Inpatient Census 2019: parts one and two

6. Patients receiving Forensic Services (additional detail)

• 488 (15%) patients in the 2019 Census were receiving Forensic Services
• Patients receiving Forensic Services are mostly males of working age
• 4 out of 5 patients receiving Forensic Services were either Overweight or Obese as at the 2019 Census

Forensic psychiatry is a specialised branch of clinical psychiatry which relates to mentally disordered offenders and others with similar problems. For the purpose of the analysis contained in this section, forensic patients were identified if NHS Boards indicated "yes" to the following Census question: is the patient being managed primarily by forensic services?

There were 488 patients primarily managed by Forensic Services in the 2019 Census. This is an increase on the 475 patients reported in 2018.

It should be noted that NHS Greater Glasgow & Clyde, NHS Lothian and NHS Tayside contain Forensic Regional Units which provide services to patients from other NHS Boards. NHS Fife also provide a low secure Learning Disability (Forensic) Regional Unit for the treatment of patients from other NHS boards. The State Hospital (a Special NHS Board), provides a National Service (including for Northern Ireland).

Table 15: Number of forensic patients by NHS Board, 2014 – 2019

NHS Board	2014	2016	2017	2018	2019
NHS Ayrshire & Arran	*	*	16	18	19
NHS Borders	0	*	0	0	0
NHS Dumfries & Galloway	0	*	0	*	*
NHS Fife	31	34	39	35	39
NHS Forth Valley	20	*	*	*	*
NHS Grampian	42	42	40	41	37
NHS Greater Glasgow & Clyde	128	122	119	123	119
NHS Highland	*	*	*	*	*
NHS Lanarkshire	19	15	20	25	28
NHS Lothian	65	47	56	51	72
NHS Tayside	65	55	64	62	49
NHS Western Isles	0	0	0	0	0
State Hospital	121	117	111	108	109
Scotland	507	458	484	475	488

* Suppressed due to small numbers

Age and Gender

The vast majority of patients receiving forensic services are working age males. Male patients made up 89% of all forensic services patients in the 2019 Census, 4 percentage points lower than 2018. Only 9% of forensic patients are aged 65 and over.

Figure 11: Working age males made up 85% of all forensic patients in the 2019 Census, while males in general made up 89%
Psychiatric, Addiction or Learning Disability Inpatient Beds, NHS Scotland, Forensic Patients, 2019 Census

Ward Type

Most forensic services patients were treated in a forensic ward, 409 (84%), of which 55 were in a learning disability ward. A further 24 (5%) of patients were in a dementia ward, while 17 (3%) were in an intensive psychiatric care unit.

Ward Security Level

There were 179 (37%) patients receiving forensic services in a low security ward in the 2019 Census. A further 124 (25%) were in a medium security ward, while 109 (22%) were in a high security ward. Only 4% were in a general psychiatric ward, compared with 71% of all mental health, addiction or learning disability patients.

Specialty of Consultant

A total of 449 (92%) patients receiving forensic services were seen by a forensic psychiatrist. There were 24 (5%) patients being seen by a consultant whose specialty was "Psychiatry of Old Age".

Length of stay in hospital

Patients receiving forensic services tend to have longer average (median) lengths of stay. The average (median) time since admission at the 2019 Census for patients receiving forensic services was just under two and a half years. This compares with non-forensic services patients who had an average (median) admission time of three months.

Table 16: Average (median) length of stay for forensic and non-forensic patients, 2019

Group	Average (median) number of days since admission	Approx. number of years / months
Forensic Services Patients	896	2 years, 5 months
Non-forensic Services Patients	100	3 months

Of the 488 patients receiving forensic services in the 2019 Census, 370 (76%) had been in hospital for over a year. Only 17 (3%) patients had been in hospital for less than two weeks.

Table 17: Banded length of stay for forensic patients, 2016 – 2019

Banded days since admission	2016		2017		2018		2019
Less than 2 weeks	10	2%	13	3%	13	3%	17	3%
At least 2 weeks, less than 1 month	10	2%	15	3%	*	*	10	2%
At least 1 month, less than 3 months	23	5%	36	7%	*	*	21	4%
At least 3 months, less than 6 months	49	11%	34	7%	43	9%	33	7%
At least 6 months, less than 1 year	45	10%	58	12%	43	9%	37	8%
At least 1 year, less than 5 years	202	44%	203	42%	226	48%	234	48%
5 years or more	119	26%	125	26%	114	24%	136	28%

* Suppressed due to small numbers

Health and Wellbeing

Mental health morbidities

NHS Boards returned diagnosis codes (ICD-10) for any mental health condition for which patients in the 2019 Census had a diagnosis. Of the 481 patients receiving forensic services for whom diagnosis information was returned, 197 (41%) had 2 or more mental health conditions. This compares to 24% for all adult patients.

The most common condition for patients receiving forensic services was schizophrenia, with 298 (61% of all) patients having this condition. This is higher than the 28% reported for all adults. Likewise, patients receiving forensic services are much more likely to have a personality disorder, 1 in 4 forensic patients compared to 1 in 10 for all adults in the Census.

Figure 12: Certain mental health conditions are more prominent in patients receiving forensic services compare to all adults, for example Schizophrenia (61% compared to 28%)
Psychiatric, Addiction or Learning Disability Inpatient Beds, NHS Scotland, Forensic Patients, 2019 Census

* All mental health diagnoses are based on ICD-10 codes. Primary and secondary diagnoses included
** Personality disorders and autistic spectrum disorder counts also rely on respective questions on these disorders
*** Patients may have more than one diagnosis

Physical health co-morbidities

A total of 261 (53%) patients receiving forensic services had at least one physical health co-morbidity based on the suite of Yes/No physical health questions (see page 23) as at the 2019 Census. This is lower than the 59% reported for all adult patients, though forensic patients tend to be younger which may account for this finding.

The majority of patients receiving forensic services who had a physical health co-morbidity had only one condition (47%). The most common physical condition for patients receiving forensic services was diabetes, 81 (17%) followed by dyslididaemia (14%).

Figure 13: The majority of patients receiving forensic services with a physical health co-morbidity had one long-term physical condition, while 5% had 4 or more
Psychiatric, Addiction or Learning Disability Inpatient Beds, NHS Scotland, Forensic Patients, 2019 Census

Physical Health Check

The majority of patients (90%) receiving forensic services who were admitted within the last year received a general physical examination. A similar proportion (91%) admitted over one year ago had received an annual physical health check.

Overall, in the 2019 Census, a total of 441 (90%) forensic patients with returned information (1 was missing) received some form of physical health check, slightly lower than the 92% reported for all adult patients.

Lifestyle factors

BMI (Body Mass Index)

BMI (Body Mass Index) was calculated for forensic patients where height and weight information was returned. Some patients were excluded because height and weight were extreme outliers (<10 forensic patients). A total of 231 (48%) patients receiving forensic services were obese, while 155 (32%) were overweight. This means that 4 out of 5 forensic patients are overweight or obese compared to 3 out of 5 for all adult patients (excluding eating disorder wards).

Smoking, alcohol and other substance misuse

This section contains analysis of patients with alcohol dependence and/or substance misuse based on responses for a combination of questions. A minor methodological change was made in 2017 (see Section 8 for further detail).

A total of 138 (28%) forensic patients smoked tobacco in the 12 weeks prior to the Census. This is 1 percentage point higher than 2018, however it is lower than the 36% reported for all adult patients.

In the 2019 Census, 147 (30%) of forensic patients had a dependence on alcohol / harmfully used alcohol. There were 20 forensic patients with an alcohol related ICD-10 code. The proportion with a dependence on alcohol / harmfully used alcohol is similar to previous years and continues to be higher than for all adult patients (21%).

A total of 164 (34%) of forensic patients had abused substances (excluding alcohol) in the four weeks prior to their admission. There were 61 patients with a drug related ICD-10 code. The proportion who had abused substances (excluding alcohol) is 2 percentage points lower than 2018 though it continues to be much higher than for all adult patients (18%). The most commonly used substance was cannabis (63% of forensic patients using substances), followed by amphetamines (16%).

Self-harm

Information on self-harm was returned for 431 (88%) of forensic patients. Of these, 57 (13%) had self-harmed in the week prior to admission. This is 4 percentage points lower than 2018. Of those 57 patients, the majority (84%) had self-harmed by non-accidental injury. Patients can self-harm in more than one way.

Suicidal ideation

Information on suicidal ideation was returned for 458 (94%) forensic patients. Of these, 14 (3%) had expressed suicidal ideation on admission to hospital, similar to 2018. This is much lower than that reported for all adult patients (11%).