Independent Forensic Mental Health Review: final report

4 Recommendations: Women’s pathways

The interim report noted widespread agreement that current arrangements for women’s forensic care in Scotland are inadequate.  People spoke of a lack of ‘joined-up thinking’ and co-ordination at both national and local levels.  The absence of agreed pathways and services for women creates difficulties accessing appropriate services at medium and low security.  It can delay women’s rehabilitation and progress into the community.  It also makes it more likely that they will have to move away from their home Health Board to access appropriate care and treatment.  In particular, the lack of high secure provision for women within Scotland was universally seen as unacceptable.  The existing arrangements to access the high secure provision available in England were also described as very challenging.

After the publication of the interim report, the Review heard from clinical teams and relatives of women who had spent years being moved from service to service to try to access the care and treatment they needed.  This included experiences of high and medium secure care in England.  They expressed frustration, despair and anger at the ‘lamentable lack of facilities for women’.  They described how the distance of these placements from home disrupts relationships with family and friends.  This has an adverse impact on the women’s mental health.  However, it also affects the wellbeing of their families, particularly if they have children.

In recognition of these issues, NHS Board Chief Executives commissioned the Forensic Network to complete a review of the Women’s Service and Pathways across the Forensic Mental Health Estate in January 2018.  The results of its options appraisals and recommendations for development for all three security levels were published in March 2019.^[10]  A Short-Life Working Group was set up to take forward its recommendations, but the Chair of that group agreed to postpone its work until the outcome of this Review was known.

Forensic mental health services need to develop clear pathways for women from high secure through to community services.  This must include agreed pathways in and out of secure care, including transfers from prison.  Parity of provision with men must be developed for women throughout the forensic system.  Such provision should respond to any differences in needs between men and women whilst ensuring consistency in relational, physical and procedural security between services.  In particular, there is an urgent need to make high secure provision available to women within Scotland.

4.1 High security provision

There is no high secure facility for women in Scotland.  The State Hospital had previously provided this but closed the service in 2007/8.  It was closed on the grounds that there was little or no demand for high secure services for women in Scotland.  There had also been public criticism of the significant costs of the service per person.  Women requiring high secure care therefore are referred to Rampton Hospital in Nottinghamshire, England.  The National Services Division of NHS Services Scotland (NSD) supports this pathway through a national risk share scheme that provides funding for cross-border forensic mental health care and treatment.

The number of women transferred to Rampton confirms that there is demand, but it remains small.  Since 2011, NSD has paid £4.5 million to Rampton for the high secure care and treatment of four women from Scotland.  In each year, Scotland has been using either one or two beds.

The Review heard evidence that the Rampton high secure pathway is not fit for purpose.  One issue is that the cross border nature of the pathway does not allow for the transfer of women who are on remand or have outstanding charges.  Any woman in this position, who is in need of high secure care and treatment, has to be cared for within the medium secure female estate in Scotland until decisions on their legal issues are reached.  Another issue is that the referral process is not quick and does not always result in Rampton agreeing to accept the person.  This can leave teams in medium secure units in Scotland continuing to look after women they consider require high secure care and treatment for long periods of time.  These gaps means that women with high secure needs can be detained in seclusion in medium secure units and it is not possible for them to engage with other people in those circumstances.  The Review is also concerned about difficulties repatriating women back to Scotland because everyone who has progressed from Rampton has done so by transferring to medium secure facilities in England.

The lack of high secure care for women in Scotland raises human rights concerns on the grounds of gender discrimination.  Requiring women to transfer to England for high secure care when men receive it in Scotland creates inequalities in respect of the right to a private and family life as well as access to the appropriate level of care and treatment.  Additionally, women receiving high or medium secure care in England have no right to appeal against their detention in conditions of excessive security in the way that they would have in Scotland.

There is agreement there should be high secure services for women located in Scotland.  There is disagreement however as to how that should be done.  The Forensic Network Women’s Services and Pathways options appraisal narrowly recommended a national high secure service for women be developed through co-location of high secure within one of the existing medium secure units.  The second-placed option was to develop a women’s service within the State Hospital.  The report noted a significant divergence of views between which of these was the best option.  The evidence received by the Review confirmed this significant difference of opinion remains.

The proposed co-location solution is seen to offer smoother transitions for women as well as a more flexible use of resources in response to the potentially fluctuating demand.  However, as the Forensic Network’s report highlights, the timescales of delivering the proposed co-location solution could be significant.  NHS Lothian agreed to consider this proposal further, looking at how this could be realised within the Orchard Clinic, its medium secure unit.  This consideration raised concerns about its feasibility and emphasised that progression on these developments should not be rushed.

The proposal to develop a women’s service within the State Hospital was considered a better alternative by most people who spoke to the Review.  They acknowledged that detention at the State Hospital could be extremely isolating for women due to the very low numbers requiring high secure care at any one time.  However, many clinicians and managers pointed to the existing spare capacity and the relative speed with which this could be achieved set against the time and cost associated with any new build.  They felt women would gain greater access to family and social support, years earlier, if this model was adopted.

The severity of the concerns about high secure provision for women are such that the Review considers arrangements need to be made urgently to provide high secure care for women within Scotland.  It recommends that the high secure service is provided within the State Hospital in the immediate future.

Recommendation

Recommendation 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.

4.2 Women’s pathways in forensic mental health services

There is a lack of co-ordinated forensic mental health pathways for women.  The original configuration for forensic mental health services outlined by the Scottish Executive in 2006 suggested that the needs of women with mental illness could be addressed by one national medium secure unit, regional low secure units and community based specialist services.  This is not the configuration that developed.  The Orchard Clinic in NHS Lothian and Rowanbank Clinic in NHS Greater Glasgow have medium secure beds for women but they are not nationally funded.  This means beds can be purchased by other areas but only on a ‘spot purchase’ basis when capacity allows.  There was no regional co-ordination in the development of low secure provision.  As the interim report said, many NHS Boards rely on independent or out of area provision if they require low secure provision for a woman. Or, they place women in services which do not best meet their needs or aid their recovery, like intensive psychiatric care units (IPCUs).  This lack of a clear pathway to access and progress through forensic mental health services for women needs to be addressed.  Given the relatively small numbers of women involved, the Review found a general consensus that there needs to be a national or regional solution.

The Forensic Network’s Inpatient Census reported 65 women receiving forensic mental health services in November 2018.  This number reduced to 37 in November 2019, 10 of whom were in medium secure.  The overall reduction is primarily the result of the Ayr Clinic, one of the independent providers of low secure care, recording 30 fewer women in its return than the previous year.  This was because they realised that these women did not meet the definition of ‘forensic’ set out by the Forensic Network for its census.  The variation in these figures suggests that women may be disproportionately affected by existing ambiguities around the remit of forensic mental health services (discussed in Section 3).  The Forensic Network’s definition of ‘forensic’ for its census focuses on people who are detained and treated under a criminal section of our mental health legislation or who have previously been detained in high or medium secure services.  It is recognised that this does not capture a group of people who are nonetheless cared for in low secure services.   These people do not have offending histories but have been transferred into these secure settings because their behaviour has not been able to be safely managed by generic services.^[11]

The Review met a number of women in this category during its visits to low secure services.  Many of them had a primary diagnosis of personality disorder.  Their care and treatment was supervised by forensic clinicians in the Ayr Clinic and in NHS Forth Valley.  Neither service considered these women to be ‘forensic’.  They need the skills of forensic specialists however to help them manage the risk of harm to themselves (as opposed to risk of harm to others).

4.2.1 Transferring women from prison to hospital

People raised concerns about prison transfers for women.  The lack of forensic beds for women was felt to contribute to difficulties in transferring women from prison when they need secure hospital treatment.  These concerns align with the findings from the European Committee for the Prevention of Inhuman or Degrading Treatment report on Scottish prisons in 2019.  Their report found that while transfers for men were possible, the situation for women was entirely different.  It suggested that the lack of high secure facilities appeared to play a key role in decisions to keep women in need of psychiatric hospital care in prison.^[12]

Following the interim report, the review sought additional evidence from clinicians involved in the transfer of women from prison to forensic inpatient services.  They argued that provision of high secure services for women would not, in itself, address the issues they face.  This is because women’s level of offending more often meets the criteria for low or medium secure care.  As such, it is the provision in these settings alongside a lack of IPCU provision in the women’s local area that creates many of the difficulties and delays they experience when trying to agree transfers.  Another reason is that even when beds are available, community admissions will be prioritised over prison referrals as they need to be brought to a place of safety.  There are concerns that this lack of access to beds for women in lower conditions of security may be creating a higher threshold for referring women out of prison than men, resulting in them potentially carrying a higher degree of psychiatric morbidity.

An additional limitation in the options for women in prison is that they can often present with complex trauma or behaviours that represent more of a risk of harm to themselves than others. If there is no diagnosed mental illness hospitals will be reluctant to admit, leaving nowhere for these women to be transferred to.

The Forensic Network established a system for monitoring transfers from prison to forensic mental health services in 2018.  It reports five transfers from HMP Cornton Vale between February 2018 and May 2020.  The Review considers it likely that this under-represents female transfers.  NHS Forth Valley clinicians told the Review that there had been at least another four transfers by May 2020, and 11 altogether in the first 10 months of 2020.  They also provided the length of time for referral for five transfers.  The average length of time between referral and transfer was 43.2 days.  A recommendation relating to data collection on prison transfers is made in Section 5.5.2.

The Forensic Network’s Women’s Service and Pathways report makes recommendations regarding the future of medium secure and low secure provision for women.  The Review recommends that the Short Life Working Group set up in response to the Forensic Network report is reformed to consider how the issues around women’s pathways should be addressed.

Recommendation

Recommendation 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 in 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.