Monitoring the Mental Health Act in 2022/23

In our 2022/23 State of Care report, we reported that over the last year we have continued to see the impact of the pandemic on the mental health of children, with demand for services still increasing.

NHS monthly data shows that the number of children and young people undergoing treatment or waiting to start care has reached new records, with 496,897 open referrals to children and young people’s mental health services in November 2023.

During 2022/23, the ongoing effects of the pandemic are being compounded by the cost of living crisis. In November 2022, NHS England’s report, Mental Health of Children and Young People in England 2022, found that among 17 to 22 year olds with a probable mental disorder, 14.8% reported living in a household that had experienced not being able to buy enough food or using a food bank in the past year, compared with 2.1% of young people unlikely to have a mental disorder.

It is likely that the rising cost of living will have a further impact on children and young people’s mental health, especially those who live in communities with the highest levels of deprivation.

Children and young people continue to experience delays in accessing care. Data published in the report from the Children’s Commissioner on Children’s Mental Health Services 2021-22 showed that in 2021-22, the average waiting time in England between referral and the start of treatment increased to 40 days, up from 32 days in the previous year.

This delay increases the risk of their symptoms worsening and/or them being cared for in inappropriate environments. Analysis of NHS England data by the charity YoungMinds shows that in the year to March 2023, there were 21,555 urgent referrals to mental health crisis teams, up 46% on 2022.

In this section, we explore the importance of early intervention and the impact of being treated in environments that are unsuitable for their needs, where discharge may be delayed due to poor provision of care in their community.

The importance of early intervention

In 2019, the NHS Long Term Plan set out NHS England’s plans for improving access to children and young people’s mental health services over 10 years. Following the pandemic, and the negative impact this had on children and young people’s mental health, the government announced it was investing £79 million to boost mental health support for children and young people.

Despite this focus and additional investment, in December 2022 the mental health charity SANE reported that the expansion of mental health services was not fast enough to meet rising needs, leaving many children and young people with limited or no support.

In the March 2023 report, Children’s Mental Health Services 2021-22, the Children’s Commissioner described hearing from children in inpatient mental health settings that they wanted more earlier intervention to prevent crisis admissions. The report found that when children go to A&E, they sometimes present multiple times before an inpatient admission is considered.

Early intervention including, for example, home visiting programmes, school-based learning and mentoring schemes can reduce risk factors for young people and increase the chance of lifelong recovery from mental illness. As a result, ensuring that children and young people have easy access to early intervention support is crucial.

However, in October 2023, the Royal College of Occupational Therapists reported that almost two-thirds (65%) of paediatric occupational therapists say the cost of living crisis is making it more difficult for children and young people to access the therapies and interventions they need. The report, which details the findings of their 2023 children and young people's survey, highlighted that:

• 56% of families are having to reduce activities that would support their child’s wellbeing, such as swimming lessons
• almost half (49%) are unable to take time off work to attend occupational therapy appointments
• 47% are so worried about money that they cannot prioritise occupational therapy.

In October 2023, to support children and young people and ensure that fewer reach crisis point, the government announced almost £5 million funding for early support hubs, set up to deliver mental health support for children and young people.

Separate to our monitoring work, our inspection of Somerset Foundation NHS Trust highlighted how investment in early intervention can significantly improve outcomes for children and young people. We found outstanding practice relating to the trust's specialist community teams, which had implemented a number of strategies to decrease their wait times. This included, for example, working in partnership with voluntary sector organisations, investing in early intervention such as the mental health in schools team, and upskilling staff so more could deliver therapy.

We found that their efforts over the past 4 years have resulted in achieving a no wait list for children and young people to access the service, and a decrease in referrals. As a result, caseloads for staff were lower and there were also better outcomes for those who did not meet the criteria to access the service.

Impact of delays in care

Increasing demand and issues with accessing help early on means that too many children are facing long waits for mental health support. These delays are having a huge impact on children, young people and their families. Through our inspections and monitoring visits, providers have told us that children are typically presenting with worse mental health issues than before the pandemic.

This is supported by a survey from YoungMinds, which highlighted that more than half of young people reported that their mental health got worse while they were waiting for support. Over a quarter (26%) said they had tried to take their own life as a result of having to wait for mental health support.

Analysis of NHS data by YoungMinds shows that the number of children in mental health crisis has reached record levels in England. These are children with the most acute mental health symptoms, who might need to go to hospital as a result of psychosis, severe self-harm or suicide attempts.

The charity found that, for the first time, urgent referrals of under-18s to mental health crisis teams reached 3,732 in May 2023, 3 times higher than in May 2019.

Children and young people in inappropriate settings

The MHA Code of Practice is clear that children and young people should have:

• appropriate physical facilities
• suitably trained staff
• a hospital routine that will allow their personal, social and educational development to continue as normally as possible
• equal access to educational opportunities as their peers.

However, high demand and a lack of specialist beds in services for children and young people mean that those with mental health needs continue to be cared for in inappropriate environments that do not meet these requirements. We continue to see children and young people with mental health needs being admitted to adult wards or general children’s wards, often for extended periods and in locations far away from home. This can present serious risks for them.

As we highlighted in our last MHA annual report, we continue to see examples of children and young people being admitted temporarily to section 136 suites because of a lack of alternative beds. These suites are designed as a place of safety for the admission of a person from a public place where there is an urgent need to keep them safe, under section 136 of the Mental Health Act. As self-contained units, these can provide relatively suitable accommodation for children and young people, provided that appropriately trained staff are available, but it removes such suites from their intended use. We have seen examples where suites are occupied for several days in these circumstances.

We are carrying out work as a priority to identify why children and young people continue to be admitted to unsuitable settings. This involves working with internal and external stakeholders to design and implement solutions so that all children:

• will not be asked to move to a placement that isn’t safe
• will not be asked to live with other patients who are adults
• will be given the opportunity to express their wishes about where they are placed
• will only have people caring for them who understand their needs and can meet them.

We will consider the issues that affect the quality of care for children, and what actions we can take as the regulator to prevent children being cared for by providers who cannot meet their needs.

When we find that a child is being treated in an unsuitable setting, we hold a review meeting to look at the provider’s actions. If the child is in an acute hospital, we ask the provider to respond and give updates and assurances on finding a suitable bed. We also check whether they have held a risk summit with the commissioners about the individual child. In cases involving autistic people and people with a learning disability, we check whether patients have been placed on the dynamic support risk register. Where possible, we also raise these cases with integrated care boards (ICBs).

We are now assessing the performance of local authorities and integrated care systems in how they provide care in the local population. One of the priorities set by the Secretary of State is around assessing leadership, which includes checking if the integrated care system:

• adequately involves people with appropriate experience and expertise in its activity, such as directors of children’s services
• ensures its plans, strategies and commissioning decisions adequately consider the health and wellbeing outcomes for babies, children and young people, and the voices of children, young people and families.

Adult wards

The MHA states that children and young people admitted to hospital for mental health treatment should be accommodated in an environment that is suitable for their age. The Code of Practice highlights the “clear difference between what is a suitable environment for a child or young person in an emergency situation and what is a suitable environment for a child or young person on a longer-term basis.”

We are concerned about the suitability of adult wards for children who require mental health treatment. By their nature, children on adult wards are often not able to socialise with others their own age, miss out on peer support and have limited access to educational opportunities. In addition, staff who are often used to treating adults may not tailor the care they provide to meet the needs of younger patients.

Beyond the initial crisis, hospital managers need to consider the appropriateness of mental health care that can be provided on the adult ward, as well as whether the patient can mix with people of their own age, receive visitors of all ages, and access education. Under the MHA, admission to an adult ward must only happen in exceptional circumstances, where this is considered suitable for the person. If a patient under 18 years of age is admitted to an adult ward for longer than 48 hours, the hospital managers must tell CQC.

Last year, we reported a 32% rise in the number of people under 18 being admitted to adult wards (260 admissions in 2021/22 compared with 197 in 2020/21). Figures this year show that the number of notifications has dropped by 25% and are now similar to 2020/21 figures at 196 notifications.

Of the 196 notifications received in 2022/23, the vast majority (85%) of admissions were classed as emergency, with the remainder planned admissions (14%). The main reason provided for admitting the child to an adult ward was because there was “no alternative mental health inpatient or outreach service available for young people”. Where specified, most patients were given a single room (76% of admissions).

The length of time children and young people spend on adult wards has fluctuated in recent years. Figures from the Mental Health Services Data Set (MHSDS) show the number of adult bed days within a reporting period that are used by children, but they do not show the number of children. For example, 10 bed days could mean that 1 child may have been on an adult ward for 10 days in a month, or 10 children may have been on an adult ward for 1 day each. In 2022/23, across England children and young people spent on average 313 bed days per month on adult wards, reflecting the high demand for specialist mental health beds for under 18s.

We have also seen young people who needed a psychiatric intensive care environment waiting on an acute mental health ward, which can pose serious risks to their safety.

People have also told us about their concerns around the way in which children and young people are transitioned from children’s services into adult services. Guidance from the National Institute for Health and Care Excellence (NICE) is clear that practitioners should start planning for adulthood from year 9 (age 13 or 14) at the latest. However, we have heard examples of young people being moved onto adult wards as soon as they turn 18, and feeling like they are suddenly being expected to act as an adult.

Young people have reported how this can make their anxiety worse and their families have described the differences in responsibility of care and the daily structure and activities within the environments. Providers need to make sure that transition planning is in place and individual needs are considered when children and young people are going to be moved into the care of adult services.

General children’s wards

The MHA Code of Practice is clear that children and young people should be treated by staff who have the right training, skills and knowledge to understand and address their specific needs. But we remain concerned that children and young people with mental health needs are being treated on paediatric wards intended to treat children with physical health needs.

A recent report by the Healthcare Services Safety Investigations Body (HSSIB), found NHS paediatric wards may not be a safe environment to care for children and young people exhibiting high-risk behaviours. The report highlights the potential negative impact on the wellbeing of patients and their families, as well as a risk to other patients and staff. Primarily designed to care for patients who only have physical health needs, there are many self-harm and ligature risks present on paediatric wards. In addition, the crowded and noisy nature of paediatric wards make them unsuitable for children and young people experiencing a mental health crisis.

We are particularly concerned that if children and young people with an eating disorder are admitted onto a general children’s ward first, they may not have the safeguards of the MHA or access to advocacy support.

Out of area placements

When a young person under 18 goes to hospital, they should be placed as close to home as possible. In 2016, the Five Year Forward View for Mental Health set a target of ending out of area placements for adults and children by 2020/21. However, between April 2022 and March 2023 on average there were still 388 out of area placements started each month. A member of our service user reference panel (a group of carers and people who are, or have been, detained under the Mental Health Act) told us about carers with family members who are under 18 and detained far from home. They explained how this makes it difficult to have regular contact with families and can make the experience of being detained feel more isolating.

As we highlighted in our last MHA report, out of area placements can also present challenges when patients are ready to be discharged, such as securing appropriate community support back in the person’s local area.

Issues with unsuitable environments

Whether on a general children’s ward, adult ward or in acute admissions, the care given to children and young people is compromised by the fact that these wards are not designed for children and young people who have mental health needs.

As reported in our last MHA report, we remain concerned that many of the settings do not meet people’s sensory needs. For example, often noisy and bright wards can create a particularly difficult sensory environment for autistic people and people with a learning disability. Services must determine each patient’s unique sensory profile and preferences to ensure they receive care that meets their needs.

But we did not find this had happened in all services:

For an autistic patient we were unable to locate a sensory assessment. In the absence of such an assessment it was difficult to ascertain what reasonable adjustments needed to be made.

Ward for female children and young adults aged 8 to 18 years of age, March 2023

At another service, staff raised concerns that the ward dynamics and acuity of other patients were challenging and often detrimental to autistic patients who were regularly admitted there.

We also continue to see wards in need of repair. For example, we have heard how a lack of a family visiting room, broken equipment and loud environments can negatively affect the experiences of children and young people:

The ward had been without communal televisions for several months after they were broken… There had been no water machine on the ward for several months after it was broken. Patients had to ask staff for drinks.

Children and young people’s mental health inpatient service, August 2022

Besides the education room, there was no evidence of any other therapeutic activities on the ward. The patient activities cupboard was locked. The sensory room was unlocked and could be freely accessed by patients, however it was noticeably minimalist with limited sensorial decoration.

Low secure mental health ward for female patients up to the age of 18, January 2023

Detention under the Mental Health Act 1983 provides children and young people with a number of important safeguards, such as the right to appeal against detention. The 2007 amendments to the Act resulted in greater protections for the rights of children and young people. These include the duty to ensure an age-appropriate environment. However, staff on non-specialist wards may not be familiar with these safeguards.

Increased risk of restrictive practice

A lack of designated inpatient beds for children and young people has also led to inappropriate ward layouts, as services attempt to accommodate people with differing mental health needs.

From our monitoring activity, we are concerned that this, combined with issues highlighted in the workforce section of this report, are leading to the use of blanket restrictions. We encourage providers to challenge the use of blanket restrictions to ensure that they are not unintentionally restricting people’s liberty and therefore at risk of infringing people’s human rights. Providers must make sure that any blanket restrictions in place do not conflict with an individual’s tailored care plan. We have heard from young people that bathrooms and bedrooms were locked despite being ligature-free:

The bathrooms within bedrooms were locked even though they were ligature free. Young people were unaware why this was.

Mixed-gender child and adolescent (CAMHS) psychiatric intensive care unit (PICU), December 2022

At another service, we were concerned about a blanket restriction meaning that lights were left on at night for all patients:

All the children and young people we spoke with told us they had to sleep with the lights on at night. The children stated they were unable to sleep at night and have raised the issue with the staff on several occasions.

Psychiatric intensive care unit (PICU) for children and young people of all genders between the ages of 8 and 18, January 2023

At an eating disorder service, patients told us that staff were ‘too rough’ when administering the nasogastric feeding tube, which caused them distress:

Some staff, especially agency staff, were considered by patients as rough when restraining patients for nasogastric (NG) feeding. Patients found the experience of waiting to be NG feed distressing as they knew what was about to happen especially when they were waiting in a group in the lounge and seeing peers being called out to have a feed. They told us that this was made worse by staff wearing gloves as they came into the lounge and staff not waiting to close the lounge door before starting to restrain them to take to the room where the feed was to be administered.

Eating disorder ward for children and young people, July 2022

Our concerns were echoed in a recent report by HSSIB, which found that therapeutic elements on paediatric wards can end up being reduced or removed and restrictive practices having to be implemented to manage situations. This can include secure areas with restricted access and exit, police or security presence and use of restraint and sedations.