Written evidence submitted by Dr Virginia Davies (CYP0013)

Addressing injustices in hospital provision for children and young people: how to achieve better provision of mental healthcare in the physical healthcare setting of acute trusts.

The distressing reality that mental healthcare for children and young people in acute trust settings is woefully under-provided, is not news.  But with acute trust debts being written off, hospital trusts and commissioners of services have a timely opportunity to address this age and condition-based discrimination.

Delivering a just service for under 18s depends upon attitude, resources and adequate knowledge of the tasks involved.  This article aims to describe the current landscape, summarise the arguments for better integrating mental into physical healthcare settings, articulate the tasks involved and the challenges for commissioning and providing, and finally share examples of current service models across the country.

Ultimately commissioning and provider choices will be constrained by resource pressures, but this article aims to underscore why commissioning and providing a portmanteau, ‘no wrong door’ hospital service for children, young people and families (CYPF) is worth the headache of thinking outside old commissioning and provider boxes.

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Current reality: fragmentation and inequality

Last year, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report into ‘Mental Healthcare in Young People and Young Adults’ 1 concluded that

• Mental healthcare was not given the same level of importance as physical healthcare in general hospitals
• General hospital staff were not receiving enough support from mental health professionals in the general hospital setting, particularly with regard to risk management

Despite these damning findings, the report did not advise commissioners how they could use their purchasing power to exact a more equitable provision of mental health care for young people (YP) in hospital settings. And many of NCEPOD’s recommendations can be nominally implemented with superficial changes to job definitions and training plans.

And this year, having stated in 2015: “What is particularly worrying is that children with physical, learning or mental health needs are telling us they have poorer experiences” (in hospitals)3, Ted Baker, CQC’s chief inspector of hospitals’ noted in the 2020 Assessment of Mental Health Services in Acute Trusts (AMSAT) report4 “Physical and mental health care have traditionally been delivered separately. While investment and improvements in mental health services are welcome, physical and mental health services will only truly be equal when we stop viewing physical and mental health as distinct. Services need to be built around all of people’s needs and not determined by professional or interest groups….

Many of the people attending acute hospital emergency departments with physical health needs may also have mental health needs. These people are in a vulnerable position and need to be treated with compassion and dignity. This must be in a way that makes them feel safe and upholds their human rights. In our report, we raise concerns that people with mental health needs are not always receiving this level of care. How well they are treated in an emergency department, or elsewhere in an acute hospital, is often linked to the importance that mental health care is given by the trust board. Acute trusts must do more, but they also need support from mental health trusts to develop better and more integrated approaches to care.”

AMSAT makes some welcome recommendations for integrated care systems and acute trusts, however, with no absolute commissioning directives around ‘whole person’ hospital care, most trusts will choose to overlook this central aspect of patients’ - and especially children’s - care.

The tendency for adult and physical health priorities to set the agenda within acute trusts means that children and young people with mental health needs seem always to be last in the queue. This is despite the well-known rates of co-morbidity between long term physical and mental health conditions in children 5, 6,7, 8, and the immediate, let alone long-term, resource implications of failing to address the psychiatric co-morbidities of these children and young people (CYP).9

from:, Meltzer H, Gatward R, Goodman R, Ford T. (2000) Mental health of children and young people in Great Britain. Office for National Statistics. London: The Stationery Office

The levers of integration

As AMSAT points out, if integrated treatment of mind and body is to be achieved, it must be underpinned by effective service level agreements between stakeholders.  The principles which guide such contracts were well articulated in ‘Side by side’10, published last February. This UK-wide consensus statement, agreed by the Royal Colleges of Physicians, Nursing, Emergency Medicine and Psychiatrists, calls on all parties to work together to better care for patients with mental health needs in acute hospitals.

‘Best care’ is characterised by

• Co-location of physical and mental health staff
• Reciprocal competencies in each staff group, physical and mental
• Joint ownership of CYP whilst in the hospital

Addressing the second and third aspects, reciprocal competencies and joint ownership, can be relatively easy, but as Ted Baker observed in AMSAT: ‘Where high-quality leadership for better mental health in acute trusts was lacking, we saw how there was more likely also to be a lack of appropriate training to support staff and poor working relationships between acute and mental health trusts.’4

Reciprocal competencies: Exchange programmes for junior doctors and nurses are already in place in some areas. Likewise, many health practitioner training programmes now contain modules offering reciprocal competency qualification, and frameworks such as the UCL competency framework11 allow staff to register as having reached different competencies in relation to mental health training. This model could be used to determine levels of mental health competency and capacity within the acute trust workforce. ‘We Can Talk’ training, used by many trusts, allows staff to feel better equipped to talk about mental health issues with CYP, detect safeguarding issues and provide signposting, but is less a CAMHS-competency framework.12

Joint ownership of patients can be interrogated by examining a Trust’s pathways and protocols. These agreements can usefully confirm which team will take lead responsibility for a young person’s care. CYP who have used hospital emergency departments during mental health crisis describe how the experience of feeling unwanted at a time of particular vulnerability puts them off returning13. Given increasing rates of self-harm and suicide in young people14,15, this is not a desirable outcome.

The biggest challenge to achieving genuine side by side working is co-location of physical and mental health staff. But this is not simply an issue of estate management and a lack of space, it is because co-location of mental and physical health provision presents a challenge to the very notion of what an acute hospital is about. Acute trust functioning and the commissioning of services within hospitals remains mired in an out-dated notion of physical healthcare.  Within this conceptualisation, physical health is divorced from the unconscious and from emotional and irrational reactions to physical ill-health and disease, let alone family psychological factors, and care packages are linear processes.

Key considerations in commissioning integrated CYP care

Four main areas need to be considered when negotiating contracts for integrated acute trust care for U18s

1. The range and complexity of mental health tasks to be addressed
2. Commissioning discontinuities and fragmentation between adult and child, mental and physical, local and regional/national/international services
3. Funding sources for non-patient facing activities, including staff support and professional development
4. Ensuring a single ‘front door’ for CYP and their families

1. Broadly speaking, three mental health tasks need to be managed in the acute trust setting: crisis/emergency mental health presentations; non-urgent psychiatric or psychological issues; systems issues around complex cases. Box 1 gives more detail.

Box 1

2. Commissioning discontinuities and fragmentation are rife for U18s in hospital, with 16 and 17 year olds most disadvantaged despite having the highest rates of psychological morbidity16.

Emergency attendance data for one London teaching hospital over the period 2013 - 2019

The age discontinuity between paediatric commissioning and CAMHS commissioning, especially given the former’s non-alignment with educational transition points, is surely an area for urgent attention by Integrated Care Systems. ICSs are tasked with breaking down barriers to care as part of delivering the NHS long-term plan,17 but with Covid having changed the commissioning landscape, how will the new block contracts impact this?

How does the commissioning arrangement work when a hospital functions not only as a local ‘district general’, but also as a regional, national and possibly international specialist referral centre?  Most acute trusts have arrangements in place for costing physical healthcare packages involving national and international patients, but these rarely take into account potential mental health needs.

3. Funding sources for non-patient facing activities, including staff support, are vital for the sustainability of any integrated service. Significant amounts of non-patient-facing activity are involved in clinical tasks 1 and 2 (see box 1). A 75-minute crisis consultation will often require at least as much time again, often more, liaising not only with other hospital and primary care staff, but also other agencies, especially social care and education, as well as adult mental health if parental mental illness is a factor. Emergency tariffs rarely cover the hours of work involved, nor the numbers of mental health staff who may need to be involved. Tariffs need to contain adequate funding for staff with sufficient knowledge of child and adolescent mental health to complete this important liaison work and payment by results has often meant that provider trusts end up running these services at a loss.

Mental health staff are also important for delivering staff support, something that became very obvious during the recent pandemic. Plenty of evidence exists for the benefits on staff wellbeing of reflective practice18,19, but this is rarely factored into commissioning agreements between acute providers and commissioners.

4. Finally, how does the commissioning arrangement ensure that CYP and their family are NOT having to visit multiple ‘front doors’ and tell their story multiple times? Having on-site, integrated mental health staff ensures that, not only do CYPF have an experience of one extended team caring for them, meaning that any mental health professional coming to see them has a good sense of their physical context and is already well-briefed on their possible mental health difficulties, but they can access mental healthcare even if they come from a family or culture where attending CAMHS or having mental health needs is unacceptable20. Equally, if their family of origin is chaotic and/ or their emotional and behavioural presentations stems from child neglect or abuse, the hospital provides a one-stop shop. This offer is unlikely to be the case if commissioning relies on in-reach from local CAMHS.

Examples of some current models for CYP mental health provision

With these considerations in mind, commissioners and providers can consider which of the following models is best for their acute trust/s

1. Acute trust-employed U18s mental health service covering the emergency department (ED), wards and outpatients. Team deliver in-house training, staff support and reflective practice (Whittington, London)
2. Mental health trust-employed ED psychiatric service (adult practitioners) and CAMHS crisis team see U18s ED emergencies and those admitted for less than 24 hrs. Acute trust-employed paediatric (ie under 16s) mental health team see all other cases, including crisis admissions of more than 24 hours. Paediatric mental health team deliver in-house training, staff support and reflective practice (John Radcliffe, Oxford).
3. Mental health trust-employed ED emergency service, with on-site U18s mental health team during working hours. On-site mental health team see certain groups of inpatients and outpatients as part of acute-trust funded, condition-specific service level agreements eg Tourette’s, as well as ‘generic’ inpatients and outpatients if funding is agreed on a cost-per-case basis by local commissioners. Large acute-trust employed, condition-specific paediatric psychology service, separate to mental health team. Paediatric psychology service deliver in-house training, staff support and reflective practice (Evelina Children’s Hospital, St Thomas’ Hospital, London)
4. Acute trust-employed under-25s out-of-hours mental health emergency team as well as CAMHS in-reach during normal working hours. Acute trust-employed community counselling service providing in-reach or outpatient services for children on wards or out-patients, as well as paediatric staff support (Blackpool Victoria Hospital, Blackpool).

A binary choice?

In effect, commissioners and providers working within integrated care systems have two broad choices when they consider mental health provision for CYPF in acute trust settings:

• an embedded, multidisciplinary children’s psychological medicine team, staffed by practitioners such as paediatric psychologists, child and adolescent psychiatrists, child mental health nurses, child psychotherapists, physical therapists and social workers, all directly employed by the acute trust and working across all settings.
• two separate mental health teams, one employed by the mental health trust and seeing crisis/emergencies (uni- or multidisciplinary, with nurses usually providing the unidisciplinary input) and one employed by the acute trust seeing all other cases (uni- or multidisciplinary, with psychologists usually providing the unidisciplinary input)

In an ideal world, where team boundaries are minimised, the first model is preferable. Such embedded services allow CYPF access to timely mental health care, when and where they need it, with staff versed in their physical health needs, and without the long waits that currently plague access to CAMHS services. Clinical scenarios involving acute behavioural disturbance on paediatric wards or the need for urgent and ongoing psychiatric care for CYP in intensive/high dependency care cannot wait around for funding requests that take weeks to agree. Equally, CYP with disabling unexplained physical symptoms may not appear to mental health commissioners to be ‘mental’ and legitimate recipients for funding (not fitting usual CAMHS eligibility criteria), so then fall between posts.

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It is hoped that this paper gives commissioners and providers the questions and framework to query current arrangements and to ask themselves:

Full article and references available at https://www.cambridge.org/core/journals/bjpsych-bulletin/article/no-wrong-door-addressing-injustices-and-achieving-better-mental-healthcare-provision-for-under18s-in-acute-physical-healthcare-settings/51C3308E99FBFE7168D6E39FF9468C08

February 2021