Written evidence submitted by The Royal College of Emergency Medicine (CYP0112)
The Royal College of Emergency Medicine (RCEM) works to ensure high quality care for patients by setting and monitoring standards of care in Emergency Departments; we are the professional voice of over 10,000 Emergency Medicine clinicians across the UK.
Access vs Demand
In the last three years, the likelihood of children and young people (CYP) having a mental health problem has increased by 50%, with 1 in 6 children aged 5-16 now likely to have a mental health issue, yet access to Mental Health services has not kept up pace with demand. To contextualise that, the number of young people arriving to Emergency Departments (ED) with a mental health problem has tripled since 2010. This data on ED attendances of young people with Mental Health (MH) attendances is gathered by third sector organisations and NHSE must begin publishing this data on an annual basis.
The last few years have seen increased investment and welcome commitments to increase access to and improve children and young people’s mental health services through the NHS Long-Term Plan and the Green Paper on Children and Young People’s (CYP) Mental Health. They were an important step forwards, but they do not go far enough. The NHS will never be able to meet the scale of need on its own. In addition to investing in NHS mental health services, we need a radical new holistic approach to prevent the development and escalation of mental health problems in children and young people.
The pandemic has shone a light on pre-existing issues. Sadly, as is often the case, the most vulnerable in society are more likely to be subject to health inequalities and disparities in access to healthcare. In 2016, the most deprived CYP overall were 58% more likely to go to EDs than the least deprived. This illustrates the stark reality of the role EDs play in supporting patients that may be failed by other parts of the system. While there has been a focus in recent years on population health, this should be widened to specifically look at the wider determinants of mental health issues.
RCEM conducted an online national survey in 2018 asking EDs about services for CYP presenting to the ED with Mental Health problems in their department. 24% of departments responded that their services had improved in the last year and 16% felt services had deteriorated, while 59% had not changed. These findings imply that there were little tangible improvements since the Green Paper was published in 2017, however we recognise that investment in services since then may have yielded some changes. RCEM plans to repeat this survey in the autumn of 2021 so get a more accurate picture of whether service provision has improved.
2. How inpatient care can be improved so that it is not creating additional stress on children and young people, and how the use of physical and medical restraint can be reduced?
Emergency care settings often represent the first point of contact for vulnerable children who are seeking help in a crisis. Ideally, children should be recognised by effective mental health services within community settings before they reach emotional or behavioural crisis point in emergency settings.
The RCEM National Survey in 2018 revealed that overall services for CYP coming to the ED with an acute mental health problem were rated as poor by 53% of respondents, good by 8% and awful (i.e., concerns about safety) by 12%. Furthermore, when asked how long a CYP would wait to be seen by any Mental Health decision maker if they presented between 3pm and 7pm, 48% estimated the CYP would wait 12-24 hours and 22% thought they would be seen within four hours. It is clear from this that substantial investment would have been needed since 2018 to have made a positive impact following this damning report.
Assessment by specialist CAMHS teams is currently reported by ED clinicians as still very slow. Many places do not offer services into the evening and these services are often covering several hospitals. Whilst there is a standard for adults that patients should receive a crisis response from a MH professional within an hour, this standard does not exist for CYP. RCEM recommends the creation of a nationally agreed standard for the hours of availability of CAMH services to be extended until 22:00. Although 24/7 would be equitable, many professionals do not think it is fair to do an assessment overnight for CYP. Furthermore, if a CYP cannot be assessed in a timely manner, the patient should be admitted; this may be on a Paediatric ward. Some Liaison Psychiatry services will review CYP who are 16 and 17, rather than leave them to wait for CAMHS. We support this model as it means the patient gets seen by a professional with expertise in a timely manner. However, some patients with complex needs or risks will need to be reassessed by CAMHS the next day, but the initial contact can be therapeutic and reassuring for patients.
Consideration should be given to training and expanding Adult Liaison Psychiatry services and Psychiatric trainees so that they are able to assess CYP with additional support from CAMHS on-call consultants. Adult services need to be resourced to do this, as will CAMH services to provide the support and access to rapid follow up clinics.
There is also less acceptance about when a CYP can be assessed. Adult services are encouraged to assess a person as soon as they are "fit for assessment" even if they may need a few more hours of observation or treatment. CAMH services are more likely to wait until a CYP is "fit for discharge" before coming to assess them. This is unfair for the CYP as their main issues have not been addressed for several hours.
Where there has been investment in services, there is visible improvement. The following response is taken from the RCEM 2018 survey:
We have recently had funding as a pilot for 3 months which has been incredibly successful, and we are working on this being commissioned. We would also like this service at the weekends. It has been successful on all levels. Great and rapid service for young people. Massive reduction on admissions, removal of time wasted from clinicians trying to get hold of CAMHS, reduction in breaches. Really amazing service.
ED Staff Skills
RCEM recognises that it is essential for staff working in urgent and emergency care settings to have the right skills and competencies to be able to identify and appropriately help children presenting with mental health needs. The scheme “We Can Talk” has been set up as a training initiative for ED and paediatric staff and has been cited by staff as improving their confidence when interacting with a young person who is mentally unwell.
Developing and maintaining strong links between emergency departments and children’s CAMHS and social care services is important in order to ensure that appropriate and timely CAMHS and social care support is available for children in crisis. Consideration should be given to training and expanding Adult Liaison Psychiatry services and Psychiatric trainees to be able to assess CYP with additional support from CAMH on-call consultants. Adult services need to be resourced to do this, as will CAMH services to provide the support and access to rapid follow up clinics.
Unfortunately, the trend in Mental Health funding is that no funding is given unless savings can be demonstrated from the improved service. For this patient group there will be savings for having shorter times in ED, less admissions etc, but these savings are unlikely to be able to fund a specialist service. There is however a moral and ethical need to improve services for this group of patients. The impetus should be on providing services that are shown to be effective and not always cost saving.
ED Environment and Reducing Stress for Patients
Both ED and paediatric wards need to create safer spaces for CYP with MH problems. The RCEM 2018 survey asked respondents what kind of facilities and expertise they had for CYP presenting to ED with MH problems. Most respondents said they had no facilities in their ED, 19% (16/86) of respondents said they had a dedicated adolescent room, 13% (11/86) said they had some expertise in their ED - either specific individuals with training or just those that had taken an interest. We suggest each Emergency Department has a dedicated adolescent room. National guidance on what this could look like would be helpful. In practice, most wards and EDs lack space and making one cubicle MH friendly leaves us short of assessment spaces for patients. The lack of funding for liaison teams and physical space in which to assess children and young people has created huge pressures on EDs. Furthermore, there is a belief in many communities that EDs are the only place to go to get concerns addressed in a timely manner. If a patient presents to the ED, they will likely get reviewed whereas going to via their GP can often mean a referral and months of waiting. Whilst a national recommendation for safe spaces for CYP with mental health issues would provide a useful framework to benchmark services, it does not negate the fact that children should not be spending long periods of time in acute settings. Within other specialties, there is an expectation for patients to receive rapid assessment, streaming to appropriate support, and accessible admission, but we are yet to see the same urgency regarding mental health.
Stress for children and young people in the ED is often a result of long waits in inappropriate facilities. Many EDs do not have the space to provide a separate quiet room for CYP with mental health problems. RCEM has resources in our MH toolkit which encourage building and adapting a space where possible.
A pilot study involving 15 EDs across the UK was carried out in August 2018. In relation to how pilot sites were meeting standards of care for children and young people presenting mental health crises, the results revealed that:
The majority of services did not have policies in place for the management of an acutely distressed child. In situations where a child becomes highly distressed and unmanageable with verbal measures or family holding, both pharmacological and physical restraint should be regarded as a last resort - it should only be utilised when in the best interest of the child. Preventative measures such as calming methods and techniques to de-escalate behaviour should be considered in the first instance. Restraint should be conducted in accordance with clear guidelines; staff should be appropriately trained, children should be monitored for signs of deterioration, and staff should ensure that communication with the parent/carer about the reasons for restraint/use of sedation are clearly documented.
High levels of bed occupancy in mental health trusts are an important indicator of pressure in other parts of the system. The Royal College of Psychiatrists recommends a maximum bed occupancy of 85% yet bed occupancy data reveals that this has consistently not been achieved since 2013. This leads to long waits for patients on Paediatric or Adult acute wards. In fact, Britain has 9.4 specialist inpatient beds per 100,000 young people for those who are suffering from conditions such as anxiety, depression, psychosis, self-harm, and suicidal thoughts. That places Britain 18th in a league table of the 28 EU countries.
3. The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing?
Without question, wider changes to the mental health system are needed to bring about any significant improvements to children’s mental health in this country. There needs to be a greater focus on creating accessible community services that can provide both preventative and more acute treatment. The current CAMHS process is not working; only one in three CYP are currently able to access NHS support for their mental health and in 2019, only 10% of GPs agreed that they usually felt confident that a referral to CAMHS would result in treatment, with 76% disagreeing. The lack of confidence that primary care workers have in the system is telling and indicates that an expansion of CAMHS is crucial. However, this is not enough. Even when CYP do receive an appointment for treatment, waiting times can be greater than 12 weeks and often they do not receive any support during this time. Young Minds found that two-thirds of children were not signposted to any support whilst waiting for a CAMHS appointment and 76% of parents stated that their child’s mental health deteriorated during this wait. Eating Disorders are a particular concern where demand outstrips provision and patients can deteriorate rapidly without early intervention. There are many problems too with integration of physical and mental health care. Even with greater funding into CAMHS, hundreds of thousands of young people with a diagnosable mental health condition will be left without support as the NHS cannot meet the demand on its own.
We recommend the creation of an integrated mental health service, known as mental health hubs, that will bring together the work of the NHS, local councils, and voluntary organisations in one space, and that can be accessed both in-person and virtually. These hubs would offer an alternative to an ED as they would be a place that children can safely attend and receive initial assessments, de-escalation, and some treatments without the need for a formal section or senior mental health review. This would reduce the pressure on the emergency system and create a focused, more comfortable environment where CYP can receive appropriate care.
By joining up these services, there would be improved access to mental health treatments for CYP, but crucially, mental health hubs would also be able to provide a greater focus on early intervention to help manage and improve CYP mental health conditions before they further deteriorate and reach a crisis point. Not only does an early intervention model help to improve the mental wellbeing of children, but early intervention techniques have been proven to be cost-effective and save money in the long term. Without effective intervention and treatment for those with mental health conditions, there are a variety of long-term costs that could arise, including reduced earnings, and increased government spending on education, social care, and criminal justice. Place2Be, an organisation that provides early intervention work in schools, found that for every £1 spent on early intervention, there is a saving to individuals and society of £6.20. Early intervention services at mental health hubs would be provided by community organisations and act as a form of support for those waiting to receive CAMHS treatment with an NHS professional. As part of this early intervention model, we also support an online mental health self-management hub to be used alongside the physical hubs, to provide tailored information and advice for young people, as well as online and telephone services.
4. How the Government can learn from examples of best practice, including from other countries?
Across the country, crisis helplines have proven to contribute towards the improvement of MH problems in CYP. They can help CYP during out-of-hours meaning that those suffering from a mental health crisis may not have to attend an ED, which is often the only other option available. The government has pledged that every single area in England will have a 24/7 age-appropriate NHS telephone crisis service for CYP by 2023. Covid-19 has helped to accelerate this rollout, but it is unclear in how many areas to what extent the all-age service extends to.
A study of the Hope Service, a multi-agency service in Surrey which provides mental health support to CYP, highlights the wider effects that helplines can have in keeping children with mental health issues out of hospital. Specifically, the Extended Hope Assessment and Support telephone service, which was funded by the Department of Education, offered out-of-hours service to young people, and was staffed by community psychiatric nurses. Between October 2015 and July 2016, 23% of the calls prevented Tier 4 admissions; 17% prevented A&E presentations, 16% prevented placement breakdowns, and 10% prevented paediatric ward stays. Therefore, we call for more funding to be given to services like these across the country.
The ‘First Response Service’ run by Cambridge and Peterborough NHS Foundation Trust serves as an example of best practise and is an approach that we recommend is applied across the country. This service provides 24/7 access throughout the whole year and can easily be accessed through calling NHS 111 and selecting ‘option 2’. FRS was set up by the Cambridgeshire and Peterborough Mental Health Concordat – a joint initiative involving health providers, commissioners, Cambridgeshire and Peterborough Clinical Commissioning Group, police and Cambridgeshire, Peterborough and South Lincolnshire Mind. This initiative highlights the effective ways in which NHS services, local councils, and voluntary organisations can work together to provide care. Calls are taken by trained staff and those who need it will be offered urgent face to face assessments either at home or close to where they live as well as specialist follow up. Over 17s may be offered a couple of hours of support at a crisis lounge or online equivalent, run by MIND. These community-based services are essential in managing CYP mental health and can mean that children do not need to attend EDs, which as we have made clear, can have further detrimental effects on the mental wellbeing of young people.
Mental Health Hubs:
As highlighted in our response to question 3, mental health hubs are a good way of bringing various NHS and community mental health services into one place to make accessing services easy and comfortable for the individual. The Headspace hubs currently operating in Australia are an example of best practise that the UK Government could follow. These centres are a “one-stop-shop" for young people as they offer help regarding mental health, physical health, alcohol and drug usage, and work and study support. They are designed with young people and centres differ based on the needs of the local community meaning that the most effective and appropriate support can be offered. Alongside this, they also offer:
This holistic approach means that CYP have a variety of options and support that is available to them at all times and can fit their needs. Mental health is not simply a clinical issue and therefore this approach can identify the wider determinants of mental health issues so that support can be provided before it’s too late. Headspace have also identified some of the ways in which their services can be improved, including the introduction of intensive home-based care, clinicians with expertise in complex syndromes, and interface with hospital-based services:
“Strong national oversight to assure integrative commissioning, stronger financial models, additional funding streams, longer tenure and greater depth of expertise will strengthen the capacity of the model.”
Therefore, we recommend that mental health hubs are developed around partnerships between the NHS and hospital services, councils, schools, and voluntary organisations to ensure that CYP receive access to early-intervention services as well as specialised and emergency services. Moreover, this form of collaboration would fit well into the aims of Integrated Care Systems and the joined-up working that is already happening within them.
 The Children’s Society (2021) https://www.childrenssociety.org.uk/what-we-do/our-work/well-being/mental-health-statistics
 Young Minds (2021) https://youngminds.org.uk/get-involved/campaign-with-us/act-early/
 Nuffield Trust (2017) https://www.nuffieldtrust.org.uk/files/2017-12/nt-admissions-of-inequality-web.pdf
 Royal College of Emergency Medicine (2018) https://www.rcem.ac.uk/docs/RCEM%20Guidance/RCEM%20National%20Survey%20on%20CAMHS%20Report%20v3%20final.pdf
 RCEM (2018) National survey on Mental Health services for Children and Young People in the Emergency Department. https://www.rcem.ac.uk/docs/RCEM%20Guidance/RCEM%20National%20Survey%20on%20CAMHS%20Report%20v3%20final.pdf
 RCEM (2019) Mental Health in Emergency Departments. A toolkit for improving care. https://www.rcem.ac.uk/docs/RCEM%20Guidance/Mental%20Health%20Toolkit%202019%20-%20Final%20.pdf
 Royal College of Psychiatrists (2020) https://mentalhealthwatch.rcpsych.ac.uk/indicators/bed-days-for-children-and-young-people-in-camhs-tier-4-wards
Royal College of Emergency Medicine (2021) https://www.rcem.ac.uk/RCEM/Quality-Policy/Policy/RCEM_CARES.aspx?WebsiteKey=b3d6bb2a-abba-44ed-b758-467776a958cd&hkey=55bc6020-0493-4d68-8657-e91e4b81b411&=RCEM%20CARES&New_ContentCollectionOrganizerCommon_2=4#New_ContentCollectionOrganizerCommon_2
 Young Minds (2021) https://youngminds.org.uk/get-involved/campaign-with-us/early-intervention-review/
 Young Minds (2021) https://youngminds.org.uk/get-involved/campaign-with-us/act-early/