1.1 Background to the review
In March 2019, the Minister for Mental Health announced an independent review into the delivery of forensic mental health services in Scotland. Derek Barron, Director of Care at Erskine, was named Chair of the review later that year in May.
Forensic mental health services specialise in the assessment, treatment and risk management of people with a mental disorder who are currently undergoing, or have previously undergone, legal or court proceedings. Some other people are managed by forensic mental health services because they are deemed to be at a high risk of harming themselves or others under civil legislation. The review was set up in recognition of changes and developments in the delivery of these services over a number of years. The changes include a decline in the number of people detained in levels of high security at the State Hospital, the development of medium secure services, the introduction of appeals against conditions of excessive security and plans for a secure National Adolescent Secure Inpatient Service for Scotland.
The review's remit and purpose is set out in its terms of reference which can be found at Annex A: Terms of Reference. Under these terms, the review has to consider the following parts of the forensic mental health system:
- Strategic direction, ongoing oversight and governance arrangements;
- Demand, capacity and availability across the forensic secure estate;
- High secure provision;
- Community forensic mental health services;
- Forensic mental health services and the justice system; and,
- Forensic mental health services for client groups with particular needs.
The client groups named in the terms of reference are: people with a learning disability or a neurodevelopmental disorder; women; children and young people; and older adults.
The review is supported by a secretariat team that started work in July 2019 and three working groups that were established over the summer of 2019. Over 60 people are on these working groups, from more than 45 organisations. Together they represent: people with lived experience of forensic mental health services; their relatives, carers or representatives; organisations commissioning, delivering and monitoring forensic mental health services and those providing support services; staff-side and professional organisations; and organisations involved in legal and court proceedings.
The review is expected to make some recommendations for change. These will be published in its final report, which was originally expected in June 2020. The review was suspended from 17 March until 20 July 2020 to allow the Chair and its working group members to focus their efforts on responding to the COVID-19 pandemic. The review now expects to publish its final report in January 2021.
1.2 Background to this report
The review opened with a 'listening' phase. This was to give as many people as possible the opportunity to share their experiences of forensic mental health services in Scotland.
The review provided two ways for people to share their views. Firstly, people could respond to the review's formal call for evidence which ran from 14 October 2019 until 31 January 2020. Responses could be made online, by email or over the phone. The review received 103 responses to this call: 56 were from organisations and 47 from individuals. The organisations that responded are listed at Annex B: Responses to call for evidence.
Secondly, the Chair met face-to-face with people. He visited 10 secure hospital sites between August 2019 and January 2020. The Chair met with groups of people with lived experience, their family members and members of staff to hear about their experiences and understand the range of services being delivered. In total, 88 people with lived experience, 16 family members and 188 staff shared their views during these visits. Advocacy workers helped to amplify the views of people with lived experience at a number of these meetings. The Chair also met with some people individually and spoke at a number of conferences. He had a meeting with one staff team via video conference in July 2020 because a visit to their hospital site was not possible due to COVID-19. The review's engagement activities are listed in Annex C: Engagement activities supporting the call for evidence.
The review also considered over 200 supplementary documents including reports, articles and guidelines. These documents were attached as additional information to people's written responses, provided by members of our working group or identified by the review team as relevant to the terms of reference.
This report is a summary of what people told the review during this 'listening' phase. It provides an account of the key themes and related issues people described within the forensic mental health system. It draws on supplementary material to add further information where necessary. This report does not make any value judgements about different points of view or decisions about what should happen next.
1.3 How the analysis was done
The call for evidence did not have set questions that people had to answer. A series of prompt questions were provided to help people shape their responses, if needed. The content of the visits and meetings was also led by what people wanted the review to know. Therefore, the data analysed in the report is mainly qualitative: it captures a range of organisational perspectives and personal experiences. These were sometimes shared in great depth and detail. To make the most of the richness of this data, each written submission, comment from the face-to-face meetings and piece of supplementary evidence was coded and thematically analysed with the support of qualitative analysis software, NVivo.
The content of this report reflects the themes which emerged most clearly from the data and some of the suggestions for change. Care was taken to ensure that quieter voices and more marginalised points of view were not lost. Appropriate weighting was applied to evidence which provided an alternative perspective, identified an issue of particular importance or addressed an element of the terms of reference. Many of the issues raised are relevant to more than one theme. These issues are discussed under the theme they relate to most closely.
1.4 A note on terminology
There are many terms that are used to describe people who use mental health services including 'patients', 'users', 'clients' and 'experts by experience'. The term 'carer' can sit uncomfortably with family and friends who support people in the system. The range of professionals who work across forensic mental health is extensive, covering a diverse range of specialisms. The review spoke to service managers and a wide variety of clinicians across multi-disciplinary teams.
In all cases, the review aims to use language which emphasises the humanity of the people who responded to the review, whilst accommodating the need for consistency, brevity and anonymity. For people who have received or are receiving forensic mental health care and treatment, this report uses the terms 'people with lived experience' or 'people receiving care'. The terms 'family' and 'staff' or staff 'team' are used to describe the other major perspectives. If a point came from one professional group in particular then this is specified. 'People' is used when the same point had been raised from multiple perspectives or from more than one person with lived experience. The term 'learning disability' used in the report reflects the wording in Scottish mental health legislation. However, the review recognises that 'intellectual disability' is the preferred terminology among clinicians and other groups.