Call for reform of system treating children with SEN as mental health inpatients

The report, Far Less Than They Deserve: Children With Learning Disabilities or Autism Living in Mental Health Hospitals, published by children's commissioner for England Anne Longfield, calls for reform of the system to prevent children going into hospital.

Vulnerable children are currently subject to a "postcode lottery" of community support, the report states.

Among a raft of findings are that many children's experiences are leaving them traumatised, with parents feeling powerless to intervene.

There is "shocking evidence" of poor practices and sedation, children being kept in hospital for too long, in some cases are spending months and years away from their communities, as well as far from home.

The findings are revealed after the commissioner's office exercised statutory access to information held by NHS Digital, which was supplemented by hospital visits and interviews with families.

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Some families reported the physical care needs of their children had been neglected, with one family saying their son had not been washed for six months while in hospital.

In her introduction to the report, Longfield states: "While our research highlights some excellent staff working in hospitals, we were overwhelmed with stories of poor practice.

"Successive government programmes have been introduced to address these long-standing problems, and yet the number of children in hospital remains stubbornly high, with community support for children with a learning disability or autism a postcode lottery.

"I am concerned that the current system of support is letting many children down and does not meet obligations under the United Nations Convention on the Rights of the Child.

"A national strategy is needed to address the values and culture of the wider system across the NHS, education and local government so that a failure to provide earlier help is unacceptable, and admission to hospital is no longer seen as almost inevitable for some children.

"Much better data should be collected on length of stay and delayed transfers of care in children's mental health hospitals, in the same way that this information is closely scrutinised in physical health hospitals, and NHS England should use incentives to reduce them."

The number of such children in mental health hospitals more than doubled from 110 to 250, between March 2015 and February this year, according to the report.

NHS England states that this huge difference is due to previous under-reporting, with numbers in 2017 being 260.

However the report states: "Even with the adjusted figures, the number of children in hospital has not reduced.

"It is very concerning that the NHS has failed to record accurately the number of children in long-term inpatient care, their conditions and their outcomes."

The government said that children with autism and learning disabilities must receive high quality, safe and compassionate care and that it was "determined" to reduce numbers in hospital.

It claimed that significant investment in community support has led to a 22 per cent reduction across all ages since March 2015.
 
It aded: "The NHS is committed to reducing numbers of people with a learning disability and autistic people who are inpatients in mental health hospitals by 35 per cent by the end of March 2020 and through the Long Term Plan we will reduce numbers even further by investing in specialist services and community crisis care and giving local areas greater control of their budgets to reduce avoidable admissions and enable shorter lengths of stay.
 
"The CQC is also undertaking an in-depth review into the use of seclusion, segregation and restraint  - which should only be used as a last resort - in order to improve standards across the system."

Key numbers from the commissioner's report:

• Of the 250, 130 were on a children's mental health ward, 25 were in a specialist learning disability unit and 60 were on low or medium secure units.
• Nearly three quarters of these children have autism but not a learning disability. Around one in seven have a learning disability only, and another one in seven have both.
• At the end of February 2019 on average, children with autism, a learning disability or both had spent six months (184 days) in their current hospital stay, and eight months (240 days) in inpatient care in total.
• Around two in five (95) children had spent at least six months in their current hospital spell with their current provider.
• Around one in seven (35) had been there for at least a year.
• Nearly half (115 children) had been receiving inpatient services (across multiple providers) for at least six months across their current period of care, while around one in five (55) had done so for at least a year.
• Nearly one in four children (60) had a total length of stay of at least six months and were in a ward at least 50 km (31 miles) from home.
• Around one in 10 children (25) had a total length of stay of at least a year and were in a ward at least 100km (62 miles) from home.

The commissioner's recommendations include:

• Ministers to launch a cross-government national strategy with funding and clear targets to ensure there is the right support available in every area to stop these children going into hospital.
• At a regional level, NHS England should actively monitor all children in inpatient settings and cases at risk of admission (for example those in residential special schools), then work with local commissioners to reduce length of stay and reduce the risk of admission.
• Better data to be collected on length of stay and delayed transfers of care in children's mental health hospitals, in the same way that this information is closely scrutinised in physical health hospitals, and NHS England should use incentives to reduce them.
• Before children are admitted there should be proactive and face-to face-assessment of the child, in consultation with family and community services, with a clear plan as to why a hospital admission is necessary, what will be treated in hospital and what the child is being prepared for on return to the community.
• In order to protect children's rights, appropriate monitoring needs to be in place of the quality of care while in hospital.
• Local authorities need to maintain and make proper use of risk registers to identify the children in their area with severe disability, communication needs, autism or other complex conditions where there is a risk that the child might need hospital admission due to challenging behaviour.
• Action to be taken to improve care within hospitals and hospitals to focus on recruitment of high-quality staff.
• Culture change in the system needed, with higher expectations and standards for units and staffing and tougher inspection by the Care Quality Commission.
• There should be clear requirements placed on those who commission care for children in hospital that they regularly visit to observe the quality of care, attend relevant meetings and interrogate data on incidents, rather than the child simply being placed and forgotten about.
• More transparency is needed over restraint approaches from providers.