Forensic mental health services delivery reform - option appraisal process: final report

Part A

Executive Summary

1. In March 2019^[1], the Minister for Mental Health commissioned an independent review into the delivery of Forensic Mental Health Services chaired by Derek Barron, Director of Care at Erskine. The Independent Review into the Delivery of Forensic Mental Health Services in Scotland was set up to examine the delivery of forensic mental health services, recognising the changes that had happened over time.

2. The Review’s remit and purpose as set down in its terms of reference^[2] included:

• strategic direction, ongoing oversight and governance arrangements;
• demand, capacity and availability across the forensic secure estate;
• high secure provision for Women;
• community forensic mental health services;
• forensic mental health services and the justice system; and
• forensic mental health services for client groups with particular needs.

3. This is the final report of the Planning and Collaboration Short Life Working Group (“the Group”) set up as part of the Scottish Government’s Response^[3] to the Final Report of the Independent Review of Delivery of Forensic Mental Health Services Chaired by Derek Barron.

4. The Scottish Government are grateful to the time and energy invested by the individual members of the Group and their stakeholder representatives in their contributions to this work. Further details of the Group can be found on the Scottish Government web site^[4] .

5. The overall aim of the Group is in enabling the best services possible for people who find themselves in receipt of forensic mental health care. Their work here is an attempt to review and propose a redesign of the planning and governance of the delivery of the health care component of forensic mental health services within the wider health and social care landscape. This milestone will inform the wider Barron Delivery Programme in how planning and governance can help improve the interface between forensic mental health services and other service bodies.

6. The Option Appraisal Process was held in two parts with Part One - The Long List; hosted on 12 April 2022. Of the 51 stakeholder participants, 45 returned individual scoring sheets. The results produced a shortlist of the Options 1, 2, 6 and 7.

7. Option Appraisal Process Part Two – The Short List; took place on 24 June 2022 where a total of 38 stakeholder participants returned their individual scoring sheets out of a total of 49 participants. The results show Options 2, 6 and 7 as very close with Option 7 slightly in front and Option 1 as the least favoured option.

8. Analysis of the participant scores showed a preference for Option 2 with Options 6 and 7 in relatively close favour and Option 1 lowest.

9. With the quality assessment criteria weighting applied to scores, this resulted in a reverse in ranking between Option 7 and Option 2.

10. Participation in the options appraisal process included the Group membership as well as 62 additional stakeholders, of which a cohort of 24 were present at both option appraisal workshops parts one and two.

11. The results verify the necessity of having convened the Group to explore the recommendation that a new NHS forensic board be established and whether alternatives to that recommendation might redress the system issues highlighted by the Independent Review. Results also suggest that the Group, together with relevant stakeholders remain of the view that the status quo is in need of change. However, as the scores show, there was no clear consensus on what the preferred governance model should look like^[5].

Background

The Short Life Working Group

12. The Scottish Government published its Response to the Final Report of the Review in October 2021. The Response to Recommendation One, that a new NHS Board should be created for forensic mental health services in Scotland, whilst recognising the excellence of staff delivering services today, also accepted that the ongoing system challenges which led to the commissioning of the Review mean that the status quo of how services are governed needs to be improved.

13. The Response concluded that change is needed to enable improvements to the patient journey. Views on how those changes are delivered are mixed amongst stakeholders and thus this Group was set up to explore options for governance, strategic change and increased partnership working across the forensic mental health landscape.

Group Governance

14. Membership of the Group was drawn from subject matter experts in the delivery of forensic mental health services in Scotland including from the fields of Psychiatry, Psychology, Intellectual Disability, Service Management, Regional Planning and at Chief Executive level. Forensic Mental Health Services at all security levels were represented.

15. NHS clinicians and health service leaders were complemented by representatives not directly involved in the delivery of health services but considered an essential connector in these early stages of the Barron programme. Barron’s work had a healthy focus on what people said mattered to them. People with experience either as a service user or practitioner were at the heart of Barron’s findings. Therefore, a member of VoX was appointed to the Group to continue the strong person centred approach.

16. Group members included Hannah Axon, COSLA; Jim Cannon NHS Scotland Director of Regional Planning (North); Gary Jenkins, Chief Executive, The State Hospital and mental health lead for NHS Scotland Chief Executive Group; Gordon Johnston, Director, Voices of Experience (VOX); Ms Michele Mason, Area Manager, Edinburgh Support in Mind Scotland; Dr Jamie Kirkland, Consultant Clinical Psychologist, Forensic Intellectual Disability Services NHS Glasgow and NHS Fife; James Meade, NHS Forensic Services General and Service Managers and member from West region; Professor Lindsay Thomson, Medical Director, Forensic Network and School of Forensic Mental Health; Linda Walker, Head Occupational Therapist in NHS Lothian & Allied Health Professional Mental Health Lead.

17. The Scottish Government Deputy Director for Improving Mental Health Services chaired the Group’s formal meetings which took place monthly from the Group’s inception in November 2021 to its last meeting held in July 2022. Kate Bell provided professional advice to the Group around the options appraisal process and supported the chair in leadership of meetings. The Forensic Mental Health Reform Team provided Secretariat to the Group.

18. Records of meetings of the Group are published on the micro site within the Scottish Government web space: Planning and Collaboration Short Life Working Group. Anyone who wishes to find out more about the work of the Group can contact officials at forensicmentalhealthreformteam@gov.scot.

19. The Group conducted the majority of their work within the formal meetings; including formulating ideas in developing the long list of options. In addition to these formal meetings, a series of workshops were held in 2022 in April, May and June to which additional stakeholders were invited. Both the Chair and professional adviser for the options appraisal process regularly encouraged members to work with their own stakeholder populations in adding to and further exploring the suggested long list of ideas as well as to propose any additional ideas. Officials worked with members of the Group articulating the long list of options and developing the detail of the various models being proposed.

20. It is recognised that this work has been a small, but essential first step within a large complex programme of work set within a diverse system landscape of multiple interfaces. For services traditionally delivered by local authorities such as social work, COSLA’s representation on the Group was a vital connector and conduit for the voice of that local authority environment. The work of the Group will be important in shaping the governance arrangements and work-plan of the Barron Programme Board. Although the work of the Group did not result in a clear preference, it corroborated the view that today’s strategic governance and planning infrastructure needs change. Officials are advising Ministers on the results of the work of the Group including suggested delivery models. Feasibility studies around these suggestions will form part of the work-plan in the design of implementation of the outcome of the work of the Group.

21. All Group members acknowledged a key part of their role was to present the varied views of their represented stakeholder groups. This was evident during stakeholder engagement when healthy debate and exploration of options was had between participants and members of the Group.

Scope of Work of the Group

22. The Group’s published Terms of Reference suggested that their scope of work include Recommendation Two aimed at reviewing the definition of Forensic Mental Health Services, as well as a range of other interdependent recommendations set out in the final report. Whilst the Group touched on Recommendation Two and agreed a working definition of Forensic Mental Health Services in establishing parameters for their work around Recommendation One; it was acknowledged that the wider Barron Delivery Programme, with its diverse stakeholder interests, was the appropriate environment to explore whole system relationships. The Group therefore, focused its options appraisal around NHS services.

23. The Barron Delivery Programme will be available to share with stakeholders in the autumn of 2022.

Lived Experience

24. The Group was mindful of the importance of recognising how the voices of people with lived experience had helped to shape the recommendations made in the Barron Report and wanted to ensure that those voices were echoed in their work. This was often a challenging concept to honour as the subject area of planning and governance can be something seen as far removed from people in receipt of services.

25. To help somewhat verify the Group’s interpretation of the voice of lived experience through the work of Barron, visits were arranged to meet with patients within two medium secure units; Rohallion in Perth and Rowanbank in Glasgow. The patients had a good awareness of the work of Barron, and through their accounts of their experiences with us, confirmed that issues highlighted by the Review, such as delays in transitions and discharge, remained. In addition to the facility visits, discussions were had with the Scottish Independent Advocacy Alliance who reached out to their networks. This engagement led to an increase in the proportion of patient representatives engaged in the Option Appraisal Process.

Definition of Forensic Mental Health Services

26. The Group were mindful of the range of interpretations of the term “forensic mental health” and worked together to agree the following as a working definition to support the option appraisal process. Anyone who wishes to challenge this definition and/or offer revision suggestions is encouraged to email officials at forensicmentalhealthreformteam@gov.scot

“Forensic mental health services provide person-centred, safe and effective assessment; care and treatment; for persons with severe and disabling mental health disorders* who pose a risk of harm to others; and who have come to the attention of the criminal justice system (or whose behaviour poses a risk of such contact); in conditions of therapeutic safety and security in hospital (high, medium or low), or in the community and in criminal justice custody.”

*as defined in the Mental Health (Care and Treatment) (Scotland) Act 2003, whether or not they are, or may be, managed under its provision.

27. Not only did the Group seek clarity in relation to how forensic mental health services were defined in this context, they also queried how service boundaries were considered in relation to the task in hand. That is whether their remit related exclusively to forensic mental health services delivered by the NHS and practitioners employed by the NHS, or the wider team of professionals who make up the multi-agency team delivering care for forensic mental health service users in hospital or a community setting.

28. The Group initially agreed that because people’s progress with their patient journey can often depend on access to other services, that any decisions around system change should consider the impact on and relationship with other relevant services.

29. Given the Group’s membership, their scope of work and the authority this afforded the group, the options appraisal process of considering and assessing a full range of governance options focussed on NHS services. Any decisions on design and implementation of changes to how wider services, such as housing, are planned and/or delivered in practice, were out of scope of the work of the Group.

The Option Appraisal Process

30. The Scottish Government’s Mental Health Directorate Professional Adviser in Strategic Change, Kate Bell directed and closely managed the design and delivery of the options appraisal process throughout, this work included collating and assembling the Case for Change document and working closely with Group members on key aspects of process for the options development and appraisal.

31. Option appraisal is a common multi-criterion decision making method within the public sector. As in all service change projects it is necessary to engage widely with stakeholders throughout the process, alongside the joint working.

32. The Group’s efforts focused solely on the options appraisal process. Activities included developing the Case for Change, the long list of options, and the quality assessment criteria with weighting and ranking.

Step One – The Case for Change

33. The Group agreed a Case for Change which sets out the rationale for their work in the context of the Barron’s findings in relation to Recommendation One Figure 1 Extract from the Independent Review Final Report- Creating a Single System. The document offers a comprehensive overview of the background to the Group’s purpose in relation to the Barron Review as well as the process of design and implementation of an options appraisal process.

34. The Case for Change was circulated amongst all participating stakeholders in advance of workshops. Participants were also provided with a comprehensive participant pack to supplement the information provided within the Case for Change document.

Step Two – Option Development

35. The Group worked together in developing a Long List ( Figure 2 The Long List) of options and these were considered by a wider stakeholder group brought together in a series of workshops in March, April and June. The objective of the stakeholder workshops was to aid participant understanding of each option on the long list to enable them to score each option using the quality assessment criteria and arrive at a short list of options.

36. The long list of 9 options included the status quo as Option One, which is standard in option appraisal. Scoring and weighting systems offer a way to robustly assess the relative merits of the options against what is currently in place. Barron Recommendation One became referred to as Option 2. In addition to Barron’s Recommendation One, the long list included an extended version of this, to also include custody settings. Three further options involved a new NHS Board or “body” providing governance for some security levels. The remaining options included one seeking to strengthen the existing Forensic Network; one where an existing board would act as the host board and finally a regional approach where each region would have its own governing body made up the long list of 9 options.

Step Three – Development of Quality Assessment Criteria

37. The Group agreed that the internationally recognised six dimensions of healthcare quality (Institute of Medicine) as integrated within Scotland’s Healthcare Quality Strategy would be adopted as the Quality Assessment Criteria for this options appraisal. Records of these meetings are available on the Scottish Government website and anyone who wishes to learn more about how this was done is encouraged to contact officials at forensicmentalhealthreformteam@gov.scot.

38. Following strong feedback from workshop part one that the options appraisal process would benefit from the quality assessment criteria being more customised, the Group conducted further work and agreed a revised set of criteria used in the final (part two) workshop. Whilst there was some discussion around the development of this revised criteria set during Group formal meetings, the majority of work around this was carried out by the Option Detailing Group and endorsed by the full Group.

Barron Review Final Report Recommendation One

“It is recommended that a new NHS Board should be created for forensic mental health services in Scotland.

All forensic mental health services, including both inpatient and community services, should be brought under the management of this new Forensic Board.

Forensic learning disability services at high and medium security should also be brought under the management of this new Forensic Board. The Review considers, however, that forensic learning disability services at low security and in the community should remain under the management of, or transition to management by, generic learning disability services.

The new Forensic Board should not be based in the State Hospital. To do so would be to further alienate and disenfranchise clinicians and managers across the country who already perceive there is significant power, resources and focus sitting inappropriately at the high secure level. The new Forensic Board must demonstrate practical engagement with all of its new service areas. Serious consideration should be given to basing the Board out with the central belt, or as a minimum not within Edinburgh or Glasgow.

The new Forensic Board will supersede the role of the Forensic Network in providing strategic oversight of the forensic system. However, care should be taken to ensure that the Forensic Network’s valuable role in advancing governance and professional networks within the forensic system is not lost during this transition, and is incorporated into the governance framework of the new Forensic Board where appropriate. The School of Forensic Mental Health should also be retained.”

Figure 1 Extract from the Independent Review Final Report- Creating a Single System

Figure 2 The Long List

Developing the Options

39. The Group were briefed on the process for undertaking an options appraisal during the first formal meetings. Ideas around possible options soon began to emerge from Group members which became formulated as the long list of options.

40. These early Group meeting discussions were dominated by how to describe the individual options; how each option might satisfy Barron’s recommendations and how the option would impact upon services, the workforce and service users. The complex nature of the single system recommendation was evident in these discussions and oftentimes the Group opined that their role was extremely difficult.

41. In acknowledgement of the strength of feeling of the complexity of the task shared by the Group, a consensus that it would beneficial to break down and share the task was reached. To this end, Option Teams were formed from Group membership with Option Team Leads appointed to direct the work around developing the narrative in describing the 9 individual options.

42. The 4 Option Leads, went on to present options at the Options Appraisal Part One Workshop.

43. Whilst objectivity by the members of the Group in their work developing options as part of Option Teams was assumed; members made explicit acknowledgement of their neutrality in relation to options throughout the course of their work in the Group and within workshop settings.

Developing Detailed Options

44. Officials worked closely with Option Teams to support their development of Option descriptions, which was not straightforward. The difficulty experienced in arriving at option descriptions continued to amplify the complex nature of the system being examined.

45. The Option Team Leads presented the Option Descriptions during options appraisal workshop part one which arrived at a short list of 4 options including the status quo, Barron’s Recommendation One, the extension to Barron with custody settings and the option relating to a network based approach.

46. Participants offered feedback that the option descriptions were not presented with consistency in workshop part one and concerns were raised around the neutrality of Option Leads. Following this feedback an Option Detailing Group, in preference to several Option Teams, was established as a sub-group of the main Group. The Option Detailing Group was made up of individuals from lived experience, clinical, management, chief executive and planning roles with the Scottish Government Professional Advisor for Strategic Change as chair. This sub-group met twice weekly to further develop the detail of the 4 short listed options with a template approach to ensure that similar information and consideration was given for each of the options.

47. An official presented the detailed 4 short listed option descriptions to the option appraisal workshop part two and a Group member offered an overview and how the various options might affect current governance arrangements.

48. Participants had been provided with the detailed descriptions in advance of the workshop and were invited to field questions to the workshop organisers in advance.

49. In working through the detail of each of the short listed options, the Option Detailing Group undertook examination of the legislative landscape and sought advice around methods of how a new NHS board could be established. One possible solution for Options 2 and 6 lay within the use of a legal instrument to review the existing functions for which health boards hold legal responsibility.

50. Detailed work of the group around Option 7 explored a range of ways to deliver a partnership based approach to improving planning and governance with considerations including the Strategic Network model, the Public Bodies (Scotland) Act and models used in other parts of the United Kingdom. The Group held the view that the structured and supported model of strategic networks may offer an effective solution. The Group therefore focused on this model within the workshops. National Services Division from NHS National Services Scotland support the creation and management of Strategic Networks of which there are 5 in operation today in Scotland.

51. The Group recognised the purpose of a partnership based approach as being not about altering where accountability lies, but rather in facilitating and co-ordinating partner collaboration in solving and debating complex and widespread issues. A Strategic Network would therefore not satisfy Barron’s recommendation one directly but may perhaps offer the response needed in today’s evolving policy and delivery landscape.

Conclusion and Next Steps

52. Overall, the outcome of the Options Appraisal Process suggests that continuing the status quo for the strategic governance and planning of forensic mental health services in Scotland is not supported.

53. The results reveal that although there is a desire for change, the results of the option appraisal process reveal that the appetite for that change is closer to strengthening and building on the status quo than for systemic transformation.

54. Both options 2 and 6, whilst being a shift from the status quo, offer the preservation of health services being governed through the familiar structure of a health board. Option 7 offers the possibility to improve upon the established infrastructure that exists in the Forensic Network and strengthen its role. Option 7 also accepts that accountability would remain with territorial health boards and The State Hospital.

55. Scottish Government officials will present policy advice to Scottish Ministers around the outcomes of the work of the Group within the wider context of the forthcoming Barron Delivery Programme as well as the broader health and social care policy landscape including the evolving National Care Service and considerations being given to reform of mental health and incapacity law.

56. Publication of an interim report of progress made with our Response to the Barron Review, including next steps following the conclusion of the work of the Group, will be available in 2023.