MENTAL HEALTH BLOG WEEK. Dr Avirup Gupta, a practising clinical psychiatrist in the NHS, describes his first-hand experience of observing the transition between child and adolescent and adult mental health care, and suggests some solutions to the problems this can entail
Child and adolescent mental health services across the country face many challenges at the point where their patients, at the age of 18, “graduate” to adult mental health services.
As a frontline consultant psychiatrist in the NHS, I come across a significant barrier that affects young people more than others. It’s the lack of continuity of care.
The National Institute of Health and Care Excellence (NICE) has published a quality statement that patient experience wherever possible should be delivered by the same healthcare professional or team throughout a single episode of care. This often fails to happen at the point of transition from adolescent to adult mental health services. Long-term therapeutic relationships with professionals and patients are disrupted once they hit their 18th birthday.
Transition planning to adult mental health services are, more often than not, both disrupted and difficult to achieve. In many cases they are not as seamless as they should be. This has a negative impact on the young person’s well-being and can lead to lowered quality of life and care.
Where is the gap?
As a practising clinician, I see examples of high workloads in adult services and difficulty in coordinating staff, making it harder for adolescent mental health services and adult mental health services to meet with the young person and their carer in a handover meeting which is planned and coordinated.
There is a lack of consensus between frontline child and adolescent staff and managers on the exact transition age. Staff often feel pressured to move young people from adolescent to adult services on turning 18, while adult mental health services often hold the view that the adolescent services should have the flexibility to work with people beyond 18 in some cases. This often makes it difficult to standardise care.
The commissioning guidelines and arrangements do not make this any easier. Usual commissioning arrangements mean that the young person requires a new referral to an adult mental health service despite the adolescent mental health services staff determining that he or she would require ongoing treatment. The lack of clarity about the terms on which adult mental health services would accept the young person, makes the transition even more difficult because of the myriad of various mental health pathways, teams and referral pathways – all of whom may have slightly differing acceptance criteria.
Struggling to match demand
In addition to this is the fact that certain diagnostic entities have hardly any appropriate commissioned adult services to meet patient needs. For example, if a young man has a diagnosis of an autistic spectrum disorder, as a young adult he would struggle significantly to receive appropriate ongoing mental health care and support.
I distinctly remember a teenager who came to my team when he turned 18 with more than one mental disorder, one of which was an autistic spectrum disorder for which I couldn’t offer him appropriate care and treatment. The impact on his mother and their family was so significant that this led to severe carer stress and complaints made to the local Member of Parliament. It took some six years of discussions before an appropriate assessment and treatment package was commissioned for him from a specialist autism unit.
NHS England and NHS Improvement ensure transition guidance, pathways or performance measures; they require structured conversations to take place with the young person transitioning to assess their readiness, develop their understanding of the condition and then empower them to ask questions. Whilst the transition guidance remains excellent, robust evaluation of the effectiveness and implementation of the guidance remains critical in ensuring maintenance of care standards. I believe that this is key to assessing the impact of transition quality, and NHS England and NHS Improvements must evaluate this.
Improving the process of transition
Right from my medical school days, we were taught about individualised medicine and tailoring a treatment plan for the individual and to take into account their needs. In the long term, NHS England will benefit from services to move from age-based transition criteria towards more flexible criteria based on an individual’s needs. This is likely to enable young people transitioning from one service to another to experience the comfort of flexibility, reduction in transition anxiety, improvement in transition quality and accessing adult services with confidence.
I have often had cause to worry about transition quality before, during and after transition from adolescent mental health services to adult mental health services. In my experience the care of the young person before, during and after transition ought to be clinically audited in accordance with clinical governance procedures, and the results disseminated across adult and adolescent services. This is likely to reduce the gap in the quality of care, identify areas to improve, and foster a culture of quality improvement that leads to improved care standards.
In order to narrow the wide range of experience in care quality that an adolescent faces when being moved to an adult mental health service, it’s important to focus on questions raised by adolescents and their families. In my view, a quality assurance team set up and dedicated to transition management could be an option. This could be in the form of a multi-agency team that works across services, has access to psychologists, and has support workers, social workers and occupational therapists who work with young patients flexibly for a period of time until transition is safely completed. There are of course other options to consider in this situation based on available local services and pathways.
The Healthcare Safety Investigation Branch (HSIB), part of the NHS Confederation, in July 2018 published an investigation report into a breach in patient safety after a case of suicide of a young person during a transition process of moving to adult mental health services. The findings, many of which I have reflected on in this blog, make grim reading. More worrisome is the fact that I can identify the observations in that report as issues which could be affecting care in other NHS settings today.
While the NHS has a clear focus on achieving a higher quality of transition, I feel that we require more efforts and political will to ensure that we have as high a quality of care as we have quality standards.