We carried out a comprehensive investigation examining the transition between inpatient children and young people’s mental health services (CYPMHS) to adult mental health services (AMHS). The report highlights when young people are in either children’s or adult mental health services, care delivery is usually ‘understood and consistent’, but moving between these services creates a number of challenges.
Impact of transition
The investigation found young people may be discharged from inpatient care because they have reached ‘transition’ age and not because their mental health needs have changed. The report emphasises different criteria for ongoing inpatient care as an ‘adult’ may mean young people are discharged into an alternative setting which is not suitable to meet their ongoing needs, for example bed and breakfast hostels.
A foundation of the investigation was to understand the impact on young people of the transition from inpatient CYPMHS to AMHS. Over the course of our investigation we carried out interviews with children and young people, and interviews with families, including bereaved families. We also spoke to patient forums across mental health providers and carried out patient, family and carer focus groups facilitated through the mental health charity Mind’s networks.
We heard consistently from patients, families and carers the transition was initiated because the young person was approaching or had reached a specific age, usually 18 years old. They shared that often their mental health needs had not changed and the move was a source of anxiety, especially where they were receiving appropriate care to help them move towards recovery but were now presented with an imminent move to a new provider and as the report says ‘the unknowns that would entail.’
Many young people, families and carers also told HSSIB they were not involved, engaged or given information to help them prepare for their next stage of care. Bereaved families often described transitions as a stressful process, and one which contributed to the poor outcomes for their loved ones.
Staff concerns
The investigation also undertook extensive conversations with staff in mental health providers and those that commission and oversee services to gain their insights into the challenges and risks.
Many shared the same concerns patients, families and carers had given, that moving children and young people based on age may be inappropriate and could have an impact on their safety. However, some also described services as ‘stretched’ and that the age of 18 provided ‘one concrete way to move people on and keep flow through the system.’
Whilst many agree that a more individualised and flexible approach to transition was ‘the right thing to do’, they told us that the current systems, resources and funding did not always support this. The investigation did hear from providers that had implemented more flexibility into their transitions and could give examples of where this had resulted in better outcomes for young people, families and carers.
Safety recommendations
We have made a safety recommendation to NHS England to review mental health service specifications and commissioning guidance to support a more consistent approach to needs-based transitions.
The report emphasises inpatient CYPMHS to AMHS transitions cannot be looked at just in terms of mental health providers – it spans health, social care, local authority provision and education. The investigation highlights in order to facilitate safe and effective transitions, providers and partners need to be working together. However, this is not happening in a consistent and integrated way across England. The report states there is ‘no alignment, equity of access or clear responsibility and accountability for children and young people’s health, education and social support that spans their transition from childhood to adulthood.’
As a result, we have recommended that the Department of Health and Social Care identify ways to support closer cooperation between local government, education and health systems.
Investigator’s view
Craig Hadley, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB), says: “The report acknowledges that the delivery of mental health care is complex and services are routinely experiencing high demand. However, an inconsistent approach to transitions, compounded by a lack of integration between health, social care and education puts the safety and wellbeing of vulnerable young people at risk.
“Evidence shows that a more flexible approach to transition is much safer and more therapeutic for young people. There are examples of organisations taking this type of approach, but they are not underpinned by a system that supports this overall. We heard from providers and commissioners that to achieve flexibility they ‘were pushing the boundaries of how inpatient care had been delivered in the past.’
“The safety recommendations from this investigation are aimed at improving collaboration and supporting inpatient transitions that are based on needs rather than age. The move from inpatient children and young people’s services to adult services currently happens at an already challenging time of life for young people and it should not be made harder for them, and their families. The reality is, as we say at the end of the report, the person did not change, their needs did not change, their risks did not change – the health, care and education system changed around them because they were a day older.”
