Independent Forensic Mental Health Review: final report

Message from the Chair of the Review

In May 2019 the Minister for Mental Health, Clare Haughey asked me to chair a Review into the Delivery of Forensic Mental Health Services in Scotland.  I was delighted to accept this invitation and began work on the Review in June 2019.  I would like to thank the Minister for giving me the opportunity to lead this important piece of national work.

I could not have done this without the support of my employer Erskine (the veterans’ charity).  They allowed me to be seconded one day per week to undertake the Review.  I want to thank them for this support and to colleagues in Erskine who also took on additional work to allow me the time I needed to focus on the Review.

As a new Chair, I felt it important to meet with Chairs from other reviews to gain their insights into the role I was about to undertake.  I am therefore grateful to the Chairs who gave me their time and shared their expertise.  A key piece of advice they gave me was about the importance of the secretariat in supporting reviews.  Throughout the Review I have been extremely fortunate to be supported by a secretariat team who have been tenacious and hardworking.  Their dedication has been invaluable.

I would also like to acknowledge two other groups who have generously and warmly shared their time and expertise with me.

First, I was fortunate to have made a series of visits to forensic mental health wards across Scotland before the coronavirus pandemic put a stop to such face to face engagement in March 2020.  My requests to visit were universally welcomed and thoughtfully planned out to ensure I met with people from the widest range of services.  I had the privilege of meeting with staff and the people receiving care and treatment on these wards, as well as the families of those in hospital and people in community settings.  Other people took the time to submit their thoughts to me in writing or meet with me individually.  To each person who gave of their own time to share their views and opinions, I’d like to say: ‘Thank you for your input, thank you for sharing your experiences’.

Second, the work of the Review has been ceaselessly supported by people who volunteered their time and expertise to be in one of our three working groups.  These 64 individuals, representing 49 different organisations, have been essential in helping me get to the heart of the issues.  Group members were always available to provide further information, clarify facts and spread awareness of the work of the Review.  I would like to acknowledge their contribution and say thank you to each member for sharing their wisdom and knowledge.  They have been open, generous and rightly challenging with their expertise, opinions and suggestions throughout the work of the Review.  However, the final recommendations in this report were not agreed with them and therefore their active participation in the work of the Review does not signify endorsement of the outcome.

I have also pulled on the expertise of other people to gain a deeper understanding of specific issues and happily accepted a number of invitations to participate in conferences and group meetings to discuss the work of the Review.

All of these people have helped shape this report.  I’d like to say thank you to everyone who took the time to engage with this important piece of work.

The Review published its interim report in August 2020.^[1]  It brought together what people had told the Review were the key issues and challenges in forensic mental health services in Scotland.  This final report focuses on my recommendations for tackling the issues highlighted.  The interim report identified two over-arching themes characterising the forensic mental health services in Scotland: system-wide variation and severe challenges around capacity and the transitions of people through the forensic.  The current landscape of services has developed organically over the years, responding to local pressures and demands.  As such, whilst its day to day operation is characterised by a great deal of hard work and good will, it fails to deliver a consistent rehabilitation pathway for the people within its care.

Systemic variation poses a challenge to joined-up working which, together with pressures on capacity, lead to inefficiencies and inequalities that could surely be avoided.  For instance, I was more than a little surprised to learn that NHS Scotland as a whole spends millions of pounds a year in cross-charges for accommodating people out of area, while at the same time fails to charge for people from North Ireland being treated at the State Hospital.  This variation is compounded by incomplete data collection and monitoring across the system, which prevents the degree of co-ordination and planning that would be appropriate to this relatively small and highly specialist set of services.  My take-away impression has been that forensic mental health services are sorely lacking a central co-ordination and management function and are in need of a governance structure that can provide both the proper oversight and authority to effectively deliver change.

These over-arching structural problems cannot be divorced from their impact on the lives of people within the system.  Informed by the PANEL principles (a human rights based approach of Participation, Accountability, Non-discrimination, Equality, Empowerment and Legality), I have endeavoured to place the voices of people with lived experience at the centre of my thinking and actions in chairing this Review.  I visited multiple inpatient settings to speak with people receiving care and treatment and the family members supporting them.  I have therefore heard first-hand experiences of the detrimental impact that systemic variation and limited capacity have on people’s lives.  I was saddened and disappointed to witness people’s frustration at having transitions delayed by reasons of procedural bureaucracy or unit capacity rather than being determined by their clinical need.  Also to hear of the uncertainty created by different restrictions being applied in units at the same security level, and to see examples of vulnerable people being forced to share dormitories in the 21st Century, was especially troubling for me given the length of time people can spend in forensic mental health services.  In light of the restrictions placed upon people within the forensic system, it is vital that all services prioritise person-centred practices underpinned by a commitment to upholding human rights.

For some groups of people, my concerns are particularly acute.  This Review has confirmed existing fears that arrangements to provide high secure care for women outwith Scotland are not fit for purpose, neither procedurally nor from a human rights perspective.  We must make urgent arrangements to offer high secure care for women within our own borders.

In many ways, I feel that this Review has been a timely one.  I have been confronted by a system that appears to be nearing the edge of crisis.  Despite the efforts of the hard-working and committed staff in the NHS and supporting organisations, it feels like only a matter of time before some parts of the system give way under the pressure or are subject to legal challenge.  Nonetheless, I wish to conclude on a point of optimism.  Many of the people I have spoken with, including staff, individuals and their families, have expressed hope that this Review could offer an opportunity for meaningful change.  It is also my hope that the recommendations in this report can guide the establishment of a forensic system that works holistically, with co-ordinated services that offer a smooth and consistent rehabilitative pathway for all the individuals in its care.

Derek T Barron, RMN, MSc, FQNIS

Director of Care, Erskine

Chair of the Review