CONSULTATION ON FORENSIC MENTAL HEALTH SERVICES
1.HDL (2006)48 on Forensic Mental Health Serviceswhich was issued in June 2006 (and is attached at Annex A for ease of reference) set out our assessment of the needs for the future provision at high, medium and low in the secure forensic estate based on the understanding at that time of patients numbers and demand at each level of security.
2.In May 2006 the provisions in the Mental Health (Care and Treatment) (Scotland) Act2003 which allow patients in the StateHospital to appeal against being held in conditions of excessive security were introduced. Around the same time the Forensic Way Forward Group, chaired by Garry Coutts, Chair of NHS Highland, was established to oversee the movement of patients deemed ready for transfer from the StateHospital to suitable provision at regional and local level.
3.Considerable progress has been made in this with the number of patients in the StateHospital currently at around 185 (as opposed to 240 when the HDL was issued). We now also have a clearer picture of the level of need of the different groups of patients needing care in the forensic estate and have therefore reviewed the original proposals in the light of this. We would welcome your views on the assessment we have developed using the new information that is available to us.
Services for Learning Disabilities
4.In June 2006 the StateHospital held 26patients with learning disability and the assessment was that many of them would move on to medium or low secure. The assessed need for beds was 12 at the StateHospital and 16 in medium secure. The paper suggested around 60 beds in low secure in six units across the country (though with some redevelopment of these services, no overall increase in bed numbers).
5.At present there are 20 patients in the StateHospital and the assessment is that by 2009 this will have fallen to 10 or 11 (including 2 patients from NI who will continue to require special security). There is currently no waiting list for assessment for the StateHospital (a change from previously). There are 3 patients in medium secure facilities provided by Northgate Prudhoe NHS Trust (part of Northumberland Tyne and Wear NHSTrust) funded by NSS under the National Service arrangements.
6.It appears that the original projected need of 16 medium secure learning disability beds is still reasonable and that the likely need is between 12 and 16 beds. There is the potential for some patients currently in robust low secure settings to move to medium secure accommodation. That suggests the current planning presumption is correct. GreaterGlasgow Clyde (GG&C) have made provision for 4 beds at Rowanbank with the potential to increase that number to 6.
7.However, it is now considered that the previous presumptions (1) that there might be 2 units; and (2) that they would be co-located with the other LD services should be reviewed:
(1) It is thought that with a projection of 12-16 beds a single national centre (ideally designated and funded as a National Service) would be likely to provide a better quality of care and to better attract suitably experienced staff; and
(2) The physical security measures offered by co-location with mental illness medium secure facilities potentially allows for better care and treatment options.
8.Views are sought on whether a 12-16 bed medium secure learning disability unit could be accommodated within one of the three existing/planned medium secure units (either within the existing bed complement or as an addition) with such a unit possibly being funded as a National Service available to all boards.
9.In addition, we would welcome information about the current arrangements that boards have in place to meet their needs for low secure learning disability beds, particularly where that arrangement is to purchase these from another NHS Board.
Services for Women
10.In June 2006 the StateHospital held 21 women, with a plan to reduce that number to zero by 2009. There has been good progress in doing so and currently only 5 women remain. With further moves to Rowanbank and the Orchard Clinic planned that number will reduce to one patient later this year. This confirms the analysis that there is not sufficient need in Scotland to support the continuation of high secure female beds at the StateHospital and that to do so would give concerns in respect of quality of care and quality of life for patients. It is intended that RamptonHighSecurityHospital, Nottinghamshire, will provide accommodation in the event of any future need for high secure accommodation for women.
11.HDL(2006)48 proposed 8 medium secure beds and 16-24 low secure beds for women. The original proposal was that the 8 beds would form a single specialist unit hosted in Rowanbank. However, the picture has since become more complex. There are currently 11women accommodated in the Orchard Clinic of whom about half would require medium secure accommodation and the remainder low secure accommodation. There are currently no arrangements in place to provide low secure accommodation for women.
12.It is now considered that it may be more desirable for the Orchard Clinic and Rowanbank to offer both medium and low secure accommodation for women though we recognise that there are conflicting clinical opinions. This would reduce the need for transfers from one part of the country to another to access low secure accommodation as part of the step down process. However, there areboth legal and practical issues which need to be addressed if this option is to be implemented. It will be necessary to ensure that the low secure accommodation is sufficientlyseparate from the medium secure accommodation to allow the regulations in relation to safety and security and to appeals against excessive security to be implemented effectively.
13.Current accommodation at Rowanbank and the Orchard Clinic could provide nationally about 20 beds for medium and low secure needs for women. This is a little short of the 8 + 16-24 beds suggested as necessary by the HDL. However, the Covenant Churchill Clinic in Ayr is currently accommodating 11 women patients in low secure accommodation (though they have redevelopment plans which will reduce this to 10). If it is considered acceptable to use private sector provision in this way this would give a total of 30 beds for women in Scotland. This is in the middle of the projected need for beds for Scotland.
14.This would suggest, subject to consideration of locality issues, that the North of Scotland would not require to create low secure facilities, but would, instead, access these through the Orchard Clinic, Rowanbank or the Covenant Churchill. It may be that there is value in exploring a similar arrangement with the Covenant Churchill tothe contract for provision which is being established with the Priory and Huntercombe for eating disorder services. Such an agreement would mean that the Covenant Churchill would hold the risk in respect of under occupancy of beds rather than NHS Scotland. However, there is a risk that, over time, most women from the north of Scotland would be cared for in Ayr which may not be desirable.
15.Views are sought on whether the provision of medium and low secure beds for women should be on the basis on a single national specialist unit or split across the existing units in Edinburgh and Glasgow.
16.View are also sought on whether it is acceptable to use the Covenant Churchill Clinic, Ayrshire, to provide low secure services for women from the North of Scotland and potentially other areas if demand exceeds available places in the Rowanbank and Orchard Clinic?
17.Should the provision for women at low secure be taken out of the Orchard Clinic/Rowanbank figures? While this would leave adequate space within the current numbers for medium secure needs further development would be required elsewhere of low secure beds for women. Views would be welcome on how this might be provided.
Overall Provision
18.Good progress is being made through the Way Forward Group overseeing patients moving from the StateHospital and in particular with a number of patients moving direct to low secure accommodation. The proposals in the HDL were for a total of 120140beds (3040 for Orchard Clinic; 60-70 for Rowanbank; 30 for North of Scotland group (NOSG)). Setting those proposals against more recent discussions gives the following outcome.
18.1The Orchard Clinic has 50 beds, but projects a need for MMI between 30 and 40. 11 beds are currently occupied by women, which means that if the need is at the high end of the scale it is correctly sized, but there is the prospect of under-occupancy as low secure facilities are created;
18.2Rowanbank has 74 beds with an assessed need of 60-70 MMI beds (breakdown: 46/48MMI rehab beds, 10 admission beds, 6 IPCU beds). At present 68 beds are designated for medium secure for women and 4 for LD. Taking account of both of those groups would reduce the available to beds to 62, at the lower end of the current projection. Were LD held elsewhere that would give 66 beds for MMI, in the middle of the projection;
18.3NOSGis currently planning to offer 32 beds against a projected need of 30beds for MMI (and in the context of proportionately higher numbers of low secure beds than in other regions);
19.Views would be welcomed on whether these proposals continue to meet the expectation of NHS Boards for overall provision at medium and low secure. It would be helpful if respondents could set out any specific concerns which they may have about these proposals.
Future planned work
20.The Forensic Way Forward Group along with Scottish Executive and regional chairs will:
20.1continue to monitor patient flow and assess the robustness of the MMI projections. The total figure of 120-140 may be high even taking account of greater use of medium secure for remands or patients in low secure stepping up. The current plans give us around 130 medium secure beds nationally;
20.2consider whether to incorporate the LD unit within existing plans or as an addition to one of the units. If provided as an addition, the likelihood is that 4-6 beds would be sufficient to ensure the figures for MMI are not unduly squeezed;
20.3consider whether the provision for women at low secure should be taken out of the Orchard Clinic/Rowanbank figures. This would leave adequate space within the current numbers for medium secure needs but further development would be required elsewhere of low secure beds for women. Views would be welcome on how/where the low secure might be provided; and
20.4review the position on low secure provision for MMI, particularly in the SEAT (South East Area Team) and WOS (West of Scotland) regions.
Consultation
20.It is within the context of the above proposals and considerations that views are being sought on the proposals for provision for women and for patients with learning disability at medium and low secure.
21.Responses should be sent by Tuesday 18 September 2007 to:
Geoff Huggins
Deputy Director Mental Health
Directorate of Health Care Policy and Planning | Mental Health Division
Scottish Executive
St Andrews House
EDINBURGH
EH1 3DG
Please e-mail responses to: .
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CONSULTATION QUESTIONS
Services for Learning Disabilities
1.Should a 12-16 bed medium secure learning disability unit be accommodated within one of the three existing/planned medium secure units (either within the existing bed complement or as an addition) with such unit being funded as a National Service available to all boards?
2.In addition we would welcome information about the current arrangements that boards have in place to meet their needs for low secure learning disability beds, particularly where that arrangement is to purchase these from another NHS Board.
Services for Women
3.Should the provision of medium and low secure beds for women should be on the basis on a single national specialist unit or split across the existing units in Edinburgh and Glasgow.
4.Is it considered acceptable to use the Covenant Churchill Clinic, Ayrshire, to provide low secure services for women from the North of Scotland and potentially other areas if demand exceeds available places in the Rowanbank and Orchard Clinic?
5.Should the provision for women at low secure be taken out of the Orchard Clinic/Rowanbank figures? While this would leave adequate space within the current numbers for medium secure needs further development would be required elsewhere of low secure beds for women. Views would be welcome on how this might be provided.
Overall Provision
6.Do the proposals set out in this paper continue to meet the expectation of NHS Boards for overall provision at medium and low secure? It would be helpful if respondents could set out any specific concerns which they may have about these proposals.
Directorate of Health Care Policy and Planning | Mental Health Division
Scottish Executive
July 2007
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ANNEX A
HDL (2006)48 FORENSIC MENTAL HEALTH SERVICES
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NHS
HDL (2006) 48
Health DepartmentDirectorate for Service Policy and Planning
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Version 1.1
Dear Colleague
FORENSIC MENTAL HEALTH SERVICES
1.The Forensic Mental Health Managed Care Network (Forensic Network) was established in 2003 to advise on policy and service development in respect of forensic mental health services.
2.The Forensic Network has worked in a consultative way with clinicians, managers, service users and others to develop papers on a range of issues relevant to service delivery. The consultation papers and comments on the papers can all be viewed or downloaded from the web at
3.At the “Beyond Walls” conference on 4 October 2005, Dr Kevin Woods, Chief Executive NHS Scotland, announced that the Health Department would review the outcome of those consultations and identify the elements that would be published as national policy and guidance. This is summarised below.
Policy / GuidanceSecure Care Standards
Conflict Resolution
Liaison between NHS Boards and the Scottish Prison Service / Services for Women
Services for Learning Disabilities
Definitions of Levels of Security
Configuration of Forensic Mental Health Services
4.In addition work has been taken forward by the Forensic Network in conjunction with the Chairs of the Regional Planning Groups on the configuration of forensic mental health services. The agreed Scotland and regional analysis of inpatient beds is set out as Annex A to this HDL and the analysis should guide NHS Boards and Regional Planning Partnerships in the development of local services.
5.There are now clear expectations of the forensic service configuration that is required within Scotland to provide a full range of forensic inpatient services and the level at which those services should be commissioned. Those expectations are set out in the table below.
28 July 2006
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Addresses
For action
Chief Executive, NHS Boards
Chief Executive, The State Hospitals Board for Scotland
Medical Directors
Regional Planning Directors
For information
Chairs, NHS Boards
Chief Executives, NHS Local Authorities
Directors of Social Work/Chief Social Work Officers
Chief Executive, NHS National Services Scotland
Chief Executive, NHS Education for Scotland
Chief Executive, NHS Quality Improvement Scotland
Director, Mental Welfare Commission for Scotland
Chief Executive, Mental Health Tribunal for Scotland
Medical Director, Forensic Network
Royal College of Psychiatrists, Scottish Division
Royal College of Nursing, Scottish Division
British Psychological Society, Scottish Division
Scottish Social Services Council
Scottish Commission for the Regulation of Care
Chief Constables
Crown Office
Northern Ireland Office
Home Office
Scottish Partnership Forum
Appropriate voluntary organisations
______
Enquiries to:
Geoff Huggins
Room 3E.02
St Andrew’s House
EDINBURGH EH1 3DG
Tel: 0131-244 3749
Fax: 0131-244 5076
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Version 1.1
National / Regional / LocalHigh secure male mental disorder
High secure male learning disability
Medium secure female mental disorder
Secure child and adolescent services / Medium secure male mental disorder
Medium secure learning disability
Low secure female mental disorder / Low secure male mental disorder*
Low secure learning disability*
Community services
*though in each case smaller boards may wish to commission services regionally or from other Boards
6.We recognise that even as the forensic estate develops and is better able to provide a range of regionally and locally based inpatient services there will still be patients whose needs can only be met through out of area placements.
National Overview of Patient Flow/Appeals against Excessive Security
7.The Minister has established, following consultation with NHS Chairs, a national overview group to monitor patient flow from the StateHospital to ensure that the system is functioning as it should and that patients are not held in conditions of higher security than is appropriate to the risk that they present. The group is chaired by Garry Coutts, the Chair of NHS Highland and reports to the Minister. The specific tasks of the group are to:
track applications to and decisions made by the Mental Health Tribunal for Scotland
monitor the progress of NHS Boards in acting on decisions of the Tribunal
track the progress in resolving entrapped patient cases (this is the group of patients who we have decided do not need to be held at the StateHospital)
work with and receive reports from the regional groups to ensure that provision was in place for patients should accommodation be required
develop an assessment of the number of patients at the StateHospital who might make a successful application to the Tribunal
consider national commissioning arrangements for places outside Scotland where accommodation is not likely to be available
8.In addition, the Minister has decided that forensic sub-groups should be established by each of the three Regional Planning Groups working under the framework established by NHS HDL (2004) 46. The role of these sub-groups will be to:
continue to develop regional services for forensic patients
monitor patient flow through the system to ensure capacity continues to become available for new cases as they arise