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The National High Secure Services for WomenRampton Hospital

Dr Sue Elcock

Consultant Forensic Psychiatrist

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Positive about integrated healthcare

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Rampton Hospital

Clinical Directorates

Directorate 1

-Mental Health Services

-National Learning Disability

-National Deaf Service

Directorate 2

-Personality Disorder Services

-National High Secure Healthcare Service for Women

-Dangerous & Severe Personality Disorder Directorate (The Peaks)

Support Services Security Department Therapies and Education

Department Social Care Services Facilities Department Corporate Services

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Therapies & Education Department

4 Departments – 135 staff / 18 patient areas Occupational Therapy Team Education (including Patients Library) Art Therapies Speech and Language Therapy Operations Support:

• Chaplaincy• Technical Instructors • Relief Pool • Administration

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One National Service Women’s Mental Health : Into the Mainstream Implementation Guidance

2003: one national service

1991 345 women in high security

-Female beds at Ashworth closed in 2003

-Female beds at Broadmoor closed mid 2007

-Female bed at Carstairs Hospital 2008

NHSHSW new build (50 beds) opened January 2007

3 Women’s Enhanced Medium Secure Services (46beds) 2007

1993 - 2000 the average women’s population in prison increased by 111.5% compared to a 42% increase for men

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NHSHSW

50 beds Emerald A 6 Beds -Learning Disability Unit Emerald B 6 Beds -Intensive Care Unit

Topaz 12 Beds -PD Admission/Treatment Ward

Ruby 14 Beds -PD Treatment Ward

Jade 12 Beds -Mental Health Ward

Diamond Resource Centre -Day care services for women

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De-escalation

Quiet Rooms

Low Stimulus

Seclusion

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Referral and Assessment Process

1. Existence of Mental Disorder requiring detention and treatment in hospital.

2. Availability of Appropriate Treatment.

3. Presenting a Grave and Immediate Risk to others.

Referral

Assessment bySenior

Clinicians from NHSHSW

Reports submitted

to Admission Panel

Panel Decision

*Secretary of State Direction to Admit can bypass the above process

and direct an admission

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2008 2009 2010 2011 2012 2013TOTALS

2008-2013

NHS Standard Medium Secure

6 5 6 8 5 11 41

NHS WEMSS 1 5 4 3 2 0 15

Independent Medium Secure 2 8 3 4 2 5 24

HMP 3 5 4 3 4 4 23

Other 1 0 0 2 1 0 4

Totals 13 23 17 20 14 20 107

Referrals

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Admissions

2008 2009 2010 2011 2012 2013TOTALS

2008-2013

NHS Standard Medium Secure

1 1 1 0 1 5 9

NHS WEMSS 0 1 3 1 0 0 5

Independent Medium Secure

2 2 2 3 1 2 12

HMP 1 3 1 3 4 2 14

Return from Trial Leave 2 1 0 1 0 0 4

Other 0 0 0 1 1 0 2

Totals 5 8 7 9 7 9 45

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Conversion Rates

○ 2008 5 admitted from 13 referrals 38.5%○ 2009 8 admitted from 23 referrals 35%○ 2010 7 admitted from 17 referrals 41%○ 2011 9 admitted from 20 referrals 45% ○ 2012 7 admitted from 14 referrals 50%○ 2013 9 admitted from 20 referrals 45%

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Discharges

2008 2009 2010 2011 2012 2013TOTALS

2008-2013

NHS Standard Medium Secure

8 0 0 7 3 7 25

NHS WEMSS 8 1 1 2 0 0 12

Independent Medium Secure

5 5 0 3 0 1 14

Prison 0 1 1 1 0 2 5

Totals 21 7 2 13 3 10 56

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The Population

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MHA (2012)

MHA Section Number of Patients

37/41 22

47/49 7

41(5) 7

3 5

37 3

Total 44

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Length of Stay (2012)

years Number of Patients

0 - 1 7

1 - 2 4

2 -5 22

5 - 10 7

10 - 15 3

15 - 20 1

Total 44

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Challenges

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Co-existing self injury and violence

Balancing the risks to patient and staff

Managing superficial and life threatening self injury

Use of seclusion and mechanical restraint in exceptional circumstances

Recognising and supporting impact on staff

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2009 : 25% of all forensic services incidents (2376 of 9323)per month 173 – 246 staff sickness 5-12%

Oct-Dec 2009: 574 incidents: 30% self injury (173) 48% violence (277)

of 277 violent incidents: 95% to staff5% injury during restraint

9% physical assaults 49% threats/verbal abuse

Jan – June 2009: 230 seclusion episodes (32-45 per month)27 episodes of continuous obs (1-11per month)

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Seclusion and segregation: balance violence and self injury risks

Safe and Exceptional Use of Mechanical Restraint Policy

Trauma and Self Injury Programme: adapted risk reduction approach to self injury

Specialist supervision

Post Incident Defusing and Debriefing (NICE)

Promote staff well being: OH, physio, sickness policy

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Integrated Care Pathway

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Women’s Service Pathway: Assessment stage (incorporating early treatment and engagement)

Concurrent PathwaysLink to ICP Map 4

Assessment Stage:Interventions & Activity

MDT Assessments (6 months)

LEARNING DISABILITY

STREAM

MENTAL HEALTH STREAM

PERSONALITYDISORDER

STREAM

INTENSIVE CARE STREAM

CORE ASSESSMENT SET(2)

CARE STREAM SPECIALIST ASSESSMENTS

(3)

INITIAL MDT FORMULATION(4)

6 MONTH CPA MEETING(5)

CPA CARE PLANLink to CPA Pathway

REFERRAL OUT OF SERVICE

(6)

PATHWAYENDS

COMPLETION OF DISTRESS SIGNATURE

(7)

TASI PROGRAMME

LINK TO ICP MAP 5:GENERIC ACTIVITY

MDT MEETINGS

NAMED NURSE INTERVENTIONS

THERAPEUTIC MILIEU

SOCIAL CARE PATHWAY

HEALTHY LIFESTYLESPATHWAY

TEDPATHWAY

PHYSICAL HEALTHPATHWAY

SECURITY PATHWAY

MDT MEETING:MDT ASSESSMENT PLAN

(1)

MEANINGFUL DAY PLAN(8)

OUTCOMES FOR ASSESSMENT STAGE

(9)

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Women’s Service Pathway: Foundation Stage - Early Treatment and Engagement (6 -12 months)

Concurrent PathwaysLink to ICP Map 4

Concurrent ActivityFoundation InterventionsCore Foundation Interventions

LEARNING DISABILITYCARE STREAM:

FOUNDATION INTERVENTIONS (3)

MENTAL HEALTH CARE STREAM:

FOUNDATION INTERVENTIONS (4)

PERSONALITY DISORDERCARE STREAM:

FOUNDATION INTERVENTIONS (5)

INTENSIVE CARE STREAM:

FOUNDATION INTERVENTIONS (6)

SERVICE CORE INTERVENTION:

TASI PROGRAMME(1)

COMMUNICATION SKILLS GROUP

(8)

MEANINGFUL DAY PLAN(10)

SERVICE CORE INTERVENTION:

DIALECTICAL BEHAVIOURAL THERAPY

(2)

DIRECTLY WORKING WITH ANGER AND AGGRESSION

(7)

SOCIAL CARE PATHWAY

HEALTHY LIFESTYLESPATHWAY

PHYSICAL HEALTH PATHWAY

TEDPATHWAY

SECURITYPATHWAY

LINK TO ICP MAP 5GENERIC ACTIVITY

MDT CLINICAL MEETINGS

NAMED NURSE INTERVENTIONS

THERAPEUTIC MILIEU

ACCESS TO LEGAL SUPPORT AND ADVOCACY

CPA PATHWAYRECOVERY PLANNING

(9)

OUTCOMES FOR FOUNDATION STAGE(11)

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Women’s Service Pathway: Treatment Stages

Concurrent Pathways and Activity

Individual Risk and Offence Focused Work

Core Interventions

PHYSICAL HEALTH & WELLBEING

Link to Primary Healthcare / Healthy Lifestyles Pathway

LEARNING DISABILITY

CARE STREAM(1)

OCCUPATIONAL & ARTS THERAPIES

Link to TED Pathway

INDIVIDUAL VIOLENCE / ANGER MANAGEMENT

(6)

ARSON TREATMENT GROUP(ALSO INDIVIDUAL)

(7)

SUBSTANCE MISUSE TREATMENT PROGRAMME

(8)

CASE MANAGEMENT

CONCURRENT PATHWAYS

LINK TO ICP MAP 4

BEHAVIOURAL ANALYSIS(LD STREAM)

(9)

SUBSTANCE MISUSE AWARENESS GROUP

(5)

MENTAL HEALTHCARE STREAM

(2)

PERSONALITY DISORDER

CARE STREAM(3)

OUTCOMES FOR TREATMENT STAGES(10)

LINK TO ICP MAP 5GENERIC ACTIVITY

MDT CLINICAL MEETINGS

NAMED NURSE INTERVENTIONS

THERAPEUTIC MILIEU

ACCESS TO LEGAL SUPPORT AND ADVOCACY

TASI PROGRAMME:(4)

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Women’s Service Pathway: Consolidation Stage

Consolidation Stage

YES

LEARNING DISABILITY

CARE STREAM

MENTAL HEALTHCARE STREAM

PERSONALITY DISORDER

CARE STREAM

SELF MANAGEDRECOVERY & RELAPSE

PREVENTION PLANS(1)

DISTRESS SIGNATURE(2)

PROMOTING INDEPENDENCE(3)

MEANINGFUL DAY PLAN (4)

MDT REVIEWS / CPA REVIEWSNO

DISCHARGE PATHWAY PLAN(5)

RECOVERY & RELAPSE PREVENTION PLANS

(6)

PROVIDER IN-REACH(SOCIAL CARE PATHWAY)

DECISION TO TRANSFER OR DISCHARGE YES

REFORMULATION ANDRETURN TO PATHWAY

RETURN TO PRISON

MINISTRY OF JUSTICE

NOT SUITABLE

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Women’s experiences of

self injury and trauma

Audit 2007 Approx 80% of patients had experienced abuse

Most had experienced complex trauma with residual symptoms Often linked to their index offence

76% of women employ self injurious behaviour as a coping strategy Many engaging in life threatening self injury

On average over 50 incidents per month across the ward areas Staff injuries due to intervening to prevent self injury

The Background

NICE Guidance Self-Harm: longer-term management (133) Nov 2011

The key priorities for implementation when working with people who self-harm include:

Trusting supportive relationships Awareness of stigma and discrimination Non judgemental approach Involvement in decision making about treatment and care Foster autonomy and independence where ever possible Continuity of therapeutic relationships Information communicated sensitively

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The National High Secure Healthcare Service for Women Trauma and Self Injury Programme

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Positive Risk Reduction Through Systemic Change

3 levels:

Proactive Approaches educating patients and staff about living and working with self injury and the impact of trauma

Interactive Approachesto create positive ward atmospheres which focus on managing and minimising self injury in a way which is helpful to all who live and work there

Enhance Resources in CAT, DBT, CBT and trauma therapies (e.g. EMDR) to support women to use different ways of coping

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Level 1: Proactive Approaches

Skincare and Camouflage

Training

Self help packs

Trauma education groups

Wound care pack and training

Staff TrainingPatient involvement

Patient Rep group

Wellbeing groups

Enhancing capacityProactive approaches

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Level 2: Interactive Approaches

Sensory signatures

Individualised Distress signatures

Guide to aid helpful responses

Shared formulation

Adapted approach to Reducing harm

Champions Staff/patients

Ward milieu

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Level 3: Therapy Interventions

Cognitive Analytictherapy

CAT

Cognitive Behavioural Therapy

CBT

Eye Movement Desensitisation and

Reprocessing EMDR

Dialectical Behaviour Therapy

DBT

Therapy OptionsIndividual/Group

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‘I now understand the difference between when I am impulsive and when I am spontaneous’

‘It has helped me trust my named nurse and the

team, they get where I am coming from, I can now

ask them when things get bad in my head’

‘I don’t feel so ashamed to talk about how it feels inside when

everything builds up. Stops me hitting someone or

cutting my arms’

‘It gives me something that’s just about me , not what I’ve done’

‘It gives me a framework as a nurse to gain understanding of what the woman is

experiencing from her own view”

‘opportunity to look at what helps reduce distress

It is what I should be doing as a nurse, this aids recovery’

‘The most helpful thing was learning about the

vicious cycles I didn’t realise that avoidance

doesn’t help.’

‘I would like to share what I have learnt with my mum I think she will

understand me better.’

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No of incidents of Self Harm in Women's Service1 Apr 2009 to 31 Dec 2013

0

10

20

30

40

50

60

70

80

90

No. o

f Inc

iden

ts

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Dialectical Behavioural Therapy

Focus on regulating emotions, mindfulness, distress tolerance and acceptance

Recommended by NICE for BPD where recurrent self harm is a priority

Foundation treatment to women with personality disorders

Expanded provision to two DBT groups running continuously including an adapted group

Preparatory work before full engagement

More responsive to needs of women

Weekly therapy group and individual session

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Cognitive Analytic Therapy

Focus: patterns of relating to self and others and the therapeutic relationship

Integrative approaches recommended in NICE BPD guidelines

Expanded provision by: supervision of CAT Trainees (Practitioner and Psychotherapist) specialist placements for final year Clinical Psychology and Forensic

Psychology Trainees

supervised clinical practice for qualified staff

Weekly sessions via 16 or 24 sessions

Therapy tools

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Cognitive Behavioural Therapy

•Focus on thinking, behaving, and feeling

•Recommended in NICE Guidelines on PTSD

•Provided by TASI Programme Co-Leads

•Programme support for CBT training

•Weekly therapy sessions

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Combines elements of exposure therapy, cognitive therapy, and body work

Also recommended in NICE Guidance on Post-Traumatic Stress Disorder (PTSD)

Pilot project started April 2010

Challenges implementing

Eye Movement Desensitisation and Reprocessing

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The Future

•Develop physical healthcare provision - physical healthcare suite

•Truly national service working with Scotland and N Ireland

•CIPs

•National Women's Personality Disorder Strategy

•National debate about number of high secure beds needed

•WEMMS evaluation

•Need to establish seamless pathways for women through the different tiers of secure services with seamless entry/exit criteria

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Contact details: susan.elcock@nottshc.nhs.uk