This is the 2020/21 edition of Monitoring the Mental Health Act
Key points
- As highlighted in our 2020/21 State of Care report, there have been increasing concerns around the impact of COVID-19 on the mental health of children and young people, and services’ ability to meet this increased demand.
- We are particularly concerned about the number of reports of children and young people being placed in unsuitable environments while they wait for an inpatient child and adolescent mental health (CAMHS) bed.
- While we support the government’s objective to reduce hospital admissions for people with a learning disability and autistic people under the MHA, this can only be achieved by an increase in community support, including trained staff, and high-quality alternatives to admission.
Children and young people under the MHA
As highlighted in both our 2020/21 State of Care report and provider collaboration review on children and young people’s mental health, there have been increasing concerns around the impact of COVID-19 on the mental health of children and young people, and in turn concerns about services’ ability to meet this increased demand.
We are particularly concerned about the number of reports of children and young people being stuck in unsuitable environments while they wait for an inpatient child and adolescent mental health (CAMHS) bed. As highlighted in NHS Confederation’s report ‘Reaching the tipping point’, this reinforces concerns expressed by providers about availability of beds. We have had many approaches from providers seeking advice or leverage over what to do about this, and see this often through our monitoring work.
For example, in June 2021 we were alerted by an IMHA of the admission of a 15-year-old to a seclusion room on a low secure ward. The young person had never been in hospital before and did not require this level of physical security, but no other bed was available. Although she was quickly moved on to a more appropriate placement, the patient was traumatised by the experience. We heard that the whole episode had not been handled well; initially the seclusion room en-suite was locked and she was given a bedpan, and had no bedding provided until she asked for it. She was allowed access to the visitors’ room during the day after expressing distress to staff over being in the seclusion facility.
As part of our monitoring role, providers have to notify us when a patient under the age of 18 is cared for on an adult ward for more than 48 hours. This enables us to consider visiting or other follow-up action in individual cases, and provides intelligence for our regulatory role in inspecting the wider health and care services. In 2020/21 we were informed of 197 such placements, shown by legal status at figure 1. All but 34 (17%) of such admissions were under the MHA.
Figure 1: Notifications of placements on adult wards lasting 48 hours or more by legal status on admission, April 2020 to March 2021, England
Most of these extended admissions of children and adolescents to adult facilities are due to a lack of age-appropriate alternatives (figure 2). The number where an adult bed was positively identified as clinically or socially appropriate (for example because the adolescent was nearly 18, or was otherwise mature such that a CAMHS placement would be unhelpful or risky) accounts for only about 15% of the total.
| Reason | Under 16 | 16-17 | Not specified |
|---|---|---|---|
| Immediate admission required for safety of the child |
16 | 92 | 0 |
| No alternative CAMH inpatient or outreach service available |
15 | 103 | 1 |
| Not specified / other | 4 | 12 | 1 |
| An adult ward was clinically the preferred option |
1 | 20 | 0 |
| An adult ward was socially the preferred option |
0 | 8 | 0 |
Source: CQC notifications
Most admissions (128) were to adult acute wards and psychiatric intensive care units (PICUs) (26).
Eighteen notifications specified that admission was to a health-based place of safety (a health-based location normally used for assessment when a person appearing to have mental disorder is brought there under police powers). As these are essentially single-occupancy, and not specifically an ‘adult’ service, in some cases this may be the least-worst option. For example, in one case the use of a place of safety enabled family members and specialist CAMHS staff to stay with the very young patient overnight, which could not have been managed due to pandemic restrictions had the child been placed on an acute ward.
However, not all child or adolescent patients being cared for in adult wards had access to CAMHS, with 32 notifications explicitly stating that they did not have access to this service.
Most services (165, or 84%) told us that the patient had access to advocacy services, although this was not necessarily advocacy specifically for children and young people. Twelve notifications explicitly told us that no advocacy was available, including three health-based places of safety (where independent mental health advocacy services would not normally operate).
We are also concerned that admissions of children and young people to adult wards are increasing. In the first three months of 2019, we were notified of 45 admissions lasting 48 hours or more. Over the last two years this has increased; in 2020 there were 56 notifications during the same period, and in 2021 there were 66 admissions in the first three months.
This is supported by the November 2020 report from the Children’s Commissioner. ‘Who are they? Where are they? Children locked up’, which similarly suggested that these types of admissions were rising. This was based on data of a reported 205 such admissions (regardless of length of stay) in the first three months of 2020 compared to 74 in the same period over 2019. It is acknowledged in the report that there may be data quality issues with those notifications. The Children’s Commissioner further suggested that the overall number of child admissions to adult mental health wards “suggests a lack of capacity in children’s wards”.
While this is likely to be the case, preventing inappropriate admissions is not simply a matter of providing more specialist beds. Demand can be reduced through the development of robust community-based provision and flexibility in the specialist support offered to wider hospital-based services. We welcome NHS England’s announcement of a funding boost for children’s mental health services, including £10 million capital funding to provide extra beds at units. However, we are aware that this will be in a context of considerable reduction in services – including community services that could provide alternatives to hospitalisation – over several years.
People with a learning disability and autistic people
We support the government’s objective to reduce hospital admissions for people with a learning disability and autistic people under the MHA or other alternative legal framework. However, this can only be achieved with sufficient investment in community resources, including trained staff.
Under the MHA, people with a learning disability have to show ‘abnormally aggressive or seriously irresponsible conduct’ to be admitted to hospital. This is not currently the case for autistic people. We welcome proposals in the reform of the MHA to strengthen these admission requirements, and also extend these to include autistic people to prevent avoidable admissions. However, changes to legal thresholds alone will not prevent admission to hospital, and need to be supported by an increase in community support and high-quality alternatives to admission. We are encouraged that this is acknowledged in the government’s response to its White Paper consultation.
We welcome the intention to introduce a legal duty on commissioners to ensure an adequate supply of such community services. At present, the MHA only provides specific legal duties on commissioners to designate beds available for general emergency admissions, or that are suitable for patients under the age of 18. These duties are frequently not met. As such, we would welcome a widening of our MHA monitoring remit to extend to commissioning bodies, as was also suggested in the White Paper.
Since 2018, we have carried out thematic work to review restrictive practices in the care of autistic people, and people with a learning disability, most of whom were detained under the MHA. We have focused on chemical, manual and mechanical forms of restraint, and forms of seclusion and segregation. We gave formal evidence to the Joint Committee on Human Rights (JCHR) and are pleased that its findings and recommendations echo our own. We published a report on the findings from our thematic review in December entitled Out of Sight – Who Cares? We are encouraged that the government has accepted in full or in principle all our recommendations as they relate to the Department of Health and Social Care, and will look to work with other agencies over the implementation of the rest.
In September 2021 we published Home for Good. This celebrates the stories of eight people who successfully transitioned from long-term hospital placements to thrive in community services across England, and outlines the common threads of success including multi-agency partnership; person-centred planning with family involvement; and appropriate accommodation.
Throughout 2020/21, MHA Reviewers took part in Independent Care and Treatment Reviews (IC(E)TRs) of people with autism and/or a learning disability who were held in segregation in hospitals. We discuss these reviews and their findings in detail in the section on Independent Care and Treatment Reviews.
Next page
The MHA and mentally disordered offenders