Bed shortage sees mentally unwell children sent hundreds of miles for care

Hundreds of acutely unwell children have been admitted to adult psychiatric wards and many sent hundreds of miles for hospital care due to a national bed shortage at young people’s mental health units, an investigation by Community Care and BBC News has found.

Our investigation, based on data obtained under the Freedom of Information Act from 51 of England’s 58 NHS mental health trusts, found there were 350 under-18s admitted to adult wards at NHS trusts in the first nine months of 2013-14. The figure marks a 36% increase on the 257 children admitted to adult units in the 12 months of 2012-13. In 2011-12 there were 242 children admitted.

The figures also reveal that 12 under-16s have been admitted so far in 2013-14, compared to 3 in both 2011-12 and 2012-13. One child admitted to an adult ward this year was 12 years old.

In response, NHS England said that treating under-18s on adult wards was “totally unacceptable in the majority of cases”.

Patients sent hundreds of miles away

Out of 18 NHS trusts that provided data on out-of-area placements, 10 had sent children to young people’s units more than 150 miles away in 2013-14. The furthest distance was from Sussex to Bury – a journey of around 275 miles. Sussex Partnership NHS Foundation Trust said a lack of available children’s beds, which are commissioned centrally by NHS England, meant they “simply couldn’t find anywhere nearer” to get the intensive care the child needed.

A leading psychiatrist said sending unwell children such long distances for treatment was “appalling” and isolated young people from their friends, families and local support teams. The children’s commissioner for England said the practice was a “serious concern”.

The impact on patients and their families is stark. We spoke to the mother of a 12-year-old girl from Hull who was sent 130 miles away to a mental health unit in Stafford. The girl’s child and adolescent mental health services (CAMHS) team, who had been searching for a bed for two days, were told the Stafford bed was the only one available.

The mother, who asked that her and her daughter were not identified, described the experience.

“One time [when I visited] she got upset because she didn’t want me to go and they had to prise her off me. They put her in a room and as I was leaving the unit she was shouting out the window ‘mummy, mummy don’t leave me, please don’t leave me mummy’,” she said.

“It [your child experiencing a mental health crisis] is not just like breaking an arm. It’s emotionally draining and to cope with that as well as having to travel, it’s the most difficult thing a mother could ever have to deal with.”

In response, NHS England said it wanted young people to be treated as close to home as possible and said it had launched a “rapid review” of problems with children’s inpatient services following a spike in demand. The review will conclude next month.

‘Inappropriate’ care

The Mental Health Act 2007 puts a duty on the NHS to provide “age appropriate” care to patients under 18. The government’s flagship mental health crisis care policy states that this means: “not an adult ward, unless [the patient’s] needs made it absolutely necessary”.

Yet Community Care found evidence that a shortage of beds, not patient need or professional judgement, was the driving factor behind many admissions of under-18s to adult units. Data obtained from social care regulator the Care Quality Commission showed that a lack of children’s beds was behind more than a third (45) of the 124 alerts the CQC had received about under-18 admissions so far this financial year.

The government’s crisis care agreement also states that children’s inpatient care should be provided “close to home, friends and school” unless these are contributing factors to the patient’s mental health crisis.

Leading mental health professionals told Community Care that a combination of cuts to community mental health services for children and commissioning failures had left inpatient services overwhelmed. The quality of crisis care on offer to children is often falling well short of expected standards as a result.

Dr Michael McClure, consultant child psychiatrist and clinical director for child and adolescent mental health services at Central North West London NHS Foundation Trust, said his teams experienced regular problems getting children’s beds for patients.

“It’s a consistent problem now with CAMHS that they have young people misplaced in adult wards getting inappropriate care,” said McClure.

“Sometimes we have to make 50 to 100 phone calls around the country looking for a bed. They [young people] shouldn’t be shunted around into inappropriate facilities, however much the staff there try to help them.”

Asked about the impact of children being sent to hospitals long distances from home, Dr McClure said: “I think it’s appalling. It may be the first time they’ve had a breakdown. They need to stay in touch with the people they know and love and if they’re having to move 200/300 miles, it’s very difficult for the family to stay in touch. It’s also difficult for the local CAMHS team to stay in touch. It’s poor care.”

Commissioning failures

NHS England took on responsibility for commissioning children’s mental health beds nationally in April 2013. Local GP commissioners retained a duty to commission community (tier 1 to 3) children’s mental health services.

Dr McClure said the split in commissioning responsibilities had led to a lack of “joined up thinking”. He said the government and NHS England needed to back up their claims that mental health is a priority with investment in young people’s services.

“We get slogans – ‘no health without mental health’. We don’t want slogans, we want decent funding for CAMHS and good access for inpatient services,” he said.

“If community services were properly funded to allow home treatment of some of these young people, they wouldn’t need to be admitted in the first place. Similarly, when they’ve been in hospital and they are almost well enough to be discharged, they could be discharged a little bit earlier and looked after at home. That would release a bed and a new young person could be admitted.”

Faye Wilson, chair of the British Association of Social Workers’ mental health forum, agreed that commissioning in children’s mental health is currently inadequate.

“The most vulnerable children, what I’d call tier 3 or 4 cases, are too often only getting clinic appointments and CAMHS is a nightmare in some areas,” she said.

“When a child is admitted to an adult ward there should be a protocol in place. They should be put in a specific child-friendly room. The question is how often is that happening in reality given the current level of pressure in the system?”

Dr Maggie Atkinson, children’s commissioner for England, said the distances children are being sent for care is worrying.

“To be 200 or more miles away from the people who love you, even if you’re desperately ill and need psychiatric treatment, must add to your concern and worry, and theirs. The truth of the matter is that the system has made things very patchy. If you’re in a big city its far likelier you will have access. If you’re in a very isolated rural or coastal place its less likely and that’s a serious concern. It’s our job to level the playing field.”

In the meantime, children in mental health crisis could experience similar care to that provided to Nicola Mattocks. The 16-year-old from south London has been admitted to hospital for mental health care four times since she turned 14. Each placement has been at a unit more than an hour away from home, making it difficult for her father – her primary carer – to visit.

“I couldn’t see my dad as often as I’d like and my friends couldn’t get there as it was so far away. I was in a strange place and I couldn’t see anyone I was familiar with. I felt quite alienated,” she said. “It didn’t help [being so far away]. I was in a place that I didn’t know or understand which made me feel more ill.”

NHS England and the Department of Health respond

Dr Jacqueline Cornish, NHS England’s national clinical director for children, young people and transition to adulthood, said: “Children and young people with mental health problems being treated in adult settings is totally unacceptable in the majority of cases.

“We recognise there is an issue around bed availability within tier 4 child and  adolescent mental health services, where we see the most seriously ill patients, which we are working hard to address. We want to improve services and move towards patients being treated as close to their homes as possible.

“When NHS England took on responsibility for tier 4 CAMHS last year within a short time we became aware of an increased demand for inpatient care, problems with availability of beds in some areas and the absence of national planning. When these issues came to light we immediately began a rapid review. This three-month review will conclude next month and will help to inform decisions about how services should be provided in the future. As part of the review we are looking at current provision, level of demand, admission criteria and areas of best practice.”

A Department of Health spokesperson said: “Children and young people’s mental health is a priority for this government and NHS England. That’s why we have invested £54m to improve child and adolescent services through better monitoring, sharing best practice and improving access to specialist talking therapies for young people.”

Sarah Brennan, chief executive of the charity Young Minds, said the increase in children placed on adult wards was predictable following cuts to early intervention services over the last four years.

“The lack of help early on means we are letting children’s problems escalate to serious levels,” she said.

“This, alongside the lack of accurate data about the mental health needs of our nation’s children and young people, means commissioning has been based on out-of-date, inaccurate information, leading to out-of-date provision.”

Download trust-by-trust data on admissions of under-18s to adult wards

Related articles:

• Patients at risk as unsafe mental health services reach crisis point
• ‘The beds crisis makes me embarrassed to work in mental health’
• ‘We are firefighting: the mental health funding shortage that’s hitting frontline care’

Andy McNicoll is Community Care’s community editor