Currently in NHS Scotland there is no direct inpatient service provision for adolescent patients who require Intensive Psychiatric input. This means patients are often referred to, or remain cared for, in services that do not fully fit their needs. This was highlighted by the Mental Welfare Commission in their Young Person Monitoring Report (2020). Scottish Government subsequently commissioned Julie Metcalfe, Clinical Director CAMHS in NHS Greater Glasgow & Clyde, to undertake a national review of existing provision for young people under 18 years who had needs and risks that required intensive psychiatric care. This review looks at current support and provision provided across Scotland, and outlines the factors to be considered in making appropriate care settings, facilities and staff available for young people with intensive psychiatric care needs in future. This report collates the findings from a range of consultations, along with relevant data on admissions, and provides a review of relevant literature, including guidelines for IPCUs elsewhere in the UK.
As there is no dedicated IPCU provision for young people under 18 years in Scotland, individuals who require this level of care are generally either nursed in an "open" psychiatric inpatient ward or are transferred to an adult IPCU. Sometimes secure accommodation is sought to meet needs and risk in a non-NHS setting, or other solutions are found that do not completely meet need. Consultation discussions outlined the challenges (e.g. strain on nursing resource, risk of harm to other patients) of nursing a young person who required more intensive nursing support than a service could offer, as well as the difficulties of nursing a young person in an adult ward (e.g. different models of working, seclusion). Specific inpatient and social work services have been able to provide alternatives to referring to an adult IPCU unit (e.g. developing High Dependency Units), however, these options have limitations, are not appropriate for every service, or are not possible to deliver in every regional inpatient service.
Caution is required regarding the validity of data gathered for the review, as referrals and other relevant data, have not been systematically recorded across Scotland in the past. Nonetheless, collated data suggested that 44 young people were referred to adult IPCUs for the period of 2016 to 2020, and 30 of these referrals were accepted.
The review team led consultations with clinical staff from various services across NHS Scotland to determine current practice and gaps in provision for young people requiring this level of input. Consultation discussions were also held with staff from NHS Greater Glasgow & Clyde Violence Reduction Service, the new National Secure Adolescent Inpatient Service in NHS Ayrshire & Arran, and with Chief Social Work Officers from across Scotland. The report provides recommendations for the design of young person IPCU provision based on these discussions.
Ahead of designing any IPCU provision for young people, the review team recommends ensuring consultation with young people, considering the needs of transgender and non-binary individuals, considering all issues that may lead to inequality of access, and consulting with organisations in any proposed sites. Clinical recommendations highlight the importance of using as much resource as available to facilitate young people remaining in the least restrictive service possible by intervening to meet need as early as possible, and highlights the value of ongoing multi-agency and community support in situations where admission to IPCU is required. Operationally, this review recommends the importance of a national steering group to maintain consistency (particularly if developing regional services) and training being provided by NES for staff working in Intensive Psychiatric Care settings.
Evidence gathered in the review was used to develop key (non-financial) objectives (e.g. provide age appropriate IPCU care, integrate social work links, provide access to meaningful activities), which were weighted in terms of priority. Options for IPCU provision were then considered in terms of these weighted objectives. Justification for this process was informed by the range of consultations, data gathered, and literature reviewed. The option of purpose-built regional units adjacent to existing inpatient services was the highest scoring out of this process.
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