New safety watchdog publishes report on transition of young people to adult mental health services

The Healthcare Safety Investigation Branch sets out a number of safety recommendations for both NHS England and NHS Improvement.  

On 9 July 2018 HSIB published their second final investigation report. This follows fast on the heels of their first report.

This time it relates to the transition from Child and Adolescent Mental Health Services (CAMHS) to adult mental health services.

The investigation related to the suicide of “Ben” three weeks after his 18^th birthday. He had been referred by his GP aged 17 years and six months to CAMHS with a history of low mood and recent thoughts of harming himself. He was also noted to find managing change difficult. He was under the care of CAMHS for eight months. He had previously talked about taking his life when he turned 18.

There are findings in relation to Ben’s management and national findings too.  

Locally these include:

• Transition planning was hampered by a lack of shared care. 
• CAMHS staff and managers had differing perceptions about flexibility with transition age.
• Ben was not managed in line with the Care Programme Approach.
• There was an inability to recognise escalating risk.

Nationally these include:

• Young people using mental health services would benefit from a flexible, managed transition from CAMHS that has been carefully planned and incorporates a period of shared care and provides continuity of care and follow up after transition.
• No standardised methods or tools used to manage transition in mental health trusts (unlike acute trusts).
• There is evidence that moving to a flexible model, providing services up to the age of 25, can minimise barriers and reduce risk.

As a result of the investigation, HSIB identified six safety recommendations - five of these are directed to NHS England or a combination of NHS England and NHS Improvement:

• Work with partners to identify and meet the needs of young adults with mental health problems that require support but do not meet current criteria to access adult mental health services.
• Require Clinical Commissioning Groups to demonstrate that the budget identified for current children and young people’s services is spent only on that group.
• Ensure transition guidance, pathways or performance measures require structured conversations to take place with the young person.
• Move from age based criteria towards more flexible criteria based on an individual’s needs.
• Work with commissioners and providers to ensure that care is shared in line with best practice, including joint agency working.
• Care Quality Commission to extend the remit of its inspections to ensure the whole care pathway is examined.

HSIB have also made two safety observations. 

For child and adolescent mental health service and adult mental health service clinicians to be trained in a safe and effective transitions from child and adolescent to adult mental health services and for NHS England to consider developing a method to identify where CCGs spend on child and adolescent mental health services per capita is lower than reasonably expected.

Interesting points within the main body of the report include:

• In order to aid understanding of the chronology in chapter two dates are not given but instead references made to days, for example Day 8 and Day 22.
• The investigation conducted a focus group in a different geographical area to the event and that identified a number of similar themes.
• Age 14 -25 is the highest risk period for mental health conditions to emerge.
• A survey of voluntary sector providers found that many considered adult mental health commissioners were not making an appropriate contribution to funding services for young adults.
• Like the first HSIB report in this case, they also looked internationally to Australia, Denmark and to a European Union-wide study.
• The role of educational institutions is also covered in chapter five.
• Lessons from the acute sector are also considered from the areas of diabetes, cystic fibrosis and sickle cell disease management.
• Good examples of CAMHS transition across the country are set out at chapter 5 paragraphs 5.10.11 – 5.10.21.