Independent Forensic Mental Health Review: final report

2 Recommendations: Strategic governance and oversight

Governance is the way in which services are structured, sustained and regulated.  It is about the strategic oversight, direction and co-ordination of those responsible for leading service provision.  Accountability is a key component of governance.  It is the subsequent process of holding service managers to account for their actions, decisions, policies and service administration.

The current configuration of NHS Scotland’s forensic mental health services for inpatients developed from principles set down by the then Scottish Executive to NHS Chief Executives in 2006.^[7] It also reflects the three different levels of secure hospital provision described by the Forensic Network in its Security Matrix.^[8]  As such, in general:

• High secure services are provided at a national level;
• Medium secure services are provided at a regional level; and,
• Low secure and community services are provided at a local level.

The different national, regional and local commissioning levels set down for the different services creates a varied governance landscape across forensic mental health services in Scotland.

There is a unique level of transparency, oversight and accountability around the operation of the national high secure service.  This service is located at the State Hospital and is governed by its own Special NHS Board - the State Hospitals Board for Scotland.

There are three medium secure units providing regional services.  These are: Rowanbank Clinic at Stobhill Hospital in Glasgow; the Orchard Clinic at the Royal Edinburgh Hospital in Edinburgh; and, Rohallion Clinic at the Murray Royal Hospital in Perth.  NHS Greater Glasgow and Clyde, NHS Lothian and NHS Tayside, respectively, provide these services as part of the overall health provision for which they are accountable.

The development and oversight of low secure and community services is then the responsibility of local territorial Health Boards and/or Health and Social Care Partnerships.  The provision of these services in each area varies as it has developed in response to local need over time, with some areas providing no specific forensic mental health services.  More detailed information about the available provision at each security level across Scotland is provided at Annex E: Forensic mental health inpatient provision.

Each governing body has different priorities, resources and population needs.  This has led to a disparity of forensic mental health provision as they have each made resource allocation decisions that best meet their own circumstances.  This is understandable but when looked at from a national perspective can present as an inequality of access to services depending on where a person lives.  It also means that the forensic mental health services in Scotland are a collection of distinct services rather than one integrated system where a system wide view of services, standards and resourcing can be achieved.

The Forensic Network was created as the mechanism to support strategic oversight of these services in 2003.  It aims to:

• bring a pan-Scotland approach to the strategic planning of forensic mental health services;
• address fragmentation and inconsistency across the estate;
• streamline patient pathways throughout the estate; and,
• determine the most effective care for mentally disordered offenders.

The ability of the Forensic Network to do this work is made difficult in two ways.  First, it lacks operational authority, particularly with regard to strategic decision-making and management.  As such, it does not have the power to require services to follow its guidelines or implement its recommendations for change.  It also has to rely on voluntarily engagement with its data collection exercises.  Second, it is located in the State Hospital.  This is a clear source of tension and disengagement for people working in other levels of security.  People suggested that it tended to come up with ‘grand plans’ that would only ever work in the State Hospital.  They felt that for it to be seen as independently supporting all parts of the forensic system, it needed to be separated out from the State Hospital both in governance terms and physically.

The Review’s interim report presents strong views about the wide variation and gaps in existing governance, oversight, responsibility, protocols, practice and provision across the forensic mental health services.  Even in areas where guidance was described as ‘ample’, inconsistencies in practice were still felt to prevail.  People highlighted marked differences in service provision, ethos and experiences of care, as well as a lack of clear pathways for people to access the services they needed.  Staff spoke about services at the same security level having different requirements for admitting people into their care.  Variation was found not only in forensic inpatient and community services but in the degree to which the expertise of forensic mental health professionals was available to the criminal justice sector.  The issue was summed up by one clinician who described the system as missing a ‘central brain’.

People recognised that flexibility to respond to local need was necessary to deliver person-centred care.  However, the differences in services highlighted to the Review were experienced more as inconsistencies, inequalities and frustrations by the people for whom these services were provided and the staff delivering them.  Such differences mean that people’s experiences and outcomes are affected by factors that are not related to their care needs or risk management requirements.  There were calls for a more integrated approach to service development and resourcing rather than what was described as a ‘postcode lottery’ affecting care and treatment.

There are also concerns that forensic mental health services are not allocated the resources they need for service delivery and improvement.  Staff raised concerns that a lack of understanding of the complexity and level of risk associated with these services at Board or Health and Social Care Partnership level can mean that they are deprioritised due to financial considerations rather than need.  People also questioned the current distribution of resources across different parts of the forensic system.  In particular, people expressed frustration about a lack of resources in low secure services and in the community.  This was often linked to the idea that the State Hospital receives a disproportionate amount of funding.  People felt that resource allocation across the services had not been changed to reflect that the number of people in high security has reduced since the introduction of appeals against excessive security in 2006.

2.1 Creating a single system

The Review found general consensus that there is a need for greater strategic oversight and accountability across forensic inpatient and community services as a whole.  The lack of oversight is one reason that led to this Review being necessary and it is important that this is not perpetuated in years to come.  There was not, however, consensus on how this would best be achieved.  Suggestions made to the Review included:

• greater use of service level agreements;
• Scottish Government guidance or bolstering the powers of the Forensic Network;
• further regional development of services;
• a national approach to minimum standards or service specifications; and,
• the replacement of the State Hospitals Board with a national body with a wider remit across forensic mental health services.

The Review recommends that a new NHS Board is created for both forensic inpatient and community mental health services.  This will provide oversight of the whole forensic system.  It will have the operational authority to commission and manage services.  It will also provide the high level of transparency and accountability that is appropriate to mental health services involved in restricting people’s liberty.

The Review is conscious that a national body is not universally supported.  There are concerns that the complexity of the current system rules this out as an option or, at the very least, would present long-term challenges in implementation.  There are fears that creating a national body could negatively impact on the flexible and creative ways of working required to meet the needs of people in care at regional and local levels.  Further centralisation of the system was also seen as risking a ‘drain-away’ of regional talent or expertise from other parts of the system already struggling to attract staff.

The Review appreciates these concerns.  Steps will need to be taken to mitigate against these potential risks.  However, the Review is strongly of the view that the creation of a single national Board presents the opportunity to bring together all the existing forensic mental health services into a new, integrated and co-ordinated forensic mental health system.  This new Forensic Board will then be able to meaningfully address many of the issues identified in the interim report which the development of standards alone could not.  These include:

• the allocation of resources;
• the management of capacity and transitions across the system;
• information sharing internally and with partner organisations;
• the development of a specialist workforce;
• the identification of strategic priorities; and crucially,
• the establishment of clear pathways into, out of and through the forensic mental health system for the people in its care.

As a former Integrated Joint Board Lead Nurse, and advocate of integration, the Chair is acutely aware that the recommendation to include community forensic mental health services within the new Forensic Board may not seem aligned to the current Scottish Government policy on health and social care integration.  However, the forensic population is both small and highly complex, carrying a high degree of risk.  These services are not best supported by non-specialist management.  As such, the Review believes that integration would be best achieved through the creation of a single national forensic mental health system.

Recommendation

Recommendation 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.