2 Underpinning themes
Two aspects of the forensic mental health system seemed to underpin the issues that people raised. First, the effectiveness of the system is hampered by limited capacity. NHS secure units and wards lack beds in the rights places and there is not enough suitable accommodation in the community. Second, Scotland's forensic mental health system is characterised by variations in both provision and practice. These can be experienced as unfair or inconsistent by people receiving the service. The impact of both limited capacity and inconsistency is evident in many of the themes described in the rest of this report.
2.1 Capacity within the forensic mental health system
Staff spoke about NHS services within the forensic mental health system as functioning 'at capacity'. Managers said that services should optimally be operating at 80% to enable clinical responsiveness. However, most services reported running at full capacity most of the time. Resourcing issues affect the availability or quality of provision in some areas. Getting an inpatient bed at an appropriate security level can involve long waits and out of area placements. When services operate at capacity for long periods of time it is said to have a negative impact on the care and treatment people receive. It can also affect staff retention and welfare. Lack of suitable accommodation in the community is having a negative impact on individuals awaiting discharge and knock-on effects for the system overall. One team described people 'being placed where there is a bed rather than where fits their needs'.
People said that specialist forensic services represent a high cost for a relatively small number of people. They also felt, however, that the system is under-resourced. This is delaying progression and discharge and some people said it is increasing the threshold for access to services. Variations in funding arrangements are associated with concerns that some services are not allocated the resources they need for service delivery and improvement. This can cause unwarranted variations in people's care and length of hospital stay. Some providers felt that the integration of forensic services into Health and Social Care Partnerships places them at risk. They feared decreases in understanding, funding and prioritisation of the specialism.
Some people queried whether resource allocation reflects population and need across different parts of the forensic system. A number of people felt that the 'beds are in the wrong places'. Some suggested that resources had not moved with the forensic population following the reduction of people in high security after appeals against conditions of excessive security were introduced. People also expressed frustration about the lack of resources in low secure services and in community services. This theme was consistently brought to the review's attention.
Differences between NHS Boards' funding models were said to pose challenges when arranging people's transitions. People spoke of 'wrangling' over who should pay for specialist support. Boards that rely on services in other areas expressed frustration about difficulties accessing them when demand is high.
To function effectively, forensic mental services rely on appropriate funding for other services. These include advocacy, education, structured community activities, work placements and support workers or befrienders. People raised concerns about 'patchiness' and reductions in third-sector provision. They said that the short tendering and commissioning cycle for such services contributes to uncertainty about their future.
Some services highlighted the need for new investment into the fabric of their forensic units. This was needed to bring lower secure facilities up to low secure standards and to improve ageing units.
2.1.2 Availability of NHS forensic beds
Frustration about a lack of beds was a consistent theme. The system relies on people being able to move – or 'progress' – from high security provision, through medium secure units, into conditions of lower security. The ultimate aim is for people to be discharged back into the community, with support from forensic community mental health teams (CFMHTs) or general adult community mental health services (CMHTs). This progression relies on beds being available when needed so that people can move through the system in a timely way and be at a security level with the least restrictive conditions necessary to manage their risk.
The review was repeatedly told about waiting lists for low secure services and two of the three medium secure units. This means people remain in inappropriate levels of security because of lack of beds at the appropriate level. One team said that this means 'people are here for much longer than they need to be'. People talked about a 'bottleneck' in low secure services and the review heard of people waiting months or years for places in lower security to become available. A lack of suitable accommodation or support packages in the community means people are not being discharged when they are ready. This reduces the ability of low secure units to accommodate people referred from conditions of higher security or general mental health services such as intensive psychiatric care units (IPCUs).
The pressure on beds means a small number of people continue to be admitted to the State Hospital under the Exceptional Circumstances Clause. It also increases the reliance of NHS Boards on independent or out of area provision, especially for women.
There are no high secure beds for women in Scotland and the number of beds for women in medium and low secure settings are reported as being too few to meet demand. High and medium secure provision for men with learning disabilities is provided on a national basis and is nearly always full, with high secure running at or above its occupancy rate in recent years. More details on the provision for women and people with learning disabilities are given in section 7. There are high secure beds available in the State Hospital for men with mental illness.
There is consensus that having people in an inappropriate security level limits their access to appropriate care and treatment. Managers were keen to address this but there was a sense of frustration in their efforts. One team was concerned that even if the problem was solved for their own unit, it would not address the overall constraints on beds and could exacerbate inequalities across the system. Another team who had tried to propose wider system changes spoke of not being able to get the agreement needed from other areas.
One Health Board recommended a needs assessment of the whole forensic estate including an examination of funding structure, trends in population flow and provision of services at regional and national levels. NHS Greater Glasgow and Clyde has proposals for extending both its medium and low provision. Other suggestions included: developing more specialist forensic rehabilitation or step-down units or low secure units; reinstating high secure provision for women within Scotland; greater clarity and collaboration around the processes for accessing secure beds across the forensic estate; and increasing resources in the community.
2.1.3 Out of area placements
Lack of beds means that some NHS Boards rely on placing people out of area, including with independent providers. People can therefore find themselves far away from their support networks. People said this makes it harder to maintain connections with family and friends. Family members highlighted that financial support for visiting out of area services is only available at the level of the State Hospital.
Placing people out of area is associated with significant costs for the 'home' Health Board. Funding arrangements between areas usually operate on a 'per case' basis. The National Services Division provides national risk share funding to resource and co-ordinate referrals outside Scotland. People felt there was a gap for similar coordination between NHS Boards in Scotland.
2.1.4 Community resources
Community Forensic Mental Health Teams (CFMHTs) play an important role in helping people to remain well in the community. They also support people through acute periods of mental ill health, helping them to avoid unnecessary returns to forensic inpatient care. They can provide intensive home care treatment or refer people to general adult mental health wards or IPCUs as required.
CFMHTs said they feel like the 'poor relations' in terms of resources within the forensic mental health system. They feel that less priority is given to, for example, their service development or setting standards of care, than for inpatient services. CFMHTs are often small and there is a lack of guidance about appropriate staffing ratios. Teams spoke of having to manage increasing workloads within existing or reducing staff numbers. Some teams are looking to address gaps in their service, for example in governance and leadership, skillsets and referral routes and pathways. Lack of resource in these teams was also said to contribute to difficulties in arranging accommodation and support for people ready for discharge into the community. In rural locations, CFMHT staff felt there was insufficient recognition of the resource impact of working in the community where they have to spend significant periods of time travelling to meet with people and conduct assessments.
The majority of people come under the care of a CFMHT after being discharged from hospital but some CFMHTs also take referrals from CMHTs. However, some CFMHTs who had accepted non-forensic referrals said this had created expectations and resulted in CMHTs being more likely to escalate people's care into forensic services. This placed additional strain on CFMHT resources.
Some CFMHTs highlighted that they provide training for support staff who will be working with people coming out of the forensic system. However, high staff turnovers and limited CFMHT resources make it difficult to build up that skillset or for the training offer to be sustainable over the longer term.
2.2 Variation across the forensic mental health system
Despite the review receiving a number of documents relating to guidelines and standards for forensic service provision, people spoke a lot about the way that provision varies in practice. They highlighted that this variation means that people's experiences and outcomes can be affected by factors that are not related to their care needs or risk management requirements. People receiving care consistently raised concerns about these variations in the system.
People said that a person's journey through the forensic system can depend on the nature of local provision and individual working relationships. They spoke of differences in referral criteria and service-specific approaches to information sharing. People also spoke widely about variations in governance, protocols and practice, as well as differences in service ethos and experiences of care.
People felt that flexibility to respond to local need is important but that there should be a national approach to guidance and resourcing rather than a 'postcode lottery' affecting care and treatment.
2.2.1 Variations in forensic services in secure hospitals
At the highest level, variation is a consequence of forensic mental health services being a specialism for a relatively small inpatient population. There is one national high secure service based at the State Hospital, three medium secure units providing services on a regional basis, while lower security and community services have been developed at local Health Board level. This creates inequalities of access to care and treatment depending on where a person lives. A significant number of people called for equal access to services across the forensic estate.
People spoke widely about variations in governance, protocols and practice, as well as differences in service ethos and experiences of care. Diversity within a system can provide the potential to respond in a more flexible and person-centred way to individual need. However, people more often framed differences as examples of inconsistency and inequalities within the system. Clinical teams, for example, spoke of the frustration of knowing that the different approaches taken in different units could benefit some people more than others but that there is no option to 'choose' which unit to refer someone to.
There are different risk management approaches in different clinical teams and areas. People with lived experiences see this as inconsistent, unfair or making little sense. It also makes it harder for them and their families to know what to expect in different places. People who had moved through the system spoke of ways in which practice differed, even between wards in the same units. They spoke of variations in restrictions, rates of progression, opportunities for activities and ward culture. Some people with lived experience felt there were different rules for different people. Advocacy organisations noted that differences in ward culture affected how their workers were received.
2.2.2 Variations in community forensic mental health services
Many people commented on the lack of a consistent community pathway for people within forensic services. CFMHTs operate on a range of models. They have differing staff compositions, remits and terms of access. They are also not available in all parts of the country. Consequently, people spoke of an inequity in service provision across the country.
People felt there was a need for clearer guidance around CFMHT service specifications. They said variations in practice include whether teams were willing to accept restricted patients who cannot return to their home health board or take on public protection liaison roles for people they would not normally look after. Any reliance on negotiation and good will to access these services rather than clear guidelines was not thought to be an appropriate and equitable way to work.
2.2.3 Oversight and governance
People called for a more standardised approach to the provision of forensic mental health services. One clinician lamented that the service was missing 'a central brain'. People suggested more steering from government guidance, more detailed service specifications or the creation of a national body for the oversight and coordination of forensic services across Scotland. A key point was that any such oversight body would need to have operational control, allowing it to direct actions.
The Forensic Network was set up in 2003 to bring a pan-Scotland approach to planning of services, pathways and strategic planning, as well as teaching, training and research. It is hosted by the State Hospital. People spoke positively of the learning, development, networking and training opportunities that it provides. But some people felt that it was not as inclusive as it could be and that this meant it struggled to get consensus around some of its work. It was felt this would always be a problem if the Network 'is hosted by one Board'.
Staff felt that inter-organisational relationships could be improved. People spoke of absences of inter-organisational arrangements and instances where formally agreed service arrangements had been reviewed or discontinued because of lack of resources. People called for: regional joint working; a greater use of service level agreements; and a more coherent strategy between NHS Boards and their partner agencies. A number of services spoke of trying to make regional or national arrangements but being unable to bring everyone required on board.
People recommended that forensic pathways should be reviewed and that legislative, procedural and administrative processes should be streamlined. They hoped this would increase efficiency and reduce timescales for people moving through the system. In particular, several recommendations were about the transition pathways to lower security, rehabilitation and community care. People requested co-ordinated development plans, earlier referrals and a standardised approach to identifying accommodation and support in the community. They also asked for clearer specifications for community forensic services and criteria for people with lived experience moving back to general adult mental health services.