In-patient child and adolescent mental health services treat and care for the most severely ill and disturbed young people. NHS provision is insufficient to meet the need and as a result children and young people are often admitted to independent sector units or inappropriately to adult psychiatric wards or paediatric wards. Although it is accepted that units are diverse in terms of their admission criteria and models of care, there is little information about the service available. The Department of Health has responded to this by funding the National In-patient Child and Adolescent Psychiatry Study (NICAPS), a comprehensive and detailed review of these services in England and Wales.
Previous reviews, which included in-patient services (NHS Health Advisory Service, 1986, 1995; Audit Commission, 1999), identified two key themes: (a) a lack of services for those aged 16-18; and (b) a need for better coordination of services and joint working. Other themes included problems with staffing, proximity of services to patients' homes and provision of emergency services. The provision of emergency beds, staffing and outcomes for specific disorders have also been identified as issues for inpatient services (Reference Cotgrove and GowersCotgrove & Gowers, 1999).
The first stage of NICAPS was a survey of members of the child and adolescent faculty to obtain their views about the key issues for these services.
Method
A questionnaire was sent to all 474 members of the Royal College of Psychiatrists' child and adolescent faculty with addresses in England or Wales. A single question was asked: “Briefly, what do you think are the main issues relating to child and adolescent psychiatric in-patient services?” A follow-up letter was sent 4 weeks after the first forms were posted.
A content analysis was conducted on the responses. First, the free text replies were broken down into component statements or ‘text units’. The two authors reviewed the statements and independently created a coding frame that would fit these qualitative data. The two coding frames were then compared and a final version was negotiated. The authors then independently coded the statements and any discrepancies in the coding of text units were discussed and resolved.
Results
Two-hundred and seventy-four forms were returned. These included 29 that were returned with no comment, giving a total of 245 usable replies. Further investigation indicated that addresses were incorrect for approximately 10% of non-responders and we adjusted the denominator to 454 members, resulting in a 60% response rate.
The 245 usable replies provided 1033 distinct statements. A total of 38 themes were derived from these statements. These formed the basis of the coding frame. There was consensus between the raters regarding the coding of statements.
Table 1 displays the range of commonly occurring themes and the frequency with which they were identified by respondents. The most frequently reported were lack of emergency beds and facilities (36%); insufficient number of beds (25%); poor provision for severe or highrisk cases (24%); and poor liaison with other services (20%).
Table 1. Range and frequency of commonly occurring themes, as reported by Child and Adolescent Faculty members
| Rank | Sub-theme | Frequency n (%) |
|---|---|---|
| 1 | Lack of emergency beds and facilities | 89 (36) |
| 2 | Lack of beds | 61 (25) |
| 3 | Poor provision for severe or high-risk patients | 58 (24) |
| 4 | Insufficient liaison with the patients' local services | 50 (20) |
| 5 | Poor geographical proximity | 45 (18) |
| 6 | Need for increased range of specialist services | 41 (17) |
| 6 | Admission criteria too selective | 41 (17) |
| 7 | General poor planning of services — geographic distribution of services | 40 (16) |
| 8 | Difficulties finding a bed and long waits for admission | 35 (14) |
| 9 | Funding problems | 32 (13) |
| 10 | Concern about where to manage conduct disorder and ‘social admissions’ | 30 (12) |
| 11 | Problems recruiting nursing and multi-disciplinary staff | 27 (11) |
| 13 | Need for standards and guidelines | 25 (10) |
| 14 | Need for training — maintaining a high level of skill including therapeutic skills | 23 (9) |
| 15 | General problems with treatment — need for a wider range of treatments | 22 (9) |
| 17 | Problems with patients' length of stay — impact of inadequate local services | 20 (8) |
| 17 | Managing patients in other settings | 20 (8) |
Discussion
The single open question proved an effective method of obtaining psychiatrists' views. The alternative of providing categorised response options might have influenced or constrained respondents' replies.
There are some limitations to the study. First, the response rate was only 60%. We do not therefore claim the results to be representative, but rather illustrative of the range of issues relevant to faculty members. Second, the frequency of the responses is dependent upon the coding system, for example we could have combined lack of beds with staffing or funding problems in a more frequent general resources theme. Third, the most important comments may not necessarily have been the most often reported.
Emergency beds/facilities
Provision of emergency facilities was the most frequently reported theme among the psychiatrists surveyed. Respondents who raised this theme commonly expressed concerns about the admission of young people in crisis to paediatric or adult psychiatric wards. Statements typically referred to the ‘need for emergency beds’ and the ‘lack of emergency admission services’. The lack of quantifiable estimates of need for emergency services has been previously highlighted as an important related problem (Reference CotgroveCotgrove, 1997). This is particularly pertinent in light of the recent finding that over one-third of trusts felt they could not respond effectively to young people presenting in a crisis (Audit Commission, 1999).
Numbers of beds
Some respondents referred to the fact there were no child and adolescent psychiatric in-patient services available in their area. They reported that even for routine admissions patients were often accommodated in either paediatric wards or adult psychiatric wards until they could be placed out of the area or were well enough to be otherwise discharged.
Provision for adolescents appears to be a particular concern (NHS Health Advisory Service, 1986). The Audit Commission has reported that one in five health authorities are ‘unclear’ about the age ranges covered by their services and one in three commission services only for those up to the age of 16. They conclude that “despite several specific reviews of adolescent care, services for young people remain patchy”.
Liaison with other services
Many respondents commented that effective communication between local services is important to ‘ensure timely admissions and discharge with effective follow-up’. Others reported the difficulties they experienced establishing joint working with other agencies and locally-based services. Problems integrating with local services were attributed to the fact that ‘most units are regionally focused’.
Previous reports have highlighted problems of joint working (NHS Health Advisory Service, 1986, 1995; Audit Commission, 1999). The Audit Commission commented specifically on the difficulties when several health authorities fund a unit.
Provision for severe or high-risk cases
Many respondents were concerned about the inadequate provision for those who are severely ill and in need of secure accommodation. Statements that typify this concern include “units are unable to admit seriously disturbed young people” and “there is a need for more forensic services or secure and semi-secure services”. It is likely that at least some young people admitted to adult psychiatric wards are those with severe psychiatric illnesses whose needs cannot be met by in-patient child and adolescent mental health services. One respondent commented that in-patient services only offer a “modified residential provision of Tier 3 services” and that “they do not cater for the urgent placement of very disturbed or forensic patients”.
Many respondents (17%) emphasised a need to increase the range of specialised units catering for severe or high-risk cases. In particular, specialist units for ‘acute psychiatric’ conditions were reported to be lacking, as were facilities for children suffering from conduct disorder and children suffering from psychiatric problems and learning difficulties. Concern about lack of provision for severe or high-risk patients and the lack of specialist services was not specifically identified in previous reports.
A joint working group of the adult and child and adolescent faculties is considering the problem of admission of young people to adult psychiatric wards, which relates to the three most common themes reported. The National Service Framework for Mental Health (Department of Health, 1999) refers to the admission of adolescents to adult wards and recommends protocols should be agreed locally between adult and child and adolescent mental health services.
There may be no solution to the lack of beds generally and the lack of specialist and emergency provision other than to provide more resources. Communication between agencies, however, might be more amenable for more local action.
As a result of this survey several changes were made to the design of NICAPS. For example, NICAPS will now look more closely at emergency referrals made to child and adolescent in-patient services and other local services. Concern about poor provision for high-risk cases will be explored by asking for the reasons why young people are not admitted and are turned away. Also, information will be obtained during site visits about the units' liaison with the patients' local services.
Conclusion
The survey identified a range of themes that have served to focus NICAPS on pertinent issues. It has also informed the design of the data collection tools. The data collected throughout the course of NICAPS will enable further exploration of the issues raised both by this survey and by previous reports.
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