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

Part B - Stakeholder Engagement Workshops

Understanding the Long List – 8 March 2022

Workshop Objective

1. Having worked together in developing a long list of options, this first workshop was designed to facilitate the process of widening stakeholder engagement around option development and understanding.

Participant Profile

2. The Group were asked to invite one or two individuals whom they considered key stakeholders in this work resulting in 11 additional people joining group members to participate in discussion. These included representatives from the social work sector; lived experience and prisons. This cohort were subsequently invited to forthcoming workshops.

Workshop Approach

3. A detailed programme was designed to provide a comprehensive overview of the rationale and background to the work setting out information around the option appraisal approach, and help participants make a meaningful contribution.

4. Workshop participants remained together throughout the duration of the workshop. Participants were encouraged to present views around the options within the workshop or to provide comments to the Group Secretariat after the event.

Results and Next Steps

5. Following this session the options remained under development. In light of this, consideration was given to whether the option team approach should continue and it was agreed that spreading the workload amongst the Group membership whilst building Group understanding was the preferred approach. Option Teams continued to work with the Group Secretariat in developing the 9 options.

8th March Understanding the Long List Workshop Participation

1. Deputy Director: Improving Mental Health Services, Scottish Government

2. Professional Advisor, Mental Wellbeing and Social Care Directorate, Scottish Government

3. Scottish Government, Principle Medical Officer (Forensic Psychiatry)

4. NHS Forensic Services General and Service Managers

5. Director, Voices of Experience, VOX

6. Professional Social Work Advisor for Adult Mental Health, Directorate of Mental Health, Scottish Government

7. Forensic Network Manager

8. Medical Director, Forensic Network and School of Forensic Mental Health

9. Policy Manager, COSLA

10. NHS Forensic Services General and Service Managers

11. Chief Executive, The State Hospital

12. Director of Regional Planning (North)

13. Head Occupational Therapist & & Allied Health Professional Mental Health Lead

14. Forensic Intellectual Disability Services, NHS Glasgow and NHS Fife Psychology Group

15. Lead for Forensic LD services, Forth Valley

16. Head of Policy and Workforce, Social Work Scotland

17. Consultant Clinical Psychologist, Glasgow and Clyde

18. Aberdeenshire HSCP

19. Team Leader Mental Health/MHO, Argyll and Bute HSCP

20. South West Locality Mental Health & Substance Misuse Manager, Edinburgh HSCP

21. NHS Clinician -Consultant Psychiatrist Consultant Forensic Psychiatrist & Interim Associate Medical Director, Rohallion Clinic

Options Appraisal Part One – The Long List - 12 April 2022

Workshop Objective

1. This, the first of two options appraisal workshops was designed to appraise the long list of 9 options to arrive at a short list.

Participant Profile

2. 51 stakeholders were in attendance and took part in the appraisal of the options. The participants included NHS clinicians, some NHS management and a number of representatives from the social work sector and partner organisations. The group whose representation did not correlate with its significance was patient/lived experience.

Workshop Approach

3. The Group agreed the Quality Assessment Criteria which was based upon the six dimensions of healthcare qualityii which feature in the Scottish Government’s 2010 Healthcare Quality Strategy and agreed by the Institute of Medicine, and applied the following ranking and weighting. The Group also agreed the ranking and weighting of the criteria as shown below.

Figure 3 Quality Assessment Criteria Options Appraisal Part One

Criteria	Rank	Weight
Safe	1	35
Person Centred	2	20
Equitable	3	18
Effective	4	12
Timely	5	10
Efficient	6	5

Figure 4 Options Appraisal Scoring Guidance

Value	Appraisal	Definition
5	Excellent	Fits all elements perfectly
4	Very Good	Fits elements very well
3	Good	Fits some elements well
2	Unsatisfactory	Meets a few elements
1	Poor	Only one elements met.
0	Offers benefit no	No elements met at all

4. The 9 options were presented by Option Team Leads to the workshop followed by breakout group sessions. A total of 5 breakout groups were formed for the purposes of reflecting upon the option presentations and to conduct individual scoring activity. Participants were divided amongst the 5 breakout groups in accordance with their profession and geographical coverage.

5. Participants were requested to return their completed scoring sheets by the next working day.

6. The table below sets out the original descriptions of the long list of options and the corresponding option team leads.

Figure 5 Option Presentation Approach Using Option Team Leads

Option	Title	Option Description	Lead
1	Status Quo	Current model included as baseline	Ian Dewar
2	Barron NHS Board Forensic Health	New NHS Board for Forensic Mental Health Services including in-patient and community
6	Forensic Mental Health Services in Health and Justice	New body governing all levels of security as well as all MH services in the criminal justice system
3	NHS Board HM Security	New NHS Board covering both High and Medium security inpatient services	Gordon Johnston
5	NHS Board Low Security and Community	New body for Low Security In-Patient and community services
4	NHS Board HML Security	New body covering High, Medium and low security inpatient services	Jamie Kirkland
7	Managed Service Network	New Managed Care/Service Network with formal accountability and competent commissioning role	Lindsay Thomson
8	National Hosted Service	One body (existing NHS territorial Board, NSS or NCS) hosts Forensic Mental Health Services (High/Medium Secure) with low secure and community services devolved to local arrangements	Jim Cannon
9	Regional Forensic Mental Health Partnerships	Establish bodies in each region for MLC	James Meade

Option Appraisal Part One Results

7. Participants coded their scoring sheets in accordance with their perspective/profession. There are two coded groups with only one member and a higher number in groups 1 and 2. There were 25 NHS and 20 Non-NHS Participants.

8. The chart below at figure 7 shows average scores for each of the 9 options by the participant coded groups.

Figure 6 Option Appraisal Part One Profession/Participant Groupings

Codes	Profession	Number in Group
1	NHS Clinician	15
2	NHS Service Manager	10
3	Health and Social Care Partnership	6
4	Third Sector Organisation Representative	1
5	Social Work including MHO	6
6	Patient/Carer Representatives	6
7	Scottish Government/National	1

9. The tables below show scores unweighted and with weightings applied. Unweighted scores across the 5 Breakout Groups showed 3 groups scoring Option 2 highest with one group favouring Option 6 and one favouring Option 7. With weightings applied, Option 2 appears as the majority favourite.

Figure 8 Breakout Group Scores Unweighted

Breakout Groups
	Group 1	Group 2	Group 3	Group 4	Group 5	Totals:
Option 2	222	178	153	130	136	819
Option 7	163	135	145	149	124	716
Option 6	235	124	124	110	98	691
Option 1	147	138	126	143	114	668
Option 4	192	115	107	85	119	618
Option 8	126	123	90	115	134	588
Option 3	148	106	102	81	120	557
Option 9	113	95	89	94	119	510
Option 5	87	79	72	60	66	364

Figure 9 Breakout Group Scores Weighted

Breakout Groups
	Group 1	Group 2	Group 3	Group 4	Group 5	Totals:
Option 2	3766	3007	2545	2180	2364	13862
Option 7	2843	2317	2402	2539	2083	12184
Option 1	2585	2418	2191	2463	2516	12173
Option 6	3944	2117	2058	1826	1667	11612
Option 4	3289	1975	1802	1449	2123	10638
Option 8	2093	2107	1483	1947	2319	9949
Option 3	2538	1851	1700	1379	2058	9526
Option 9	2007	1654	1567	1530	2079	8837
Option 5	1507	1362	1218	1004	1128	6219

12 April 2022 - Option Appraisal Workshop - Part One Participation

1. Deputy Director: Improving Mental Health Services, Scottish Government

2. Professional Advisor, Mental Wellbeing and Social Care Directorate, Scottish Government

3. Policy Manager, COSLA

4. Director, Voices of Experience, VOX

5. Medical Director, Forensic Network and School of Forensic Mental Health

6. Forensic Intellectual Disability Services, NHS Glasgow and NHS Fife Psychology Group

7. Professional Social Work Advisor for Adult Mental Health, Directorate of Mental Health, Scottish Government

8. Scottish Government, Principal Medical Officer (Forensic Psychiatry)

9. NHS Forensic Services General and Service Manager

10. Head Occupational Therapist & & Allied Health Professional Mental Health Lead

11. Director of Regional Planning, NHS North Region

12. Chief Executive, The State Hospital

13. Area Manager, Edinburgh, Support in Mind Scotland

14. Lead For Forensic Ld Services In Forth Valley

15. Team Leader Mental Health/MHO, Argyll and Bute HSCP

16. Mental Health Development Coordinator, Carers Trust

17. Clinical Nurse Manager, The Orchard Clinic, Forensic Mental Health

18. Senior Mental Health Advocate – Secure Care Independent Advocacy Perth & Kinross

19. Consultant Nurse and Senior Lecturer. Forensic Mental Health Nursing Group

20. Adults Policy and Practice Lead, Social Work Scotland

21. Clinical Service Manager Forensic Community Service

22. Consultant Forensic Psychiatrist / Clinical Director, Forensic Mental Health, Rowanbank Clinic

23. Chief Officer, COSLA, Health and Social Care

24. South West Locality Mental Health & Substance Misuse Manager, Edinburgh HSCP

25. Forensic Network Manager/ Chair of Carer Co-ordinator Group – FN Professional Group

26. Consultant Forensic Psychiatrist, Clinical Lead for Mental Health Specialist Services

27. Consultant Forensic Psychiatrist and Clinical Lead, Rohallion Clinic and FCMHT

28. Team Leader, Forensic Community Mental Health Team, NHS Lanarkshire

29. Chief Executive of East Ayrshire Council and Lead for Health and Social Care at Solace

30. Chief Officer, Highland HSCP

31. Head of Service Review in our Quality Assurance Directorate – Health Improvement Scotland

32. Adult Consultant Psychiatrist

33. AHP Professional Advisor Mental Health, Scottish Government

34. Heads of Psychology Service Chair

35. Clinical Pharmacist. Chair of Pharmacy Leads – FN Professional Group.

36. Forensic Lead AHP, Directorate of Forensic Mental Health & Learning Disabilities

37. Development Manager, Scottish Independent Advocacy Alliance

38. Network Officer, Scottish Recovery Network

39. Interim Professional Lead for Psychology

40. Chartered and HCPC Registered Forensic Psychologist (AFBPsS). Head of Psychological Services - HMP Kilmarnock

41. Consultant Forensic Psychiatrist, The State Hospital

42. RCPsych in Scotland - Medical Managers. Deputy Medical Director, Mental Health and Addictions

43. Consultant Clinical Psychologist, Rowanbank Clinic

44. Assistant Chief Officer, Adult Services. Glasgow City HSCP

45. Clinical Nurse Manager Forensic, Rehabilitation & Intensive Psychiatric Care Unit

46. General Manager Mental Health and Learning Disabilities

47. President, Mental Health Tribunal for Scotland

48. Legal Secretary, Mental Health Tribunal for Scotland

49. Director of Psychology / Head of Clinical Services (Mental Health & Learning Disability)

50. Consultant Child and Adolescent Psychiatrist Forensic CAMHS

51. Consultant Forensic Psychiatrist, Rowanbank Clinic

52. Consultant Forensic Psychiatrist, Clinical Director, Orchard Clinic

53. Patient's Advocacy Service, The State Hospital

54. Senior Manager (Practitioners), Mental Welfare Commission

55. Senior Social Worker Adult City Health and Social Care Partnership

56. Senior Practitioner/Mental Health Officer South Community Mental Health Team

57. General Manager Mental Health and Learning Disability Services

58. Head of Adult Services: Learning Disability & Recovery, East Renfrewshire health & Social Care Partnership

Options Appraisal Part Two - The Short List - 24 June 2022

Workshop Objective

1. The aim of this second options appraisal workshop was to assess and score the 4 short listed options.

Participant Profile

2. In the interests of consistency in participant profiling throughout the workshop series, organisers ensured that distribution lists for subsequent workshops included those in attendance at previous workshop. We increased the number of attendees at this workshop and in particular, increased the proportion of participants with lived experience. The largest group, NHS clinicians was complemented by good representation from social work and other partner organisations.

3. Participants confirmed their grouping on their scoring returns. The table below shows the number of participant returns from each grouping. The Part Two workshop in June had a similar percentage split of NHS to non-NHS as Part One, with 23 and 15. There were 49 attendees recorded at the June workshop. These included 19 participants who were also in attendance at workshop Part One. This total does not including officials and Group members. 38 individual scoring sheets were returned.

Figure 10 Option Appraisal Part Two Participant Grouping and Returns

Participant Grouping	Group	Count
NHS Clinician	1	17
NHS Management	2	6
Social Work	3	5
Patient or Patient Representative/Advocacy Organisation Representative	4	4
Representative from Third Sector Organisation	5	2
Representative from Partner Organisation	6	2
Other	7	2

Workshop Approach

4. Feedback from the first options appraisal workshop in April was incorporated into the design of this workshop including:

a. The Group agreed that workshop participants required more detailed information on Governance arrangements in the context of the scope of work of the Group. To help build this understanding, a member of the Group provided a detailed presentation around how the various options might affect strategic planning and governance of forensic mental health services in Scotland. The presentation set out the fundamental point that the remit of the Group was restricted to this context of governance, with clinical governance entirely out of scope.

b. The Option Detailing Group developed the detail of each of the short listed options with consistent facts and a standardised format to aid consistency in how options were developed and also how they were presented during workshop settings.

c. An overview of each option was presented to the workshop by one official in the interests of neutrality and consistency and the participants were asked to score all options during the workshop. Breakout Groups were not used in this workshop in favour of a group question and answer session with all participants as well as during scoring.

5. Customised quality assessment criteria reflective of the work of Barron was developed with rankings and weightings agreed by the Option Detailing sub group. The Assessment Criteria Description Table gave suggested points to consider when assessing the options against the criteria

Figure 11 Quality Assessment Criteria Options Appraisal Part Two

	Criteria in Ranked Order	Weight
1	Integrated Forensic Mental Health Service	30
2	Governance, Accountability & Powers & Legal Competency	25
3	Capable and Appropriate Workforce Capacity	20
4	Lived Experience	15
5	Quality of Care	6
6	Feasibility	4

 

Assessment Criteria Description Table

	Theme	Ways to Consider How the Option Satisfies the Criteria
1	Integrated Forensic Mental Health Services	To what extent does this option provide whole system working, joined up services, systems, processes in the context of the wider health and social care landscape? When considering long term change, how might this model fit within the developing model being described as The National Care Service?
2	Governance -Accountability & Legal Competency	To what extent does this option provide the operating authority across all areas of Forensic Mental Health Services? Would this option have the necessary accountability and authority to be able to make decisions as a single system, as recommended by Barron? Can the option be delivered with Scotland’s current legislative infrastructure?
3	Capable and Appropriate Workforce Capacity	Does the option provide the best arrangements to consolidate services increasing the opportunities for improvements, recruitment, retention and culture? Will the potential for improvement be an attractive career choice for those who work in forensic mental health services?
4	Lived Experience	To what extent does the option meet the needs and aspirations of patient’s/service users/families?
5	Quality of Care	Safe & Effective -To what extent does this option create safer systems and processes for patients, staff and other service users? Equitable To what extent does the option improve equity of service provision throughout Scotland for all groups, including women and people with intellectual disability? Will it help enable people to receive an equitable forensic mental health care service, irrespective of their group or locality? Person Centred - To what extent can this option ensure that people receive the right level of forensic mental health care with minimal delays at key transitions points? Timely & Efficient - What implementation timeframe is this option likely to require? Is the length of time prohibitive and does that affect the option’s feasibility?
6	Feasibility	To what extent is the option deliverable within current resources?

Option Appraisal Part Two Results

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

7. Upon application of the Quality Assessment Criteria weightings the results profile almost levelled Options 2, 6 and 7 with Option 7 slightly in front. Weighting the scores also resulted in a widening of the gap between options 2, 6 and 7 and set Option 1, the Status Quo as the lowest scoring option.

8. Options 7, 2 and 6 remain very close within the weighted results, which suggests the outcome of the options appraisal process offers no clear preferred option. On the other hand, Option 1 does appear as being the least preferred option.

9. The data below illustrate the similar scoring patterns of each participant group with NHS clinicians indicating a very slight preference for Option 2. The group representing people with lived experience also scored Option 2 most favourably and the group representing the social work sector scored Option 7 highest.

10. The data also shows that Option 2 scored highest in each of the quality assessment criteria except for the criteria Feasibility, where Option 7 scored highest.

Figure 12 Options Appraisal Part Two Raw Scores Sorted

Values	Partner Organisation	NHS Management	NHS Clinician	Lived Experience	Social Work	Third Sector	Other	Grand Total
Option 2	35	99	335	96	87	43	37	732
Option 7	34	113	310	58	99	22	19	655
Option 6	33	76	283	77	82	26	29	606
Option 1	31	92	285	35	63	19	13	538

Figure 14 Option Appraisal Part Two Weighted Scores Sorted

Values	Partner Organisation	NHS Management	NHS Clinician	Lived Experience	Social Work	Third Sector	Other	Grand Total
Option 7	668	2294	6169	1195	2021	496	419	13262
Option 2	588	1646	5765	1646	1436	710	597	12388
Option 6	720	1515	5707	1601	1667	533	594	12337
Option 1	451	1472	4560	473	930	291	175	8352

11. Whilst there appeared to be a couple of participant scoring sheets that appeared to deviate from the Options Appraisal Scoring Guidance (Figure 4 Options Appraisal Scoring Guidance); analytical tests confirmed that the perceived anomaly was not statistically significant and therefore could not be categorised as an anomaly.

12. The scoring pattern of this perceived deviation from scoring guidance impacted the results causing Option 7 to be slightly favoured over Option 6, once scores had weightings applied.

Figure 16 Results of Option Appraisal Part Two without Perceived Scoring Deviations

Values	Partner Organisation	NHS Management	NHS Clinician	Lived Experience	Social Work	Third Sector	Other	Grand Total
Option 6	720	1515	5488	1601	1667	533	594	12118
Option 2	588	1646	5463	1646	1436	710	597	12086
Option 7	668	2294	4969	1195	2021	496	419	12062
Option 1	451	1472	3710	473	930	291	175	7502

13. The results verify the necessity of convening the Group to explore the recommendation that a new NHS forensic board be established and whether alternatives to that may redress the system issues highlighted in 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, there was no clear consensus on what the preferred governance model should look like.

14. With each of the options we looked at in detail, there were differing views from the stakeholders involved with the Group over the past 5 months.

15. During the June workshop we heard doubts that the network approach in Option 7 meets the criteria set out in the Independent Review as well as an acknowledgement that option 7 may indeed be beneficial in enabling local influence over decision making to continue.

16. There was general recognition among stakeholders that the Barron recommendation – Option 2 may streamline decision making within forensic mental health services. Its limitations to reach beyond the NHS however, was seen as making that option insufficient to enable it to address the enduring issues which cause delays in enabling patient discharge.

17. Option 6, which added custody settings to Barron’s recommendation for an NHS Forensic Board, received some support. Overall this option’s perceived complexity appeared to outweigh its ability to represent a solution which could overcome the challenges the system needs to conquer.

24 June 2022 Option Appraisal Workshop Part Two Participation

1. Deputy Director: Improving Mental Health Services, Scottish Government

2. Professional Advisor, Mental Wellbeing and Social Care Directorate, Scottish Government

3. Head Occupational Therapist & & Allied Health Professional Mental Health Lead

4. Chief Executive, The State Hospital

5. Area Manager, Edinburgh, Support in Mind Scotland

6. Policy Manager, COSLA

7. Director, Voices of Experience, VOX

8. Medical Director, Forensic Network and School of Forensic Mental Health

9. Forensic Intellectual Disability Services, NHS Glasgow and NHS Fife Psychology Group

10. Professional Social Work Advisor for Adult Mental Health, Directorate of Mental Health, Scottish Government

11. Scottish Prison Service

12. Clinical Specialist/Lead Occupational Therapist, Rowanbank Clinic

13. Senior Mental Health Advocate, Secure Care Independent Advocacy Perth & Kinross

14. Chartered and HCPC Registered Forensic Psychologist (AFBPsS). Head of Psychological Services - HMP Kilmarnock

15. Professional Social Work Advisor for Adult Mental Health, Directorate of Mental Health, Scottish Government

16. NHS Clinican

17. NHS Clinician -Consultant Psychiatrist Consultant Forensic Psychiatrist & Interim Associate Medical Director, Rohallion Clinic

18. Service Manager, Mental Health & Learning Disabilty Service ,H&SC, North Lanarkshire

19. Team Leader, Forensic Community Mental Health Team, NHS Lanarkshire

20. Director, Voices of Experience, VOX

21. Consultant Nurse and Senior Lecturer. Forensic Mental Health Nursing Group

22. South West Locality Mental Health & Substance Misuse Manager, Edinburgh HSCP

23. Medical Director, Forensic Network and School of Forensic Mental Health

24. Clinical Service Manager, Forensic Community Service

25. Collective Advocacy Project, Royal Edinburgh Hospital

26. Consultant Forensic Psychiatrist, The State Hospital

27. Mental Health Development Coordinator, Carers Trust

28. Patients Advocacy Service, The State Hospital

29. Standards and Indicators Lead, Healthcare Improvement Scotland

30. Head of Adult Services: Learning Disability & Recovery, East Renfrewshire health & Social Care Partnership

31. Consultant Forensic Psychiatrist, Honorary Senior Lecturer, Associate Postgraduate Dean, Royal Cornhill Hospital

32. Chief Executive, The State Hospital

33. Policy Officer, COSLA

34. Patient Representative

35. Senior Practitioner/Mental Health Officer, South Community Mental Health Team

36. Patient Representative

37. Social Work Mental Health Manager, South Lanarkshire Council

38. Team Lead, Highland Forensic Service

39. Network Officer, Scottish Recovery Network

40. Forensic Intellectual Disability Services, NHS Glasgow and NHS Fife Psychology Group

41. RCPsych in Scotland - Medical Managers. Deputy Medical Director, Mental Health and Addictions

42. Head of Policy and Workforce, Social Work Scotland

43. Consultant Forensic Psychiatrist and Clinical Lead, Rohallion Clinic and FCMHT

44. Senior Manager (Practitioners), Mental Welfare Commission

45. Lead Forensic Mental Health Advocate, Circles Network Rowanbank Clinic

46. Professional Lead for Psychology, NHS Greater Glasgow & Clyde

47. Clinical Nurse Manager, The Orchard Clinic, Forensic Mental Health

48. Lead For Forensic Learning Disability Services In Forth Valley

49. Policy Lead, COSLA

50. Consultant Clinical Psychologist, Professional Lead for Forensic Clinical Psychology, NHS Lothian

51. Consultant Clinical Psychologist, Rowanbank Clinic

52. Adults Policy and Practice Lead, Social Work Scotland

53. Clinical Nurse Manager Forensic, Rehabilitation & Intensive Psychiatric Care Unit

54. Consultant Forensic Psychiatrist, Clinical Lead for Mental Health Specialist Services

55. Head Occupational Therapist & & Allied Health Professional Mental Health Lead

56 Service Manager CMHT and Senior Forensic Nurse Practitioner

57. Lead Psychologist SOLS / Forensic Network Lead Serious and Violent Offenders

58. AHP Professional Advisor Mental Health, Scottish Government

59. Consultant Forensic Psychiatrist / Clinical Director, Forensic Mental Health, RowanbankClinic

60. Heads of Psychology Service Chair

i Forensic Mental Health Services – Planning and Collaboration Short Life Working Group - gov.scot (www.gov.scot)

ii Across the Chasm: Six Aims for Changing the Health Care System | IHI - Institute for Healthcare Improvement