10 months, 13 days and counting: Are we ready for the new duty to provide Age Appropriate Environmen

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10 months, 13 days and countingAre we ready
for the new duty to provide Age Appropriate
Environments?

• Kathryn Pugh
• 18.5.09

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This presentation covers

• Some key issues and new developments at Tier 4
• MHA 2007 Amendments which have particular impact
  on commissioning and providing services for under
  18s
• The new duty to provide an Age Appropriate
  Environment - what does it mean?
• What myths and legends are out there?
• How to ensure the new duty is met through a whole
  system approach
• How can NMHDU help you?
• What do you need to do ?

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MHA joins a policy and legislative context
supporting comprehensive CAMHs

• National Service Frameworks
• Every Child Matters
• UNCRC
• Human Rights Act
• Comprehensive CAMHs PSA targets and extra funding
  for personnel and capital
• Childrens Acts esp 2004 Duty to Co-operate
• Ministerial commitment to end under 16s on adult
  wards by November 2008
• The CAMHS Review

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Tier 4 current issues

• Shortage of specialist provision ED, LD
• Reduction in beds for under 12s
• Wide variation in access to general adolescent
  beds across the country
• Growth of Community Intensive Services changes
  case mix and intensity
• Low level of access to emergency CAMHS provision
• No nationally recognised ideal or prescribed
  model of care
• Staff recruitment, retention and training
• Variation in how services are commissioned
• Anecdotally, more placements out of area

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Horizon Scanning Opportunities

• National Tier 4 Steering Group
• CAMHS Review
• ITBAC
• Training and Workforce Development
• National Mental Health Contract
• World Class Commissioning and DCSF Commissioning
  Support Programme, moves towards Specialist
  Commissioning

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MHA 2007 Implementation Timetable

• January 2008 Phase One Consent
• November 2008 Phase Two
• Definition of Mental Disorder
• Criteria for Detention
• Supervised Community Treatment
• Nearest Relative
• Deprivation of Liberty safeguards
• Professionals Roles
• MHRT
• ECT
• Code of Practice
• April 2009 Phase Three Advocacy
• April 2010 Phase Four Age Appropriate
  Environment

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Code of Practice 5 Guiding Principles inform
decisions

• Purpose Minimise harm/maximise safety and
  wellbeing/protect patients and public
• Least restrictive alternative minimise
  restrictions on liberty
• Respect recognise diverse needs, values and
  circumstances
• Participation involvement in care planning
• Resources effective, efficient equitable use
• The Principles apply to children and young people
  as well as over 18s

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Age Appropriate Environment and the MHA

• Government commitment to commence by April 2010,
  but from November 2008 PCTs must tell LA
  (proactively) and Courts (where asked) where CAMH
  beds have been or could be commissioned.
• The extra time was and is to give commissioners
  and providers time to plan to be ready
• It should not slow down progress if this goal can
  be achieved earlier

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Age Appropriate Environment

• Under 18s must be accommodated in an environment
  suitable for their age (subject to their needs)
• Applies to detained and informal/voluntary
  patients
• Hospital managers have a duty to consult with
  appropriate clinician to establish what
  appropriate environment is for that young person

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What is a suitable age appropriate environment
for an under 18 year old?

• Physical facilities e.g. access to things young
  people like to do
• Staff trained to work with children and young
  people
• Routine which allows them to develop personally,
  socially and to have access to education e.g.
  visits from parents, siblings, friends, tuition
  for exams
• Source Code of Practice 2008

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When you admit or plan to admit a child or young
person under 18 ask...

• What constitutes an environment which is suitable
  for a patient of this age?
• Is there something about the patient which means
  you should use an environment which wouldnt
  normally be deemed suitable?
• If no age appropriate environment is available,
  do patients needs justify using other
  accommodation instead?

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It is not good enough to say we have a safe
adult ward, Ask is there an atypical, or
overriding need?

• Atypical need e.g. a young person who will be
  18 two weeks after admission may be better on the
  adult ward so that care does not have to be
  transferred within a very short time and
  therapeutic engagement with the adult team can
  take place
• Overriding need e.g. a 16 year old in a
  psychotic crisis may have to be admitted
  immediately to a bed in the designated place of
  safety on an adult ward then transferred to a
  CAMHS ward if no suitable CAMHS bed is
  immediately available

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Code of Practice even in an emergency, a bed
for a child or young person must be safe

• Preferably be in discrete accommodation, with
  staff who have experience of working with young
  people
• Staff must always be CRB checked to work with
  children and have the checks updated
• If the responsible clinician is not from CAMHS,
  staff on the ward must have access to CAMHS
• If the environment is not suitable for ongoing
  care, the child or young person must be
  transferred asap

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Appropriate environment means consideration of
other children and young people

• The interests of other children and young people
  who may be in the same environment must be
  considered and protected
• However this does not cancel out the needs of the
  individual being placed - if the needs of other
  children and young people means the individual
  cannot go into a particular unit their needs must
  be met appropriately elsewhere

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How do you know if you have an appropriate
environment?

• QNICs standards !
• Robust assessment shared protocols if CAMHS
  clinicians cannot staff emergency rotas good
  support and training of AMHS followed up by swift
  reassessment
• What are your arrangements to move overriding
  placements onwards?
• If your trusts has to use adult wards even if
  briefly, are adult services aware of Royal
  College Draft Standards?

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The Safe and Appropriate Care for Young People on
Adult Wards standards, The Royal College of
Psychiatrists Research and Training Unit

• Piloted now
• Standards achievable but challenging
• Relationship with CAMHS key
• Already leading to improvements
• Staff Training esp. consent
• Safeguarding and Risk
• Assessment
• Will move to AIM accreditation

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Myths and legends

• Under 18s should never be on adult wards..
• As of December 2008, the government has
  prohibited under 16s on adult wards, but 16 and
  17 year olds could be admitted in overriding or
  atypical cases. Adult services should not
  withdraw wholesale as this could put some young
  people at serious risk - consider safeguarding
  issues and 2004 Duty to Cooperate
• If we adapt part of an adult ward to take under
  18s we have met the requirements .
• No, the default position is that under 18s should
  be on a CAMHs unit, placing an under 18 on an
  adult ward should only be for overriding or
  atypical cases

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Myths and legends

• Only a CAMHS clinician can detain an under 18
  year old
• No. It is good practice to ensure at least one
  person involved in detaining an under 18 year old
  has relevant expertise, but it is not a
  requirement.
• Our unit is for 16-25s, is that acceptable?
• It may be appropriate sometimes, but each young
  person must have an assessment and be treated
  individually.
• But our ward is a whole life Eating Disorder
  unit.
• Each young person must be assessed individually
  according to guidance, there are no exceptions
  based on the nature of the illness. Under 16s
  cannot be placed with adults.

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Are under 18s on adult mental health wards
really still a problem?

• It is a problem for children, young people,
  parents, carers and professionals see Pushed
  into the Shadows and Out of the Shadows, 11
  Million
• 2007-2008 , 16973 under 18 OBDs on adult
  psychiatric wards
• Q 3 2008-9, 11,263 under 18 OBD on adult
  psychiatric wards forecast outturn of 15017
• Local Delivery Plan Returns 2007-8, 2008-9
  estimate

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• Including the beds planned as a result of the
  31M Capital investment, and assuming nil bed
  disinvestment, by 2010 there will be a minimum of
  48 more adolescent beds than in 1999, and 6
  more than 2006
• Source Psychiatric Bulletin 2007 OHerlihy et
  al

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Increase in general inpatient beds 1999-2006
beds across the regions

• Region Beds per M 2006 Increased
• N East 12.7 7
• London 28.6 47
• E Midlands 10.2 5
• S East 20.9 12
• East of England 10.8 8
• Yorks/Humber 9.1 -19
• S West 10.5 30
• W Midlands 12.5 20
• N West 10.5 27
• All England 15 19
• BOLD indicates areas where more than 33 provided
  by independent sector
• General - admit cyp with a wide range of
  disorders
• Source Psychiatric Bulletin 2007 OHerlihy et
  al

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Do we need beds, beds and more beds?

• Performance of the system is defined by its
  admission rates, capacities and lengths of stay
• In other words if your CAMHS beds are full
  young people have to go elsewhere
• But also consider could you use resources to
  plan different care pathways?

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Can community based models help?

• Maintaining a young person in their community is
  as important to an under 18 year old as it is to
  an adult service user. Untreated mental illness
  and crisis admission can be traumatic and lead to
  family breakdown
• Community teams can engage early with children,
  young people and families to build trust,
  supporting admission if required
• Prevention of unnecessary admission and speeding
  safe discharge is humane as well as an efficient
  use of resources

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What is out there now?

• Range of local solutions to meet needs of young
  people with severe mental illness with EIP as a
  Trojan Horse
• Services developed show the need to develop
  mature interdependent trusting relationships
  between community teams and inpatient providers -
  CAMHS or AMHS
• Philosophy of care is to support in the community
  wherever possible, but to accept that for some
  young people inpatient care is necessary
• Similar characteristics to Crisis Teams in adult
  services

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What about the cost?

• Young person on an adult ward for 30 days bed
  cost plus 11 obs 24/7_at_ 50 per hour 49,580
• Young Person CAMHS unit 30 days 14,040
• Community Intensive Treatment Team 1 year
  16,000
• Cost to a young person of dropping out from
  school, rejecting services, family despair
  lifelong struggle
• Long term cost to services ??

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Your mission should you chose to accept it .

• Is your Trust Board aware of the new duty and
  implications as purchaser or provider?
• Is your CAMHS Partnership working with your
  Local Mental Health Partnership Board on joint
  audits and solutions?
• What are the expectations of the Local
  Safeguarding Childrens Board ?

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Use the System Dynamic model to help you to plan

• Access is via Chimat tools and data section -
  www.chimat.org.uk
• You can save the model by downloading the
  programme you may need to get your IT team to
  do this for you or put on your own PCT to export
  data
• The model can be run via the internet, on any
  computer but you CANNOT save the model or the
  data

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http//www.headspacetoolkit.org/
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http//www.mentalhealthshop.org/products/rethink_p
ublications/the_mental_health_ac.html
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Lets make the most of this opportunity !

• The MHA 2007 changes impact on how we care for
  all under 18s, not just those who are detained
• Providers and Commissioners for CAMHS and AMHS
  need to consider care pathways in and out of
  inpatient settings and explore ways to improve
  emergency access, admission prevention and early
  (safe) discharge
• We need to support Adult Services to understand
  how to keep young people safe
• Resources could be used more effectively
• This is a real chance to create a more effective
  model of care

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Products available now

• Legal Guide from your MHT MHA Implementation
  lead or http//www.mhact.csip.org.uk/silo/files/cy
  p-legal-guide-21-jan-09.pdf
• Rethink Parents leaflet will be posted to
  Trusts or http//www.rethink.org/about_mental_illn
  ess/who_does_it_affect/children_and_mental_illness
  /index.html
• Safe and Appropriate care for Young People on
  adult mental health wards http//www.rcpsych.ac.uk
  /clinicalservicestandards/centreforqualityimprovem
  ent/safecareforypaudittool.aspx
• Children and Young Peoples professionals and
  commissioners section on the NIMHE website
  http//www.mhact.csip.org.uk/workstreams/the-menta
  l-health-act-amendment-workstreams/children--young
  -people.html
• System Dynamic Model http//www.apho.org.uk/resour
  ce/view.aspx?QNCHMTSMOD

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• Advocacy in Somerset, Headspace toolkit
  http//www.headspacetoolkit.org/
• Coming soon
• DVD
• Commissioning Guidelines

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• www.mhact.csip.org.uk
• Kathryn.pugh_at_nmhdu.org.uk

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References

• Psychiatric Bulletin (2007), 31, 454-456.
  OHerlihy, Lelliot, Bannister, Cotgrove, Farr and
  Tulloch Provision of child and adolescent mental
  health in-patient services in England between
  1999 and 2006
• 11 Million (Office of the Childrens Commissioner
  in England) 2007 Pushed Into the Shadows- young
  peoples experience of adult mental health
  facilities , 2008 Out of the Shadows