Independent Forensic Mental Health Review: final report

6 Recommendations: Person-centred practices

6.1 Care and treatment

6.1.1 Multi-disciplinary working practices

Multi-disciplinary team (MDT) working is the bedrock of high quality forensic mental health services.  It refers to the collaboration between staff from different clinical professional backgrounds, including social work, to manage the care of people with complex health and risk management needs.  It underpins holistic care and treatment, helping to ensure that people receive appropriate and timely interventions.  Each member of the MDT brings a different perspective, a different skillset and a different way of working with people.  It is this collective approach that adds value to a person’s treatment and it is important each area of expertise is afforded appropriate respect and influence in decision-making.

Staff reported that good multi-disciplinary and multi-agency working is associated with better outcomes and reduces distress for people receiving care and treatment.  However, when this fails was associated with negative outcomes such as people not receiving the services they require.

Terminology and language can be an insight into how a person or system functions.  The interim report recorded concerns about the ongoing dominance of a ‘medical model’ in forensic mental health services.  Overall, this Review has not seen evidence that forensic medical professionals are failing to adopt a ‘whole person’ or ‘biopsychosocial’ approach to care and treatment.  However, the Review team did find that the phrase ‘medical model’ was used to raise concerns about medical dominance within MDTs.  Partly this dominance occurs because of responsibilities and accountabilities set down in legislation.  Whilst acknowledging this, the Review considers the over reliance on one discipline for decision making to be unhelpful and detrimental to whole system care, wrapped around the need of individuals.

Equally, the Review team was disappointed to witness failures to treat multi-disciplinary professionals with parity of esteem.  For example, the Review Team heard the term ‘my nurses’ used more than once, by other professionals, in discussions.  Nursing is a profession in its own right, and its practitioners carry their own professional accountability and autonomy of practice.  Neither nurses nor other professional groups ‘belong’ to other professionals.

Many people highlighted examples of integrated and collaborative MDT working well at a local level.  They indicated that good MDT working is supported by clear guidance about different professions or agencies’ roles and responsibilities and strong information sharing.

People said that when social work professionals are embedded in the forensic team then services are more co-ordinated around the needs of the individual.  In addition, Mental Health Officers and social workers frequently provide a degree of continuity and consistency as people move through the system.  They can provide a longitudinal perspective to assessments and a balance in MDTs as they have the independence and ability to challenge clinical decisions.  The Review was therefore disappointed to note that at present social workers were rarely embedded as core members of forensic MDTs.

It was highlighted several times that the Care Programme Approach (CPA) facilitated MDT involvement and communication.  These meetings should include representation from all the professionals involved in a person’s care, treatment and risk management in order to produce a multi-agency plan that addresses all of that person’s needs. Several people also flagged the use of an Enhanced CPA as good practice for people within the forensic system.

Recommendations

Recommendation 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.

Recommendation 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.

6.1.2 Participation and decision making

A commitment to person-centred practices means that people should be able to participate in decisions about their care and treatment as much as possible.  As the interim report stated, there are people who feel involved in choices about their treatment options, their medication and changes to the ward environment.  However, other people do not feel listened to.  They spoke about staff invalidating their advanced statement or producing reports about them that had not been discussed with them and with which they disagreed.  Other people reported uncertainty or gaps in their understanding of parts of the mental health system.  They felt that this information could be better communicated.

People must be given opportunities to access all the information they need to participate fully in their care and treatment.  This information must also be communicated in ways that they can understand.  This is important as Speech and Language Therapists and advocacy staff warn that the communication needs of the forensic population may be significantly underestimated.

Recommendations

Recommendation 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.

Recommendation 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.

Recommendation 26: General information and advice for people within the forensic 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.

6.1.3 Involving family and friends

As the interim report said, family members or close friends of people receiving forensic mental health services often felt like they were not sufficiently involved in decision-making processes.  Experience varied between different units.  People spoke of difficulties accessing information and feeling like staff failed to recognise their expertise.  They told the Review of times when their warnings about a deterioration in their relative’s mental health while in the community had gone unheeded – resulting in crises that might have been prevented.  All of this limits their ability to input into their relative’s care. It leaves them feeling more anxious and more likely to experience difficulties supporting their relative on discharge.

‘Respect for carers’ is one of the Millan principles upon which the Mental Health (Care and Treatment) (Scotland) Act 2003 is based.  As such, the role and experience of carers must be respected.  They should also receive appropriate information and advice and have their views taken into account.^[15]  They can provide critical information about their relative and are an integral part of their support network throughout their time in forensic mental health services.  Moreover, when people are discharged into the community, family members frequently play a lead role in their care.  It is therefore vital that they have access to relevant information about their relative’s care and treatment.  While issues of confidentiality and consent must be respected, there is much that can be done to proactively support and engage family members.  The Care Programme Approach (CPA) supports their involvement.  Unfortunately, however, some family members told the Review they had faced ‘clinical defensiveness’ at CPA meetings.  The Review also heard that clinical teams could be inflexible about the timing of these meetings, making it difficult for family members to attend, especially if the person was being cared for out of area.

Family members spoke of how little they understood about forensic mental health services when their relative was first admitted.  They wanted to be given more information right from the start.  They spoke of having to ‘pick things up as they went’ and relying on peer networks to help them understand what was happening.  While these peer networks were valued, family members wanted dedicated carer support staff or advocates to help them navigate the system.  They also expressed a need for direct access to training to support them to look after their relative.  It was felt that  staff needed to be more aware of carers’ rights and options, with carers' organisations emphasising the rights not only under the Mental Health (Care and Treatment) (Scotland) Act 2003 but the Carers (Scotland) Act 2016.

Carers’ organisations said that their staff can also be unfamiliar with the forensic system and that this can be a barrier to family members getting the support they need.  They felt they needed more information or training about forensic mental health services in order to support carers effectively.  They also told the Review that sometimes their input can be actively resisted by some services.  This is unhelpful and counter-productive.

There are people who are being cared for outwith their home Health Board area.  The travel costs involved for families can often make it more difficult for them visit.  The Review heard that financial support is available to family members of people who are detained in the State Hospital but not in other hospitals.  This creates an inequality both for the families and for those being cared for at a distance as it makes it harder to maintain their social networks and contacts.

Recommendations

Recommendation 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.

Recommendation 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.

Recommendation 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.

Recommendation 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.

Recommendation 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.

Recommendation 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.

6.1.4 Complaints

People who are subject to compulsory powers are in a vulnerable position when it comes to raising any concerns they may have about their care and treatment.  People explained that they would not complain for fear of punishment.  Others advised that in order to progress you needed to simply comply and ‘keep your head down’.  People and their families had experience of their complaints being dismissed as part of their illness or simply not responded to.  The Review was contacted by two families who have felt it necessary to go to the media as they feel their concerns are not being listened to by the hospital system.

There needs to be a transparent and trusted way in which people and their families can raise concerns they have about their care and treatment.  The development of a new Forensic Board provides an opportunity to design informal and formal feedback processes that address the specific vulnerabilities of people in forensic wards.

Recommendations

Recommendation 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.

6.1.5 Transfer of suspension of detention plans (SUS)

As explained in Section 5.3.3, restricted patients have to have any suspension of their detention (SUS) in hospital authorised by Scottish Ministers.  In 2017, the Mental Welfare Commission asked for the processes for granting SUS for restricted patients to be reviewed to ensure that people were not unnecessarily subjected to greater restrictions when they transferred from one hospital to another.  At the end of 2018, the Scottish Government issued guidance to all Responsible Medical Officers setting out how SUS plans could be transferred.  This Review found these new guidelines seem to have made no discernible change in practice, nor was the flexibility within the system to do this well known.  When asked about their top priority for change by the Review, people still most commonly said that they would like their SUS plans to be able to transfer with them.  People who had lost their SUS for sustained periods after their transfer to low security spoke of it feeling like they had gone ‘backwards’ or ‘not achieved anything’.  They spoke of waiting months to regain freedoms they had previously been granted elsewhere in the system.

Transferring to a new place and a new clinical team can be a period of increased risk for the person.  As such there needs to be a period of time after transferring to any new setting to allow the person to settle in.  It allows the person to get to know their new clinical team and for the clinical team to begin to understand them and their risk.  However, the reduction of previously earned SUS, for any significant amount of time, undermines the principle of reciprocity.  It also adds time to a person’s rehabilitation path and therefore the time they are detained.

Recommendations

Recommendation 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.

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.

6.2 Social and environmental practices

The interim report highlighted the importance of the ward environment on people’s experiences of comfort and safety.  When someone spends a significant period of time in hospital, services should be provided in environments that respect the individual, provide a degree of privacy and encourage them to believe in and value themselves.  As mentioned earlier in this report, people can spend a number of years receiving inpatient forensic mental health care and treatment.  Data from the Forensic Network’s census in 2019 reported that women had been in their current hospital for an average of 1349 days (3.7 years) and men an average of 1641 days (4.5 years).  Given these long stays, it is vital that the ward environments and social practices enable people to feel as ‘at home’ as possible and contribute positively to their rehabilitation.

People spoke to the Review about the importance of a therapeutic physical environment in forensic inpatient settings.  Factors including levels of privacy, crowding and sensory stimulus (like noise and imagery) can all affect people’s levels of stress.  As such, the nature of the physical environment can work to exacerbate or mitigate aggression.  This can then potentially affect the numbers of incidents in an inpatient environment.  Evidence points to a more therapeutic environment being one that:

• ensures people have space to regulate their social relationships;
• uses design features to reduce noise; and,
• gives people access to daylight and opportunities to go outside.^[16]

6.2.1 Physical infrastructure and fitness for purpose

Poor physical infrastructure has a negative impact on ward safety and security as well as care and treatment.  Proper upkeep is therefore important not only to keep people safe and secure but also to support people to feel valued and at ease.  Several responses to the Review from inpatient units highlighted concerns about the fabric of their buildings.  Staff highlighted elements of their wards that are no longer fit for purpose.  The Review saw examples of wards in many of the places they visited which, irrespective of age, were in need of more focused routine maintenance or were poorly decorated.  A smaller number of wards did not meet the physical standards appropriate to that level of security.

The physical layout of some wards is interfering with their day to day functions.  Several members of staff flagged up that older buildings lack dedicated spaces for delivering interventions such as psychological therapies.  This means that some people are unable to receive parts of their care and treatment in an appropriate setting.  Similarly, many families identified that dedicated facilities for visitors are absent or unfit for purpose.  The Review noted that the outdoor space available to wards on some units were limited in space.  This restricts access to recreation, exercise and therapeutic activities.  Some units have allowed these outdoor spaces to become overgrown with weeds and moss.  This may discourage people from using it and does not support people feeling valued.

The nature of communal and social spaces affects the atmosphere of a ward and can have a significant impact upon the experiences of people living there.  The Review was concerned by the limited size of free circulation and socialising space in many areas it visited.  A person’s access to personal space must be balanced with risk management requirements.  However, grouping people together in small areas for prolonged periods of time is likely to have a detrimental effect on mental wellbeing and distress levels.

Recommendations

Recommendation 36: The poor state of repair of current forensic 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.

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

6.2.2 Person-centred practices

Access to personal and private space is important to support individual dignity.  It also allows people to self-regulate their exposure to potentially stressful social situations.  The right to respect for private and family life is set down under Article 8 of the European Convention on Human Rights (ECHR).  It is not an absolute right but forensic mental health services need to ensure that any limitations placed on a person are proportionate and can be justified in terms of managing a person’s risk.  As noted in the interim report, the Review found considerable variations in social practices and restrictions related to this within inpatient environments.  These variations were often not explained by the differences in security levels.  Blanket rules are also applied in some areas rather than person-centred approaches.  These fail to support the individual autonomy and decision making necessary to ensure the service is recovery focused and rehabilitation orientated.

People highlighted the following variations as having a particularly significant impact on their wellbeing:

• freedom of access to their bedrooms and belongings;
• opportunities for private conversations; and,
• access to technology.

These concerns resemble those highlighted to the Mental Welfare Commission when it visited the low and medium secure estate in 2017.^[17]

The Review was disappointed to find people in one area were required to share rooms, including some in four bedded dormitory accommodation.  Individual bedrooms themselves were of variable standards with different rules being applied across the same levels of security, by different clinical and managerial teams.  There are still some low and medium secure wards preventing everyone accessing their bedroom for large parts of the day.  Staff explain this is to encourage participation in ward activities and discourage isolation.  However, other wards are taking a more person-centred approach where bedrooms are kept open.  If there are concerns about someone’s isolating behaviour, they are then encouraged and supported to spend time in the communal areas as part of their care plan.

It is important to people that they have some choice about the belongings they can keep on wards.  However, people spoke critically about the different rules in different services about the number and type of belongings they could have.  People worried about having to reduce how many belonging they had or no longer being allowed certain items due to different restrictions in different hospitals.  This was not only confusing for people, but added to the stress they felt about transferring between services.  As the interim report set out, people receiving care felt that decisions around these restrictions were not always based around an assessment of their need.  They felt decisions were made arbitrarily or depended more on the staff’s ability to keep track of belongings or available space on the ward.  The Review recognises the risk element related to the number and type of personal possessions a person has in their room, however, this should be balanced with a consistent, person-centred approach to the issue.

In addition to the lack of appropriate visitor’s facilities in some parts of the forensic estate, in several units people highlighted that ward layout or practices prevented them from conducting private telephone conversations with family or friends.  This lack of privacy was identified as a barrier to maintaining personal relationships.

The Review team witnessed other restrictive practices during its visits to inpatient units.  For example, people on a number of wards said that they were not allowed to use the kitchen to make their own cups of tea.  It is the view of the Review that such restrictions are infantilising and contrary to the principles of person-centred practice, rehabilitation and the least restrictive option.   As the interim report highlighted, people particularly appreciated when there were more opportunities use the kitchen, for example, to plan and prepare meals for staff and others on their wards.  In some areas the Review found evidence of professional silos further restricting access to kitchens and indicating a less than whole team approach to rehabilitation.  During a number of the Review’s visits, the kitchen was described as the ‘OT kitchen’ with its use restricted to sessions with occupational therapists.  This suggests that other members of staff were not involved in or were reluctant to support people to use these facilities.  Rehabilitation should not simply be the domain of one profession.

There are inconsistencies in the level of access that people have to technology including laptops, mobile phones, the internet and games consoles across and between security levels.  The Scottish Government the Forensic Network to set up a Communications and Specified Persons Short Life Working group to look at the use of communication and technology in mental health settings.  It initially reported to the Scottish Government in November 2018, but the Forensic Network has now been asked to update further in light of developments in the use of technology since then, including as a result of the coronavirus pandemic.

Technology is now a fundamental part of active participation in society.  It allows people to more easily access education, shopping, banking, benefits and the job market, as well as staying in touch with friends and family.  Ensuring that people have opportunities to learn the skills and knowledge to use technology safely and confidently as part of their rehabilitation pathway is critical, therefore, if they are not to be disadvantaged on discharge.  People the Review spoke to on forensic wards wanted staff to receive IT training in order to support them to develop these skills and also inform the development of less restrictive practices.

There should be a consistent, positive risk taking approach to the access of technology for people, supported by trained staff and educational programmes, across all levels of security.

Recommendations

Recommendation 38: Everyone subject to detention within the forensic system should have their own single room.

Recommendation 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 related to technology.

Recommendation 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.

6.2.3 Community placements

As part of a safe and successful rehabilitation programme, a person needs to have access to meaningful, structured activities.  These promote skills development, social inclusion, structured routine and employability prospects.  In the early stages of a person’s journey, when they are subject to greater restrictions, these will primarily be provided by inpatient services.  However, as they progress, people need to access community placements or vocational opportunities.  By providing these, consistently in both inpatient and community settings, the aim is that people gain more ownership over the activities they are involved in and recognise for themselves the benefit of a having a routine in its own right.  This can then be a protective factor once a person is discharged and has to adjust to the loss of the constant support and routine that was previously provided by the ward environment.  There is also an expectation that people will be able to demonstrate that they have successfully engaged in, and have in place, structured community activities to support any application for conditional discharge.

The Review heard that in some areas there is a worrying decline in the number of community projects capable of accommodating placements for people from the forensic system.  People reported community resources closing down or just a lack of availability.  Providing services to people with a forensic background can incur additional management, reporting and staff training obligations which all add to costs for the service providers.  For some providers the reputational risk of doing so is just considered too great.  In addition, changes to commissioning for some funded placements that were designed to increase accessibility have actually reduced accessibility for people from forensic mental health services.  For example, the Review heard that a number of structured community placements now require their users to use self-directed support.  This is not available to inpatients and so these placements cannot be accessed until a person is discharged.  Any reduction in the availability of placements is not only an issue in terms of providing the structured activity required to allow a person to rehabilitate successfully to the community, but reduces the ability of services to get an activity or placement that matches a person’s individual goals and interests.

In terms of reciprocity, as long as people in the forensic system are expected to take part in structured activities, there is a requirement on authorities to provide the appropriate services.  The Scottish Government therefore has a responsibility to ensure that suitable, skilled placements are available to support the rehabilitation of people back into the community.

Strong working relationships between statutory and third sector organisations are vital for successful activities and placements.  These need to be underpinned by appropriate information sharing protocols as well as highly skilled staff to deliver an appropriately, person-centred experience.  Third sector organisations have asked for more support to navigate the legislative requirements around disclosure when looking to work with people with a forensic background.  Allied Health Professionals have identified this as a wider need for anyone supporting someone with mental health issues and criminal convictions.  They have shared a draft guidance document with the Scottish Government to fill this gap.

Recommendations

Recommendation 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.

Recommendation 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.