Independent Forensic Mental Health Review: final report

5 Recommendations: Capacity and transitions

Forensic mental health services should be underpinned by an ethos of rehabilitation, recovery-focus and reciprocity.  As such, people need to be able to move, or ‘progress’, from higher levels of security through lower levels of security and back into their communities in a timely way.  Currently, however there are waiting lists for services at low and medium security.  This means that people’s transitions between secure service and discharges to the community are being delayed.  As they wait, they are not being held in the least restrictive conditions necessary to manage their risk.  This risks breaching their human rights.  There is an appeal process for people who think they are being held in conditions of excessive security at high and medium security levels but not at low.

Delays in transfers and discharges risks people becoming de-motivated and more vulnerable to further mental health setbacks and greater institutionalisation.  Occupational therapists working in one low secure setting described how they found themselves having to develop new interventions to address issues for people that would not have occurred if a person had been discharged when they were first deemed ready.  This situation is clearly counter-productive and conflicts with the principles of a recovery-oriented service and reciprocity.  Keeping people unnecessarily in conditions of higher security also constitutes over-treatment and so represents low value health care.

The evidence in the interim report was clear that there was an issue with timely transitions through and out of forensic inpatient services.  The Review met people waiting for accommodation to be identified to support discharge.  Many people also spoke about the delays they experienced in transferring to conditions of lower security as they had to wait for beds to become available.  One person in a low secure ward explained that there is ‘always a waiting list for moving’.  However, lack of capacity in the system also impacts on the ability of services to respond to emergency referrals from courts, prisons, the community and general adult services.

Clinicians spoke of finding it difficult to get a bed in either medium or low secure when they needed it.  They explained that, ideally, forensic services should operate at around 80% capacity.  This would allow the system to manage emergency admissions and transfers, as well as support the needs of people already in wards more therapeutically.  They spoke however of the current system operating at 100% and people being placed on the basis of who it might be least disruptive to move or where there was a bed rather than on clinical need.  The requirement for clinical teams to constantly reprioritise and move people in response to new admission requests was witnessed by the Review team on more than one of its visits.

There are other indications that the system as a whole is under pressure.  Data from the Mental Health Tribunal for Scotland (the Tribunal) confirms that people in both high and medium security continue to make applications about being detained in conditions of excessive security.  People in high security have been able to make applications against their detention in conditions of excessive security since 2006.  This right was extended to those detained the Scotland’s medium secure units in 2015.  Applications require to be supported by a report from an approved medical practitioner and nearly all of them are granted.  However, a high number of cases return automatically to the Tribunal as the person has not been transferred to the conditions of appropriate security within the time period determined by the Tribunal (which cannot be more than three months).

In 2019, there were 14 applications from people being held in high security, only one of which was refused.  The Tribunal held second hearings for eight cases where the person had not yet been transferred.  That same year, there were 13 applications from people in medium secure units.  Ten of these were granted (three people were transferred prior to the hearing).  The Tribunal held second hearings for 12 cases they had previously granted, only one of which was refused.  This supports the evidence in the interim report that these applications are driven by a lack of beds at the right security level, rather than disagreements over the appropriate level of security itself.  This creates pressure to hold Tribunals that would not be necessary if beds were available.  It also points to a system unable to effectively manage capacity in a person-centred, therapeutic manner and services that are often required to engage in brinkmanship when it comes to these appeals.  The number of applications made to the Tribunal is also likely to under-represent the number of people who are being held in conditions of excessive security over this time.  This is because, as the interim report detailed, not everyone who is entitled to appeal chooses to do so.  One person, for example, explained to the Review that they had decided not to appeal, because even if they won, it was ‘not as if a bed is magically going to appear’.

Another indicator of capacity issues is that people continue to be admitted to the State Hospital under the Exceptional Circumstances Clause.  This process allows for a person, even though they do not require high secure care and treatment, to be cared for at the State Hospital for short periods of time when there is no bed available elsewhere.  Data from the State Hospital shows that people can be waiting in excess of 6 months under these circumstances before a space becomes available in the appropriate level of security.

The State Hospital started charging other Boards for these beds in April 2019.  Costs charged in this first year were £1.1 million, split between seven Boards.  Between 2015 and 2018, there was an average of three exceptional circumstance admissions each year.  In 2019, this increased to seven.  In 2020, the State Hospital capped the number of exceptional circumstance admissions to eight.  This was initially as a result of arrangements put in place in response to the coronavirus pandemic, and then as their own patient numbers increased.  As such, the Forensic Network reported in August 2020 that this ‘compensatory mechanism for medium secure overflow is close to being exhausted at present’.

The Review also met, and was told about, people who were receiving their care and treatment outwith their local or regional services due to lack of provision or available beds in their own area.  These out of area placements place people further away from their support networks.  They were reported to be more common for women and people with learning disabilities.  The data the Review received from services about their out of area placements was incomplete.  It did however show that the vast majority of NHS Boards have at least one person receiving forensic care and treatment out of area.  Eleven Boards provided the Review with information on how much they had spent on out of area forensic care in 2019-2020.  This totalled over £13 million.  While this includes costs for independent care and provision in England, a considerable proportion of this is cross-charging between different NHS Boards within Scotland.

If actions are not taken to address the issues of capacity and the impact it is having on people moving through the system, the system is in danger of grinding to a halt.  People must have access to the care and treatment they need in the correct level of security.  There are two areas that require immediate attention: the pressure on medium secure beds and delays in the discharge process that are creating a bottleneck of people waiting to leave low secure service.  Until the latter is better understood, monitored and addressed, the full extent of the capacity issues across the system as a whole will remain unclear.  To allow for more effective monitoring and management of capacity and transition issues longer term, a robust data management and monitoring system that covers forensic mental health provision across all levels of security and community provision must be developed.

5.1 Data collection and reporting

There are key gaps in the data collected and reported on around forensic mental health services.  This makes it hard to assess how the system as a whole is performing.  In particular, data needs to be collected to allow monitoring of community forensic provision, waiting times for transfer between services (including transfers from prisons) and delayed discharges.  The Review was also surprised that no one is monitoring how long it takes for a person to complete their rehabilitation journey from initial admission into forensic mental health services until their discharge.  Data is only reported on how long people spend at each level of security.

The Scottish Government and the Forensic Network collect annual data on the number of forensic inpatients in Scotland.  They use different definitions to identify the forensic inpatient population and are snapshots of different moments in time but both indicate that the forensic inpatient population in Scotland sits at around 500 people.

Table 1: Total number of forensic inpatients in Scotland*

	2013	2014	2015	2016	2017	2018	2019
Forensic Network Census	522	502	526	456	503	510	478
Scottish Government Census	-	507	-	496	522	516	525
(within NHS Scotland)	-	507	-	458	484	475	488
(placement outwith Scotland )	-	-	-	38	38	41	37

* The Forensic Network’s Inpatient Census provides an overall total that includes people in independent provision within Scotland.  The Scottish Government Census reports numbers for people receiving their treatment from NHS Scotland separately from those who receive treatment out with NHS Scotland.

There is no equivalent national data collection that captures the number of people receiving community forensic mental health services.  Scottish Ministers monitor the number of people who are subject to a compulsion order and restriction order, who have been conditionally discharged into the community.  As of December 2020, there were 63 people, but this is only one very specific group of people receiving forensic mental health services in the community.  The Review asked the services in each NHS Board how many people were being looked after by community forensic mental health services across Scotland.  Not all services provided this information, leaving the Review unable to shed any further light on this neglected but integral part of the system.

The Review repeatedly met, and was told about, people waiting to transfer to conditions of lower security people or waiting on community provision to support their discharge.  However, there is no central collection or reporting on where people are waiting, or for how long.  The Forensic Network collates weekly bed position figures for the high and medium secure units.  This includes the number of people waiting to enter and leave these services but not the length of time people are waiting.  No bed position figures are collected for provision at low security.  Responses to the Review from services across NHS Boards indicated there is no consistent approach to monitoring and reporting on delayed discharges from forensic inpatient services.

Both the Scottish Government and Forensic Network annual surveys collect the average length of time people spend in their current hospital setting.  In 2019, the Scottish Government reported the average time since admission for a forensic patient was two years and five months.  It reported 48% of people had been admitted to their current unit between one and five years ago.  28% had been in the same place for over five years.  The Forensic Network’s annual census reported an average overall mean admission length of 1618 days (4.4 years).  It also provided a breakdown of this by security level.

Table 2: Mean length of admission by security level

Security level	Mean length of admission
High Secure	2195 (6.01 years)
Medium Secure	998 (2.73 years)
Low Secure[13]	1586 (4.34 years)

Source: Forensic Network Inpatient Census (2019).

Table 2 shows that people spend a number of years in each security level.  While there are people who will spend significantly less time in forensic inpatient services, many require to progress through more than one level of security as part of their rehabilitation journey and so will be with the services for significantly more time.   If a person currently in low secure services had spent the average length of time progressing through each security level as outlined in Table 2, they would have been in forensic inpatient services for over 13 years.  However, no one is monitoring or reporting on the actual total length of time it takes for a person to complete their rehabilitation journey through these services.  The Forensic Network advised that it is developing an Inpatient Database that will allow data from the entirety of a person’s admission into forensic inpatient services to be examined.

It was people receiving the services who spoke to the Review in terms of the entirety of their time in forensic mental health services.  One person in a low secure ward spoke of their ‘slow and steady’ progression from high secure.  Overall, it had taken them 12 years and they reflected that they felt that for them, that timing ‘was about right’.  Another felt that there were predetermined times to get through different parts of the system.  They suggested it takes between 10 to 20 years to progress from high secure to discharge.

Recommendation

Recommendation 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).

5.2 Pressures on medium secure services

As mentioned above, the Forensic Network collates the weekly bed positions for high and medium secure units.  In August 2020, it completed a longitudinal analysis of this data from July 2018 to July 2020.  Over 2019 and 2020, there was an average of 23 people waiting to transfer from high security to medium security each week.  It does not collate the length of time people are waiting.  The Review requested additional data from the State Hospital.  This showed that in November 2020 there were 13 people waiting to transfer from high security.  They had been waiting between 7 – 22 months.

The Forensic Network’s analysis concluded that the medium secure services for people with mental illness remain ‘under significant pressures’.  It also suggested that medium secure services have been running at or close to capacity since 2016.  It calculated that if all of the people waiting to transfer from medium security to low security could do so, there would be some capacity across the medium secure estate in Scotland as a whole, but that Rowanbank would still have a waiting list.

During the Review’s visits to the medium secure units in autumn 2019, Rowanbank reported there were 20 people waiting for admission (including people currently in medium secure provision out of area) and 10 people waiting to move on.  The Orchard Clinic had only started to have a waiting list for it service over that last year.  It had seven people waiting to access its service and seven people waiting to transfer out.  Rohallion reported that it typically had at least one bed available.  The Review followed this up with each of the units in October 2020.  At that time, Rowanbank had 18 people waiting for admission (including those in medium secure provision out of area) and 11 waiting to transfer to conditions of lower security.  The Orchard Clinic had seven people on their waiting list and 10 people who were identified for discharge, including to conditions of lower security, or whose discharge was delayed due to lack of accommodation in the community.  Rohallion had no one on their waiting list but had five people waiting to transfer to low security.^[14]  These numbers illustrate how the lack of beds available in low security is impacting on the ability of medium secure units to progress people through their service in a timely way.  Only Rowanbank would continue to have a waiting list for admissions if all the people waiting to transfer out could do so.

NHS Greater Glasgow and Clyde is alert to these issues.  They have been considering expansion plans for Rowanbank since 2013.  A full business case for an additional 18 beds was completed in 2018.  Progress on this had been postponed pending the outcome of this Review.  Delays in progressing this are a source of frustration for staff there.  In the meantime, the majority of applications against detention in conditions of excessive security continue to be brought against NHS Greater Glasgow and Clyde.

The medium secure estate is under pressure.  On a national level, if movement of people to low secure were to improve, figures suggest that medium secure services could operate within its current capacity.  However, this would still be at a relatively high bed occupancy rate.  This would limit its ability to respond to emergency admissions from prisons, courts or general adult services.  It would also not prevent continued waiting lists for Rowanbank.  The Review therefore supports the proposal to extend Rowanbank.  This should reduce the number of cases of people being held in conditions of excessive circumstances or under exceptional circumstances in high secure.  It would also provide the opportunity for people currently placed out of area across the medium secure estate to be returned their home Health Board’s regional unit, with the resultant benefits for the person, their family and their wider support network as well as the service itself.

It will be for the new Forensic Board to review the extent to which this increased capacity in the West impacts on the capacity across the system in the longer term.

Recommendations

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

Recommendation 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.

5.3 Delays affecting discharges into the community

As the previous section outlined, medium secure services are being negatively impacted by the lack of capacity in lower secure settings.  People spoke of a ‘bottleneck’ in the system at low secure caused by delays in people being discharged from these services.  The issue most often cited for these delays, and the consequent lack of available beds, was difficulties identifying appropriate accommodation and support packages in the community.  These issues were said to particularly affect people with more complex needs, including co-morbidity or learning disabilities.  Section 7.1 considers people with a learning disability in more detail.

5.3.1 Community accommodation and support packages

The successful rehabilitation of people through forensic inpatient services relies ultimately on there being places and support available for them to return to in the community.  People told the review however that a lack of suitable accommodation and support packages with appropriately trained staff is leading to some discharges being excessively delayed sometimes for years.  One Community Forensic Mental Health Team member suggested, ‘it is not health that is holding up the process, it is accommodation’.

Family members felt like no one was taking responsibility for making the necessary arrangements in the community.  One said that ‘social work blame the NHS and vice versa’.  Section 25 of the Mental Health (Care and Treatment) (Scotland) Act 2003 specifies that local authorities ‘shall’ provide the necessary care and support services (including residential accommodation) for people with a mental illness who are not in hospital.  However, requirements for people in hospital are less stringent; local authorities ‘may’ provide such services.  It seems that people at the point of starting the discharge planning process on the forensic pathway can be left in a netherworld between ‘in hospital’ and ‘not in hospital’ where no one is fully accountable for ensuring that the necessary arrangements are made.

As the interim report set out, people in hospital under a compulsion order with a restriction order (sometimes referred to as a CORO), a hospital direction or a transfer for treatment direction are subject to special restrictions.  These ‘restricted patients’ need to have particular stages of their progression agreed by Scottish Ministers.  Their Responsible Medical Officer or Mental Health Officer must inform the Restricted Patients Team in the Scottish Government of any undue delay in identifying accommodation.  An official will then write to the relevant Director of Social Work.  One team spoke positively about being able to take course of action which had helped accommodation to be identified.

The principle of reciprocity very much extends to a person ultimately being able to access the accommodation and support identified as necessary for them to be discharged.  Financial restraints preventing or delaying the necessary support being put in place are indefensible from a human rights perspective.

A person in forensic mental health services can spend several years having their liberty restricted.  This naturally leads to them losing any tenancy they previously had.  On completion of sufficient progress with the treatment that society has deemed that they need to comply with, they should then have sufficient priority placed on their housing needs, by the local authority, to enable them to resume their life in the community.  Sufficient priority makes no difference, however, if appropriate accommodation or support is simply not available.

Clinicians are concerned about the lack of variety of provision in the community to meet the many models of care required for people leaving forensic mental health services.  They stressed the need for more creative or responsive housing models rather than reducing choices, as some areas have, to either single occupancy tenancies or supported accommodation as these cannot meet the needs or wants of everyone.

These issues also exist within the wider context of the recruitment and retention issues facing social care providers.  Successful support packages rely on there being people appropriately trained, supported and remunerated to staff them.  Staff spoke of having been placed in the difficult position of having to consider inferior support packages that did not meet all of the requirements they had identified for a person’s discharge, knowing that do so would be effectively setting the person up to fail.

Providers of support packages in the community are commissioned by bodies such as Health and Social Care Partnerships, local authorities and the Scottish Government.  Commissioners should ensure the remuneration structure for support workers working with people leaving forensic mental health services, is such that skilled, knowledgeable workers are retained in these specialist services.

Data is not collected on the number of people in low secure settings who are waiting on accommodation or a support package to support their discharge.  The length of time that they have been waiting is also not collected.  As explained earlier in this report, the Forensic Network collates weekly bed positions for the high and medium secure units which include the numbers of people waiting to access and transfer out of these services, but do not currently collect the same information for low secure settings.  When the Mental Welfare Commission visited low secure wards in 2017, it identified 61 people who were waiting to move on to either a rehabilitation setting or the community.  In autumn 2020, the Review asked low secure services for similar information. The information that was received indicated that 52 people were waiting for accommodation.  The time they had been waiting ranged from three days to 5.5 years. Three services reported no delays.

The Review also asked how each service reported these delays.  Most did record delays but the methods varied.  People suggested that the current methods used underestimate the number of people affected.  They also highlighted a lack of parity between how these delays were reported and monitored in acute (physical health) services.  An additional issue is that the time at which a discharge becomes delayed can be harder to pinpoint for restricted patients.  This is because they require to go through a pre-discharge process which relies on accommodation being identified.  They then need to have a series of overnight stays in this accommodation before their Responsible Medical Officer is able to apply for conditional discharge.  As such, for them, it is any delay in progress towards conditional discharge as the result of waiting for accommodation or support packages that need to be captured, monitored and reported.

People should not be waiting excessive lengths of time for accommodation or support packages to support their discharge.  They should certainly not be waiting years as the Review heard some people have been.  Most of these people have been progressing through the forensic system for a number of years by the time they reach this point in the rehabilitation journey.  Their arrival at this point should be a surprise to no one.

Recommendations

Recommendation 8: The data management system developed for forensic mental health services by the Information and Statistics Division (ISD) of NHS National Services Scotland must 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.

Recommendation 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.

Recommendation 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.

Recommendation 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.

Recommendation 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.

5.3.2 Appeals against conditions of excessive security in low secure settings

There is general consensus that the difficulties exiting low secure services are made worse because there is insufficient legal redress for people who remain in low secure settings for reasons other than clinical need.  As explained earlier in this report people in medium and high security can make an application to the Mental Health Tribunal for Scotland (the Tribunal) if they feel they are being detained in conditions of excessive security.  People in low secure services cannot.  There was widespread agreement that an equivalent right is needed for people in low secure services.

People in low secure services should have the same rights as people elsewhere in the system in respect of challenging the conditions in which they are detained.  There also needs to be a legal mechanism to address the issue of people’s discharge being delayed because of a lack of community resources.  This mechanism needs to extend beyond people solely in low secure services as people can be discharged into the community from other levels of security.

Recommendations

Recommendation 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.

Recommendation 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.

5.3.3 Discharge planning processes for restricted patients

Restricted patients need to have particular stages of their progression agreed by Scottish Ministers.  This includes transfers between hospitals or authorising any leave from hospital.  The steps required to get these agreements are set out in the Scottish Government's Memorandum of Procedure on Restricted Patients (MoP).  Clinical teams reported using similar procedures for non-restricted patients (minus the need to seek Ministerial approval).

The identification of accommodation is a key part of the pre-discharge process for restricted patients, alongside its approval by Multi-Agency Public Protection Arrangements (MAPPA) and a carefully thought out plan of Suspension of Detention (SUS).  This plan is expected to include a series of overnight stays in that accommodation.  The MoP expects that a person subject to a compulsion order and  restriction order will complete at least four months of overnight stays prior to conditional discharge.  It also expects the person to build up from one night per week to a maximum of four nights per week in monthly increments.

Clinical staff and people with lived experience felt that this pre-discharge process could be streamlined.   The Review was told it was ‘clunky’, not responsive to individual need and left beds empty on wards for significant periods of time.  The Review feels that some of these concerns may be based on either a lack of understanding of the degree of the existing flexibility available within the MoP or the frequency with which Responsible Medical Officers choose to make use of the flexibility.  The MoP is a long and complex document which may add to confusion around what it does and does not say.  The Scottish Government is in the process of updating it.  This provides an opportunity to review any administrative aspects of the discharge process that could be streamlined, while continuing to appropriately support people’s successful discharge and protect the public.  It is also the time to provide it in an accessible format to allow for greater transparency and understanding.

The staged progression of overnight stays to accommodation set down in the MoP has implications for a person’s finances.  Social security benefits to assist with housing costs are not available until the person is spending over 50% of their time in the accommodation.  That would not be until the four-night stage.  This means that for people who are eligible and reliant on these benefits, there is a period of time during which they require to go into debt to pay for their accommodation for the earlier testing stages in their accommodation.  This adds an additional risk factor into what is already one of the highest risk transition points in a person’s rehabilitation.

Recommendations

Recommendation 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.

Recommendation 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.

Recommendation 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.

5.4 Community forensic mental health teams

Community forensic mental health teams (CFMHTs) play an important role in helping people to safely discharge from inpatient services and remain well in the community.  They also support people through acute periods of mental ill health, helping them to avoid unnecessary returns to forensic inpatient services.  However, as the interim report highlighted, people in these teams described themselves as the ‘poor relations’ in terms of resources and service development within the forensic mental health system.

Community services have been developed at a local level.  There is no standard service specification for CFMHTs.  It is unsurprising then that the Review found that the remit, referral criteria and staff composition for these teams vary.  They are also not available in all parts of the country.  This creates inequity in service provision depending on where a person lives.

There are variations in CFMHTs’ referral criteria.  Some services accepted referrals predominately or solely from forensic inpatient services.  Others accept a broader population, taking referrals from GPs, social workers and prisons.  These variations mean that people leaving prison or people who have a personality disorder diagnosis may be accepted by some CFMHTs and excluded by others.  Some staff felt the remit of community forensic mental health services needed to be reviewed and discussed, particularly the extent to which they should be supporting people who are not subject to restriction orders or do not have a history of compulsory detention.

There is little guidance about the professional composition of CFMHTs or appropriate staffing ratios.  These aspects of the teams therefore also vary between areas.  There was however consensus about the importance of multi-disciplinary working at a community level.  CFMHTs require fully multi-disciplinary staff teams in order to manage the diverse needs of those on their caseloads.  Social workers have an especially important role here, for example, supporting the development of accommodation options and support package arrangements.  There is also a requirement to liaise with MAPPA about people on restriction orders and many people managed by CFMHTs receive support packages from community third sector providers.  Where CFMHTs remits include managing people who have previously been detained in prison, they need staff members able to work more closely with the criminal justice system.

Community service resource and development should be given its due place in whole service planning.  There has been a disparity in attention and provision for these services compared with medium and high security.  Some CFMHTs reported not being able to meet the demand for their services.  Others had experienced staff not being replaced when they left.  If progress is made in addressing the bottleneck of people waiting to be discharged from low secure services, a growing number of people will require management under CFMHTs in the coming years.  They must be appropriately resourced to meet this demand.  Estimates of demand should consider that, at present, people on the pathway from low secure units to a CFMHT are not typically expected to be managed by generic mental health services for many years.  Some may never move on to generic services.  If CFMHTs are to operate with a broader remit than referrals from forensic inpatient services, this will also require additional resource.

Recommendations

Recommendation 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.

Recommendation 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 project the demand for CFMHTs over the coming years.  This should inform what additional resources may be required by CFMHTs to meet future demand and be factored into its planning.

5.5 Prison issues

5.5.1 Mental health services in prisons

The Review was asked to consider the delivery of forensic mental health services in prisons.  As set down in the interim report, in seeking to look at the specifically ‘forensic’ mental health services in prisons, the Review concluded that the current provision of ‘forensic’ services is limited, in the main, to visiting forensic psychiatrists who are primarily doing a general adult psychiatrist primary care role e.g. treating depression, anxiety and stress disorders.  There is little work that is actually forensic in nature.  Mental health nursing input does not come from a forensic specialism but rather from a community mental health nurse perspective, with a focus around primary care nursing, both physical and mental health, with little or no learning disability nursing input.

A distinction was therefore drawn by the Review between the specialist forensic mental health in-reach services to prison and the provision of general mental health care in prisons.  The Chair felt strongly that the latter sat outwith the remit of the Review.  If it were to be included, he felt it had the potential to dwarf issues specific to forensic mental health provision.  Prior to the publication of the interim report, he wrote to the Minister of Mental Health on this basis.

The Chair confirmed to the Minister that the review would not be looking at prison healthcare in the general sense but would continue to look at the referral process from prison into the forensic system.  The Minister accepted this.  The Chair noted that prison healthcare was an important and complex area of healthcare that should be subject to its own review, and which may more usefully consider the provision of both physical and mental health care in prisons together.  Working group members also felt it was worthy of a separate review and generally acknowledged the pragmatism of this approach.  The Review wants to equally acknowledge here, however, that some members felt, and continued to consider any mental health care provided in a prison is forensic and so part of forensic mental health services.

5.5.2 Transfers between prisons and secure hospitals

People in prison can be transferred for forensic mental health treatment in hospital.  Evidence provided for the interim report suggested these transfers for men take place relatively quickly, with positive comparisons made to the time taken elsewhere in the UK.  Section 4.2.1 has more detail about transfers for women.  The Forensic Network started monitoring transfers from prison to forensic mental health services in February 2018.  By May 2020, it had recorded 70 referrals.  The average length of time for transfer following an urgent referral was 11.4 days.  The average length of time for non-urgent referrals was 27.4 days.  The time taken for transfer is calculated from ‘referral’ but it is not clear which part in the transfer process this refers to.  The Forensic Network suggests it is typically the date on which the referring psychiatrist approaches a hospital service to request a further assessment and potential transfer, but recognises that there remains ambiguity about this.

The Review was told by staff about the multiple referrals, assessment and delays that can occur throughout the process.  For example:

• it can take time to obtain the necessary detail about the person’s full offending history, which is required to assess the appropriate level of security required;
• an initial referral for a high secure bed may be turned down which then requires a subsequent referral to made to a medium secure service; and,
• a person requiring medium secure care will be assessed by their regional unit, but they may have no available bed and so a subsequent referral and assessment needs to be done by a medium secure unit that does.

The prompt transfer of people in prison requiring care and treatment in hospital is critical.  However, in a system where waiting lists are operating at medium and low secure services, prison transfers can impact on the progression of people already within the hospital system.  This is because the transfer of acutely unwell prisoners is likely to be prioritised over someone waiting to transfer from a higher level of security where they are known to be stable and well in a clinical environment.

The Review considers that the data collected by the Forensic Network on transfers from prison to forensic mental health services may be underestimating the time the process takes from start to end.  It is not clear that the ‘date of referral’ from which the length of time is calculated at present is consistently interpreted or captures all the steps that have to take place prior to any formal referral being made.  Furthermore, given the voluntary basis on which the Forensic Network receives any data, the Review is concerned that it is not receiving the full information on the number of these transfers.  As noted in Section 4.2.1, this is a particular concern in relation to women.

The Review was also concerned by the repeat assessments for referrals to medium secure units.  This is linked to the current lack of capacity when a bed may not be immediately available in the person’s regional medium secure unit.  A person is initially assessed by their regional medium secure unit.  If they are assessed as suitable for admission but there is no bed, they are then referred to a medium secure unit where there is a bed.  This unit then carries out their own assessment.  This repeat assessment process is not in the interests of the person in prison requiring forensic mental health hospital treatment.  It seems to add additional delays into the process to reassure the professionals within it.  The Review heard evidence that at least one person inflicted further self-harm upon themselves in prison in the time taken between two such medium secure assessments being done.   It was suggested to the Review that there should be a single point of referral for access to medium secure services.

Recommendations

Recommendation 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 services from prisons.

Recommendation 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.