Time to raise the standard: children presenting to emergency departments in mental health crisis

For the first time, the College has developed an audit toolkit to support Emergency Departments treating children to monitor how well they are meeting the 70 “Facing the Future” standards. Dr John Criddle and Dr Virginia Davies discuss the development of the toolkit and its impact for children in mental health crisis.

Published in June 2018, the fourth edition of RCPCH Facing the Future: standards for children in emergency care settings was developed by an expert working group.

The toolkit developed to help Emergency Departments (EDs) monitor their performance against the standards enables services to inform action planning and collect data. The College can use this data to benchmark improvements across the network.

Insights from the pilot study

A pilot study involving 15 EDs across the UK was carried out in August 2018. The pilot highlighted positive practice and informed further development of the audit tool prior to a national data collection exercise in 2019.

There was wide variation in the total number of standards being met (46% - 90%), with EDs experiencing higher rates of attendance more likely to meet standards (Table 1).

Table 1 - Total number of children’s emergency standards met by size and site

Pilot site Number children and young people seen in ED per year Percent of standards met
1 18,000 46%
2 29,000 53%
3 41,000 54%
4 30,000 66%
5 34,000 70%
6 60,000 73%
7 43,000 74%
8 28,000 76%
9 28,000 76%
10 20,000 76%
11 36,000 77%
12 27,000 80%
13 60,000 86%
14 45,000 89%
15 65,000 90%

An especially worrying picture emerged in relation to how pilot sites were meeting standards of care for children and young people presenting in mental health crisis. Of all the service domains described in the standards, those pertaining to mental health were less well achieved:

  • Only six sites were able to provide adequate and appropriate space for children and their families in crisis.
  • Only five were able to access age-appropriate inpatient facilities, specialist staff and regular mental health review for those detained in the ED for more than four hours awaiting a mental health bed.
  • The majority of services did not have policies in place for the management of an acutely distressed child.

The view from the frontline is clear; there is inadequate access and inconsistent provision of appropriate care for children and young people in crisis.

However, despite some EDs struggling to support children and young people’s mental health needs in-house, 13 of the 15 pilot sites had telephone support from a paediatric mental health practitioner 24 hours a day, seven days a week, for advice and face-to-face assessment when appropriate.

Elsewhere, there were areas where standards were well met. These included meeting the needs of children with complex health problems, safeguarding, the safe transfer of children and providing clear policies and support around unexpected patient deaths.

Looking to the future

One in eight (12.8%) 5 to 19 year olds had at least one mental disorder when assessed in 20171 and the leading cause of death in young people aged 5 to 19 years old is suicide2.

Yet the view from the frontline is clear: there is inadequate access and inconsistent provision of appropriate care for children and young people in crisis. Without the urgently needed investment in community child and adolescent mental health services (CAHMS), including in schools, the number of children and young people presenting to EDs in crisis will continue to rise. Children’s EDs must work with CAMHS to ensure children and young people have better emergency access to mental health services.

Preventing mental health problems escalating to crisis point is the logical place to start and the overall uplift in mental health funding from the NHS Long Term Plan will support better mental health provision in schools and colleges. Children and young people in mental health crisis need services delivered by staff with adequate training and access to the right levels of specialist supervision. Care must be provided as close to home as possible, with involvement of the family in planning and information sharing wherever practicable.

The Long Term Plan has committed to expand timely, age-appropriate crisis services for children and young people which will ultimately help to reduce pressures on emergency departments.

Without the urgently needed investment in community CAMHS, including in schools, the number of children and young people presenting to EDs in crisis will continue to rise.

Children and young people under the age of 20 make up 26% of ED attendances which are predicted to increase by 50% by 2030, with 200,000 additional visits each year3. The Long Term Plan has the power to prevent and protect children from ill mental health. Supported with sufficient political will, it has the ability to properly address the needs of children and young people in crisis by ensuring that emergency care settings are meeting the College’s Facing the Future standards, with a workforce able to provide strong, sustainable and appropriate 24/7 mental healthcare for vulnerable children and young people.

The RCPCH is leading a national audit of the emergency standards, and EDs that see children are encouraged to submit data.