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

5 Theme Four: Person-Centred Practices

5.1 Care and Treatment

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.

In September 2023, the Scottish Government published the Core Mental Health Quality Standards to support general adult secondary mental health services. The Scottish Government wants these standards to support equitable and non-discriminatory access to mental health care and support, as well as equity in the experiences and outcomes of people using services.

These standards are currently being implemented in adult secondary services, along with psychological therapies. In the future, there is the intention to implement these core standards across tertiary services, which includes Forensic Mental Health services.

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.

The National Workforce Strategy for Health and Social Care in Scotland was published in 2022 by COSLA and the Scottish Government. This Workforce Strategy sets out a national framework to achieve our vision of a sustainable, skilled workforce with attractive career choices where everyone is respected and valued for the work they do.

One of the strategy's aims is to provide £22m for local authorities from 2022/23 and recurring after that to provide additional Social Work workforce capacity within local authorities.

The Scottish Government is committed to establishing a National Social Work Agency (NSWA). Our intention is that the National Social Work Agency will provide professional leadership and have national oversight of the social work profession. It will drive change and continuous improvement in social work education, professional development, national workforce planning, improvement approaches, and provide effective support for implementation of policy in local systems.

Our partners and stakeholders, including COSLA, and the social work workforce are supportive of establishing a National Social Work Agency and are engaged in its development.

The remit of the NSWA will extend to all registered social workers, including social work students, in the public, third and independent sectors.

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.

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

The Continuous Quality Improvement Framework (CQIF) is a framework that was developed in conjunction with Healthcare Improvement Scotland (HIS) with the aim of supporting forensic services in furthering their development and delivery of care. It allows services to be involved in an estate-wide approach to service development, allowing for benchmarking and development across the forensic mental health estate in Scotland and a clear way of meeting the requirements of NHS CEL (2007). The framework and review process uses a multi-disciplinary approach to share good practice and support learning through a culture of openness and facilitated enquiry. Reviews were undertaken in three year cycles, with the first round being held between 2011 and 2014. A second round of reviews was held in 2016 – 2019. A third round was due to commence in 2020 but was delayed due to the pandemic. Since then, the Forensic Network has reviewed the Care Quality Standards used within the reviews and has been considering how to support the implementation and visit phase. The Forensic Network have been seeking additional resources to support this as it is resource-intensive.

The CQIF standards do not currently fully capture these recommendations. However, the Scottish Government has discussed with the Forensic Network the potential for these to be incorporated into future revisions of the standards. Due to resource issues, this work is not currently underway. This work should be considered under the responsibility of the new governance structure once operational.

Guidance on the underlying principles of the Mental Health (care and treatment) (Scotland) Act 2003 has previously been published, namely the Code of Practice and the Mental Welfare Commission for Scotland's guidance, Rights in Mind. We will write out to stakeholders to re-emphasise the importance of ensuring that patients are afforded their rights. The Scottish Government has noted the potential crossover between these recommendations and the Scott Review. Going forward, any work undergone should explore this connection and the scope for a joined-up approach.

5.2 Carer and Family Related 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.

The Scottish Government has funded NHS Education for Scotland (NES) to enhance the existing Equal Partners in Care (EPiC) training resource. EPiC is used by staff in health and social care settings who work with carers.

In response to NES and Carers Trust Scotland's exploration of the need for specific carer awareness education for staff working across mental health services, we have funded NES to work with national carer organisations and key stakeholders, including unpaid carers, to develop a synchronous masterclass session.

The Scottish Government also funded the development of Triangle of Care, a best practice guide that supports mental health services in ensuring the identification and meaningful engagement of unpaid carers. It outlines the information, advice, and support that carers require to continue in their roles as expert partners in care.

Although health boards, public authorities, and employers are responsible for ensuring that training is available to their staff and undertaken, the Scottish Government will promote existing training and resources through our regular engagement with health boards and mental health networks.

The Scottish Government understand that further work needs to be considered to progress these recommendations, especially in appointing a carers contact in every unit and establishing an advocacy service for forensic carers. This work should be considered under the responsibility of the new governance structure and as part of future service delivery planning.

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 Care Programme Approach 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.

Recommendation 33 . The new Forensic Board and people receiving forensic mental health services and their family members (or other carers) should codesign informal and formal feedback processes that address the specific vulnerabilities of these groups in the forensic system.

Whilst these recommendations fall under the responsibility of individual health boards, the Scottish Government will continue to liaise with boards to understand the difficulties faced by family and carers of those within forensic mental health services.

Using the work of the Forensic Carer Forum and Carers Coordinators group, both supported by the Forensic Network, examples of best practices should be highlighted, shared, and built upon to improve the engagement and participation of family members and carers.

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 Care Programme Approach 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.

Officials plan to take forward a programme to review all of the processes and procedures for Restricted Patients. As part of this programme, the Memorandum of Procedure will be revised. This will include guidance on the process for carrying forward existing SUS upon transfer. Due to resource issues, progress on this work has currently been stalled.

5.3 Social and Environmental Practices

Recommendation 36. The poor state of repair of current 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.

Recommendation 38. Everyone subject to detention within the forensic inpatient services 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 quality and safety of mental health estates is an important issue for the Scottish Government. We expect Health Boards across the country to place significant emphasis on the environments in which mental health services are delivered and on patient safety.

We are progressing with work to develop a standardised tool to help assess the clinical environment in mental health estates across the country. The tool focuses on reduced ligature points, improving patient safety, and ensuring a therapeutic environment and experience. We have piloted the tool, which received positive feedback. As part of the Mental Health and Wellbeing Delivery Plan, we are fully committed to implementing this tool across inpatient services.

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.

The Scottish Government issued the response to the 2018 and 2021 reports to the Forensic Network in January 2024.

We agree with the importance of communication and technology for patients detained in secure mental health settings and their families and friends. The Government acknowledges the increasing role of technology in access to and the care and treatment of individuals for those providing services.

The Scottish Government is committed to working in partnership to design and deliver a programme of work and to adopt a collaborative and inclusive approach to developing solutions that will deliver improvement and reform.

Any plan that aims to deliver work derived from the recommendations should align with the new Mental Health and Wellbeing Strategy and the Digital Mental Health Programme. It will be important to consider the current financial climate, which may mean that actions that make the most difference will have to be prioritised.

This will allow further work to be undertaken to assess the practicalities of implementing each recommendation, including whether services currently have the infrastructure to support these changes and possible associated costs.

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.

The Scottish Government initially explored this recommendation with Allied Health Professional (“AHP”) Leads group members. It identified that no official system currently monitors the availability of placement providers.

The Scottish Government will continue to work with AHPs and offer support to develop this work.

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.

The draft guidance to support people with criminal convictions and mental health conditions into work, volunteering, or education was last reviewed in 2016. Substantial changes in legislation, such as the addition of the Management of Offenders (Scotland) Act 2019 and the updated Data Protection Act 2018, have since had to be reflected.

The Scottish Government coordinated and engaged with the AHP working group to facilitate the updating of the guidance, working closely with the Chief Nursing Officer Directorate (CNOD). The group consulted with stakeholders such as Disclosure Scotland, Recruit with Conviction, and people with lived experience to ensure the document was accurate and supported people with criminal convictions and mental health conditions into work, volunteering, or education.

The guidance was successfully launched at the Annual Forensic Allied Health Professions Conference on 1 June 2023 and published on the Scottish Government website.