How can a young person wait over 90 hours in an emergency department for a bed

We have recently been involved in a difficult case of a young person who remained in a local emergency department bed for over 90 hours while several specialty registrar (StR) doctors spent the majority of their on-call time attempting, and failing, to find an appropriate available bed. Over the course of this time, at least 40 units were contacted, numerous referral letters faxed and the case was handed over 6 times, all while the young person waited in an unsuitable setting that offered little to meet his mental health needs. 
 
Although this is an extreme case, it reflects the trend we have observed of difficulty in finding beds, especially out of hours, and the fact that bed finding is becoming a major aspect of our on-call time. As Hillen & Szaniecki demonstrated,1 the majority of referrals are made between the hours of 5 pm and 9 am when daytime services are closed. 
 
We have read with interest the findings of NHS England’s Child and Adolescent Mental Health Services (CAMHS) tier 4 report2 published in July 2014, which reported that the number of NHS-funded CAHMS tier 4 beds has increased by just 136 in the past 8 years, compared with a 284 rise between 1999 and 2006. This means that there were 1264 beds available nationally in January 2014. The BBC have declared this a problem of ‘patchy provision’ and, based on their findings, NHS England have identified a need and promised ‘up to 50 new beds around the country with further beds moved according to need’.2 While this goes some way to providing more beds, this is only part of the problem. 
 
There is currently no system to find out which beds are available at any given time and no external support to make the bed-finding process efficient. In our experience, weekly published lists are not representative of genuine availability and are quickly obsolete. There is no universal referral form so each referral necessitates new paperwork and often indiscriminate, convoluted processes of speaking to each individual bed manager, night nurses and support staff who do not have the responsibility to admit patients out of hours. A young person with complex problems and behaviours that need careful management is considered too risky for an open ward and so they are refused. Beds alone will not solve this; we need places that can be accessed out of hours with appropriate staffing levels and staff adequately trained to confidently manage the potential risk. 
 
Because of these difficulties in admission, we are concerned that a prolonged wait in an emergency department will become more commonplace and that measures such as the Mental Health Act 1983 will be used to compel young people into admissions as their mental health deteriorates while waiting for a bed, and low-secure units become the default due to their ability to tolerate risk. 
 
We are surprised that there is no centrally produced daily bulletin of national bed states and no provision to make NHS England accessible out of hours to assist with finding a bed. There is an urgent need for a better central system to ensure that vulnerable young people are not left in emergency departments without proper care.

We have recently been involved in a difficult case of a young person who remained in a local emergency department bed for over 90 hours while several specialty registrar (StR) doctors spent the majority of their on-call time attempting, and failing, to find an appropriate available bed. Over the course of this time, at least 40 units were contacted, numerous referral letters faxed and the case was handed over 6 times, all while the young person waited in an unsuitable setting that offered little to meet his mental health needs.
Although this is an extreme case, it reflects the trend we have observed of difficulty in finding beds, especially out of hours, and the fact that bed finding is becoming a major aspect of our on-call time. As Hillen & Szaniecki demonstrated, 1 the majority of referrals are made between the hours of 5 pm and 9 am when daytime services are closed.
We have read with interest the findings of NHS England's Child and Adolescent Mental Health Services (CAMHS) tier 4 report 2 published in July 2014, which reported that the number of NHS-funded CAHMS tier 4 beds has increased by just 136 in the past 8 years, compared with a 284 rise between 1999 and 2006. This means that there were 1264 beds available nationally in January 2014. The BBC have declared this a problem of 'patchy provision' and, based on their findings, NHS England have identified a need and promised 'up to 50 new beds around the country with further beds moved according to need'. 2 While this goes some way to providing more beds, this is only part of the problem.
There is currently no system to find out which beds are available at any given time and no external support to make the bed-finding process efficient. In our experience, weekly published lists are not representative of genuine availability and are quickly obsolete. There is no universal referral form so each referral necessitates new paperwork and often indiscriminate, convoluted processes of speaking to each individual bed manager, night nurses and support staff who do not have the responsibility to admit patients out of hours. A young person with complex problems and behaviours that need careful management is considered too risky for an open ward and so they are refused. Beds alone will not solve this; we need places that can be accessed out of hours with appropriate staffing levels and staff adequately trained to confidently manage the potential risk.
Because of these difficulties in admission, we are concerned that a prolonged wait in an emergency department will become more commonplace and that measures such as the Mental Health Act 1983 will be used to compel young people into admissions as their mental health deteriorates while waiting for a bed, and low-secure units become the default due to their ability to tolerate risk.
We are surprised that there is no centrally produced daily bulletin of national bed states and no provision to make NHS England accessible out of hours to assist with finding a bed. There is an urgent need for a better central system to ensure that vulnerable young people are not left in emergency departments without proper care.

I prescribe, therefore I am?
In their qualitative study, we imagine that Martean & Evans 1 captured the views of the majority of psychiatrists on their experiences of prescribing for personality disorder. Although we could identify with all of the themes determined as reasons for prescribing, we feel that the article highlighted a number of worrying trends within the profession that need to be addressed.
There appears to have been a shift away from a psychotherapeutic approach in psychiatry toward a distinct reliance on prescribing. The authors describe a theme of utilising prescribing as a method of communicating empathy. We would argue that it is disappointing if psychiatrists can only demonstrate empathy through the use of a prescription pad. It would seem that potential harm, in the form of possible serious side-effects, addiction, polypharmacy and indeed overdose facilitated by such a prescription may be more likely than benefit. Primum non nocere would suggest that, in the absence of convincing evidence for prescribing for personality disorders, the responsibility lies with the doctor to examine alternatives.
The authors themselves identify one potential solution in their recognition that 'problems as much or perhaps more than diagnosis may be crucial to explore for patients with personality disorder'. Problem-solving therapy has been shown to improve depression, hopelessness and personal problems in patients who self-harm 2 and has demonstrated specific benefit as a preliminary measure for patients with a personality disorder. 3 Perhaps this may be a useful initial intervention to avoid feeling helpless in such consultations. Longer-term options such as dialectical behaviour therapy and specialised counselling for trauma experienced in childhood allow deflection away from the prescription.
While we acknowledge that treating patients with personality disorders is often challenging, we believe the profession needs to move away from the notion of 'I prescribe, therefore I am'. Ultimately, the increased focus on psychotherapy in the updated curricula of both the Royal College of Psychiatrists and the College of Psychiatrists of Ireland represents a positive paradigm shift in training toward a return to the psychotherapeutic, rather than solely prescribing, role of the psychiatrist. The capacity to attain subjectivity and emotion: the value of continuity of care In a refreshing and thought-provoking editorial, Yakeley et al 1 remind us about the concept of subjectivity. 'Affective subjectivity' is defined as 'the awareness of and reflection on our emotional responses and their influence on our work, and the development of a capacity for self-reflection and emotional attunement with our patients'. 1 The authors list a number of factors that have led to a reduction in the capacity of psychiatrists to develop and use affective subjectivity. One of these is the loss of continuity of care. Over the past 10 years we have seen a gradual erosion of the capacity to offer continuity of care to our patients. Psychiatric teams are now fragmented, specialist and largely separate. This enhances splitting within and between teams and makes it difficult for patients to be held in mind for very long.
When I trained as a house officer and junior psychiatrist in the early 1990s, continuity of care was awarded so much importance across the medical specialties that we worked extremely long hours to offer this. An in-depth knowledge of your patient was expected and great emphasis was placed on personally following up their progress and seeing it through. While the long hours were far from ideal, the pendulum has swung so far back that continuity of care is now largely gone. All too often the concept of holistic care is being replaced by diagnoses and treatment plans, rather than formulations based on the biopsychosocial model, 2 which include affective subjectivity. If a patient is only seen once or twice it is often impossible to expand on developmental and attachment aspects in the history or think about their meaning for the patient, psychiatrist and mental health team.
Without the capacity for doctors to follow patients through, it is very hard to allow subjective feelings to emerge or to use them in the understanding of psychological trauma. I run a Balint-style case discussion group for core trainees in psychiatry. Over the course of the year the barriers to allowing subjective feelings, so well described by Yakeley et al, gradually reduce. For most trainees a deeper understanding of countertransference and how this can help us create an empathic approach to our patients begins to develop. It is frustrating, however, that the majority of the cases brought are not seen again by the trainee. This denies the patient the opportunity to develop a trusting relationship or to experience any kind of attachment (the concept of psychiatric staff as attachment figures is described by Gwen Adshead 3 ). It also denies the trainees the opportunity to use the understanding gained from the case discussion group to help their patient.
If we are to apply subjectivity and emotion in our work, I think continuity of care needs to be revived. This in turn would enable psychiatrists, once again, to enjoy getting to know patients across a period of time using both subjective and objective skills and thus enhance job satisfaction.
It would appear that British psychiatry is retreating to a neurophobic position. 1 The disconnect between psychiatry and its medical foundations is further exacerbated by the lack of medical experience in specialties relevant to psychiatry such as neurology, endocrinology and geriatric medicine. This is related to the constraints placed on training by service provision and the separation of psychiatric and medical services. The Future of Mental Health Services Report, 2 headed by Prof. Dinesh Bhugra in collaboration with the Mental Health Foundation, called for greater collaboration between psychiatric and general medical services.
Elucidating the nature of mental illness and developing effective treatments requires enthusiastic and talented academics and clinicians. Instead of ideological turf wars, collaboration between disciplines is required to appreciate the nuanced interactions between genetics, biochemistry and the environment.
For example, the classical distinction between affective and psychotic experiences is becoming increasingly blurred. The formation of delusions is associated with a 'jumping to conclusions' cognitive bias. 3 This can result in an intolerance of uncertainty and anomalous interpretations of internal or external stimuli. There is renewed focus on the ways in which affective processes can contribute to the formation of delusions and how these mechanisms can be modified using cognitive-behavioural techniques. 4 These insights from cognitive neuropsychology are substantiated by neuroimaging studies. The salience network, an intrinsic large-scale cerebral network, shows strong connectivity between the anterior cingulate gyrus and insular cortex. This network enables switching between different dynamic brain states. Dysfunction in this network has been implicated in the formation of the key symptoms of psychosis: inappropriate salience attached to ambiguous stimuli can predispose to and perpetuate unusual