4 Information sharing and working relationships
People wanted more coordination and consistency between the different services and individuals supporting people in forensic services. Family members in particular talked about difficulties in accessing information and providing advice about their relative's care and treatment.
People spoke of the different processes and pathways are used across different NHS Boards, Health and Social Care Partnerships and local authorities. The way information about mental health and risk is presented and the quality of links between different services was seen as inconsistent. Multi-disciplinary teams (MDTs) were often identified as areas of good joint working practice within services but some staff felt that there was room for improvements in communication between colleagues with different specialisms. Some services have struggled to adapt to changes in the relationship between health and social work.
Some people recommended that more resources or more formal guidance should be provided to support joint working between different parts of the forensic system, other statutory services and third sector partners.
4.1 Family members
Family members noted variations in units' willingness to include them in decision making. Many felt that their expertise about their relatives was not recognised and that staff failed to use them as a resource in decisions about care and treatment. They felt that while they are relied on by the system to support their loved ones when they are in the community, their warnings about risk factors or deterioration of the person's mental health can go unheeded, resulting in crises that could have been avoided. A couple of family members felt that if services had listened to them then their loved one would not have committed the offences that they did. They said this could have prevented harm to others. There was a specific call for the perspectives of young carers to be valued.
Access to information and communication was one of the issues family members talked about the most. Limits on information shared with family left them feeling more anxious, less able to input into their relatives' care and more likely to experience difficulties in supporting people upon discharge. Staff spoke of a tension between wanting to be open with family members and the legal and procedural barriers to sharing personal information without a person's explicit permission. Some family members felt the regulations protecting personal information are inappropriate in forensic care. They called for new legal rights to allow them to access information about a family member's care, especially at the point of discharge. When a person gives their consent, family members want this to be recorded centrally to prevent them from being 'locked out' of communications. Family members want more information at the start of the forensic journey, as many currently have to rely on peer networks.
There was a call for the appointment of dedicated carer support staff. Some services have set up services for carers but even those admitted they could be a bit 'ad hoc' and did not always operate in a consistent fashion. Staff in one ward reported that events organised for family members were not usually well attended.
4.2 Social work
People recognised the specialist roles of social work and mental health officers (MHOs) within the system. Where there is a lack of social work input this was felt to have a negative impact on people's care.
People's MHOs and social workers can provide a degree of continuity and consistency as they move through the system. They can provide a longitudinal perspective to assessments and have the ability and independence to challenge clinical decisions. Families and people with lived experience recognised the importance of building a good relationship with the MHO but they said it takes time to develop this trust. People had experienced varying degrees of contact and consistency with MHOs. For example, one person's MHO had followed them throughout their time in the forensic system. Another family spoke positively of a social worker who had travelled some distance to see them and gather the initial family history. Others, however, spoke of how their MHOs 'chop and change', of having an MHO 'in name only' or only seeing them a month before their CPA (Care Programme Approach) meetings.
There are a variety of models for social work provision to the forensic hospital estate and only two NHS Boards said they have dedicated social work resources on site. People are more likely to be able to access social work services if they are in hospital in their 'home' area and people placed out of area can be put at a disadvantage. Social work services are supplied out of area when required but often on an ad hoc basis and 'based on goodwill' rather than any formal arrangement. People also described times when social workers would not travel out of area to see people in regional units. There was a call for nationally funded posts, more resource for MHOs and more consistency and clarity about provision across the system.
People said social work needs to be better integrated with the MDTs in hospitals. Hospital staff in one area felt that social work had 'backed off' since health and social care integration. Joint funding from local authorities for a dedicated post in a regional unit had subsequently been withdrawn. Without dedicated social work posts, others working in the system were unsure how to access social work supports, benefits and housing support. For example, nurses described feeling pressured to help people make benefits applications. They did not feel trained to do this and were anxious about 'making a mistake'. They also said that time spent on tasks previously undertaken by social workers negatively impacts other areas of work, such as the ability to staff escorted leave. Without a social worker on their team, one area was aware they were also relying on MHOs to do social work tasks that were not really within their remit.
4.3 Assessments in the forensic mental health system
Information sharing is an integral part of clinical risk management. Multi-disciplinary ways of working, including MDT meetings, were felt to support this. Co-locating services was felt to support integrated and collaborative working practices. People associated failures in MDT working with negative outcomes such as people not receiving the services they require. A number of teams requested more social work input. Specific requests were made for dedicated resources to maintain MDTs, including national funding for social work posts to ensure equality of access to the service.
Staff spoke about how different record keeping systems across units and security levels cause difficulties, delays and unnecessary repetition of assessments. They recommended the creation of a centralised system to support information sharing and a consistent electronic format for risk assessments. Recording risk information on a single electronic document would allow it to move with a person at points of transition, be updated and edited as risks change and decrease the risk of repeating complex assessments. Similarly, a more consistent approach to multidisciplinary assessments could reduce waiting times, reduce repeat assessments and make it easier to access hospital care.
The quality of referral processes for advocacy services was seen to be variable. Even when they work well they are often informal, meaning referrals tend to depend on good relationships rather than the consistent application of policies.
People said that risk assessments for people in forensic mental health services vary between regions and organisations. The same risk assessment tools are used but the formats of risk reports vary. This means that reports may need to be rewritten when people move from one unit to another. Some staff wanted to standardise risk reports into one key document reviewing all risks and laying out an integrated management plan.
Advocacy organisations raised concerns about transparency in the risk assessment process. A small number of people with lived experience and their family members suggested that information recorded in reports did not reflect their whole story or was inaccurate. One family member felt that people should have access - and time to respond – to clinical reports before they are presented at Tribunals.
Prompt assessments at or before the point that someone enters the criminal justice or forensic system were highlighted as being critical for identifying the right pathway for an individual and planning appropriate care. Considered assessments require sufficient time, an appropriate and safe environment and skilled multi-professional staffing. Thorough psychological assessments when people enter the forensic system were felt to lead to more comprehensive formulations and treatment plans for people. There was a call for adequate resource for these wherever a person entered the system.
Difficulties accessing information for people in the community mean that risk assessment and management of this group can also be variable. One Health Board said that it is not always easy to acquire a detailed forensic history for people who are not managed by MAPPA. People wanted better ways to share information about risk and needs outside of the MAPPA process. Organisations that need access to this information include the police, local authorities, the NHS and the Crown Office and Procurator Fiscal Service.
4.4 Multi-Agency Public Protection Arrangements
Multi-Agency Public Protection Arrangements (MAPPA) operate between health services, local authorities and the police to assess and manage the risks of restricted patients in the community. People reported that the quality of relationships between MAPPA partners varies regionally. Some reported strong links. In one area the co-location of MAPPA with other forensics services allows for closer joint working and information sharing. In other areas, however, there was concern that some of the staff operating in the Health Liaison role at MAPPA meetings had insufficient clinical or forensic expertise or insufficient seniority to ratify and resource multi-agency risk management plans.
There were calls for national or regional guidance to support greater consistency of MAPPA provision across Scotland. The Serious Offender Liaison Service and the Specialist Treatments Addressing Risk service were both proposed as models for a national service. They both provide case consultations, representation at MAPPA meetings, offence-focused psychological treatment and complete risk assessment and management plans for people who are high-risk.