The skylights, brightly painted corridors and large windows overlooking a central courtyard make East London's Coborn Centre for Adolescent Mental Health a far cry from how mental health care for young people was once provided in the area.
Previously, services were based at a young people's ward within the ageing and ramshackle St Clement's Hospital at Mile End, a former asylum that housed mainly adult psychiatric patients. The Coborn Centre couldn't be more different; its walls are hung with impressive paintings that have been produced by patients during sessions with a local artist.
Age-appropriate environment
The state-of-the-art building, which opened in 2006, is operated by the East London NHS Foundation Trust. Because of its east London demographic, the centre cares for mainly Bangladeshi, African and Afro-Carribean young people who display a range of mental illnesses, from schizophrenia, depression and behavioural disorders, to psychosis and eating disorders.
While Coborn is impressive, such tailored mental health services for young people sadly don't exist everywhere in Britain. In certain parts of the country, young people aged 16 and 17 who experience mental health problems are placed on adult psychiatric wards.
From next month, this should change. Following a long-running campaign by charities such as Young Minds, the practice of putting young people on adult psychiatric wards is to be curtailed. Revised legislation that takes effect on 1 April places a duty on health trusts to house 16- to 18-year-olds in an "age-appropriate environment" (see box). This adds to rules that came into effect at the end of 2008 and that ban primary care trusts from putting under-16s on adult psychiatric wards.
It is up to primary care trusts, who control the purse strings, and the mental health trusts, who deliver the services, to make this work.
Sarah Brennan, chief executive of Young Minds, has written to the board members of NHS Trusts to remind them of their new duty. She is clear about why this matters: "There are cases of young people being abused or attacked by adults on wards - of physical and sexual abuse. That's why Young Minds led the campaign on revising the Mental Health Act in 2006."
At Coborn, the provision has gone much further than the government legislation. Not only are the young patients on wards with other young people, they have their own room and the centre offers areas for group discussions, art therapy, cooking, family visits, fitness, games and television. It offers three different types of care - a three-bed psychiatric intensive care unit, a 12-bed acute ward and a day service, which has room for six young people.
Louisa Villar, clinical team leader of the daycare service, says housing young people together makes it a less intimidating experience for patients. "Coming to the psychiatric service isn't the best experience," she says. "It can be really daunting in any case, but if you have to be around scary adults it's much harder."
And John Ebbutt, a day service nurse, says that age-specific centres allow staff to rebuild the young people's trust in adults: "If they are in with adults who are unwell and aren't respecting boundaries, it does muddy the waters."
Dr Rafik Refaat, lead clinician at the Coborn Centre, says the transformation in care has been "amazing" since staff moved from the old building. "We are one of the pioneers - the first NHS adolescent unit to have a new purpose-built centre where there is an intensive care unit integrated with an acute and day service," he says.
As a child and adolescent psychologist, his job is about understanding the young person's development, looking at family background, major life events, genetic traits and their educational position. He believes that having young people housed with their peers protects them from abuse and aids recovery. "Working with the family and providing for their education is paramount," he says. "We have a school in the unit - it's unlikely an adult facility could do that."
The outcomes aren't always simple. He talks of Paul, a "very disturbed" 14-year-old with childhood autism. After five weeks in the intensive care unit, he's been released and now receives 24-hour care at home. It is a sad fact that Paul will always need this care. But the positive aspect is that the Coborn Centre's multi-disciplinary approach has enabled Paul to finally get the support he needs, says Refaat.
Eating disorders are another common feature in his patients. "They come in emaciated with serious physical and psychological problems and they leave very much better on a healthy diet and are followed by adolescent teams in the community."
The centre serves three London boroughs - Newham, Tower Hamlets and Hackney - but young people from Sheffield, Scotland and Wales also come there, due to an absence of facilities in parts of the country.
The government measures performance in this area by bed days spent by young people on adult wards. The most recent figures show that there were only 25 bed days for under-16s on adult wards last year and none in the final quarter. For 16to 18-year-olds, there were 5,254 bed days throughout 2009, of which 1,055 were in the last quarter.
Across the country there are wide disparities. Many primary care trusts boast no bed days at all for 16- and 17-year-olds. On the other hand, Lancashire Care NHS Foundation Trust reported 168, Barnsley Primary Care Trust recorded 90 and Bradford District Care Trust had 81, according to the latest Department of Health figures.
But planning is going on across the country to meet the new legislation. The Lancashire Care NHS Foundation Trust, currently the worst performer, says that in April it is opening The Platform, a new six-bed unit for 16- and 17 year-olds.
David Stout, director of the PCT Network at the NHS Confederation, says his members have had the necessary warning and the figures show "there's already been a massive improvement". Funding will have to come from existing budgets as in theory the change will not lead to higher total admissions and so is revenue neutral, he says. "In practice life is a bit more complicated," he concedes, so there may be some upfront costs in changing provision.
Location of services
But overall the bigger problem will be the location of services and young people may have to travel further from home, Stout argues: "The policy is right, but because these are specialist facilities, they will not all be on your doorstep as an adult facility might be. So admission may be further away."
The crude nature of the data presents a problem in ensuring that the age-appropriate criteria (see box), such as ensuring a patient has access to education, are put into practice. Brennan says: "Bed days is a useful indicator, but it's only an indicator. And it doesn't tell us anything about the age-appropriate environment."
So Young Minds is recommending that there is a qualitative element to the evaluation with feedback from young people who have spent time in psychiatric wards, as well as the views of their families. And Brennan is encouraging families to share their experiences on the Young Minds website. The charity is also reviewing what action to take when age-appropriate care is not forthcoming.
Brennan says it hasn't considered taking organisations to court yet, but neither has it ruled out this course of action. "We'll be seeking out the experiences of the young people coming through," she says. "We want to see the primary care trusts wholeheartedly taking on the legislation rather than setting ourselves against them." And lack of resources is not an excuse, she warns: "There's always funding if the will is there to do it. Often it's about reorganising rather than building a new block."
But at a time of cuts in public services, it can be difficult to maintain existing resources, let alone increase them. Refaat warns the alternative would be dire: "You will have a revolving door of young people coming in and out if you don't provide a high-quality service."
His colleague Mihla Sibanda, team leader at the Psychiatric Intensive Care Unit, agrees. He used to work in adult mental health services and believes that redirecting resources towards young people is not only humane but effective: "I know from the adult service what it is like when people are not helped in time. With mental illness, the earlier someone is helped the better the prognosis."
WHAT THE REVISED LEGISLATION SAYS
Section 131A of the Mental Health Act 1983 comes into force on 1 April. The thrust of the new legislation is to prevent young people being placed inappropriately on adult psychiatric wards. However rare such admissions, all NHS trusts providing in-patient adult mental health services now have a duty to ensure that age-appropriate measures are in place.
It applies whether the young people are detained under the Mental Health Act or admitted informally. Since December 2008 it has been government policy that children under 16 should never be admitted to an adult psychiatric ward. Such admissions are treated as "serious untoward incidents" and reported to the Strategic Health Authority.
The revised legislation clarifies what is considered age-appropriate care for 16- and 17-year-olds and includes four key conditions:
- Primary care trusts must provide appropriate physical facilities, such as recreational spaces - Staff need to have the right training, skills and knowledge to understand and address the specific needs of young people
- The hospital routine needs to allow the young person's personal, social and educational development to continue as normally as possible
- Young people need equal access to educational opportunities as their peers, depending on their mental state.
The legislation does not place a blanket ban on putting 16- or 17-year-olds on adult psychiatric wards. It spells out two scenarios in which it is permissable: an emergency admission for a short-term stay; and an "atypical admission", such as when a young person is almost 18, to allow continuity of care.
