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

6: FUTURE HEALTH SERVICE PROVISION

The overall policy and guiding principles set out in Part I provide the framework for proposals on the future provision of health services for mentally disordered offenders. The section deals first with the national level and then examines the provision of locally-based services as a key factor in the strategy. This section should be read in conjunction with the provisions of the Framework for Mental Health Services in Scotland (9).

6.1 Application of the guiding principles necessarily leads to a patient-centred service which delivers care at the lowest appropriate level of security as close to the patient's home as their medical condition and personal circumstances allow. They also require that the service should develop on a sound local basis and should be readily accessible to patients from mainstream psychiatric hospitals if required.

6.2 Alongside the question of resource constraints, two factors need to be taken into account:

(a) the geography of Scotland is such that for some patients from widely dispersed rural communities the appropriate specialist treatment has to be provided at a distance from their homes; and

(b) for all mentally disordered offenders, treatment considerations must be viewed in tandem with the need to protect the public.

NATIONAL LEVEL - HIGH SECURITY CARE

The State Hospital

6.3 In considering the role of the State Hospital, successive Governments have chosen not to establish medium secure facilities in Scotland but have instead concentrated investment on facilities at the State Hospital which have provided suitable economies of scale. The State Hospital has become a centre of expertise in forensic psychiatry offering a comprehensive range of treatment facilities. The Government is satisfied that the case for a single high security establishment remains valid.

6.4 The concentration of services of any degree of security on one site does limit the range of treatment options for patients who need a decreasing level of security as they recover from the acute phase of their illness. Local forensic services have developed to a varying extent in different parts of Scotland from within existing budgets for mental health services.

6.5 The present arrangements also mean that:

the State Hospital regularly comes under pressure to take referrals for which there appears to be no alternative local provision; and when State Hospital patients are ready for transfer, there can be a reluctance on the part of some local services to accept them because of a perceived lack of appropriate local services, leading to lengthy delays in their transfer which may cause distress to patients who may have worked very hard at their own rehabilitation.

6.6 The State Hospital will continue to act as the national centre providing high security services for patients with mental disorders (including learning disabilities) who are likely seriously to threaten others on account of their dangerous, violent or criminal propensities, and whose condition is characterised by actions outside the normal range of aggressive or irresponsible behaviour and which can cause actual damage, injury or real distress to others.

The Demand For High Security Care

6.7 Applying the Glancy (5) and Butler (6) "norms" to the aggregate population of Scotland and Northern Ireland leads empirically to a requirement of some 200 beds at the State Hospital. More recently, evidence from the needs assessment carried out in England (1) indicates an overall level of demand of between 150 and 200 beds for Scotland and Northern Ireland. Other assessments are underway (1998).

6.8 A national needs assessment will be conducted involving representatives of all relevant agencies including the State Hospital, health boards and Trusts, the Scottish Prison Service, the criminal justice agencies and local authorities. As the State Hospital provides a high security care service for Northern Ireland, the Northern Ireland Office will also be involved to establish that country's continuing need.

6.9 Co-ordinated assessment is necessary to inform decisions on capital and other financial allocations. The NHS Management Executive will be responsible for co-ordinating and maintaining this assessment of the need for national high security services. However, pending the results of the proposed national needs assessment, and the full operation of a complementary local service, it is assumed that the State Hospital services should continue to aim to meet demand for around 200 patients.

6.10 Services to carers, prisons and other hospitals should be such that local forensic psychiatric opinion is sought as soon as it is considered that a referral to specialist care may be appropriate. The need for a State Hospital opinion or referral will be decided where appropriate. This allows knowledge of local facilities and services to be involved in the decision and has been shown to lead to improved patient care and continuity of care in the long term, and to prevent unnecessary admissions.

Health Board Monitoring of their High Security Patients

6.11 The State Hospital Medical Sub-Committee regularly reviews each patient's case to confirm that their circumstances require their continued treatment at the State Hospital. Indications are that around 50 of the existing group of patients may not need such a high level of security if adequate alternative facilities and local support service networks were available in their home areas.

6.12 Health boards should become more closely involved in monitoring the progress of patients from their area accepted into the State Hospital from the Courts or the prisons or referred to the State Hospital from local hospitals and should develop suitable continuing and after care local services to allow these patients to return to their home area as soon as their condition warrants it.

6.13 By entering service agreements with health boards, the State Hospital will ensure that the boards retain interest in these patients while they are being treated in the State Hospital. The agreements will include a specification that no patient should remain in the State Hospital for more than 3 months after clinical agreement between the State Hospital and local services that the patient’s needs no longer justify high security care. Health boards and local authorities will therefore include a matching requirement in their overall service specification.

6.14 The NHS Management Executive will monitor the effectiveness of these service agreements and take action with any health board where patient transfers out of the State Hospital appear unreasonably delayed.

LOCALLY-PROVIDED SERVICES

Local Forensic Psychiatric Services

6.15 In line with the Framework for Mental Health Services in Scotland (9) The Scottish Office believes that health boards should organise a range of in-patient facilities from general psychiatric to more specifically forensic, short and longer term and a range of community options with general psychiatric provision with more specialist forensic care in terms of both staffing and buildings. Each board’s response will be appropriate to local needs and may involve for other responses to local health needs, joint arrangements with other boards. The concept of the "managed clinical network" (as described in the Acute Services Review Report (12)) is relevant; it implies a formal relationship between components of a service, based on standards of service, quality assurance and a seamless provision of care. Some NHS Trusts in Scotland are developing alternative lockable facilities, separate from their IPCU accommodation, designed to deal with patients who either need a decreasing level of security on their return from the State Hospital, or who need longer-term care and treatment but not in a unit where there is a high level of noise and disturbance. Experience in Scotland and elsewhere has shown that the security of patients is partly governed by the availability of well-trained and highly motivated staff and by access to facilities which engage patients in structured day time activities. The development of supporting local forensic psychiatric services should meet the demand in Scotland for suitable placements for returning State Hospital patients, and also provide, where appropriate, services to local courts, prisons and psychiatric services. It is proposed that health boards should investigate the need for a structured development of local facilities and services to provide for mentally disordered offenders from courts, prisons and returning from the State Hospital, who require assessment and treatment in conditions of lesser security than is provided at the State Hospital.

6.16 Small units suitably located throughout Scotland have the benefit of being locally-based and also integrated with local services including prisons. However, the more "medium secure" end of the spectrum of low to medium security requires a larger unit with its associated range of clinical staff and should be better able to provide the required range of services to patients by drawing upon a substantial pool of expertise and experience. In turn this would facilitate treatment at varying security levels and allow the specific needs of all patients within the group to be addressed. A larger staff grouping also helps to promote effective peer group review and clinical audit; it also generates more effective multi-disciplinary teamwork with resulting benefits for both patients and staff. An important feature of the management of care in such forensic psychiatric units will be the gradual calculated reintroduction of patients to taking responsibility for their own decisions. While this process will inevitably mean giving more choice and freedom to patients and some associated risk-taking by both patients and their therapists, it will be done against a higher basic level of security and staffing than is currently available locally.

6.17 The requirement to balance optimum unit size against the need for local services is recognised. In Scotland there needs to be a geographical distribution of these units to provide a reasonably accessible service involving close links with local services and bearing in mind also that different security requirements may apply in different areas. The staff-intensive treatment regimes required by the target group of patients indicate that units should be commissioned for multiples of around 12 patients. Good space standards and therapeutic facilities in such units are also essential to generate satisfactory performance. The staffing provision of all forensic psychiatric units should include occupational therapist, clinical psychologist and social work complements, the latter to assess the social care needs of patients and to play a key role in the co-ordination of plans for their resettlement in the community. The Scottish Office view is that 4 or 5 such units will be required, including in that number those already established in Perth and Aberdeen.

6.18 A small number of providers will deliver this forensic in-patient psychiatric service on an area or supra-board basis. The new facilities when available should reduce or remove the current requirement for forensic and other difficult patients having to mix with and live alongside more acutely ill and disturbed individuals and create a more stable and secure environment for patients, staff and the public. They will only be successful in conjunction with a range of local forensic general and community services as described. Such local general forensic and community services will be required to support the local position in all health board areas, and not only those in which the new units are established. (See paragraphs 6.30-6.34, and 7.16.) The NHS locally should determine appropriate staffing levels in the light of local needs. The Royal College of Psychiatrists recommends that in-patient forensic units of this type should have a consultant to patient ratio of 1 to 12-15 patients. The National Health Service Management Executive will ensure that proposals for area or supra-board forensic psychiatric units are developed by the health boards to be served by them along with a full range of local forensic services.

6.19 The contribution of experienced staff will be crucial to the development of these new facilities and should be utilised wherever possible. Supra-board forensic psychiatric units should be associated with existing forensic mental health services, bearing in mind the locality of prisons, especially remand prisons. The availability of this type of unit will improve the treatment options available to certain non-offender patients, for example, violent or difficult to place patients, whose needs are different from those of the more acutely ill patients normally considered appropriate for an IPCU. Local and supra-Board forensic services are tertiary services and should be accessed only via the responsible consultant forensic psychiatrist. Services should include in-patient facilities for medium and long-stay care, in conditions similar to those specified for IPCUs or dedicated learning disability units, for patients returning from the State Hospital, remanded and transferred from court and transferred from prison plus some general psychiatric patients requiring similar care. The local forensic psychiatric services should be resourced to provide high standards of multi-disciplinary in-patient and out-patient follow up care; to enable off-site assessment of patients and to facilitate liaison with the general psychiatric services. The consultant forensic psychiatrist in each case will ultimately be responsible for the admission decisions on individual patients.

People With Personality Disorders

6.20 The management and care of persons with a personality disorder can present particular problems alongside the care of other mentally disordered patients. People with a personality or psychopathic disorder are not a homogeneous group for whom established social, penal or medical treatment techniques have proved successful. People with personality disorder who offend are usually dealt with by the criminal justice system. Disposal, whether to prison or hospital or in any other way, will depend on the circumstances of the individual case.

6.21 Where there is doubt about diagnosis of a patient convicted of a serious offence, an interim hospital order, under the Criminal Procedure (Scotland) Act 1995, may be made to allow for further assessment or treatment for a period of up to 12 months. A recommendation may then be made for a hospital order if a treatable mental illness is considered to be present. Increased use of the interim hospital order procedure will give scope for psychiatric reports to be compiled which contain, for the benefit of the court, specific recommendations on the appropriateness of a hospital disposal. For those offenders who are convicted and sentenced on indictment but who are also mentally disordered, a hospital direction is now available so that when it is considered by the responsible medical officer the patient no longer needs to be detained in hospital for treatment, the patient may be transferred to prison.

6.22 Consideration of the disposal and wider management of personality disordered offenders will be taken forward separately by the Committee set up under Lord Maclean to examine the sentencing and treatment of, serious sexual and violent offenders, including those with personality disorders.

Operation of Intensive Psychiatric Care Units

6.23 Experience within the National Health Service in Scotland has demonstrated that the IPCU model works well for the client group for which it was designed ie short term acutely disturbed patients with behavioural problems directly related to psychiatric disturbance. Mainland health boards should continue to ensure appropriate local IPCU provision for the acutely mentally ill. There should be local needs assessment to determine the size of the service - a 12 bedded unit (or multiples of 12 or less) with generous space provision and levels of nurse staffing is the recommended IPCU model for acutely mentally ill patients.

General and Community Psychiatric Services

6.24 The needs of the mentally disordered offender should be met on clinical grounds bearing in mind the protection of the public. It will often be appropriate for general psychiatry services to be involved either right from the start or after a period in forensic care. The forensic services need to work in tandem with general psychiatry services, in a parallel and interlinking way. This will ensure that the mentally disordered offender is cared for by the right person in the right place and also that there is no inappropriate blockage of the forensic service. Service planning arrangements should bear in mind that general psychiatry services and community support will continue to be required to meet the needs of some of these patients.

6.25 The principles of good mental health care, including access to care in the community, should apply to mentally disordered offenders cared for by the general and forensic psychiatric services. At some suitable point in their treatment, many of these patients will either return to the community or, if they are forensic patients, be transferred back to the care of the general psychiatric service or other specialists, although a small number may need to remain under long term forensic care. Health boards should specify the close liaison required between the general and forensic psychiatric services and the State Hospital to allow patients to be integrated into the provision of out-patient and outreach services.

6.26 A number of patients in local hospitals and the State Hospital recover sufficiently to leave hospital. These patients are offered a placement under their home area's community care arrangements as close to their home as appropriate in the individual circumstances of each case. It is the joint responsibility of the patient's health board and local authority social work department to commission this form of care and to ensure that sufficient specialist residential provision is available to accommodate those ready to leave local hospitals. A key issue to be addressed in making this provision is that of public safety. Well-resourced after-care teams will be required for intensive follow-up of patients previously assessed to be high risk in the community.

Community Psychiatric Nurses

6.27 The management and support of many patients in the community has been shown to improve with the support of community psychiatric nurses or community learning disability nurses and wherever possible plans should be made to incorporate their contribution into the care of mentally disordered offenders. These nurses may assist in training police officers to identify and interview mentally disordered people; they may visit offenders in their home, be involved directly in group therapy sessions and may also take part in assessment visits to offenders in prison and courts. These nurses may also become key workers for some mentally disordered offenders.

The General Practitioner

6.28 The general practitioner may reduce the likelihood of delinquent or offending behaviour by the early identification, intervention and treatment of an underlying mental disorder. GPs also play a vital role in maintaining the rehabilitation of offenders released from prison or discharged from hospital and consequently they should have ready access to appropriate advice. The role of the general practitioner in relation to the multidisciplinary psychiatric team may be very specific to the needs of the patient, for instance, in focusing primarily on the patient’s general health requirements. In this regard, health boards should specify the level of inter-professional collaboration necessary to meet the needs of GPs and primary care teams. Advice should be readily available to GPs on the management of potentially violent patients.

Health Board Responsibilities For Service Development

6.29 Just as the need to maintain an effective national facility at the State Hospital is recognised, there is also a need for health boards to develop a database recording the appropriate services for people with a mental disorder whose normal place of residence is within their catchment area, and taking into account those in prisons and elsewhere in NHS care. There will also be occasions where a Board must accept responsibility for a non-resident patient, for example, because the onset of the problem behaviour took place in their area or because the caring relative is resident there.

6.30 Plans for treating mentally disordered offenders should be prepared in the context of the Framework for Mental Health Services in Scotland (9). Where a health board’s plan is judged unsuitable, the National Health Service Management Executive will require that board to submit within 6 months of being requested to do so, their proposals for the care of people suffering from a mental disorder and who have offended or are considered likely to offend. These proposals will also cover some non-offenders detained in the State Hospital, IPCU or dedicated disability unit, and those patients who have had to remain in intensive care units longer than 3 months. Patients who are unmanageable in local wards because of aggressive, disorderly, irresponsible or anti-social behaviour beyond the ordinary level of resources and skills of the mental health service and who can be expected to be a hazard or danger to themselves or others, should also be included.

6.31 The detailed specification for this local service will cover integrated multi-disciplinary assessment, treatment, rehabilitation and after-care service for mentally disordered offenders, and those non-offender patients with similar needs. It will ensure that patients have the same liberty, rights, autonomy and choice as any other member of the community within the constraints of the law and their potential danger towards others or themselves.

6.32 The broad principles on which local services will be based are as follows:

(1) all arrangements should seek at all times to reduce the risk of offending behaviour consequent upon mental disorder and thereby to afford protection to the public;

(2) service provision and delivery should be designed to meet the individual needs of patients, and patients who are clinically judged to require the high security of the State Hospital should continue to be located there;

(3) the service should be delivered flexibly and comprehensively to respond to the individual needs of patients, and should be specialised in order to attain the level of expertise required to implement individual treatment programmes effectively, providing out-patient, day-patient and community care where appropriate in addition to in-patient treatment;

(4) multi-disciplinary working methods should be adopted to ensure the most effective management, assessment and treatment of patients and support to other agencies;

(5) as continuity and consistency of care and treatment are essential, as far as possible the same team of local professionals should be responsible for the service to an individual throughout their care as an in-patient and subsequently in the community;

(6) close liaison should be maintained with the State Hospital on the care required to facilitate the earliest appropriate return of patients from each Board's catchment area.

(7) close liaison should also be maintained with prison services to ensure prisoners with mental illnesses requiring in-patient care are transferred to hospital.

6.33 Within an agreed framework, health boards and Trusts should work towards a number of specific objectives:

at local level a specialist service which works in tandem with the general mental health service and works closely with the criminal justice system; and management of the system so that the needs of patients and the requirement to protect the public are given equal consideration; suitably secure local and area forensic psychiatry accommodation for patients who have severe and enduring forms of mental illness associated with difficult and dangerous behaviour and for offender patients who require specialist services; specialist forensic community services for those who require such services, and onward referral to other agencies for those who do not; the earliest return of appropriate patients from the State Hospital to local services and the transfer of mentally disordered offenders in prison to hospital facilities where this is required; regular evaluation and review of service delivery in the context of changing needs and developments.

6.34 The psychiatric service planned by health boards should also require the development of a comprehensive service involving good working relationships with the State Hospital.

From a managerial and clinical point of view there is a need to ensure:

that no patient is admitted to the State Hospital without prior assessment by, or discussion with, and agreement of the local forensic psychiatric team; that local clinicians and managers are involved in monitoring the progress of patients in the State Hospital; that periodic multi-disciplinary case conferences are instituted for each patient; that reports for the State Hospital on patients eligible for outward transfer are produced in good time; that the assessment of patients in the State Hospital should be carried out within 3 weeks of the request to the local psychiatric team and transfers, if agreed clinically, should be accomplished within 3 months; that trial leave provisions should be made in appropriate cases; and that a range of facilities are made available as appropriate to patients on transfer from the State Hospital, including general and forensic facilities, in hospital and the community.

The health boards’ specification of these objectives should be in measurable terms. Performance indicators and outcome measures should be incorporated into the commissioning, provision and delivery of the service.

Staff Training

6.35 Clearly specified training levels agreed between health board and NHS Trusts enable staff to feel more confident in managing their duties and responsibilities. It can also lead to a reduction in day to day incidents and in the need for crisis measures, including the isolation of patients. In terms of training, teaching and research, collaboration between the State Hospital and local forensic services provides broad development of expertise, for example, through mutual exchange of consultant sessions. Professionally accredited nurse training schemes and exchange visits should be designed and developed by a joint working group involving senior staff from forensic psychiatric nursing in the local services, the State Hospital and university institutions.