Child and Adolescent Mental Health Services: inpatient report

A4.14 Patient pathways

Patient pathways – summary

Length of admission:

• 85% spent >/= 1 month in inpatient care
• 44% (32 patients) spent > 6 months in inpatient care

Those with learning disability were more likely to spend longer in hospital than those without, with a trend of longer stays the more severe the learning disability

Transfers between inpatient units within an admission:

• 73% of patients remained in one ward for duration of their hospital treatment
• 23% experienced 1 transfer to a different inpatient unit during treatment
• <5 patients experienced between 2 and 7 transfers
• No patients without learning disability had more than 1 transfer and those with mild learning disability were most likely to have at least one transfer.

Repeat admissions by individual patients:

• 84% of patients had 1 admission
• 10% had 2 admissions
• 6% had between 3 and 7 admissions

There was a wide variety of complex pathways for patients requiring specialist LD CAMH, adolescent secure or ASD-specific secure provision, which only a minority actually received in specialist units in England.

A4.14.1 Length of admission

This relates to total time in inpatient care per patient (including transfers within an admission and readmissions). For all admissions for which total admission time was given (74):

• 85% spent a month or more in inpatient care
• 44% (32 patients) spent more than 6 months in inpatient care

Those with more severe levels of learning disability tended to spend longer in hospital. Figures are % of those with each level of learning disability who spent more than 1, 3 or 6 months in hospital:

Time in hospital/ level of learning disability	>1 month	>3 months	>6 months
None	76	48	28
Mild	87	65	48
Moderate	91	68	55
Severe/profound	88	88	50

A4.14.2 Transfers between inpatient units within an admission

• Average number of transfers per admission .38 (SE. 1, SD .90)
• 73% of patients remained in one ward for duration of their hospital treatment
• 23% experienced 1 transfer to a different inpatient unit during treatment
• <5 patients experienced between 2 and 7 transfers

No patients without learning disability had more than 1 transfer and those with mild learning disability were most likely to have at least one transfer.

A4.14.3 Repeat admissions by individual patients

• Average number of admissions per patient:1.27 (SE .09, SD .84)
• 84% of patients had 1 admission
• 10% had 2 admissions
• 6% had between 3 and 7 admissions

• Those ideally requiring YPU

A number of patients (mostly with autism spectrum disorder but no learning disability) who ideally required YPU admissions were not able to access them immediately due to a lack of beds available on regional YPUs. The majority of these completed their whole admission on adult mental health wards, but some were transferred during admission to their regional YPU. A number had repeat admissions to various combinations of YPU, adult mental health or both.

• Those ideally requiring specialist units currently unavailable in Scotland

There was a wider variety of often complex pathways for patients requiring specialist LD CAMH inpatient admission (including those requiring secure or individualised provision), adolescent secure or ASD-specific secure provision, which only a minority actually received in specialist units in England. Patients often spent considerable periods making no or limited progress at home, in residential care, on one or more inappropriate ward (or some combination of all of these), whether or not they eventually had a specialist admission to hospital.

Some patients had only very brief (sometimes multiple) crisis admissions to unsuitable wards, remaining in non-hospital provision or at home between times. They therefore did not get the full assessment and treatment that a specialist unit would have given.

Examples of pathways followed by patients requiring specific types of units are given below. They are based on real situations but the information given is a composite to protect patient confidentiality.

Patient 1 (example of patient ideally requiring non-secure LD CAMH inpatient unit)

Home

while needing admission >8 weeks

↓

Learning Disability ward Private, England, 3 weeks

↓

Residential School

Out of Health Board area 2 years

↓

Adult LD ward

Local Health Board 1 year

↓

Adult care placement

ongoing

Patient 2 (example of patient ideally requiring non-secure LD CAMH inpatient unit)

Home

(with cobbled together support) while needing admission 4 weeks

↓

Respite provision

Out of Health Board area 6 weeks

↓

Paediatric ward

2 weeks

↓

LD CAMH inpatient unit

NHS England 13 weeks

↓

Home

Patient 3 (example of patient ideally requiring secure LD CAMH inpatient unit)

Home

while needing admission >8 weeks

↓

Adult LD ward

Local, 4 weeks

↓

YPU

Regional, 12 weeks

↓

Home

2 weeks

↓

Intensive psychiatric care unit

Adult, local, 8 weeks

↓

LD CAMH low secure inpatient unit

Private, England, 18 months

↓

Adult LD low secure inpatient unit

Regional Scottish provision, aged 18, remains inpatient

Patient 4 (example of patient ideally requiring secure LD CAMH inpatient unit)

Secure care placement

Out of Health Board area for 4 months while requiring admission to secure inpatient care

↓

LD CAMH inpatient medium secure unit, NHS England

16 months

↓

Local adult LD ward

6 months

↓

Home

With social care support

Patient 5 (example of patient ideally requiring individualised LD CAMH inpatient unit)

Home

while needing admission >8 weeks

↓

Residential school placement

6 weeks broke down

↓

Adult LD ward

Crisis admission out of Health Board area

2 weeks

↓

Adult LD ward

Adapted individualised in own Health Board

11 months

↓

Specialist social care placement

8 weeks broke down

↓

Adult LD ward

Adapted individualised in own Health Board

20 months

↓

LD CAMH secure inpatient unit

NHS England, ongoing

Patient 6 (example of patient ideally requiring mainstream CAMH secure adolescent inpatient unit)

Residential School

Out of Health Board area for 4 months, while needing admission

↓

Intensive psychiatric care unit

Out of Health Board area, 20 weeks

↓

Residential school

Out of Health Board area, 6 months

↓

Adolescent mental health medium secure inpatient unit, England- private

4 months

↓

Adolescent mental health medium secure inpatient unit, England- NHS

1 year, ongoing

Patient 7 (example of patient ideally requiring ASD specific secure adolescent inpatient unit)

Residential school

In Health Board area for 9 months, while needing admission

↓

Adult mental health ward

Multiple brief admissions over 2 year period

↓

Home

2 months

↓

Reinforced part of YPU

Emergency admission 4 months

↓

ASD secure inpatient unit, England- private

1 year, ongoing