We read with interest the correspondence by Myers et al ^{Reference Myers, Coyle, Kowalski and Srinivasan1} and echo their concern. In our region, child and adolescent psychiatrists are increasingly dealing with similar situations and are concerned for young people and their experience of services out of hours. We agree that there is no current system to find out bed availability and no external support to make this process efficient.

Fortunately, in our region we have an out-of-hours process whereby referrals can be made and we have agreement for two tier 4 providers to accept emergency admissions. Since this process was initiated, the referrals for out-of-hours beds have steadily increased and in the past 6 months 30 referrals were made, two-thirds of which were for people aged 17+. However, despite this process, only five young people were able to access these emergency beds in that period. The majority of young people had to wait until NHS England was available to manage the referral the next working day. Hence, there have also been calls in our region for daily bed state availability and for NHS England to be accessible out of hours.

Ensuring the best use of a scarce resource and the prioritisation of available beds requires high-quality and skilled clinical assessment. We also provide a gateway service/access assessment during working hours. This has averted the need for in-patient admission for a third of patients referred. It has been valued by referrers and ensures that the right patient accesses the right type of service. However, this service is not available out of hours.

We agree that increased bed provision is not the only solution. The divide in commissioning arrangements for tier 3 and tier 4 services means the development of alternatives to in-patient admission; outreach and crisis services and day-patient services have been patchy, too. In Birmingham we have developed a child and adolescent mental health home treatment service that has demonstrated a reduction in need for admission and cut length of stay by 50%. Birmingham has also set up daytime and out-of-hours community emergency response and assessment teams that respond to emergency referrals from all the local general hospitals.

The report published by the Health Select Committee on 5 November 2014 highlights this major problem with access to in-patient services, as well as problems with commissioning and the lack of services which bridge the gap between in-patient and out-patient services. ² It takes a whole-systems view and recognises that the problem is about more than just beds.