As the shortage of inpatient adolescent beds forces more young people in mental health crisis to be admitted far from home, Jose Mediavilla explores the legal and clinical implications
The crisis of adolescent inpatient beds for young people suffering from mental illness has come to the fore in the last year.
The numbers of children and young people being admitted to adolescent inpatient units outside of their local area is on the rise.
There have been significant increases in the number of both local and out of area referrals to adolescent inpatient units in England from April 2013.
On a general purpose adolescent inpatient unit in England the total number of referrals rose from 89 in 2012-13 to 187 in 2014-15. Whereas in 2012-13 the number of out of area referrals represented less than a third of the total number of referrals, this number surpassed the local one in 2014-15.
This exponential trend would be unsustainable given clinical resources.
‘Consent is particularly relevant when considering the legal basis for treatment’
There are clinical and legal caveats to admitting young people with a mental health crisis on units that might be hundreds of miles away from their homes.
It is essential that clinicians involved in such admissions are aware of the Mental Health Act and the Mental Capacity Act, and have a level of expertise to ensure that those admissions remain lawful.
There are serious implications for clinical demand on increasingly strained services, as well as potential quality implications to the care received by young patients admitted hundreds of miles away from their homes and families.
The House of Commons made several recommendations, among them improving accessibility to inpatient adolescent beds. NHS England’s Child and Adolescent Mental Health Services Tier 4 Report acknowledged significant shortages of inpatient provision in specific parts of the country.
Since the national commissioning of adolescent inpatient beds in April 2013, NHS England has implemented new policies to simplify and improve access to inpatient beds.
A national database was created to match demand with availability. It aims to cut waiting times for adolescent inpatient beds and enable young people to access them in crisis, as well as reducing the number of inappropriate admissions to psychiatric adult beds.
This national commissioning of adolescent beds has made the concept of “local beds” obsolete when access is needed in a crisis.
The NHS England report suggests that admission to a psychiatric hospital in a crisis carries a worse prognosis: “Services will be more effective if access is not dependent upon crisis but follows planned care pathways.”
Reasons for this might include lack of opportunities to discuss aims, expectations, duration and the young person’s consent to admission.
‘National commissioning of adolescent beds has made the concept of “local beds” obsolete’
Consent is particularly relevant when considering the legal basis for treatment. Whereas young people over the age of 16 are presumed to have capacity to make decisions about themselves, children and younger adolescents under the age of 16 are not automatically deemed to have “sufficient understanding and maturity to enable them to understand fully what is proposed”.
Crisis referrals can involve young people being asked to consent to admissions hundreds of miles away from home to be cared for by inpatient teams they have not met.
Patients may also be unaware of expectations that will be placed on them upon arrival – for example, appropriate limitations to their liberty under the duty of care that would be legally viewed as “deprivation of liberty”, as the young person would be “subject to continuous supervision or control and not free to leave”.
This decision would need to be considered as “outside of the zone of parental control” and therefore a decision that only a capacitous adolescent (over 16 years) or a competent adolescent (under 16) can make.
‘Admissions at such long distances can result in unnecessary delays in discharge’
A significant number of these requests for admission are completed in the middle of a crisis and do not carry a specific documented assessment of the young person’s competency or capacity to consent to such decision. In some of these instances, such admissions would require a formal Mental Health Act assessment to gain authority and a legal basis to treat the young person.
Admissions at such long distances can result in unnecessary delays in discharge planning given the difficulties in working with local services to facilitate a prompt discharge and reintegration back to community care.
The challenge to commissioners and providers would be to ensure not only bed availability for those children and young people that might need it but that admission to hospital occurs locally.
This will facilitate the delivery of effective treatments such as family therapy and a prompt reintegration back into community care and a safeguard to the rights of the child.
Dr Jose Mediavilla is a consultant adolescent psychiatrist at Tees, Esk and Wear Valleys Foundation Trust