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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.