- 10 Jan 2022
The Independent Review into the Delivery of Forensic Mental Health Services ('the Independent Review') makes 67 recommendations for improvements to how our forensic mental health and key partner services operate and work together. Many of these proposed reforms represent very significant changes to how services work today, some require additional investment and all changes need thoughtful implementation. The Scottish Government welcomes this report and, on 29 October 2021, set out an formal response.
The Independent Review highlighted a range of issues in the way forensic services are planned and operate in Scotland. This includes immediate operational issues such as bed availability, patient flow and transitions as well as more structural issues such as service planning and design.
The potential for negative impacts on patients as described by the Independent Review must be addressed to ensure our forensic mental health services are fit for purpose. We must do more collectively to support those in the system, including improving transitions that may be delayed by reasons of procedural blockages or unit capacity rather than being determined by clinical need.
While the need for change is clear and we are aware that the Independent Review’s recommendations followed extensive stakeholder engagement, the Scottish Government recognises that there remains a range of views on the best way to address these problems. In particular, we note the range of opinions upon the Independent Review’s recommendation for changes to the governance structures for forensic mental health services (recommendation one “creating a single system”). The Scottish Government wants to fully explore the potential implications of this aspect of the Independent Review’s recommendations, and certain other linked recommendations, as part of our approach to implementation of the review.
The Scottish Government is establishing this short life working group (SLWG), including key stakeholders, to propose changes to improve support for planning, collaboration and improvement of forensic mental health services in Scotland.
The Scottish Government emphasises that the SLWG will not revisit the work of the Independent Review. On the contrary, recognising the extensive input to the Independent Review from those with lived experience, carers and professional groups, the SLWG will consider how best to bring forward the change that is needed. Change is essential, for the reasons clearly set out in Independent Review final report.
This SLWG will be strictly time limited, with an expectation of its work concluding in Summer 2022. The SLWG will be focussed and limited in number of members, with a responsibility to engage fairly, broadly and to assess best evidence for a way forward.
By Summer 2022, this SLWG will put forward a proposal for improved governance, strategic planning and collaboration in Forensic Mental Health Services in Scotland. The SLWG in will take account of any work/changes already underway (for example, managing capacity and flow) and how it might impact on options. However, immediate improvement is not in scope for the SLWG and work to improve or deliver services should not be impeded by the work of the SLWG.
The proposal must address the issues highlighted by the Independent Review and which lead to the recommendation on ‘creating a single system’. A breadth of options will be considered. For example, planning and collaboration improvement could be part of an option that does not change accountability.
Creating a single system
It is recommended that a new NHS Board should be created for forensic mental health services in Scotland.
All forensic mental health services, including both inpatient and community services, should be brought under the management of this new Forensic Board.
Forensic learning disability services at high and medium security should also be brought under the management of this new Forensic Board. The Review considers, however, that forensic learning disability services at low security and in the community should remain under the management of, or transition to management by, generic learning disability services (see Section 7.1of the final report of the Independent Review).
The new Forensic Board should not be based in the State Hospital. To do so would be to further alienate and disenfranchise clinicians and managers across the country who already perceive there is significant power, resources and focus sitting inappropriately at the high secure level. The new Forensic Board must demonstrate practical engagement with all of its new service areas. Serious consideration should be given to basing the Board outwith the central belt, or as a minimum not within Edinburgh or Glasgow.
The new Forensic Board will supersede the role of the Forensic Network in providing strategic oversight of the forensic system. However, care should be taken to ensure that the Forensic Network’s valuable role in advancing governance and professional networks within the forensic system is not lost during this transition, and is incorporated into the governance framework of the new Forensic Board where appropriate. The School of Forensic Mental Health should also be retained: its role is discussed further under Section 8.3 (of the final report of the Independent Review).
As part of this work, the SLWG will also consider how best to take forward related, associated and interlinked recommendations of the Independent Review.
- the Independent Review recommends that the definition and purpose of ‘forensic mental health services’ should be reviewed. Working definitions are used at national regional and local level and the SLWG is tasked with proposing a shared definition which would be helpful for planning and operation of services. It is important that the proposed definition is person-centred and contributes to helping people get the services they need, without stigma and discrimination
- the Independent Review recommends services that should be part of a new Forensic Board and those which should not. The SLWG will consider the implications of creating a new board, doing so alongside other potential governance models which may be able to deliver the substance and recommendations of the Independent Review. This will include consideration of consistency, quality assurance and quality improvement as well as what new boundaries may be created by a shared definition and how to best work across these. The SLWG will facilitate consideration of options drawn from comparable specialist health services, international examples and other sectors and industries to determine a recommended model for planning, operating and improving services
- the Independent Review makes recommendations relating to the assessment of need and planning future service provision. The SLWG will consider options for planning and commissioning services that are likely to be small and specialist, especially for ‘specific populations’ such as those with intellectual disability
- the Independent Review makes recommendations on a single electronic record for forensic mental health services, highlighting the role of good information sharing in improving transitions for patients. The SLWG will consider the feasibility and merit of one system and if developed, what its reach should be. This consideration must take into account information sharing protocols with external partners and other NHS services
- the relationship between forensic mental health services and partner organisations (including other NHS services) is highlighted by the Independent Review. This is in terms of: membership of multidisciplinary teams, provision of consultation and advice, transitions between services and in preparing for discharge from inpatient services. The SLWG will consider the options to build capacity and capability for partnership and collaboration beyond forensic mental health services
Governance and membership
The SLWG will collaborate on project documents and will be responsible for setting out a robust improvement methodology for the inclusive design and description of a preferred option for service change and for ensuring that views and other evidence are reflected. For example, proposals for service change will be shared by the SLWG with all those affected by potential plans in order to take account of views and comments before submitting a preferred option.
The SLWG will be will be accountable to Ministers through the chair, Deputy Director of the Scottish Government Mental Health Division and will be supported by Professional Advisors. The SLWG will take an inclusive and consultative approach to the work. This is in contrast to a purely representative model and aims to keep the membership of the SLWG tight whilst conferring a responsibility on the SLWG to honour contributions to the Independent Review and to engage with those most directly affected by proposals for change.
Members can, with the agreement of the chair, send a substitute in their place if they are unable to attend a meeting:
- Mr Gavin Gray, Deputy Director, Improving Mental Health Services – Chair
- Ms Hannah Axon, CoSLA
- Ms Kate Bell, Scottish Government Advisor on Strategic Change
- Mr Jim Cannon, Director of Regional Planning (North)
- Ms Catriona Dalrymple, Deputy Director Community Justice
- Dr Ian Dewar, Scottish Government, Principal Medical Officer (Forensic Psychiatry)
- Mr Gary Jenkins, Chief Executive, The State Hospital and mental health lead for NHS Scotland Chief Executive Group
- Mr Gordon Johnston, Director, Voices of eXperience (VOX)
- Ms Lorraine Keith, National Family Network Coordinator (Forensic) Caring Connections Support in Mind Scotland
- Mr James Meade, NHS Forensic Services General and Service Managers and member from West Region
- Professor Lindsay Thomson, Medical Director, Forensic Network and School of Forensic Mental Health
- Ms Linda Walker – Head Occupational Therapist in NHS Lothian & Allied Health Professional Mental Health Lead
- Professor Angela Wallace, Nurse Director, Forth Valley and chair of the Women’s Pathways Group
- TBC – member - forensic intellectual disability services
- support for the work of the group will be provided and arranged by the Scottish Government Forensic Mental Health Reform Unit
The timeline below will be further developed to take account of COVID-19 and winter pressures and availability of key stakeholders to participate in and contribute to engagement sessions.
- first meeting of the group
- agree terms of reference
- decision on how to engage services, professions, lived experience
- identification of options
- examples from other specialist health services in Scotland
- international examples
- examples from other sectors and industries
- engagement session
- engagement session
- options appraisal
- finalise recommendations and share with stakeholders
- submit preferred option for change