Suicides are the second cause of death in teenagers. The number of suicide attempts among children and youth in Poland is growing all the time. According to the Police Headquarters, the percentage of young people in 2020-2023 went up by 150% and at the end of 2023 their number exceeded 2.1 thousand. It means that each day of 2023 in Poland nearly 6 minors took such attempts, one of which on nearly every second day ended in death. Suicide prevention is one of key objectives of the World Health Organisation. In line with the WHO data as much as 90% of suicides were committed by individuals in a depressive mood or state. According to some sources nearly 1 million children and adolescents in our country need support of psychiatrists, psychologists, psychotherapists and other specialists. Therefore it is essential to prevent mental disorders and develop psychiatric care for children and youth.
In 2020-2022, the number of psychiatric services for children and adolescents went up from 1.8 million to 3.8 million and in the first quarter of 2023 it was 1 million. Despite that increase the demand for psychiatric care among children and youth was not satisfied. The waiting queues were growing. From 2020 to 2023 (first quarter), the number of patients waiting for an appointment in a mental health clinic increased more than twice (from nearly 10 thousand to about 20 thousand).The treatment waiting time was getting longer and the percentage of children and adolescents admitted to psychiatric hospitals under emergency procedure continued to exceed 70%.
New model of psychiatric care in Poland
Since the old model of mental health care proved inefficient, in August 2019 the Minister of Health started to implement changes to the system of psychiatric care for children and youth. The new model, which introduced home treatment for young patients, was based on three levels of healthcare: from primary care to emergency services.
Ineffective efforts of the Health Minister
Before implementing the new model of psychiatric care the Minister of Health failed to develop a comprehensive concept of the reform. After four years of implementing the reform the access to psychiatric care for children and youth in different parts of Poland was still not sufficient or equal. In March 2023, in three provinces psychiatric treatment in day-care wards was not available at all.
As early as 2012, child psychiatry was qualified as the priority branch of medicine. Nevertheless, required employment level of psychiatrists was not guaranteed by the end of the NIK audit. Moreover, the shortages in this area were even not defined. In 2020-2022, there was an increase in the number of resident places and persons qualified for the child and adolescent psychiatry specialty. Though, in individual recruitment processes up to 85% of resident places were not occupied. Additionally, the Minister of Health was not familiar with the resources of non-medical staff, i.e. psychologists and psychotherapists. As much as 60% of the audited hospitals which transformed into the new model of psychiatric care had problems with hiring necessary staff.
After 1.5 years from implementing the Support programme for child and adolescent psychiatric wards for 2022-2023 the Minister allocated only about 18% of funds to improve the efficiency of treating young psychiatric patients.
Information about places where children and adolescents may receive support was not popularised properly. Activities to expand knowledge and increase awareness of issues related to mental health of children and youth were carried out only after three years from the reform onset. The Ministry spent over PLN 1 million on the campaign “Say what you feel. Unmask your emotions. Part 2”. It did not, however, analyse its impact on the change in attitudes and the level of citizens’ knowledge.
Changes to the regulations on psychiatric care did not cover issues which were not regulated to date and which were the source of problems in medical entities. For instance, the scope of hospital employees’ rights in terms of searching patients’ personal belongings in psychiatric wards was not defined. Regulations on video surveillance of coercive measures used in these wards by restraining patients in single rooms were also missing.
Key problems identified by NIK auditors were:
- staff shortages,
- insufficient number of mental health entities,
- overcrowded psychiatric wards for children and adolescents (in some cases young patients were refused hospital admission or their beds were placed in corridors; five doctors stepped down in one hospital because of its overcrowding),
- limitation of medical services (e.g. the casualty department in one hospital was closed which forced patients to go to another hospital),
- growing queues, prolonging waiting time (among others due to patients missing their appointments),
- unequal access to medical services,
- illegal use of coercive measures (e.g. in one hospital in Poznań a patient was restrained for over 2 months and the coercion was prolonged 235 times; in three audited hospitals patients were not examined before extending coercive measures by subsequent periods; in one case a patient was lying restrained in a corridor without being screened off from third parties; in two hospitals the coercion order was given by non-eligible persons (doctors who were not psychiatrists),
- improperly made and stored video surveillance records in two hospitals,
- extending the stay of young patients in psychiatric wards without reason (e.g. due to prolonging legal procedures where courts were trying to establish young patients’ legal standing),
- missing or insufficient regulations on conducting patient searches. In one hospital these procedures were carried out in a bathroom, where patients were naked. Also, they had earrings removed from their ears, nose, tongue and other body parts. NIK has pointed out that the efforts to ensure safety may not humiliate patients or violate their dignity. Internal regulations in this area must be legally grounded. Otherwise they represent a breach of constitutional rights and freedoms and of the Convention for the Protection
of Human Rights and Fundamental Freedoms of 1950. Therefore, NIK has recommended settling these issues in the law.
Recommendations
In view of the audit results NIK has made the following recommendations:
To the President of the Council of Ministers to boost efforts aimed at:
- defining the principles of cooperation between healthcare, education and social welfare entities;
- developing the principles of how to smoothly establish legal standing of children and adolescents staying in hospital in a way preventing prolonged hospitalisation for any reason other than medical indications.
To the Minister of Health to:
- define expected and measurable effects of the child psychiatry reform, as well as the schedule of future activities and necessary resources, including human resources;
- strengthen collaboration with other organs and entities to define the principles of cooperation between healthcare, education and social welfare system in coordinating the care of persons with mental disorders;
- continue efforts to promote mental health hygiene, using a reliable evaluation of the efficiency of social campaigns aimed at popularising knowledge about potential use of new model entities and growing awareness of issues related to mental health of children and youth, in terms of their real impact on social attitudes.
De lege ferenda proposals
NIK has requested the Minister of Health to undertake legislative works to settle the following aspects of psychiatric care:
- in the Mental Health Act:
- the scope of powers of hospital employees conducting searches of patients in psychiatric hospitals and the way in which they are carried out so as to guarantee compliance with patients' rights to intimacy and personal integrity and safety on wards;
- video surveillance should be conducted in psychiatric hospitals when using coercion in the form of restraint in single rooms, including isolation rooms, in order to ensure patient safety and standardise practice in this area;
- in the 2001 Act on the psychologist profession and the professional self-government of psychologists:
- the method of documenting the therapeutic process conducted by psychotherapists, also on the commercial market, and the scope of responsibility of psychologists and psychotherapists, e.g. to protect patient rights to documentation concerning the diagnosis and the therapeutic process and its effects.
To medical service providers in particular to:
- adhere to the principles of using and documenting coercive measures upon respecting patient’s rights,
- make sure waiting queues are managed in line with relevant regulations, which includes keeping the waiting register in an electronic form and enabling making appointments electronically and notifying patients about the service provision date,
- hire staff in a required amount of working time.
