-reach models
and greater use of technology.
It is important that changes to services are incremental and intensively evaluated in a
prospective manner, to ensure that change is positive. Quality should be the organising
principle of all we do and, where the inpatients units need better resources to achieve better
outcomes, this should be recognised. We would like to see outcomes and experience of
service being captured more meaningfully to help inform future changes to the nature of
Step 4 and 5 services, rather than changes being made on the basis of more rudimentary
data or conceptual ideas.
The College members look forward to working with each other, managers and
commissioners in the months ahead as we seek to address the needs of the population we
care for and to provide the highest possible standards of care for those children and young
people who are in need of specialist mental health services.
We trust these comments will be helpful in the context of the overall review.
Yours Sincerely
Dr Heather Hanna
Consultant Child & Adolescent Psychiatrist
Chair, Child & Adolescent Faculty RCPsychNI