Written evidence submitted by Dr Nik Johnson (CMH0096)
Self-harm among young people is a major public health issue in the UK. It affects at least one in 15 young people and some evidence suggests that rates of self-harm in the UK are higher than anywhere else in Europe (1). In 2012 the Cello report (2) described that over the last ten years inpatient admissions for young people who have self-harmed increased by 68%. In 2011 alone the hospital admissions for under 25s increased by 10%. This dramatic rise in admissions has been most noticeable in females under the age of 25 where there has been a 77% increase in the last ten years.
In January and February 2014, we conducted a survey amongst UK professionals affected by self-harm admissions to Paediatric departments in 2013. Our aim was to understand better the national picture in relation to the availability of specialist advice and staff to undertake emergency assessments and access to specialist inpatient facilities for acutely unwell children with mental health problems. A request for information was sent via established means of direct communication with members of the RCPCH (Royal College of Paediatrics and Child Health), the PMHA (Paediatric Mental Health Association) and the British Association of General Paediatrics. We received 23 responses; 83% were from Paediatricians and 17% from Psychiatrists; 65% worked in District General Hospitals, 35% in Tertiary Paediatric Units.
91% of departments had recorded a higher number of self-harm admissions in 2013 than in 2012 and the increased numbers had placed a significant strain on the department. These increased admissions impacted on a range of professions (Nurses 91%; Doctors 86%; CAMH Practitioners 86%).
Free text comments highlighted additional effects of the surge in number of hospital admissions including
When asked about the number of self-harm admissions to the department, one response quoted “391 this year, 193 last year and 70 the year before” another replied “250 (projected increase to 600 in 2014)”. Twice comments were made about increased complexity and severity of cases.
Clinicians were encouraged to suggest explanations as to why self-harm admissions had increased in 2013. In 43% of comments a reduced level of support for young people was felt to be the reason. Poor quality or a decrease in local CAMH provision was mentioned in 70% of responses. Cuts in the provision of other services, including Education, Voluntary Sector, Primary Care and Social Services, were also felt to have increased the level of admissions.
Other concerns identified the role of social media (26% of responses). “Broken and stressed families” (17% of responses) were felt to be another confounding factor which were further effected by higher levels of unemployment and reduced access to benefit and financial support for the family unit.
We found variations in the availability of specialist advice and staff to undertake emergency assessments and a consistent difficulty in identifying specialist inpatient facilities for acutely unwell children with mental health problems once the need for admission was confirmed.
Respondents from across the country identified numerous organisations who have been undertaking their own local reviews to understand the causes of such dramatic rises in paediatric self- harm admissions. In two areas, local commissioners for health services have initiated a review of the CAMH Pathway and in another area a Serious Case Review had been used to address the issue. One local area introduced support from community based workers but the respondent commented that these “At present do not seem to be working”. In Cambridgeshire and Peterborough we are working positively with our local mental health provider to improve the services we provide for children including those who self-harm.
The National Institute for Health and Clinical Excellence (NICE) advises that all children or young people under 16 years should be admitted overnight to a paediatric or adolescent ward following self-harm. Before discharge the CAMH Team should undertake assessment and provide consultation for the young person, his or her family, and professionals involved (3). However, the reality of this advice at a time when there is a lack of immediately available specialist paediatric mental health inpatient beds and a reducing number of acute paediatric medical beds across the country has led to daily challenges in bed capacity management in paediatric departments across the United Kingdom.
Our survey shows that most young people are reviewed by CAMHS the day following an admission for self-harm. However in some areas this is compromised by a lack of CAMH cover over weekends. CAMH reviews are often only initiated once the patient is “medically fit”. One respondent questioned this practice because of concerns about safely caring for these patients in paediatric wards. High risk cases need 1 to 1 specialist care from early on during the admission. Concerns were regularly raised about these slow assessment processes and the lack of CAMH inpatient beds.
NICE guidance for 16-17 year olds has been less clear(3) and in our survey one respondent raised concerns about this group as they are seen by adult practitioners and will not be automatically admitted to hospital.
Our survey had deliberately offered the respondents the opportunity to provide free comment on the subject. This provides valuable inputs to help construct a set of relevant formal review questions.
However, despite the small sample size and anonymity of the respondents, the results already highlight an important trend about self-harm in young people , in that increased self-harm admissions are straining paediatric services nationally.
This calls for an urgent review of the service provision. We hope that the information contained in this report has demonstrated the seriousness and immediacy of the problem of self-harm admissions to paediatric departments across the United Kingdom. We welcome the opportunity to work with all agencies to help solve the problem.
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2 April 2014