Researchers Propose an Alternative to Inpatient Units for Children

Writing in Child and Adolescent Mental Health, researchers outlined both the benefits and potential risks and harms of inpatient units for children. Although there will always be a need for some inpatient beds, for many children and young people intensive community interventions may yield better outcomes, be more cost-effective, and improve patient experience when compared with admission.

According to authors, children may require inpatient care for one of three reasons. These patients may present with high risk due to mental health difficulties and cannot be managed safely at home or in social care placement, or these patients require an intervention not available elsewhere. “Rarely, a third reason can be the requirement for an intensive assessment involving 24-hr observation by a specialist team, when a community assessment is not possible,” researchers noted.

However, these criteria may be subject to interpretation and not be consistently utilized across the board, leaving open the question as to whether young people who meet these criteria could be better served through an intensive community-based intervention. Hospital admission among this cohort is often chosen because it is the only option in the absence of sufficiently resourced community services, authors explained, as opposed to the best option.

Overall, research indicates inpatient admission is effective, but comes at the cost for some and holds the potential to cause harm, including:

• Separation from family and friends, with a risk of dependence and ‘institutionalization’
• Education disruption
• Adverse influences from peers, including risk of increased self-harm
• Exposure to an environment with high levels of disturbance causing distress and com- pounding difficulties
• Families and young people feeling disconnected, deskilled and disempowered
• Inpatient treatments are expensive using resources which might be better deployed to intensive community interventions
• Children and young people are over five times more likely to be physically restrained than their adult counterparts in the same trust

“There is a range of functions that community services need to provide in order to offer a comprehensive alternative to admission, and/or reduce lengths of stay” which can be provided together or separately, researchers wrote.

Functions include crisis assessment and management for those in acute crisis, intensive outreach services that are designed to encourage early discharge and reduce length of stay or transition to other services, and planned home treatment services for those who need long-term treatment. Specialist treatment services for young people with eating disorders or severe self-harm will also be beneficial when patients’ needs exceed the capacity of regular community services. According to authors, these solutions could be delivered in the patient’s home, a clinic or day hospital.

“Randomized controlled trials when alternatives to admission are compared with admission, evidence of reduced admission rates in localities that have access to high-quality alternatives to admission and data mapping service provision around the country [England] provide further evidence to support the case for developing comprehensive alternatives to admission,” authors said.

Previous research has revealed well-designed community services can reduce admission rates, lengths of stay, result in fewer harms, cost less to provide, and improve patient experience overall.

However, researchers caution against immediate reduction of inpatient beds before suitable alternatives are available. Using England as an example, they note the way National health Service (NHS) funds are distributed for young people’s mental health services has hindered progress in this area. “Highly specialized services such as inpatient care currently have a separate funding stream from regular community services,” they said. “In many places, this has resulted in a funding gap for services that should sit between regular community services and inpatient care.”

Temporarily increasing funding to admission alternatives may provide a simple solution to this roadblock, as once services are established, money will be recouped by reducing beds. Vision and commitment are needed by those in control of funding for a significant acceleration in this progress to take place, researchers concluded.