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

PART IV: THE WAY FORWARD

9: PROPOSALS

The specific proposals linked to each of the preceding sections of this report are drawn together in sequence in this part under the associated section headings and sub-headings. The form and content of each proposal is as stated earlier.

PART II: CRIMINAL JUSTICE PROCESS

2. POLICE PROCEDURES

The Service Requirement

Paragraph 2.14 Health boards and local authorities should enter service level agreements with the criminal justice agencies to provide effective and flexible local arrangements for the initial assessment and treatment of people in their charge who appear to be mentally disordered. Procurators fiscal should be involved in discussions as to levels of service. These service agreements should cover:

the use of Section 118 of the 1984 Act ("removal to a place of safety"); the availability to the criminal justice agencies of "duty psychiatrists" and "appropriate adult" services; the facilities and services that can be used for mentally disordered people diverted from the criminal justice system; the provision of specialised accommodation for mentally disordered accused persons who might otherwise have to be remanded unnecessarily in custody; and the specification should address the 3 levels of service to be provided:

(1) emergencies within 24 hours;

(2) urgent cases to be covered within one week; and

(3) routine cases to be completed within 3 weeks.

the specification should also cover the training needs of those who will be required to operate these services on a day-to-day basis.

3. COURT PROCEEDINGS

Multi-disciplinary Assessment

Paragraph 3.6 The psychiatric service provided for each health board’s residents should specify that the courts and procurators fiscal in their area require a promptly delivered psychiatric assessment service to assist the transfer of an accused person to hospital as and when required. Development of a service involving a duty psychiatrist with access to community and hospital resources would be the preferred means. The psychiatrist needs multidisciplinary support from social work, psychology, nursing and housing. The psychiatric service needs to be complemented by a multi-agency network of services.

Paragraph 3.10 A properly co-ordinated procedure for preparing multi-disciplinary assessment reports should be developed in the larger courts as a means of identifying the range of options available for mentally disordered offenders.

Bail Decision-making

Paragraph 3.12 Local authorities and health boards should review the accommodation services provided for mentally disordered persons to ensure that they are not remanded unnecessarily in custody, and that, wherever possible, they can be supported under existing community care arrangements.

4. SCOTTISH PRISON SERVICE

Psychiatric Assessment and Transfer to Hospital

Paragraph 4.7 Prison managers should arrange appropriate accommodation within the prison for psychiatric assessment and prison medical officers should ensure that full medical information on the prisoners being assessed is available to visiting psychiatrists.

Return to Prison

Paragraph 4.8 Service commissioners should require treating responsible medical officers to submit regular progress reports on prisoner patients to the forensic psychiatrist of the Prison and the Scottish Office Department of Health’s forensic psychiatric adviser. These reports should provide an early warning for both the Trust and the prison service of any intention to return the patient to prison so that the necessary care and support can be allocated on the prisoner's return. At the point of return the responsible medical officer should provide the prison and the visiting psychiatrist with an updated report.

The Service Requirement

Paragraph 4.16 The Scottish Prison Service is developing service level agreements with local authority social work departments for the provision of all social work in prison, including that in respect of prisoners with mental health problems. Prison governors will enter service agreements with local health service providers for a psychiatric service which will match the operational requirements of penal establishments. The service level agreements will cover the purchase of appropriate services from health and social work. These agreements will specify the identification and assessment of mental disorders, crisis intervention and continuing treatment on the basis of individual care plans, for those for whom transfer from hospital is either not possible or delayed, and effective programmes of after-care. The service specification should also require a same-day service for emergencies, with urgent cases being dealt with within a week and routine cases within 4 weeks of referral.

PART III: PROVISION OF HEALTH AND SOCIAL CARE SERVICES

6. FUTURE HEALTH SERVICE PROVISION

The State Hospital

Paragraph 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 and irresponsible behaviour which can cause actual damage, injury or real distress to themselves or others.

The Demand for High Security Care

Paragraph 6.8 A national needs assessment will be conducted. This will involve 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.

Health Board Monitoring of their High Security Patients

Paragraph 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 in developing suitable continuing and after care local services to allow these patients to return to their home area as soon as their condition warrants it.

Local Forensic Psychiatric Units

Paragraph 6.15 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 treatment in conditions of lesser security than is provided at the State Hospital.

Paragraph 6.18 The National Health Service Management Executive will lead in ensuring proposals for area or supra-board local forensic psychiatry units are developed by the health boards to be served by them.

Paragraph 6.19 The 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 psychiatry unit should be resourced to provide high standards of in-patient and out-patient follow up care; to enable off-site assessment of patients and to facilitate liaison with the general psychiatric services.

Operation of Intensive Psychiatric Care Units

Paragraph 6.23 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.

The General Psychiatric Service

Paragraph 6.24 Service planning arrangements should bear in mind that general psychiatric services and community support will continue to be required to meet the needs of some of these patients.

Community Services

Paragraph 6.25 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.

The General Practitioner

Paragraph 6.28 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

Paragraph 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 learning 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.

Paragraph 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.

Staff Training

Paragraph 6.35 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.

7. FUTURE SOCIAL CARE PROVISION

Public Safety

Paragraph 7.8 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.

A Local Model

Paragraph 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.

8. SERVICES FOR PEOPLE WITH A LEARNING DISABILITY

Future services

Paragraph 8.7 There should be a joint assessment of learning disability need by health boards and local authorities. Service providers should cater for the majority of offenders with a learning disability who require a comprehensive range of health, education and social work services to meet their needs.

The respective roles of agencies

Paragraph 8.10 Health boards and local authorities should ensure that an individual care plan is prepared for each person receiving a service, which takes a risk assessment into consideration. Services should be provided in the least restrictive environment consistent with public safety. An appropriate adult service should be established, with a register of identified individuals who should receive regular training. Independent advocates should be available for the service users.

The role of service providers

Paragraph 8.13 Appropriate services should be provided for offenders with a learning disability through multi-agency liaison and an assessment of the local need. There should be a range of treatment facilities (eg community, residential and specialised semi-secure or secure, which may be local or national). There should be a recognition that while the majority of offenders with a learning disability will need relatively short-term support, there is a small group who have severe enduring difficulties and will require long-term supervision.