Independent Review into the Delivery of Forensic Mental Health Services: progress update report 2024

4 Theme Three: Capacity and Transitions

4.1 Data Collection and Reporting

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.

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.

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 collect, monitor and record delayed discharges in a way that is as transparent as data collected in the acute (physical health) sector.

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 mental health services from prisons.

The Scottish Government continues to recognise the importance of good-quality data and information in managing services and transitions and improving the quality and performance of services. Therefore, we agree that an effective data management system is needed for forensic mental health services, given that there is currently no consistent approach to monitoring and recording data from these services.

The Scottish Government has made a commitment as part of the Mental Health and Wellbeing Strategy delivery plan to address the key gaps in collected and reported data on forensic mental health services during the lifespan of the delivery plan. The Scottish Government will work with stakeholders to develop an improved system of data collection and monitoring the outcomes for individuals receiving such services. Given the lack of data on practices such as delays in transfer and community forensic mental health, a data management system remains our focus, although it is our aim for the remaining financial year to collaborate with stakeholders to address delayed discharges in secure mental health services to ensure that patients' human rights are respected and realised and to create capacity in secure mental health services.

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.

The Scottish Government manually collated delayed discharge data from health boards every quarter for two years between 2022-2024. The data received by the health boards echoes Barron's conclusion that finding suitable accommodation and providing adequate support packages are the main factors in delayed discharge into the community. However given there is no consistent approach to monitoring and reporting delayed discharges in a forensic setting, the data was not always consistent or accurate. Scottish Government met with several health boards who are facing the longest delays to understand what they were doing locally combat these delays and offer support.

The Scottish Government continues to recognise the importance of people receiving the right treatment at the right time, which must also be done for the right amount of time. Mental Health systems as a whole are experiencing increasing demands and significant pressures. The Scottish Government, Mental Health directorate is working with delivery partners to manage these pressures and better understand the impact, focusing on identifying variance and providing targeted support to boards requiring the most help. This will inform how we collectively approach this issue in the future.

Supporting the Scottish Government and COSLA’s joint mission to reduce delayed discharges, Scottish Government are working in partnership with Health Boards, HSCPs, Local Authorities, the third sector and people with lived experience to reduce mental health, learning disability and adults with in-capacity delays and improve system flow. This will be delivered through a dedicated multi-agency working group that feeds into the Collaborative Response and Assurance Group, chaired by the Cabinet Secretary for Health and Social Care and COSLA Health and Social Care Spokesperson. The working group is focused on deploying targeted improvement and performance support to local systems to reduce delays, as well as generating an evidence base regarding the medium and longer-term interventions required to address systemic challenges. The group will also consider approaches to reducing inappropriate out of area placements identified through the Coming Home work.

4.2 Pressures on Medium Secure Services

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

Work to extend medium secure provision at Rowanbank Clinic has yet to commence. NHS Greater Glasgow and Clyde have advised that, due to the current financial situation nationally, this is not being progressed at this time.

4.3 Delays Affecting Discharges into the Community

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.

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.

The Scottish Government have been working with territorial Health Boards, Local Authorities and key stakeholders to improve our understanding of system pressures as part of wider delayed discharge work and what measures they have put in place to address the current issues. This is a complex piece of work with the added wider pressures on the availability of suitable social housing to meet demand and the risk profile of those being managed by Forensic Mental Health Services.

The Scottish Government will continue to work with and support key partners to ensure suitable accommodation and support packages are in place for those leaving Forensic Mental Health Services.

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.

The Scottish Government manages NHS pay, while Local Government handles pay for posts funded by local authorities. The Scottish Government does not control the pay for those in community support and accommodation services.

Although local employers have their own recruitment strategies, the Scottish Government has national measures to support increasing capacity in the adult social care sector in the short, medium, and long term.

The Scottish Government’s National Workforce Strategy for Health and Social Care, developed with COSLA, was released on 11 March 2022. The strategy outlines our vision for a sustainable, skilled workforce with appealing career options and fair work practices. It focuses on the entire workforce journey, including planning, attracting, training, employing, and nurturing the Health and Social Care Workforce.

The Workforce Action Plan is aligned with the National Workforce Strategy for Health and Social Care, placing training, wellbeing, job satisfaction, and the principles of Fair Work at its heart.

The Scottish Government and COSLA have jointly published the Mental Health and Wellbeing Strategy and the Workforce Action plan which highlights the actions to be undertaken to support recruitment, training, retention and wellbeing of the workforce.

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.

The Scottish Government continues to give consideration to developing an appeal process against excessive security conditions for patients detained in low security.

This work will be progressed taking cognisance of the recommendations of the Independent Scottish Mental Health Law Review. Given current resource pressures, this work has not yet commenced.

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.

The Scottish Government intends to undertake a programme to review the processes and procedures for Restricted Patients. The aim of the Review will be to ensure effective and efficient working practices. Once completed this work will inform the content of an updated Memorandum of Procedure. Due to resource constraints, progress on this work has currently been stalled.

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.

The Scottish Government is actively working on understanding the scale of the issue regarding debts incurred by forensic patients and the underlying financial constraints related to this.

The financial environment remains very challenging, and this is likely to continue over the next few years. The Scottish Government agrees that no one should be in debt because of housing costs incurred as part of their pre-discharge plan from forensic services, so it will continue to work with Integrated Joint Boards, Health Boards, and Local Authorities to understand pre-discharge plans and underlying financial challenges.

4.4 Community Forensic Mental Health Teams

Recommendation 18. The new Forensic Board should define the service remit of Community Forensic Mental Health Teams (CFMHTs).

Community provision is a crucial component of the forensic mental health system, and community forensic mental health teams are key to supporting mental wellbeing at a local level.

The Scottish Government has worked with Health Boards across Scotland to help understand and define the role and remit of community forensic mental health teams.

A draft definition will be tested and we are working towards sending this out for wider consultation by the end of this financial year.

Recommendation 19. CFMHTs should be appropriately resourced based on future projected demand as bottlenecks in low and medium secure services are eased.

Although health boards, public authorities, and employers are responsible for ensuring that teams are appropriately resourced, the Scottish Government will continue to work alongside CFMHTs to understand better and consider how to resolve any issues raised.

The Scottish Government and COSLA’s Mental Health and Wellbeing: Workforce Action Plan 2023-2025 looks at the whole workforce journey and how we can plan, attract, train, employ and nurture our mental health and wellbeing workforce. This includes Mental Health Nurses, Psychiatrists and other roles within CFMHTs. As part of the Workforce Action Plan, we have commenced the Scottish Review of Mental Health Nursing, which will build on the Ministerial Taskforce on Nursing and Midwifery recommendations. This Review will consider key themes such as voice, leadership and professionalism; workforce skills, education and research; the mental health nursing contribution to mental health promotion, prevention, and service provision; and the mental health nursing role in ensuring the quality and safety of patient care.

The Forensic Network is working on a CFMH mapping exercise. The goal of this is to provide a clear understanding of how CFMHTs across Scotland are made up and how they function, looking at areas such as resource capacity and referral criteria. The aim is to complete this by the end of the financial year 2024-25.

The Ministerial Taskforce on Nursing and Midwifery aims to promote and enhance the value and contribution of Scotland's nursing and midwifery professions. Given their shared and distinct challenges, it will also identify the key activity that will support the two professions in building a sustainable, attractive, fair, flexible, respected, and empowered workforce for the future.

4.5 Prison Issues

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.

The Scottish Government are drafting guidance for Health Boards on their responsibilities for persons in prison who need inpatient mental health care and treatment.

Additionally, the Forensic Network has been asked to put a clear process in place to ensure that in future, they are aware of any challenges in finding appropriate placements at the earliest opportunity and that they are then able to bring services together to identify solutions and put them in place timeously. The Network is mapping the patient pathway from prison to hospital, identifying timely referral and escalation processes, and effective liaison/communication.

The Forensic Network has been actively engaging with staff across Scotland who are involved in the prison pathway to investigate and resolve delays in transferring individuals from custodial settings to mental health services. Guidance is expected to be published in the next few months.

The guidance is expected to take into account the Sheriff Reid’s Note and include direct liaison with the Crown Office and Procurator Fiscal Service. After that, we expect that the effectiveness of the guidance will be monitored by the Network, which can support any difficulties arising.