Independent Forensic Mental Health Review: final report

3 Recommendations: Defining forensic mental health services

To establish a new NHS Board with responsibility for forensic mental health services, it will be important to establish the boundaries between what is and what is not forensic mental health care.  This will need to be supported by clear pathways into and out of forensic mental health services, for example by indicating when people move between forensic mental health services and general mental health services or criminal justice services, and how they would do so.  The interim report explained that people had varying views on who should or should not be on forensic wards.  Some felt that due to budget constraints the bar for accessing forensic mental health services had been raised, meaning some people who require specialist forensic mental health care and treatment are not getting it.  Others felt that the bar had been lowered.  They felt that forensic mental health services were now expected to accept people with non-forensic challenging behaviour and less serious offending as there was no other service available.

Forensic mental health services are set up to provide care and treatment to ‘mentally disordered offenders and others requiring similar services’.^[9]  Many clinicians who spoke to the Review felt any attempt to restrict definitions of ‘forensic’ to those who had been detained under a criminal section of the mental health legislation would not be fully representative of the work they do or that they should be doing.  Some people wanted to move towards a more needs-based approach, with fewer rules about who could be managed in forensic mental health services, and to move away from the focus on diagnosis and offending history.  There were also calls for placing more focus on early intervention and prevention.  However, people acknowledged that any extension to the remit of forensic mental health services should be accompanied by increased resourcing.  Without additional resource, services would become stretched, risking the quality of provision for the existing forensic population.

Forensic mental health services in some areas have already extended their remits to fill gaps and address the needs of populations where the skills of their specialist clinicians add a great deal of value.  Examples include provision of consultation and advice to generic health colleagues and partner agencies (discussed in Section 8), and inclusion of people with a primary diagnosis of personality disorder under some community forensic mental health services.

The position of people with personality disorder illustrates many of the tensions involved in defining a forensic population.  As outlined in the interim report, the Forensic Network’s guidance on referral criteria for admission to high and medium secure services recommends that people with a primary diagnosis of personality disorders are not admitted.  As such people with a primary diagnosis of personality disorder are generally only admitted to forensic inpatient care on a short-term acute basis or to establish a diagnosis.  If a person with personality disorder commits an offence then they are typically routed through the criminal justice system and may go to prison.  There is widespread concern that this arrangement leaves a large population of people with personality disorder in prison with unmet needs.  Forensic psychologists have indicated they have an appropriate skillset to lead on care and treatment for this group.  This raises questions about whether people with personality disorder should be reconsidered as part of the forensic population, or whether a solution lies in a particular role for the new Forensic Board to provide in-reach support to professionals working with this population.

The establishment of the new Forensic Board provides an opportunity to reimagine how forensic mental health services will be delivered in Scotland.  As such, consideration of its remit and purpose should not be undertaken in a reductive way.  Equally, it will neither be possible nor appropriate for it to be ‘all things to all people’.  A clear remit is necessary to establish the boundaries between forensic and general mental health services, and forensic mental health services and criminal justice services.  This will bring greater transparency to gaps in provision that are not being met by either forensic mental health, general mental health or criminal justice services.  These gaps must then be met.

Recommendation

Recommendation 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.