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

7: FUTURE SOCIAL CARE PROVISION

This section deals with the interlocking role of community-based social care services for mentally disordered offenders that complement the health service proposals set out in the preceding section. The emphasis is on joint working between Health Boards and social work authorities to plan and develop their services throughout Scotland.

The Framework of Community Care

7.1 Under the Government’s policy on community care, mental health services are increasingly provided by multi-disciplinary community teams or by other specialised community services. Primary care services also link with the care provided by local authority community care services, which in turn are supported by a range of partners including housing, education and voluntary and independent sector organisations. Most mentally disordered people who have, or are alleged to have, offended are not in hospital but are in the care of health professionals and social work staff in the community.

7.2 Care has to be taken to recognise the distinctive statutory supervision and accountability procedures of criminal justice social work services where the offender is subject to a court order or is on licence from the Parole Board. However, it is for health and community care services to make and fund the provision which would normally be made to a non-offending person with similar mental health needs, for the duration of the supervision, and thereafter. The assessment of the extent of this provision should be carried out by health and community care staff working closely with criminal justice social workers. It follows that there is a need for comprehensive, well-integrated community services which operate in a variety of settings, with sufficient flexibility to respond to individual needs, whether or not the offender is under any form of statutory supervision.

7.3 The Government has taken several initiatives to develop services for mentally disordered people. For example, the Care Programme Approach was introduced in the 1992 Departmental circular "Community Care: Guidance on Care Programmes for people with a mental illness including dementia" (4). A further circular on the Care Programme Approach was issued in 1996. A Mental Illness Specific Grant was also introduced in 1991 to assist local authorities in the provision of social care and has been used to fund projects for this care group. These developments complement local authorities’ general duties under Section 8 of the 1984 Act to provide after care services for any persons who are or have been suffering from mental disorders, and Section 55 of the NHS and Community Care Act 1990 to provide assessment and care management of vulnerable people including those with mental disorder. The Framework for Mental Health Services in Scotland (9) is also relevant.

7.4 Health boards and social work authorities will therefore already be including mentally disordered offenders in their local assessment and care management procedures. The available services and possible development proposals should be identified in a section in their community care plans devoted to this client group and in annual and strategic plans for 100% funded criminal justice social work services. Monitoring of these plans by The Scottish Office will seek to ensure that proper account is being taken of the need to develop these services.

7.5 NHS staff play an important role in contributing to community-based assessments and in the development of programmes of community care. Community care planning teams in developing their joint links between social work departments, housing agencies and health boards should ensure that local psychiatric and psychological services have an opportunity to contribute to the planning process. These links will also assist in the development of a joint approach to assessment and service delivery. Planning for social work services in the criminal justice system should be aligned as far as practicable with planning for community care services to ensure that appropriate access to social care services is available.

7.6 While housing bodies will not be responsible for the provision or management of most accommodation for mentally disordered offenders, they may require to provide or secure the provision of mainstream housing in some cases and manage such housing. Health boards and social work department community care services should collaborate in advance with housing departments and agencies for this purpose.

Public Safety

7.7 According to the guiding principles in paragraph 1.5, mentally disordered offenders should be held at no greater (and no less) security than is necessary. This also applies to the programme of community care for those who do not need to be in hospital. In particular this approach requires:

(a) effective systems to identify and manage individual and changing needs and risks; and

(b) a range of accommodation and other appropriate support, eg day care, home care, respite care, employment training and advocacy/befriending.

7.8 It is essential that the care and treatment of mentally disordered offenders in the community meet the requirements of the criminal justice system and of public safety. This will result in constraints on individual care plans. Some mentally disordered offenders, for example patients on restriction orders on conditional discharge and former prisoners on statutory supervision or licence, are subject to special supervision and will require specific follow-up monitoring. However, their health and social needs are likely to be similar to those of non-offenders with mental disorders and consequently, they need access to a similar range of services. Health and social work services for mentally disordered offenders should be planned and developed parallel to and linked with the general community-based mental health service with special attention to supervision and monitoring where this is needed for public safety reasons.

7.9 Each case must be jointly assessed with criminal justice and community care interests closely involved to determine an outcome which meets the following aims:

(a) safeguards public safety;

(b) delivers any statutory requirements (such as probation, etc);

(c) meets the needs of the offender in a way that is likely to reduce offending behaviour.

In the majority of cases there are no special forensic needs arising from the offending behaviour. Decisions about the provision of local services must therefore take account of the need to cater for mentally disordered offenders, and for ensuring that they gain access to them. All mentally disordered offenders, especially those who require services that take account of their "special needs", should be provided with a properly co-ordinated programme of specialised care, treatment or supervision and effective multi-disciplinary pre-release planning undertaken before discharge from hospital or release from custody. In all cases service provision is tailored to meet individual needs while ensuring that public protection is a key consideration.

7.10 Criminal justice social work has a statutory responsibility to supervise orders made by the courts and by the Parole Board on offenders, who may suffer from mental disorder, in accord with national standards on throughcare. Depending on the assessment of needs and risks and the agencies involved, day-to-day case management may be undertaken by a community care specialist, but the criminal justice social worker must retain oversight of the order and responsibility for enforcing it. In effect, the supervision requirement may be seen as a means of securing satisfactory local co-ordination of service plans between criminal justice, health and social care agencies. The main contribution of the criminal justice social worker may be in managing the interface with the criminal justice system and ensuring that any licence conditions are met.

Individual Care Plans

7.11 The Care Programme Approach (4) specifies arrangements for ensuring that people in the community who have severe and enduring mental illness and complex health and social service needs are provided with individual care plans which set out the support and care they will receive. All severely mentally ill people whether in the community or in hospital prior to discharge should be assessed for the Care Programme Approach (4). This applies to patients in all hospitals including the State Hospital.

7.12 Given the need to focus the Care Programme Approach on people with severe and enduring mental illness and complex needs, including some who also have learning disabilities, the approach should not be applied to all mentally disordered offenders. Those who do not meet these criteria would, however, benefit from care management. The principles of a co-ordinated approach and an identified key worker as set out in the guidance on the Care Programme Approach (4) for people with severe and enduring mental illness should also be applied to people with a learning disability who, on discharge into the community, are considered to be at risk of breakdown or re-offending while living in the community. Essentially the approach provides continuity between hospital and community support services. Consideration should always be given in the assessment to whether the patient will require support and supervision by a social worker with specialist mental health training. In all cases where the Care Programme Approach (4) is being followed, consideration should be given to the allocated social worker being a mental health officer.

7.13 Unless detained, a person may discharge himself or herself from the Care Programme at any time. It is therefore important that the key worker named in the Programme should take all reasonable steps to make contact with the person whatever the circumstances, so that the health and community care authorities are fulfilling their requirements to monitor and if necessary act on the person’s behaviour. It is also essential that GPs are kept informed of progress and of any decision on the part of an individual patient to withdraw from the programme.

A Local Model

7.14 Local government re-organisation provided opportunities for building fresh links between the new councils and health boards. Services for mentally disordered offenders require multi-agency working as recommended in the Framework for Mental Health Services in Scotland (9). The health board could act as the base for a local forum to consider the needs of this group. This would provide a source of co-ordinated expertise and guidance for local developments; it would also be able to identify service needs and gaps in provision. The local forum should include nominees from the health board, social work, criminal justice and community care services and housing departments; appropriate voluntary organisations should also be included as well as the police, procurators fiscal and the courts. The forum should communicate directly with both general and forensic psychiatric services in the health board area and also with the services provided for people with learning disabilities. Modernising Community Care — An Action Plan (11) sets out ways in which agencies can work on an integrated basis to secure better results for those who use community care services.

7.15 A senior group should be established to focus on agreeing shared objectives and on setting agreed strategic targets and priorities at a local level; these officers should where possible have the authority to commit their own agencies to action on services for mentally disordered offenders and to resource contributions. Further an operational group should be set up in each area with a mandate to deliver the committed action, to devise practical arrangements for securing collaborative assessments and to develop both service provision and monitoring requirements.

7.16 Some smaller health board areas will not be able to support a viable multi-agency approach to the provision of the more specialised services for mentally disordered offenders. When this is the case, a joint approach with social and health care agencies in adjacent health board areas should be pursued. A minimum scale for such a grouping might relate to a population base of around 600,000. It is of course only a guideline figure and other factors including geography, demographic distribution and the location of prisons will be relevant to the establishment of this type of liaison group.

7.17 As with other examples of community care, the local financing and commissioning implications of joint service provision will play an important part in developing local collaborative effort. Contracting-out and other arrangements must operate in the interests of enhanced patient care and add value to the contributions of individual agencies. A model for these joint arrangements is set out in the paper "Community Care: Joint Purchasing etc for Inter-Agency Working, MEL (1992) 55" (10). Similar working arrangements should be applied for services for mentally disordered offenders.

7.18 Attendance at meetings of the operational group may vary according to the task being undertaken. However, well-defined and agreed arrangements for ensuring that specialised professional contributions will be sought as part of the co-ordinated approach to service provision are essential to the success of this proposed local model.

Day Services

7.19 Access to structured day activities is central to the successful habilitation or rehabilitation of many mentally disordered offenders. These individuals have difficulty in obtaining employment and the day services should enable retraining to take place alongside any continuing rehabilitation or educational initiatives which were begun in hospital. Multi-agency centres, providing "drop in" and timetabled access to psychiatric, general medical, nursing, and social work support, will be particularly valuable. As voluntary bodies will contribute significantly to these day services, both through their own provision and through support to statutory services, their representatives should be involved at the earliest possible stage in the planning process. The Social Work Services Inspectorate has reported on day services for people with mental illness (7). This includes much valuable information on good practice.

Advice and Referral

7.20 While the pattern of services is for local assessment and determination, some level of demand for advice and referral can be anticipated on a "round the clock" basis. This means that in all areas there should be 24 hour access to advice and help.

7.21 It follows that what is needed is an effective local emergency out-of-hours network operated by someone with a list of duty contacts or a standing arrangement. The development of such a service and how it might be organised and financed is clearly a matter for local consideration. Suitable referral points can now be introduced with the aid of modern telecommunications systems and a managed rotation of on-call staff who are trained to deal with these enquiries.

Involvement of Families and Carers

7.22 Another of the guiding principles in good comprehensive service provision is that mentally disordered offenders should be cared for as near as possible to their own homes or families if they have them. Continuing care for offenders following their discharge from hospital or prison can be provided in their own homes if this is in the interests of the individual patient and their carers. This is of course subject to considerations of public safety and victim concerns.

7.23 Consequently there is an important role for patients, their families and other informal carers in the organisation and planning of these services. The Patient’s Charter requires that this should include, where possible, involvement in:

(a) care and treatment decisions;

(b) the running of particular services or facilities;

(c) service planning.

7.24 It follows that patients should become involved in planning their care as should families and carers whenever this is consistent with the patients’ wishes. When a care plan depends on a major contribution from family or other carers, this should be agreed with them in advance. Families and carers will often need to be supported in order to cope with particular stresses and with the practical effects of a family member being subject to a hospital order eg, involving possible lengthy travel to visit the State Hospital. Support for families in the early stages of psychological distress can help to prevent deterioration in personal relationships and reduce the pressures on the offender. Special attention may need to be given to the welfare of any children in the family. In terms of the Children (Scotland) Act 1995, such children will be regarded as children affected by the disability of a family member. As such they will, at the request of their parent or guardian, be entitled to an assessment of their needs in their own right by the local authority.

Voluntary Agencies

7.25 Voluntary agencies are involved in the care of mentally disordered offenders through their activities in the general field of mental health. This ranges from individual support involving advocacy on behalf of patients through to the provision of accommodation by negotiation with housing providers. Community care planning arrangements offer the basis for involvement of social work authorities and health boards along with the voluntary organisations in their area and the opportunity to create links between voluntary bodies, social work authorities and the local psychiatric services. Volunteers can act as appropriate adults in cases where police are questioning persons suspected of having committed an offence or who may have been the victim of an offence and who are thought by the police to be mentally disordered.