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5. PROVISION IN LOCAL AND REGIONAL SECURE MENTAL HEALTH FACILITIES AND THE STATE HOSPITAL

5.1 This chapter examines issues relating to provision for prisoners with severe and enduring mental health problems who require treatment in hospital, and highlights issues relating to the involvement of local or regional secure mental health facilities and the State Hospital. It is not an inspection of the hospitals or mental health facilities themselves.

THE FORENSIC MENTAL HEALTH ESTATE

5.2 Generally, hospital wards are categorised as being either high, medium or low secure. A secure ward can exist within a wider hospital context with a number of open wards.

5.3 The only high secure mental health facility in Scotland is the State Hospital at Carstairs. The hospital is part of the NHS, and is currently undergoing a period of transition, with a new hospital being built on the current site. The current capacity is 228, with 183 patients being held. By 2010, the site will have the capacity to hold 144 patients in four hubs of three wards, each with 12 patients. There will be a 12-bed ward for people with learning disabilities. No women will be held in the new facility. This is in line with anticipated demand as a result of changes in the assessment of the level of security required by patients.

5.4 Following a review, the NHS is in the process of creating three separate medium secure units. This is running in parallel to the reduction in capacity being undertaken at the State Hospital. The Rowanbank Clinic is located at Stobhill Hospital in Glasgow. It is currently being commissioned, and, once the full staff complement is in place, will have the capacity to hold 74 adults, both men and women, with a 10-bed admission unit. At the time of this inspection, it was operating at around 35% capacity, and was expected to be fully operational by 2009.

5.5 The Orchard Clinic is part of the Royal Edinburgh Hospital. It opened in 2001, and, at the time of the inspection, held 42 patients.

5.6 A new-build facility is being created at the Murray Royal Hospital in Perth. By 2011, it will have the capacity to hold 35 adults. At the time of the visit, there were two low secure units on the site with 27 patients with 10 in an admissions unit.

5.7 Once operating, the intention is that these three facilities should operate on a regional basis, each covering an area of Scotland. At present, however, there is a need for prisoners to be transferred to a unit where there are beds available. This may mean that a prisoner requiring medium secure accommodation may be located a considerable distance from their family and any community-based workers providing support.

5.8 Some frustration was expressed by staff in both NHS and prison settings with the rate at which new medium secure beds are becoming available.

5.9 There is also a variety of low secure facilities across Scotland, including a private sector unit in Ayrshire. Recent changes to the way in which prisoners are regarded means that some facilities previously accommodating prisoners cannot now do so as a result of being unable to offer sufficient security.

Views on the Adequacy of the Supply of Beds

5.10 Overall, there were mixed views expressed by NHS staff, prison staff and members of the Judiciary, about whether facilities are adequate to meet demand. This varies on a geographical basis, with some areas reporting it to be much more difficult to satisfy demand than in, for example, west central Scotland. The knock-on effect of this is that prisoners have to remain in prison for extended periods of time, in effect, on a waiting list for admission. The State Hospital only rarely has to operate a waiting list.

5.11 It can occasionally be difficult on a case by case basis for NHS staff to identify a suitable bed for a prisoner. The NHS generally operates units at, or near capacity, and this may lead to some delays in admissions. One unit holds two beds in reserve, when possible, for urgent admissions, but clearly, this is not possible everywhere.

5.12 There seem to be slightly greater difficulties in securing places for women than men although this varies from area to area. One unit noted that the women patients typically referred are small in number but "regular" and are therefore well known to staff, and may have been referred both while in prison and in the community. In one area, it was noted that moving women from high and medium secure facilities was a "good idea in principle", but there may not be suitable low secure bed spaces, particularly close to their home area.

5.13 There also seem to be some issues with securing places for young offenders. To some extent this may be practical, in that the suitability of the unit needs to be considered in terms of different legal requirements to those applying to adults. The mix of patients, and particularly the presence of any who could pose a threat to a young person, also limits choice. There is currently no specialist unit in Scotland for under-18s with forensic mental health needs.

5.14 Psychiatrists made it clear that decisions on admission, and the priority given to individual cases, was a matter of clinical judgement, based on the needs of the individual. Staff in a number of hospitals indicated that, if they were unable to accommodate a prisoner requiring admission, they would seek to find a bed in another area, even where this was intended to be a temporary measure.

5.15 A number of prison staff and members of the Judiciary expressed concerns about difficulties in finding beds for prisoners with severe and enduring mental health issues. The main concern was that, with the closure of in-patient beds across the SPS, staff were left with little choice but to locate prisoners in halls, and in some cases, in segregation units. Members of the Judiciary raised concerns specifically about the closure of psychiatric hospital beds in the community.

5.16 The physical condition of units vary, and in some locations, development is underway which will lead to outdated accommodation being replaced.

REFERRAL, ASSESSMENT AND TRANSFER OF PRISONERS

5.17 In terms of the arrangements for transfer, where there is seen to be a need for transfer of a prisoner to local or regional secure mental health facilities or the State Hospital, the first stage in the process will be referral and assessment.

The Processes of Referral and Assessment

5.18 Sentenced prisoners who are thought to require a transfer to local or regional secure mental health facilities are generally identified in discussion at the MDMHT, and by the prison psychiatrist. A referral is made to a hospital with the appropriate level of security required, with an application under the Mental Health (Care and Treatment) (Scotland) Act 2003.

5.19 The circumstances in which a prisoner would be considered for transfer to a hospital included: where he was seen to require further assessment, intensive nursing care, or care and treatment not available within a prison. Other circumstances include: where there is a "rapid deterioration of mental health symptoms"; where a prisoner is causing risk to him/herself or others; or where the prisoner is causing extreme distress to others because of his or her mental health. In the case of the State Hospital, there is a particular focus on situations where a prisoner not only require hospital in-patient treatment or assessment but also presents a high level of risk.

5.20 Prisoners are assessed by a psychiatrist to determine if they require to be held under the Act in a secure environment. The Act requires direct consultation by a psychiatrist preferably from the admitting hospital, including the State Hospital. In some cases this is straightforward where the prison psychiatrist is also the admitting hospital psychiatrist, whilst in other cases assessment by the prison psychiatrist has to be followed up by the admitting hospital psychiatrist.

5.21 Different arrangements apply to remanded prisoners where transfer is arranged through the courts for either Assessment or Treatment Orders under the terms of the Criminal Procedures (Scotland) Act 1995 - Sections 52d (Assessment) or Section 52m (Treatment).

5.22 In most prisons, there had been some prisoners in the last year, who had first been admitted to the prison and subsequently transferred to local or regional secure mental health facilities or the State Hospital. A total of 42 prisoners had been transferred to local or regional secure mental health facilities in this period, with a further five awaiting transfer. In just over half of the prisons there had been prisoners who had been admitted to the prison and later transferred to the State Hospital in the same period. There were a total of 25 such transfers in this period, with a further three prisoners awaiting transfer. Both remand and convicted prisoners were transferred.

5.23 Some prisoners may also be transferred to secure local or regional mental health facilities or the State Hospital, either directly from court, or from prison, via court, where the court has determined that this is required. These patients will tend to go to IPCU admissions, and will be admitted for four weeks as restricted patients. Following this, these prisoners either progress to a treatment order, or will return to court or prison.

5.24 The psychiatrist will also consider the level of security required. It can be difficult to make distinctions between different levels of security required with one hospital suggesting that the use of weapons, the offence, and the mental health condition of the prisoner all contribute to the decision. There is, however, no formal checklist, and the decision rests with the assessing psychiatrist. There is guidance available on the levels of security at various facilities, and psychiatrists will be aware of this in reaching their decisions.

5.25 Most prisoners are transported to hospital by RCS although a small number are transferred by SPS, usually when the requirement is at short notice. If a nurse is required there is confusion around who should provide this resource. RCS are not contractually obliged to provide a nurse, but most SPS healthcare managers believe they are. The situation regarding the provision of nursing support on prisoner escorts needs to be clarified.

5.26 Most prisoners are transported to hospital by RCS, although a small number are transferred using SPS transport when this has to be done within 72 hours.

5.27 Some information is generally provided to the hospital at this stage, although there are gaps in this and also variations in satisfaction.

Referral, Assessment and Transfer Issues

5.28 Although the referral, assessment and transfer processes are generally appropriate, a small number of issues was identified. Some related to referral, are:

• There is disagreement about the need for hospital treatment for prisoners with personality disorder, particularly between prison staff and hospital psychiatrists, with some prisons considered by the latter to be making inappropriate referrals and not taking account of the policies of the hospitals concerned.
• There is little provision for people with personality disorder. There is also little constructive discussion between prisons and hospitals on this problem. A senior hospital specialist said "current practice in Scotland is that we will not take people with a personality disorder into a forensic unit".
• In addition to personality disorder, hospital staff stated that, on some occasions, SPS may suggest that other situations required hospitalisation, when hospital staff considered that they did not.
• Some of the prisoners who are referred as potentially requiring hospital treatment would be more likely to be treated as outpatients if they were in the community.
• Some prisoners who should be transferred to hospital may not be identified as such, because they do not "make a noise".

5.29 Some issues related to the assessment, diagnosis or admittance of prisoners are:

• Conditions for assessment vary widely between prisons.
• There can be difficulties with the attitudes of some prisons to psychiatrists coming to assess prisoners.
• Psychiatrists who assess infrequently may be unaware of changes to arrangements, systems and procedures in SPS.
• The previous behaviour of a prisoner in hospital may lead to a refusal of a transfer (although this prison view was not supported by hospital staff).
• Some prison staff believe that assumptions and stereotypes about prisoners can lead to reluctance, in some cases, to admit them.
• Some prisoners who are stable, safe, supported and have the right medication may be left in prison, as may some prisoners who show no change in their presentation, when the hospital considers that there is nothing they can do for them.
• The provision of a secure and safe environment in prison may delay transfer to hospital for care.
• Some issues are difficult to diagnose.
• Drug use can make diagnosis difficult.
• Some secure mental health facilities receive referrals relating to prisoners who require higher security than they can provide.
• There is a lack of clarity about the ways in which an assessment is made about the level of security which a prisoner requires.
• There can be some tension and variation in views of the appropriate level of security for some patients, and whether individual facilities can provide this.
• Where a prisoner requires an assessment by the State Hospital, because of perceived security issues there can be a waiting period for this. There can also be a wait for assessment for private facilities, and, on some occasions, for other facilities.
• Where an assessment is required for a prisoner in one of the national facilities (Peterhead, Dumfries, Shotts, Glenochil, Polmont or Cornton Vale), this can involve substantial travelling for some psychiatrists.
• The process of form filling is perceived to be difficult, and small mistakes, particularly in relation to papers presented to court, can lead to delay.
• There is no mechanism for prisons to disagree with, or appeal against, a decision about whether a patient requires admission.

5.30 Some issues related to the transfer process, including that:

• There is, for some hospitals, a lack of information from the prison on transfer of a prisoner, such as mental health notes; nursing reports, risk assessment and security information.
• Where information is provided on transfer, it is not always felt to be reliable.
• Hospitals may have to admit transferred prisoners out of hours, and this can cause difficulties in relation to the regime and medication.
• If a nurse is required on prisoner escorts there is confusion about who should provide this resource. RCS staff are not contractually required to provide a nurse, but most SPS healthcare managers believe they are.

TREATMENT, INTERVENTION AND OTHER SUPPORT IN HOSPITALS

The Nature of Treatment, Interventions and Other Support in Hospitals

5.31 In most of the hospitals visited, the number of prisoners formed a very small proportion of the total patients, although this was slightly higher in the medium and high security facilities.

5.32 These patients have access to a range of treatment, interventions and other support which is usually the same as that available to any other patient, and includes:

• Assessment, followed by structured intervention.
• Medical treatment and input from psychiatrists.
• Psychological therapies, including CBT.
• Support from psychologists, social workers and occupational therapists.
• Support with substance misuse problems.
• Activities and recreation.
• Access to rehabilitation.

Separation and Restraint

5.33 Most of the hospitals make no distinction between prisoners and other patients, with one exception where it was suggested that prisoners require a different approach because of drug and security issues. In most cases prisoners are not systematically separated from other patients, with only one hospital saying that it would try to keep prisoners separate where possible. A number of hospitals are able to remove a prisoner to another room for "time out" and a small number use "locked seclusion" when required.

5.34 Physical restraints are used when necessary. Where these are in use, there is a focus on de-escalation, and the use of restraint is subject to strict rules. It was stressed that mechanical restraints, handcuffs or loose canvas restraint jackets would not be used. One hospital noted that a nursing assessment was required any time that thumb and wrist locks were used. The use of rapid tranquillisation was also noted.

The Involvement of Patients and their Families/Advocacy

5.35 Patients are usually involved in identifying their needs and planning their care. The means of carrying this out vary, but is sometimes part of the overall Care Programme Approach. The level of patient involvement overall is developing, with a policy emphasis on a patient-focused approach. One hospital noted meeting with prisoners once a week in the IPCU and others suggested that prisoners can attend some meetings relating to their care. One suggested that the level of involvement tends to vary depending on the stage which patients are at, with admissions patients asked to participate only at the end of a meeting, whereas settled patients can attend whole meetings in some continuing care wards.

5.36 Unlike prison, advocacy was available in all of the hospitals visited, and some hospitals have an advocacy service on-site. One hospital also identified that advocacy was available via a Freephone number that patients could dial at any time. Patients are usually asked whether they wish advocacy, and this is well-used. One identified regular group meetings between advocacy workers and patients, which was considered successful and positive.

5.37 There is also a clear emphasis in most of the hospitals on family involvement, with families and carers often invited to become involved in treatment and care, although take-up varied. One hospital, which has an ethos of family involvement, has a home liaison nurse working with families. One of the hospitals also contrasted the visiting arrangements with those in prison, with more visits being permitted in the hospital setting. One voluntary sector organisation, however, noted that there can be practical problems with visits in the State Hospital, and one hospital suggested that their policy on child visiting is stricter than in prison.

Issues and Problems with Treatment, Interventions and Other Support in Hospitals

5.38 There was general satisfaction with the treatment, interventions and other support available in hospitals, and a number of prisons reported positive relationships with particular facilities. Similarly, some prisoners reported very positive experiences of specific hospitals. Some of the reasons given include: better access to work, groups and therapeutic activities; more knowledgeable and qualified staff; less reliance on medication; less stigma and a more positive approach to mental health problems. The staff to patient ratio was also much better in hospitals than in prisons.

Gaps in Provision

5.39 Although there was a range of forms of treatment, interventions and other support offered in hospital, there were also some gaps. These gaps include:

• A lack of provision for prisoners with learning disabilities.
• A lack of provision for prisoners with personality disorder or severe behavioural difficulties with a variation in views about whether hospital treatment should be available to people with a personality disorder as their sole diagnosis. Although they can be detained in hospital under the Act, the practice in Scotland is not to do this. Prison-based staff consider however, that some prisoners in this group should be in hospital. ¹⁷
• A lack of provision for women, particularly women who are pregnant.
• A lack of age-appropriate provision in some hospitals for young people.
• Difficulties in securing places for prisoners in some catchment areas.
• A lack of provision for people who have physical health problems as well as severe and enduring mental health problems.
• General difficulties, in some instances, of finding hospital beds available at the appropriate level of security; difficulties about where people go when hospitals will not take them; and difficulties in moving people on.

The Nature of Current Provision

5.40 There were very few issues raised in relation to the nature of current provision, but these are:

• There is a potential tension between the need for advocacy to be independent and the hospital's responsibility to provide it.
• Prisoners and other patients can get different amounts of money, with one hospital identifying that prisoners get "pocket money" of £12-15 per week, whereas other patients get benefits of around £90 per week. This can lead to difficulties, with prisoners aware of the differentiation.
• Provision of treatment in a hospital far from a prisoner's home area can lead to loss of local links.
• Financial issues can impact on the placement of a prisoner, with an example given of a disagreement about the distinction between learning disabilities and mental health problems. This centred on who was responsible for providing a place and meeting costs.

The Nature of Hospital Experiences

5.41 Prisoners' experiences of hospital vary, with a number clearly believing that hospitals are more appropriate to their needs than prison, and preferable, for a number of reasons. Some, however, prefer to be in prison. A small number of issues and problems were raised with the nature of prisoners' hospital experiences, including that:

• Some hospitals' attitudes to prisoners are seen as "wary", with the suggestion that they may "... forget that prisoners are people and that there is more to prisoners than just offending".
• The length of what is perceived as "custody" could increase as a result of transfer to hospital. Some prisoners expressed concern about the impact on their liberation and preferred a time-limited period.

Staffing, Information and Other Resources

5.42 As with prison provision, some issues were raised relating to staffing, information and other resources in local or regional secure mental health facilities and the State Hospital. The main issues identified relate to:

• The availability of beds.
• One prison noted that the lack of hospital beds and the "undesirable" nature of the individuals led to a high proportion being treated with anti-psychotic medication and provided with support in prison until they could function again.
• A lack of specialist forensic intervention in one hospital.
• A lack of sufficient sessions available for the provision of support to prisons by the visiting psychiatrists.
• Difficulties with some aspects of hospital accommodation, which could constrain provision ( e.g. recreation).
• A lack of information at some stages in the transfer process and a lack of ongoing dialogue with prisons.

RETURN TO PRISON

5.43 Although many prisoners are released directly from hospital, some are returned to prison prior to their release. Some hospitals feel it could lead to a deterioration in an individual's mental health. However, there are circumstances when it might be necessary including: where a prisoner goes to hospital for an assessment and returns to prison; where a facility cannot contain a prisoner; where a prisoner has been on remand in a hospital and is then sentenced to prison; and where an illness is time-limited and the hospital is certain that a person will be well. Return to prison has to be agreed by the Scottish Ministers and prisoners should be returned to the prison they came from, unless there is a strong reason for not doing so.

The Process of Return

5.44 When prisoners are returned to prison, there is generally a process of discussion and information sharing between the prison and the hospital. This is largely satisfactory, and in some cases is very good. The processes did appear to vary between prisons and hospitals, however, with differences in local practice.

5.45 In some cases, staff from the prison are invited to a case conference prior to a prisoner's return, with relationships in these cases being very positive. One hospital identified undertaking a process of developing management plans prior to prisoners' return to prison, which proved successful with some people, and stated that returns would be part of the overall Care Programme Approach. This type of face-to-face contact does not happen in every case, however, and there are instances of information sharing being undertaken in other ways, such as by letter or telephone. A number of prisons also receive medical information from the hospital about work undertaken and a written clinical assessment or discharge summary.

5.46 Once back in prison, the prisoner may have some contact with a visiting psychiatrist, and one hospital provides some outreach work where someone has not completed their treatment.

Issues Raised with Return to Prison

5.47 A small number of issues were raised with the process of return to prison, including that:

• Where a remand prisoner has been in hospital there are some concerns that disposals can be made by a court which are against the recommendations of the psychiatrist.
• One hospital noted that RCS would handcuff people in the ward in front of everyone when taking them back to prison or court, a practice seen to be inappropriate and upsetting both for the prisoner, and other patients.
• There is variation in views between some NHS staff and RCS, in terms of the RCS risk assessment. Some NHS staff suggest that this provides a much higher level of security than is necessary.
• Although prisoners should return to the establishment from which they came, one prisoner was transferred to a different prison within four days.
• There can be a lack of nurse escorts, and a lost opportunity for verbal handover.
• It can be difficult for an organisation working with a patient in hospital to follow through with support in prison.
• There can sometimes be a delay in the provision of written information to the prison or, in the case of a small number of prisons, a perceived lack of information.

CONCLUSIONS

5.48 In terms of the processes of referral, assessment and transfer to hospital, the main conclusions are as follows:

5.48.1 Prisoners diagnosed with severe and enduring mental illness and requiring transfer to hospital may wait longer than similar people in the community. The problem may be more acute for young offenders.

5.48.2 Although the referral, assessment and transfer processes are generally appropriate, a small number of issues were identified relating to referral; some to the assessment, diagnosis or admittance of prisoners for assessment in prison; difficulties in diagnosis; some tension and variation in views of the appropriate level of security for some patients; and some to the transfer process such as a lack of information and practical difficulties such as the provision of nurse escorts and timing of delivery of prisoners to hospitals.

5.48.3 In most hospitals, the numbers of prisoners form a very small proportion of the total patients, although this is larger in the medium and high secure facilities. These patients have access to a range of treatment, interventions and support, which are generally the same as that available to any other patient.

5.48.4 Hospitals generally are clear that patients would be involved in identifying their needs and planning their care. Unlike prison, advocacy is available in all of the hospitals visited, and some hospitals have an advocacy service on-site.

5.48.5 There is general satisfaction with the treatment, intervention and other support available in hospitals, and a number of prisons report positive relationships with particular facilities. A small number of issues were raised in relation to hospitals' involvement with prisoners.

5.48.6 There are some perceived gaps in provision: a lack of provision for prisoners with learning disabilities; people with personality disorder and women; a lack of age-appropriate provision; and some geographical and general gaps. There is a small number of issues with current provision and some issues with the nature of prisoners' experiences in hospital. As with prison provision, some issues were also raised relating to staffing, information and other resources in local or regional secure mental health facilities and the State Hospital.

5.48.7 Although some prisoners are released directly from hospital, some are returned to prison prior to their release, although this is very rare. Where prisoners are returned to prison, there is generally a process of discussion and information sharing between the prison and the hospital, and this is largely satisfactory. A small number of issues were raised with this, such as the nature of RCS's approach to risk management, the timing of the return to prison and, in a few cases, information issues.

5.48.8 A number of concerns was raised about the specific situation of prisoners held in hospital who are liberated following a court appearance, in circumstances where a psychiatrist would recommend that further assessment or treatment is required.

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