Patiently awaiting change

In-patient mental health services for young people are changing,
but problems remain reports Cathy Street.

In-patient child and adolescent mental health services provide
some of the most specialist care and treatment for children and
young people with serious mental health problems. But until
recently, little information was available about these
services.

This situation is now improving with the recent publication of
several new studies most notably the Royal College of Psychiatrists
National In-patient Child and Adolescent Psychiatry Study (Nicaps).
In 1999 this study found there were 81 child and adolescent mental
health units across England and Wales, 54 of them classified as
adolescent units offering provision for young people between the
ages of 12 and 18. Each unit had an average of 12 beds.

Now children’s mental health charity YoungMinds has
undertaken an in-depth qualitative study of in-patient child and
adolescent mental health services. Stimulated by the
charity’s earlier research on the problems people have
accessing in-patient provision, the study worked with six
in-patient units from across England and Wales. A key objective of
the research was to record the views and experiences of young
people and families in order to provide information and ideas that
will help in-patient child and adolescent mental health services
become more “young-person friendly”. The study also aimed to
examine the challenges facing in-patient services as they develop
to meet current demands.

In recent years there has been a heightened interest in these
services, partly because of the apparent increase in the numbers of
young people in the UK experiencing serious mental health problems.
There is concern about patchy and disjointed services and in
particular, a lack of emergency beds. There is also growing
evidence of a shift in treatment philosophy towards more acute
care, shorter lengths of stay and individually tailored treatment.
And along with other health and social care services, there has
been a greater demand for user consultation and participation.

Perhaps as a consequence of all these factors, and the
accompanying release of new government money to try and improve
services, many in-patient child and adolescent mental health
services are changing. It is apparent that many are looking for new
ways to meet the complex needs of those referred to them and also
to work more in co-ordination with other agencies in the community.
The earlier trend of units closing or losing beds as the emphasis
switched to community-based provision has also to some extent been
reversed, with some units now expanding or new units opening.

It is within this picture of considerable change and development
that the YoungMinds’ study took place, with data being
gathered from 107 young people, 35 parents and 169 staff from
within in-patient units and surrounding services drawn from health,
education, social services and the voluntary sector.

What the YoungMinds study found gives cause for some optimism
but also continuing concern. The data gathered confirm that
in-patient provision is changing rapidly and that there are clear
areas of improvement – although it must be noted that these apply
largely at the local level, rather than nationally. These include
better accessibility either through the development of services
specifically designed to be easily accessible to young people, or
through existing services adapting and becoming more outward
looking with fewer entry restrictions and a focus on rapid
access.

There is also more evidence of inter-agency working including
the increase in posts that go across in-patient and community
services and of greater involvement of young people in planning and
evaluating services.

The changes evident within some in-patient services include more
outreach work in the community, different ways of managing staff
and the development of specialisms – for example, adapting or
refining treatments for young people experiencing psychosis or
developing family work. There has also been a general shift towards
units offering a wider range of services.

Set against these generally welcome developments are several
serious concerns. These include widespread staffing shortages at
in-patient units, inadequate sharing of information with young
people and families using services (raised by 67 per cent of the
study respondents) and a notable lack of support and resources for
young people on discharge from in-patient units (18 per cent of
respondents).

Quite clearly too, despite some recent expansion in the sector,
there are still not enough beds and gaps in service remain. This is
evidenced by the long waiting lists in the sample units and the use
of adult psychiatry and paediatric beds, used at some point by 20
per cent and 16 per cent respectively of the young people
interviewed.

Staffing, in some respects, is perhaps the most critical problem
currently facing in-patient services, especially shortages of
nursing staff. Without enough staff, units struggle to operate.
Staff may not be readily available when young people need them. The
range of activities and treatments a unit can offer and the
consistency of care can also be undermined.

The importance of staff availability was a central theme of
interviews with young people, with 39 per cent of those interviewed
reporting that they wanted more time with staff. One says: “When
you are having difficulties overcoming a problem, it is vital to
have adequate staffing as individual care is important to cope in
new and frightening situations.”

A significant number of young people (34 per cent) also
complained of being bored, with insufficient activities especially
in the evenings and weekends. Some linked the lack of activities to
staff shortages. The impact of this was often eloquently described.
“It can be bad if all you are doing is focusing on your illness –
you can focus too much and make it too serious. It’s
important to keep hold of your real life.”

The importance of units being properly staffed was emphasised by
the staff themselves. One says: “If you’ve got a secure and
supported staff team, then you get a less anxious group of
children”.

Tackling this problem will not be easy. It appears that several
factors are involved – the national shortage of trained nurses, the
perceived high stress of in-patient working and the curtailment, or
lack of, professional development opportunities (arising partly
because of these shortages). As in-patient services have tried to
adapt and develop to meet current demands, some staff have found it
difficult to adapt to new models of in-patient care, and to adjust
to the blurring of professional roles.

We concluded that the job specification for child and adolescent
mental health nursing staff, and the opportunities for specialist
training and professional development need to be reviewed –
otherwise the recruitment and retention of experienced nursing
staff is likely to remain a problem.

But there also needs to be a rethinking of the way in-patient
units are staffed. Other professionals, such as youth workers,
could be used to help ensure enough activities are offered, as well
as enough opportunities for young people to talk with trusted
adults.

– For further information about the Where Next? research
reports and booklets, please contact YoungMinds on 020 7336
8445

Cathy Street is senior researcher at
YoungMinds.