Independent Forensic Mental Health Review: final report

9 List of Recommendations

Strategic governance and oversight

Creating a single system

1. It is recommended that a new NHS Board should be created for forensic mental health services in Scotland.

• All forensic mental health services, including both inpatient and community services, should be brought under the management of this new Forensic Board.
• Forensic learning disability services at high and medium security should also be brought under the management of this new Forensic Board.  The Review considers, however, that forensic learning disability services at low security and in the community should remain under the management of, or transition to management by, generic learning disability services (see Section 7.1).
• The new Forensic Board should not be based in the State Hospital.  To do so would be to further alienate and disenfranchise clinicians and managers across the country who already perceive there is significant power, resources and focus sitting inappropriately at the high secure level.  The new Forensic Board must demonstrate practical engagement with all of its new service areas.  Serious consideration should be given to basing the Board outwith the central belt, or as a minimum not within Edinburgh or Glasgow.
• The new Forensic Board will supersede the role of the Forensic Network in providing strategic oversight of the forensic system.  However, care should be taken to ensure that the Forensic Network’s valuable role in advancing governance and professional networks within the forensic system is not lost during this transition, and is incorporated into the governance framework of the new Forensic Board where appropriate.  The School of Forensic Mental Health should also be retained: its role is discussed further under Section 8.3 of this report.

Defining forensic mental health services

2. The definition and purpose of ‘forensic mental health services’ should be reviewed by the Scottish Government at a multi-disciplinary, multi-agency level to help inform the establishment of the new Forensic Board.

Women’s pathways

High security provision

3. A high secure service for women should be opened in the State Hospital within nine months of the publication of this Review.

• The design and staffing model for this unit must be able to appropriately flex to meet the care and treatment needs of both women with mental illness and women with a learning disability.
• It will be for the new Forensic Board to review and determine appropriate arrangements for high secure provision for women in the longer term.

Women’s pathways in forensic mental health services

4. The Short Life Working Group set up in response to the Forensic Network’s report on the Women’s Service and Pathways should reform to complete its work related to women’s pathways across medium secure, low secure and community forensic settings.

• The Short Life Working Group should initially report to the NHS Chief Executives’ Group pending the formation of the new Forensic Board.
• Its work must ensure a pathway for women to transfer from prison for forensic mental health care and treatment when required.
• It should also consider the care needs of the group of women who may not meet the definition of ‘forensic’, but who are subject to conditions of security as their behaviour has not been able to be safely managed by generic services.  While it is important not to draw these women inappropriately into forensic mental health services, there needs to be clear pathways around their longer term care and treatment.  As such, representatives from the independent sector must be invited onto the Group.

Capacity and Transitions

Data collection and reporting

5. The Scottish Government should commission the Information and Statistics Division (ISD) of NHS National Services Scotland to develop a data management system to accurately collect, monitor and report on performance across forensic mental health services, including on service capacity and the timeliness of people’s transitions.

• This report identifies a number of further recommendations for specific data that should be collected, monitored and reported on within this system (see recommendations 7, 8, 20).

Pressures on medium secure services

6. NHS Greater Glasgow and Clyde plans to extend medium secure provision at Rowanbank Clinic should be progressed.

7. The data management system developed for forensic mental health services by the Information and Statistics Division (ISD) of NHS National Services Scotland should collect, monitor and report delays incurred by people assessed as ready to transfer to a different level of security.  Any delay of four months or over must be reported to the Scottish Government.

Delays affecting discharges into the community

8. The data management system developed for forensic mental health services by the Information and Statistics Division (ISD) of NHS National Services Scotland must collect, monitor and record delayed discharges in a way that is as transparent as data collected in the acute (physical health) sector.

• This should include delayed discharges and delays in progress towards conditional discharge as a result of waiting for accommodation or support packages.  The ‘clock’ should start when the clinical team and the person agree that clinically they are ready to move to the next stage of their rehabilitation journey.

9. The management bodies of all forensic mental health services must identify anyone waiting for accommodation or support packages in the community to the extent that their discharge from these services - or their eligibility to start the process towards conditional discharge - has been delayed for six months or more.

• Management bodies here refers to the relevant Health Board, Health and Social Care Partnership or independent provider providing care and treatment for the person.
• Within six months of this Review being published, these bodies must submit plans to the Scottish Government to address the outstanding needs of anyone it has identified as being delayed in this way.
• These bodies must continue to record, monitor and report on these delays on an ongoing basis until this responsibility is assumed by the new Forensic Board.

10. The new Forensic Board must work with social work teams and local authority housing departments to ensure that the commissioning process in each area provides appropriate support services and accommodation options for people with the need and risk profiles typical of individuals within the forensic mental health system.

11. The new Forensic Board must work with social work teams and local authority housing departments to develop an accommodation strategy that ensures individuals have access to community accommodation so that they can begin the discharge process in a timely manner when clinically appropriate.

12. Commissioners of community support and accommodation services should ensure that remuneration for people working in these services reflects the complexity of the forensic cohort and the need to retain skilled staff.

13. We recommend that people in low secure units should be given the right to make an application to the Tribunal where they are being detained in conditions of excessive security.  This right should be equivalent to the one which people in high and medium secure units have under the Mental Health (Care and Treatment) (Scotland) Act 2003.  It should apply to anyone in low secure services, allowing them to be moved into conditions of lesser security, including into the community.  People in secure units whose plans for discharge into the community are being delayed as a result of the non-provision of the necessary facilities for a phased move to the community should also be given a right to make an application to the Tribunal for an order that a relevant authority make the necessary provision.

• Where a Tribunal is satisfied that a person in low secure is being detained in conditions of excessive security, then it should make an order for the discharge process to begin.  Where the person is to be discharged to the community, an order must also be placed on a relevant authority to provide the appropriate accommodation and support.
• An order from the Tribunal that a person in low secure is being detained in conditions of excessive security should provide for the same time frames as the equivalent orders at high or medium secure.  This would mean the relevant authority is to make the necessary provision for the person to begin the discharge process within three months of the order being made.

14. A legal duty must be put on a relevant authority to provide appropriate accommodation, services and support for people who are due to be discharged from a secure hospital into the community.  The Review considers the relevant authority should be the local authority.

15. The Scottish Government should review with clinicians in both inpatient and community teams, as well as MAPPA and police representatives, the current discharge planning process for restricted patients to identify any aspects that can be streamlined while continuing to protect the public and supporting the best chance of a successful and sustainable discharge for people.

16. The update of the Scottish Government’s Memorandum of Procedure on Restricted Patients should be available in an accessible format to increase transparency around the processes and the flexibility within it, and the role of Scottish Ministers more generally.  This work should be prioritised.

17. The Scottish Government and the new Forensic Board need to identify funding to ensure that no one leaving forensic inpatient services has to go into debt for housing costs to complete overnight stays to accommodation as part of their required pre-discharge plan.

Community forensic mental health teams

18. The new Forensic Board should define the service remit of Community Forensic Mental Health Teams (CFMHTs).

• This service remit should specify the population that CFMHTs may work with.  The new Forensic Board may consider that CFMHTs should have a broader remit than forensic inpatient services but this must be clearly defined in order to support consistency of provision across the country.
• The service remit should also specify the expectations for its multi-disciplinary team (MDT) composition, including a requirement for social work representation, and appropriate staffing ratios for CFMHTs.

19. CFMHTs should be appropriately resourced based on future projected demand as bottlenecks in low and medium secure services are eased.

• Using available figures together with any improvements in data from increased monitoring activity, the new Forensic Board should estimate demand for CFMHTs over the coming years.  This should inform what additional resources may be required by CFMHTs to meet projected demand and be factored into its planning.

Prison issues

20. The data management system developed for forensic mental health services by the Information and Statistics Division (ISD) of NHS National Services Scotland must be able to collect, monitor and report on transfers and delays to transfers into forensic mental health services from prisons.

21. The system of multiple assessments to facilitate transfers from prison should be reviewed with the aim of streamlining the process to the benefit of the person in need of forensic inpatient services.  At the latest this should be reviewed by the new Forensic Board, however the Review considers that this could be reviewed sooner than that.

Person-centred practices

Care and treatment

22. There should be an equality of esteem between the professions in a high functioning forensic mental health service.  This should be evidenced in practice and language used.

23. The new Forensic Board should consider how best to fund social work posts embedded within the multi-disciplinary teams (MDTs) in forensic mental health services, in order to maximise interdisciplinary working.

24. People should be supported to participate as much as possible in decision-making about their care and treatment.  Staff should proactively involve people in both formal and informal conversations about their care.  Staff must communicate in a style that best enables people to understand what is happening and to voice their opinions.

25. Staff should proactively inform people about their right to request a copy of information held about them.  People need to be supported to make such requests if desired and to express their wishes about what information they receive and how this is communicated to them.

• The person’s wishes should be added to their healthcare record and staff should endeavour to fulfil them on an ongoing basis so long as that does not conflict with that person’s wellbeing.
• If staff believe they have good reason to withhold information against the person’s wishes, then that person should be afforded an opportunity to discuss this decision.

26. General information and advice for people within the forensic mental health system should always be provided in accessible formats, including Plain English and Easy Read versions.  Staff should ensure that any additional information required to ensure a person’s understanding and ability to participate in decisions about their own care and treatment plans are converted to such formats as required.

27. Each unit within the forensic mental health system must appoint a named staff member as a Carer’s Contact.  This person must have received training in carer’s rights and have sufficient knowledge to answer a carer’s initial questions and signpost them to further information and support services.

28. The new Forensic Board should be funded to establish an advocacy service for forensic carers.  This service will provide expert support to help carers navigate the forensic mental health system, represent their views and find satisfactory resolution to complaints.

29. The new Forensic Board should work in collaboration with existing carer organisations and advocacy services to develop a) information targeted at new forensic carers, and b) information and training for organisations supporting forensic carers.

30. Until such times as the new Forensic Board is formed, individual Health Boards should put in place a system to reimburse travel expenses of those family members (or other carers) who have to travel to visit a person receiving forensic mental health services out of area.  Once established, the new Forensic Board should continue to ensure financial support is in place.

31. Where a person receiving forensic mental health services has indicated their consent, family members (or other carers) should be actively supported to take part in the CPA process and their opinion recognised as that of an expert by experience.  As part of this, their availability should be taken into account when scheduling these meetings.

32. Where a person receiving forensic mental health services has indicated their consent, family members (or other carers) should be proactively informed by the clinical team whenever a change is made to the person’s care and treatment.

33. The new Forensic Board and people receiving forensic mental health services and their family members (or other carers) should co-design informal and formal feedback processes that address the specific vulnerabilities of these groups in the forensic system.

• This should include investment in the provision of collective advocacy for people in forensic mental health services.

34. The Scottish Government should re-inforce the use of its guidance on transferring Suspension of Detention plans (SUS) issued in 2018 with clinical teams and identify any ongoing barriers (clinical, administrative or cultural) prior to refreshing and reissuing to all clinical teams, as part of its ongoing update of the Memorandum of Procedure on Restricted Patients.

35. Recommendation 35: At pre-transfer CPA meetings, it must be made clear to the person that the option to transfer existing SUS is available.  Reasons for not carrying SUS forward should be clearly discussed with the person.  Their own obligations for ensuring that their SUS is carried on as planned once transferred must also be clearly explained.

Social and environmental conditions

36. The poor state of repair of current inpatient environments, including outside space where it is provided, should be addressed by individual Health Boards to ensure they are therapeutic spaces which demonstrate a value being placed on the people detained there.

37. Evidence-based design of therapeutic environments should inform the planning stages of all renovations and new developments within the forensic estate.

38. Everyone subject to detention within the forensic inpatient services should have their own single room.

39. The new Forensic Board should, under the direction of the Nurse Director, establish multi-disciplinary ‘Best Practice’ standards to guide least restrictive practices.  These must have the principle of person-centred practice at their core and should be applied consistently across all forensic inpatient settings.  The standards must include guidance around enabling people to:

• access privacy to support relationships with family and friends;
• access bedrooms;
• access personal belongings; and,
• access technology – this should be accompanied by staff training to ensure they can confidently support a positive risk approach to technology.

40. The Scottish Government should respond timeously to the Technology and Communications Group’s updated report, which the Review hopes will reflect an enabling, rather than a risk averse approach in its recommendations.

41. The Scottish Government, together with forensic mental health services, should monitor the availability of placement providers to ensure there are sufficient available to support the rehabilitation of people in forensic inpatient services and to sustain them for people discharged back into the community.

42. The Scottish Government should re-engage with Allied Health Professionals to finalise their draft guidance aimed at supporting people with criminal convictions and mental health conditions into work, volunteering or education.

Specific populations

People with learning disabilities

43. There must be a presumption that people with a learning disability who are accused of an offence will be supported to go through the criminal justice system.  They should only be diverted to hospital where this has not been possible.

44. The Scottish Government should commission a study to examine the experiences of offenders with a learning disability compared with offenders in the general population and offenders with a mental illness.  This study should compare court ‘disposals’ for similar offences, including whether people are given prison sentences or diverted to hospital for treatment.  It should also explore what kind of restrictions are associated with these ‘disposals’, and the length of time people are subject to them.

45. Low secure and community forensic learning disability services should be managed under the local Health Board/Health & Social Care Partnership generic learning disability services.  This arrangement should be reviewed within 3-5 years of the new Forensic Board being established.

46. The new Forensic Board should collaborate with generic learning disability services to develop appropriate standards for forensic learning disability services.

47. In areas without forensic learning disability services, generic learning disability services should be supported to embed professionals with forensic training and expertise within their workforce.

48. The new Forensic Board should establish mechanisms to provide consultation, advice, and professional supervision for all staff involved in the care and treatment of people with learning disabilities who have forensic needs.

49. Health and Social Care Partnership commissioners must ensure community accommodation can be adapted to meet the sensory and other needs of people with a learning disability

50. Health and Social Care Partnership commissioners must ensure that people with a learning disability have a choice about whether to move into single person or communal accommodation in the community.

People with neurodevelopmental disorders

51. The new Forensic Board should undertake a needs assessment related to neurodevelopmental disorders and forensic mental health services.  This should inform future service provision.

Children and Young People

52. The Review recommends that the National Secure Adolescent Inpatient Service does not fall under the remit of the new Forensic Board.  This position should be reviewed within 5 years of the National Secure Adolescent Inpatient Service opening to ensure this continues to provide the best pathway for young people.

53. The National Secure Adolescent Inpatient Service should set up a service to provide access to forensic specialist expertise for local CAMHS teams to support clear pathways into and out of the National Secure Adolescent Inpatient Service.

54. A clearly defined pathway should be agreed between the new Forensic Board and the National Adolescent Secure Inpatient Service for young people who do need to transition to adult forensic mental health services.

55. Clear interim arrangements need to be put in place for young people in Scotland who require forensic or learning disability inpatient facilities prior to the National Adolescent Secure Inpatient Service facility being opened.  This should be actioned by the end of 2021.

Older Adults

56. The new Forensic Board should make an assessment of age-related needs across all forensic mental health services and, based on current and projected demand, develop an older adults’ pathway that reflects the care and risk management needs of this group.

• The new Forensic Board should work with the Scottish Prison Service to consider whether older adults in prison would also benefit from age-related care in an alternative secure setting.

57. The new Forensic Board should conduct an assessment of staff training gaps around the age-related health needs of older adults, particularly around dementia, and make provisions to improve staff skills and confidence in this area.

Northern Ireland

58. The Review recommends that the State Hospital introduces charges for the care and treatment of people from Northern Ireland.  These costs should be benchmarked against the costs incurred by NHS Scotland for the high secure care and treatment currently provided to women from Scotland at Rampton Hospital.

Sharing information and expertise

Sharing information about people receiving forensic mental health services

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.

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.

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.

Provision of forensic mental health expertise to external agencies

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.

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.

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.

Research, education and training

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.

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 mental health services including shadowing opportunities and rotation through services at different security levels in order to build up an expert skillset.

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, including positive risk taking, to people from forensic mental health services.