Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland.

PART III: PROVISION OF HEALTH AND SOCIAL CARE SERVICES

This section describes the health and social care services for people defined as mentally disordered and who need assessment, treatment, rehabilitation and after care because they have come into conflict with the law. It includes an element of taking stock and illustrates both the complexities and interdependence of the various strands of service provision.

5: CURRENT HEALTH AND SOCIAL WORK SERVICES

HEALTH SERVICES

The General Practitioner

5.1 General Practitioners have an important role to play in early diagnosis and, by intervention and treatment of mentally disordered people, they may reduce the potential for anti-social behaviour and help to avoid offences against the law. GPs are also responsible for the general medical care of offenders who have been discharged from a long-stay mental hospital and consequently can support their rehabilitation programmes. Good practice guidance on the implementation of Care in the Community emphasises the need for effective inter-professional collaboration between the local psychiatric team, GPs and all members of the primary care team. The Care Programme Approach (4) in particular requires the key worker to keep the GP fully informed of adjustments and changes to individual programmes. Guidance to GPs and practice staff on the management of potentially violent patients is being prepared (1998). Effective communication between GPs and specialist forensic and general community mental health teams is essential at all times and especially when the care of the patient transfers from one team to another, ie from a young persons’ team to a team caring for adults.

Local General and Forensic Psychiatric Services

5.2 The general psychiatric service, supported by forensic psychiatrists, provides most of the care for mentally disordered people including those who offend. This service is multi-disciplinary and involves doctors, nurses, clinical psychologists, occupational therapists and social workers at its core. It covers the assessment of mentally disordered offenders; the preparation of reports for the procurator fiscal and for the courts; the acceptance into local hospitals of people diverted from, or sentenced by the criminal justice system, and of State Hospital patients who no longer require such a high level of security; and the supervision of patients, including those subject to restriction orders who are in hospital or who are conditionally discharged into the community. A circular of guidance by the Scottish Office Home Department and the Department of Health will issue in 1999.

Out-Patient and Community Services

5.3 Multidisciplinary teams and out-patient clinics provide support and follow-up for patients in the community. A proportion of these patients will be offenders. A wide range of input is possible, including continuing assessment by the psychiatric team, occupational therapy, psychological intervention and support for the patient and their family. The Care Programme Approach may be formally used to co-ordinate services.

In-Patient Care

5.4 The open door policy in psychiatric hospitals has a long history. However, not all psychiatric patients can be managed in this way. A number of groups have special needs in their psychiatric treatment. These include:

the acutely disturbed who can cause disruption and discomfort to other patients, or may harm themselves seriously and who require short periods of intensive psychiatric care; forensic admissions for assessment and treatment remitted from courts and prisons to the State Hospital. They require a well-structured programme usually in conditions that provide some security. a group of patients with a serious, enduring mental illness with associated behavioural problems. Some of these patients may have had no contact with the criminal justice system.

Many of these patients have been managed locally throughout their illness while some may have spent a period of time at the State Hospital. The clinical teams make carefully considered and planned judgments for individuals undergoing rehabilitation to establish how and when patients are ready and able to assume greater responsibility for their own treatment and behaviour.

Intensive Psychiatric Care Units

5.5 Intensive Psychiatric Care Units (IPCUs) have not been generally regarded as secure but have been used jointly to provide intensive care for acutely disturbed patients and as forensic facilities for offender patients due to the lack of specific alternative accommodation. The units provide modest physical security, for example, lockable reinforced doors and windows, but largely depend for their security on higher than average staffing levels and a skilled nursing input. An IPCU may be a mixed or single sex unit and each nursing charge is usually not larger than 12 patients. They aim to provide adequate space and offer scope for meaningful day and evening activities for the patients. There is increasing tension between the needs of mentally disordered offenders accommodated in this way and those patients requiring acute and intensive care. Referrals and refusals of admission require close monitoring by the service manager responsible for the IPCU in order to ensure that the unit can rapidly accommodate those patients who cannot be managed in more open wards.

Forensic Psychiatric Services

5.6 Forensic psychiatry, which developed as a sub-speciality of psychiatry is the area for inter-action between psychiatry and the law in all its aspects. Forensic psychiatrists are concerned with the assessment, treatment, rehabilitation and after care of patients suffering from a mental disorder including those who offend or who are considered likely to offend. The service also covers some non-offending patients including those who are difficult to manage but whose behaviour is responsive to control and treatment. They provide a tertiary service and can give specialist advice to general psychiatrists and take over the treatment of some of the more difficult patients with behavioural problems.

Secure Provision

5.7 A small proportion of mentally disordered people present sufficient risk to themselves or others to need more secure care. Beyond the IPCUs there have been some attempts to provide low secure care for patients with enduring mental illness. However the only designated secure provision currently in Scotland is that of high security care at the State Hospital, Carstairs Junction. The State Hospital provides for persons who require treatment under conditions of special security on account of their dangerous, violent or criminal propensities, as detailed in the 1984 Act. In Scotland some patients who may only require medium secure care are treated together with those who require high secure care at the State Hospital. (Security at the State Hospital is of a higher level than obtains in the medium secure hospitals in England and Wales and is equivalent to that of the Special Hospitals.)

The State Hospitals Board for Scotland

5.8 The State Hospital, is a high security hospital administered for Scottish Ministers as a Special Health Board. It serves as the Special Hospital for Scotland and for Northern Ireland and accommodates patients admitted under the Mental Health (Scotland) Act 1984 or Criminal Procedure (Scotland) Act 1995 and equivalent legislation in Northern Ireland. The State Hospital can accommodate up to 240 patients. Its ability to accept new referrals is dependent on Health Boards ensuring local facilities and support services are available for the transfer back of those patients who no longer require its special facilities.

SOCIAL CARE SERVICES

Local Authority Services

5.9 The Social Work (Scotland) Act 1968 places a general duty on local authorities to provide for those with social welfare needs, including persons suffering from mental illness, in their areas. Further to this Section 8 of the 1984 Act requires local authorities to provide after care services for "any persons who are or have been suffering from mental disorder". The National Health Service and Community Care Act 1990 (the 1990 Act) gave local authorities the lead responsibility to develop community care plans and assess the individual needs of people for community-based social work services. The Act also introduced a specific grant for the development of mental illness services.

Mental Health Social Work

5.10 Social work authorities have a general duty of assessment and care management of vulnerable people including those who have mental health problems. Social workers play a number of roles in discharging this duty. They may be care managers in community care, criminal justice or children and family social work teams; they may be members of a multi-disciplinary community mental health teams; or they may be in out-of-hours teams or they may work in hospital settings.

5.11 Social work services are available in most general and psychiatric hospitals. Hospital social workers contribute as members of a multi-disciplinary team to patient assessment, treatment and rehabilitation, and work with families or carers. They also play a key part in mobilising community resources and in the rehabilitation process for patients who are being prepared for their return to the community. In addition hospital social workers prepare reports, prior to the removal of special restrictions applied to a patient under the 1995 Act, and may be appointed to act as the supervisor for restricted patients conditionally discharged from hospital.

5.12 A small number of social workers are based in the NHS primary health care service working in health centres dealing with social problems caused by mental illness or learning disability. In these locations they can also provide social care for people when they leave hospital.

Mental Health Officers

5.13 The social work departments of local authorities are required under the 1984 Act to employ Mental Health Officers (MHOs) who are experienced social workers with specific professional qualifications and who have completed an approved training programme. MHOs have a range of statutory duties and responsibilities including contributing to the social work department assessments of mentally disordered people; involvement of relatives in short term detention procedures; applications for long-term detention; consideration of guardianship; and after care.

5.14 MHOs may be placed in any of the settings identified in paragraph 5.10. They must work closely with health professionals and can make an important contribution to work with mentally disordered offenders. MHOs are sometimes involved at an early stage with people suspected of having committed an offence, for example, in assessing people for possible detention under the 1984 Act or in the assessment of someone detained in a place of safety by the police.

5.15 Under the procedures of the 1984 Act, MHOs prepare social circumstance reports for the Responsible Medical Officer (RMO) for persons on a 28 day order to allow RMOs to make judgments about future disposal. They also prepare these reports for the Mental Welfare Commission for Scotland and provide information to the relatives of patients about their rights. They may be involved in the care of a number of mentally disordered offenders who have been placed under guardianship.

Social Work Services in the Criminal Justice System

5.16 Local authority social work departments are responsible for providing social work services in the criminal justice system under the Social Work (Scotland) Act 1968. Since 1991, the main services have been wholly funded by central government. National objectives and standards specify the detailed service requirements. Criminal justice social work services can contribute to the identification, management and treatment of mentally disordered offenders at the following stages of the criminal justice process.

Bail Decision-Making

5.17 There are bail information and supervision schemes currently (1998) available in 2 Scottish courts (Edinburgh and Glasgow). The schemes obtain and check information which can assist the court to decide whether alleged offenders, including those with mental health problems, can be released on bail, with or without supervision.

Diversion from Prosecution

5.18 In some areas, criminal justice social work services have developed diversion schemes in collaboration with local procurators fiscal. A number of these schemes are being funded and evaluated as pilot initiatives. The aim is to divert cases from prosecution where there is sufficient evidence to prosecute but where, on the basis of information provided by the police, the criminal justice social work service, other social work services or health agencies, the procurator fiscal decides that prosecution is not in the public interest and that the alleged offender could benefit from an identified service which would assist him or her to deal with problems which may have led to criminal involvement. Most of these schemes defer prosecution pending the outcome of the diversion initiative. The service which the alleged offender receives may be provided by the social work department or other health and social care agencies. The criminal justice social work service takes the lead responsibility for dealing with referrals, although it does not itself necessarily carry out all aspects of the assessment or provide the full range of services which may be regarded as part of a diversion package. The police report to the procurator fiscal may identify mental health problems as a possible reason for the alleged offending. Such problems are unlikely to be sufficiently severe to warrant action under the relevant mental health legislation but may be amenable to help from both health and social care professionals, eg minor depressive illness, alcohol and other substance misuse, learning difficulties.

Reports for the Court

5.19 Social workers working for the criminal justice social work service prepare any social enquiry report required for the courts. These reports investigate the personal and social circumstances of the offender and examine his/her offending and possible reasons for it. (They are described more fully in paragraphs 3.2-3.11).

Court-based Services

5.20 Criminal justice social work services provide services to the courts. In the busier courts staff may be present in the court and be in a position to provide immediate assistance where necessary, eg checking information, contacting relatives, or alerting a hospital if the situation requires it. (See also paragraph 3.4.). In other courts a service may be accessed on request.

Probation Orders

5.21 Criminal justice social work staff supervise offenders placed on probation by the court. Such orders range in length from 6 months to 3 years. The aim of the order is to prevent or reduce further offending by a combination of control and, where necessary, assistance to deal with problems associated with offending. Additional requirements may be included by the court to help meet these objectives. A significant number of those placed on probation may be experiencing or have experienced mental health problems and, depending on the severity of these problems, the probationer may have received, be receiving or require psychiatric treatment.

5.22 The court can make a probation order with a condition of psychiatric treatment. In these cases the probationer is required to submit to treatment for not longer than 12 months as a resident or non-resident patient. The court has to be satisfied on the evidence of a doctor that the mental condition requires and is susceptible to treatment and that treatment and supervision are available. In certain circumstances, the condition may be varied. The offender must consent to the proposals.

5.23 Criminal justice social work staff are normally responsible for supervising this type of order. They have a particular responsibility to ensure, as far as they can, that the offender attends for treatment and they must provide assistance, support and oversight. Orders of this kind require very close collaboration between the doctor responsible for medical treatment, the supervising social worker and the court. They are usually made where the court and the other professionals concerned consider that the offender does not require to be dealt with under the Mental Health (Scotland) Act 1984 but needs treatment and is unlikely to avail him/herself of it without a degree of oversight and ongoing support. The court may also consider that oversight and support of this kind reduces the risk of harm to others which the offender may constitute if dealt with in the community.

Social Work in Prison

5.24 Criminal justice social work staff based in prisons are required by national standards to give a high priority in their work with prisoners (whether on remand or following sentence) to those identified as being vulnerable, including those at risk of self-injury or with other mental health problems. They may work directly with these prisoners, assist prison staff to develop sentence plans and co-ordinate plans for discharge with the appropriate community-based health and social care agencies including, where appropriate, criminal justice social work services.

Post Prison Supervision

5.25 Criminal justice social work staff supervise offenders who are released on parole or non-parole licence, extended sentence or supervised release order and also offer a voluntary service to offenders discharged from prison. In the case of offenders discharged on licence who have a continuing mental health problem, criminal justice social work staff should be involved in pre-release planning and where necessary negotiating access to appropriate community-based health and social work services.