Independent Forensic Mental Health Review: final report
This final report sets out the Review's recommendations for change. A summary and easy read version are also available.
8 Recommendations: Sharing information and expertise
High quality care is multi-disciplinary in nature. Professionals from multiple backgrounds, including clinicians and support workers need to be involved in needs assessment, care planning, risk assessment and risk management planning. These assessments and plans should also be developed in liaison with the person, their family and supporting professionals from external agencies. The ability to effectively share relevant information is critical in this endeavour.
There are increasing requests for specialist forensic support from people in the wider health, social care and criminal justice systems who are managing or caring for people with forensic needs. Different decisions are being reached at a local level about how to respond to these needs. This has created instances of inconsistency and uncertainty about such provision across the country. There is a need for more co-ordinated or strategic approaches to sharing forensic expertise with partners.
The Review also heard about training and development needs for staff working in the forensic system as well as those in partner agencies.
8.1 Sharing information about people in forensic mental health services
Existing forms of multi-disciplinary working embedded in forensic mental health services, including multi-disciplinary team (MDT) meetings and Care Programme Approach (CPA) meetings, were consistently highlighted as facilitating good collaboration and information sharing between all the professionals involved in a person’s care. High quality information sharing is also integral to clinical risk management. The interim report highlighted that the different electronic record keeping systems across forensic units and security levels did not support good information sharing. These differences were associated with difficulties, delays and the unnecessary repetition of assessments.
Staff asked for a shared electronic health records system and consistent electronic formats for assessments to support information sharing across the forensic system. It was felt these would reduce the need for duplicating or redrafting assessments, as well as prevent the loss of information when a person moves between different forensic settings. Increasing the ease of access to relevant information in this way could make it easier to access care and treatment in an appropriate setting and help to reduce waiting times. It could also support forensic mental health services to develop protocols for sharing information, where appropriate, with external organisations involved in a person’s management or care. These organisations include generic mental health services, social work and criminal justice services, and third sector community providers.
Recommendation 59: The new Forensic Board should have a single electronic health records system. All staff in forensic mental health services should use the system and the Board should ensure that staff have access to technology of an appropriate quality to support their work.
Recommendation 60: The new Forensic Board’s single electronic health records system should include a facility to clearly record where a person does, and where a person does not, consent to their information being shared with family members and certain partner organisations.
- Clinicians should proactively seek consent to share information with appropriate family members.
- People should be given a regular opportunity to update their wishes about how their information is shared.
Recommendation 61: The new Forensic Board should develop a procedure for sharing information with external organisations to support consistent practices across forensic mental health services that balance the rights of the individual and the protection of the public.
8.2 Provision of forensic mental health expertise to external agencies
There is demand for forensic professionals to share their expertise with other individuals or agencies whose work involves care and treatment and/or risk management of people with major mental disorders and offending histories. This work may involve advising colleagues in generic mental health services as well as external partners, such as agencies in the criminal justice system. In particular, there has been a call for greater input from forensic mental health services into the Multi-Agency Public Protection Arrangements (MAPPA).
8.2.1 Multi-Agency Public Protection Arrangements
MAPPA is a set of arrangements to manage registered sex offenders, restricted patients and people who are assessed as presenting a serious risk of harm to the community. It is made up of four responsible agencies: Police Scotland; local authorities (justice social work services); the Scottish Prison Service; and NHS Health Boards. Each takes the lead for different populations, with health as the lead responsible authority for restricted patients. Restricted patients, however, represent only a very small proportion – approximately 4% – of the people managed under MAPPA.
The clinical service available to the criminal justice agencies in MAPPA and the offenders they manage is inconsistent across the country. Many of these offenders have a primary diagnosis of personality disorder and can find it difficult to access mental health services even when they have secondary diagnoses of mental illness. MAPPA requires input from mental health professionals, particularly clinical psychologists, in order to develop appropriate risk management plans for these people. There is a specific need for forensic mental health professionals to undertake this work because practitioners in generic mental health services do not always feel they have the right expertise for working with people who have offending histories. At present, however, there is no consistent route or resourcing to support the volume of forensic input MAPPA require.
The Review heard from a number of Health Boards that have developed some form of consultation and advice service to ‘plug the gap’ for people with mental disorders and an offending history who fall outside the typical remit of forensic mental health services. Included among these are the Serious Offender Liaison Service (SOLS) at NHS Lothian and the Specialist Treatment Addressing Risk (STAR) service at NHS Greater Glasgow and Clyde. However, such services are not available in all parts of the country, nor do they operate under a consistent remit.
Criminal justice agencies involved with MAPPA have expressed a desire for more consistent access to forensic mental health expertise across Scotland. As reflected in the Review’s interim report, a number of people suggested there should be a national service following models such as SOLS and STAR. There was also feedback that access to a national forensic consultation service would be of benefit to health colleagues working in generic mental health services and in remote or rural areas.
Recommendation 62: The new Forensic Board should develop a consistent way of providing consultation and advice to MAPPA and other external individuals or organisations (including other NHS services) that may benefit from access to forensic mental health expertise.
- The Scottish Government should work with the new Forensic Board to ensure that this consultation and advice service is adequately funded.
8.2.2 Court reports
Provision of psychiatric and psychological reports to the courts are critical to the smooth running of the criminal justice system. Requested by the Crown Office and Procurator Fiscal Service (COPFS) or the courts, these reports inform decisions such as whether to bring a person to trial and the appropriate ‘disposal’ for someone found to have committed an offence. As such, timely provision of reports not only impacts on fair process but also on access to appropriate care and treatment for people accused of offences.
For such a vital part of the criminal justice system, however, there is no national agreed process for the courts or COPFS to obtain psychiatric and psychological reports. There is no agreed fee structure for these reports, no statutory obligation on anyone to provide them and no approved list of providers. This lack of governance has resulted in regional variations and sometimes ad hoc arrangements which are associated with uncertainty and frustration on the part of the courts and COPFS, as well as clinicians. Current practice is also associated with delays that can mean courts fail to meet their own statutory requirements and accused persons have to wait longer to access appropriate care and treatment. The number of reports required by Scottish courts averages in excess of 1000 each year. This is associated with costs of over £555,000.
There is no statutory duty on the NHS to provide court reports and this activity is not included in NHS clinicians’ job descriptions. However, difficulties can occur when courts rely on independent providers, who can lack relevant knowledge of available service and treatment options and be unable to facilitate hospital admissions when required. Independent reports can also negatively impact on a person’s care and treatment as the NHS teams who ultimately take on the care and treatment of the person do not always have access to them. This can lead to assessments being repeated and consequent concerns about practice effects in psychological tests. As such, there was general consensus that court reports would ideally be provided by the NHS.
There needs to be a clear and consistent procedure for requesting reports that allows for equitable provision across Scotland. People suggested this could include a single point of contact to request them, specified timescales for their provision and a more standardised approach to the reports themselves. There were several calls for levels of remuneration to better reflect the cost of provision and for the creation of an administratively straightforward method of payment.
Dame Elish Angiolini’s Commission for Women Offenders report recommended in 2012 that a national service level agreement for the provision of psychiatric reports should be developed between the NHS and the courts, with the aim of increasing access and timeliness of such reports to assist the courts with sentencing decisions. This Review is aware of other scoping exercises aimed at reaching solutions at both national and local levels, which have been conducted since the publication of the Angiolini report, but none have resulted in any changes.
There needs to be a co-ordinated solution to the provision of these court reports and calls for such a solution are not new. Their provision should not be left to ad-hoc arrangements across the country nor impacted by different parts of the public sector having to argue over appropriate levels of remuneration.
Recommendation 63: The Scottish Government should bring together the NHS, the Scottish Courts and Tribunals Service and the Crown Office and Procurator Fiscal Service to agree an appropriately funded national framework to ensure the timely provision of court reports by psychiatrists and psychologists for assessment and sentencing purposes. This should be actioned within one year of the publication of this report.
Recommendation 64: The Scottish Government, together with the new Forensic Board and the relevant criminal justice agencies, should review the current limitations about which disciplines can complete court reports. They should consider what professional qualifications and training are necessary for the completion of these reports, including whether a change of law is required.
8.3 Research, education and training
The forensic mental health community is well supported in its training and development needs by the School of Forensic Mental Health. This is a virtual school hosted by the Forensic Network. It was established in 2007 to address concerns about education and training of professionals in the forensic system, to promote research and to build an evidence base for services. It has developed a suite of ‘New to Forensic’ programmes alongside NHS Education for Scotland, and academic courses in collaboration with the University of the West of Scotland and New College Lanarkshire. It also delivers a range of short courses to meet the training needs of forensic mental health professionals and partner agencies. These learning and development opportunities and the work of the School overall was highly praised by staff working in forensic mental health services.
Some staff working in forensic mental health services felt they lacked the necessary skills to work with certain groups, including older adults and people with learning disabilities as well as other neurodevelopmental disorders. A number of people emphasised that forensic staff caring for people with learning disabilities should have access to training on Positive Behavioural Support and be given the power to implement this approach within their work.
People also felt there was a need for more access to forensic specialist support, training and development opportunities for staff in generic services who may encounter people with forensic needs. People specifically spoke about needing this support in remote or rural areas. They also identified a need for early-intervention training to help GPs pick up early warning signs of people who are at risk of offending due to their mental illness or learning disability.
Criminal justice services said that they do benefit from training from forensic mental health professionals, including via the Forensic Network. But they want more in-reach to support their work with offenders living with mental illness or learning disability. Advocacy staff highlighted that they would benefit from proactive training about forensic mental health issues, rather than ‘waiting until times of crisis’.
Third sector providers play an important role in the safe discharge of people from forensic inpatient services into the community. It was widely acknowledged that the staff working in these community services require good quality training in working with people with forensic backgrounds to support their work, and that a lack of training was linked to the breakdown of support packages and people being readmitted to hospital. There is no systematic training for community providers. One community forensic mental health team described offering it in the past but had to stop. It was not part of their official remit and it had become unsustainable, in part because the high turnover of staff in the support services meant it needed to be frequently repeated. Where such training can be provided, it is valued. One third sector organisation, praising the joint working they have experienced with their CFMHT, also considered themselves ‘very lucky to be provided with training opportunities with one of the Forensic Psychologists within the team’. This all suggests efforts must be made to retain forensically-experienced staff in these third sector organisations.
People spoke more generally of difficulties accessing training opportunities due to limited resources or inflexible shift patterns. Education and training opportunities should be made as accessible as possible. This means that training should be delivered at regular intervals, at times when the most staff can attend, flexibly in small groups, or using online and video-link technology where appropriate.
Recommendation 65: The new Forensic Board must support the work of the School of Forensic Mental Health to continue developing and progressing education, training and research activities within Scotland’s forensic mental health services.
Recommendation 66: Working with the School for Forensic Mental Health and wider stakeholders, the new Forensic Board should set evidence-based standards for staff skillsets and training, that include best practice in caring for and treating people with a learning disability.
- The new Forensic Board may consider the development of a specialist training programme for professionals entering forensic services including shadowing opportunities and rotation through services at different security levels in order to build up an expert skillset.
Recommendation 67: The new Forensic Board should work with community providers and partner agencies to develop skilled staff teams who are confident and empowered to provide support to people from forensic mental health services.
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