Independent Forensic Mental Health Review: interim report

3 Transfers and transitions

The lack of NHS beds available within the forensic system creates delays in transferring people up and down security levels. The majority of people raised this as an issue and it causes frustration for everyone affected: people receiving care, clinicians and management.

Delays in transfers can lead to differences between 'actual' and 'intended' ward populations. Staff at medium secure units may have to meet the needs of people waiting for discharge to low secure or referrals to high security, alongside people with needs appropriate to that security level. Placing people with diverse needs and levels of acuity in the same ward can have adverse consequences on their mental well-being. The challenge of managing and caring for a mixed population contributes to staff shortages due to stress and illness. Staff shortages were also linked with greater restrictions of people's freedoms because escorted leave and activities may be reduced.

Some staff felt services were prioritising beds for people in their own area. They said this was understandable but that it made it more difficult to transfer people when needed. There was widespread consensus that clarity over referral pathways and processes would support decisions about the appropriateness of referrals. One Health Board said that a national framework for referrals would be helpful.

3.1 Transfers and transitions to NHS secure hospitals

3.1.1 Transfers to conditions of lowers security

A person's transfer to conditions of lower security is a critical time in their care, treatment and risk management. People saw strong joint working relationships as being critical to a successful transition. Variation in provision and bed availability in local low security units causes delays when people are assessed as ready for transfer. The review heard that two of the medium secure units and some low secure facilities are operating waiting lists. However, individual circumstances vary considerably. A small number of people said their transfers happened quickly, while many others spoke of waiting months or years for a place in their local low secure facility.

When transfers to lower security are delayed, people's progress is hampered. They can be subject to conditions of excessive security and are at increased risk of becoming institutionalised or losing motivation. Such practice is also felt to constitute 'over-treatment' and so represent low-value healthcare. In addition, the sense of reciprocity in the system is lost, leaving people feeling they have done all that has been asked of them but then not progressing as they should.

Delayed discharges, which impact on waiting lists in low secure settings, were consistently blamed on a lack of suitable and available accommodation or support packages in the community.

3.1.2 Transfers to conditions of higher security

Staff working in low and medium secure settings reported difficulties or delays in referring people to conditions of higher security. They felt such delays compromise the care and treatment they can provide to that individual and to others on the ward.

Some clinical teams involved in referrals to higher levels of security described the process as 'sluggish' and inconsistent. They suggested that referral criteria varied between units, with one team feeling like they have to follow 'unwritten guidelines'. There was a call for the referral criteria to be reviewed. People said that requirements for multiple assessments took time and that referrals were often refused. One clinician felt that 'pragmatism' had been lost from the system. However, another argued that it was appropriate for decisions that restrict a person's freedoms not to be rushed or made lightly. In one instance, where a referral had been accepted by a unit, lack of an available bed meant more assessments had to be done for a second referral to another unit.

While waiting for transfers to higher security to be agreed, staff felt they had to manage the person's high levels of distress without the staffing numbers or aspects of physical security needed to provide appropriate care and treatment. They felt this placed a strain on everyone on the ward. People with lived experience explained that when additional observations are required for one person, it reduces the amount of time staff are available to provide ward activities and escorted leave for others. They also said it changed the atmosphere on the ward.

There is a conflict resolution system available when clinicians disagree about whether to transfer someone to higher security. People raised questions about its length, cost and transparency. The Forensic Network reported that the full process has only been used twice since 2005. There is also a shortened version of the process that has been used three times.

Two teams highlighted the absence of formal arrangements or practical processes for transferring people subject to civil detention orders between secure settings. One unit explained that the lack of a national contract or process meant they had to 'ring around' colleagues to find out how to do it. As no transport could be identified in Scotland, a secure ambulance was brought up from England.

3.1.3 Transfers between prison and secure hospitals

People in prison can be transferred for mental health treatment in hospital. Prison populations can straddle more than one Health Board. Referring clinicians explained that this can make it difficult to refer people to the forensic system because there are different processes and thresholds for access to services in each area.

Transfers from prison were generally felt to take place relatively quickly, with positive comparisons often made to the time taken elsewhere in the UK. The Forensic Network established a system for monitoring transfers from prisons to forensic mental health services in 2018. By November 2019, the Network had received information on 50 transfers, three women and 47 men. The average time for transfer for urgent referrals was 11.3 days.

Some people did raise concerns about the transfer of women. The lack of forensic hospital beds for women was felt to contribute to difficulties in transferring women from prison when they need secure hospital treatment. This in turn was linked to the number of women remaining in prison despite experiencing complex and enduring mental health problems. There were reports of women who courts had identified as requiring assessment in hospital but who had to return to prison to await a hospital place because no beds were available. One person with lived experience commented on the absence of women in Scotland's forensic system and wondered if this was because they are disproportionately accommodated in prisons.

These concerns align with the findings of the European Committee for The Prevention of Torture and Inhuman or Degrading Treatment when it visited Scotland's prisons in 2018. It found that while transfer to high and medium secure facilities was possible for men in prison, 'for female prisoners the situation [was] entirely different'. They highlighted a number of women who should not have been in a prison environment as they required psychiatric hospital care and treatment. The Committee felt that the absence of a high security mental health facility for women in Scotland appeared to play a key role in decisions to keep these women in segregation in prison rather than transfer them to hospital.^[8]

3.2 Transfers and transitions in the community

3.2.1 Discharge into the community

Conditional discharge into the community is recognised as a high risk transition point. The intense support that people receive in hospitals cannot be replicated in the community. There are different models of community provision across the country offering different levels of support. This means that the approach to transitions from low secure to community services varies significantly between areas. Staff felt people's expectations needed to be managed better around what support would be available in the community as well as how much freedom they would have.

Strong and lasting relationships with professionals, support workers or befrienders can help people gain confidence and familiarity with new environments prior to returning to the community. They also help people to maintain their mental health and reduce their risk of reoffending once there. Staff and family members felt that when discharged people should have integrated support from social and healthcare professionals who know them and who know about the recovery opportunities in the local community. The inclusion of allied health professional (AHP) staff in the CFMHT teams was, for example, seen as supporting smooth discharges and sustainable living in the community by working with people while they were still in hospital to help them establish regular routines and activities prior to moving. Family members stressed the importance of involving the person's own social support system in discharge planning from an early stage.

Staff highlighted the importance of joint working with third sector organisations to support long-term, successful discharges. People need to engage in structured activities as a key part of the discharge process. Staff raised concerns that it is becoming more difficult to access appropriate vocational activities and placements in the community. These are also often time limited, which is an issue when discharge is delayed.

There is no agreed process for managing the discharge of people who cannot return to their original health board area because of victim safety, victim sensitivity or high media profile reasons. As such, negotiation between clinicians, health board managers and local authorities can be lengthy and rely on 'good will and the promise of reciprocity'. It was felt that this was not a fair or appropriate way to manage these situations.

3.2.2 Delayed discharges and their impact

Delayed discharges are frustrating and disappointing for everyone but difficulties in arranging appropriate support packages and accommodation in the community are widespread.

People said that the lack of suitable community accommodation and appropriately trained support staff is leading to some discharges being excessively delayed, sometimes for years. These problems particularly affect people with more complex needs, including co-morbidity or learning disabilities. There is a feeling that no one is taking responsibility for this. As one family member said, 'social work blame the NHS and vice versa'.

Keeping people in hospital after they are deemed ready for discharge can leave them vulnerable to further mental health issues or setbacks. As well as providing rehabilitation, staff are having to find ways of maintaining people's progress and keeping them motivated. They explained how they need to develop interventions to address issues that would not have occurred if a person had been discharged when they were first deemed ready.

Staff in some areas spoke of their frustration when people being assessed for discharge had to then meet additional 'tests' in order to get access to accommodation and support packages in the community. For example, one low secure ward felt that social work services asked for 'testing' of people that went beyond the risk assessment requirements. Another team said it seemed like it was local authorities that were dictating the level of risk. This was seen to be inappropriate and unnecessary because there is 'only so much testing you can do'.

Mental Health Officers (MHOs) complete an Assessment of Needs for community care services as part of the multidisciplinary discharge planning process. People said this is a 'massive' piece of work. A couple of social workers described frustration at having no control over the funding for people's supported accommodation. They spoke of having to apply to different funding lines within a local authority or to one department that considers all requests for supported accommodation, not just those from forensic services. For a small number of people in hospital, it is the criminal justice social worker who is responsible for accessing accommodation.^[9]

3.2.3 Rehabilitation and 'step down' facilities

A number of areas have rehabilitation wards or 'step down' facilities in the community. These support people's progress from low secure, through rehabilitation and onwards to the community. People who have transferred to these facilities appreciated them. Staff in areas with these units see them as valuable assets that can support smoother and more successful discharges. They called for the role of 'rehabilitation' to be formally recognised as a distinct forensic service because it is about 'more than just cooking and waiting for a house'.

3.2.4 Moving between forensic and general services

There are challenges moving people between forensic and general mental health services. It was felt that the pathway for leaving forensic services is not well defined: a number CFMHTs described difficulties moving people back into general mental health services. One member of staff spoke of feeling that they had to 'jump through hoops' to do so. Although some people do move to CMHTs over time, others never leave forensic care. Difficulty discharging people to CMHTs was felt to put additional pressure on the capacity of CFMHTs. However, some teams also keep people on their caseload even after they have transferred to general services, so they can easily return to forensics if required.

There was a sense that general healthcare professionals do not have consistent access to training about forensic services and that stigma around the 'forensic' label can exclude people from accessing CMHTs and general health resources. Staff talked about feeling responsible for trying to demystify 'forensic' care to help prevent people being kept inappropriately within forensic services. The stigma can also be a barrier to people in the community accepting help from this service when it is offered. One person described their initial worry about transferring to 'forensic' from general mental health services. Once in forensic services, however, they felt they received improved care, including more intensive support when unwell, which had prevented them returning to hospital. They reported that their family also felt much more supported.

It was suggested that people under multi-agency public protection arrangements (MAPPA) who have mild to moderate mental health problems, or people assessed as 'at risk' of offending but who do not meet other criteria, can struggle to access the mental health services they need in the community. There are concerns that these groups can miss out on provision because they are seen as 'not risky enough' for CFMHTs but 'too forensic' for CMHTs.

3.3 Role of Scottish Ministers

People in hospital under a compulsion order with restriction order (CORO), a hospital direction or a transfer for treatment direction are subject to special restrictions. For these 'restricted patients', particular stages of their progression need to be agreed by Scottish Ministers. This includes transfers between hospitals or authorising any leave from hospital. The steps required to get these agreements are set out in the Scottish Government's Memorandum of Procedures (MoP). Clinical teams reported using similar procedures for non-restricted patients (minus the need to seek Ministerial approval).

These procedures were often blamed for delays in people's progression or seen to be incompatible with person-centred care. Some of these concerns seemed to be based on a lack of understanding about the degree of flexibility that the MoP permits. For example, one team complained that the MoP was the reason people recalled from the community had to be admitted to medium secure facilities. The MoP does not state this and the expectation is that conditions of lower security would be more appropriate. There can, however, be delays in reaching decisions when the required professional reports are not submitted to the Scottish Government or do not include up-to-date information. For example, the review was told of one instance in which a clinician had resubmitted a previous year's report without changing any details including the date. Ongoing communication between clinical teams and the Scottish Government was felt to be important to support efficient decision-making at key points in the process.

The MoP is a complex document. The Scottish Government is working to revise and update it to make it more user-friendly, while ensuring it continues to both meet the needs of the people it supervises and maintain appropriate public safeguards.

Advocacy felt that there should be more transparency around the Scottish Government's involvement. One person queried whether the Scottish Government was best placed for this role in the risk management of restricted patients.

3.3.1 Transfer of 'SUS' plans

Many people in low secure wards spoke of losing existing plans for authorised leave when they transferred from medium secure units. These plans are called 'SUS' plans as they authorise a suspension of a person's detention in hospital. People spoke of having to be 're-tested' in the new setting in order to regain freedoms they had previously earned elsewhere in the forensic system. This is frustrating. One person in low security said that it can takes months after being transferred to 'get back out again'. People spoke of feeling like they were going 'backwards' or like they had 'not achieved anything'. One person felt that this re-testing was because the culture in forensic system is overly risk adverse.

In response to the same issue being raised by the Mental Welfare Commission in 2017,^[10] the Scottish Government issued guidance to all Responsible Medical Officers setting out how a person's SUS plan could be considered for transfer from medium to low security. This flexibility within the system was not well known among people with lived experience or some staff. Indeed many people receiving care identified allowing SUS to transfer as the most important change that the review could recommend. The review met only one person who said their SUS plan had transferred with them.

Professionals across the system acknowledged these frustrations. They agreed that reducing SUS plans for a significant period of time can be detrimental to a person's mental health and motivation. However, they explained that they do also need some time to understand a person's presentation and risk issues after transfer.

3.3.2 Discharge planning processes

Some clinical staff and people with lived experience felt that the pre-discharge process for people on COROs could be streamlined. The review's attention was drawn to the MoP's expectation that people need to undertake four months of overnight stays, building from one night per week up to four on a monthly basis. Some felt this was not responsive enough to individual needs and left some people 'treading water'. The requirements also leave beds empty on wards for significant periods of time. One person with lived experience did say that they had benefitted from this staged approach because they had been in hospital for a long time.

A number of people raised concerns that housing benefit is not available at the earlier stages of the overnight testing process. This risks people getting into debt at this critical point in their rehabilitation.

Some clinical teams wait until the successful completion of the four month staged overnights before applying for a conditional discharge tribunal. The Scottish Government issued guidance to Responsible Medical Officers about the process for requesting an expedited Tribunal hearing. If the requirements are met, a hearing can take place within six weeks of the staged process ending, instead of 12 weeks.

3.4 Other issues

There was a general feeling that there could be better communication between tribunals, MAPPA, local forensic teams and others involved in people's care and treatment. It was suggested that some procedures rely too heavily on written documents sent through the post and face-to-face meetings at predetermined intervals and that this can delay people's progression. People felt more use could be made of electronic communication methods such as email or video links to facilitate meetings. People also recommended streamlining discharge processes, including identifying appropriate accommodation and meeting MAPPA requirements.

People with lived experience gave examples of other ways in which time had been added to their stay including: a change of consultant; a person being recalled taking their place in the lower secure setting; the closure of the ward they were due to go to; and the correct paperwork not being submitted.