The Forensic Network 1 A Study of Major Change: Legislation, Education & Practice.

1The Forensic Networkwww.forensicnetwork.scot.nhs.uk

A Study of Major Change: Legislation, Education & Practice


Lindsay Thomson, MD, Medical Director, The State Hospital/Forensic Network/ Edinburgh University (Chair)

Andreana Adamson, BSc (Econ) MBA, Chief Executive, The State Hospital/Forensic Network

Ed Finlayson, CQSW, DipSW, Head of Social Work, South Lanarkshire Council/The State Hospital


Legislation Practice

Education

A study of major change


Legislation

Mental Health (Care and Treatment) (Scotland)

Act 2003“The best mental health legislation

in the world?” Holyrood Magazine (7/5/07)


Background

• 20 years out of date?

• Significant changes in mental health policy and

service delivery

• Human Rights

• Millan Committee

• MH Act Reference Group – Working Together

Legislation


MHA 2003

• Royal Assent 25 April 2003

• Preparing for Implementation Programme

• Act Implemented 5th October 2005

• 23 parts with over 300 sections

• Code of Practice, 3 Volumes

Legislation


The Act

Mental Health

(Care and Treatment)

(Scotland)Act 2003

Legislation


Principles

• Take Account of Patients Wishes

• Maximise Participation• Provide Maximum Benefit• Non Discriminatory

Practice• Take Account of Views of

Named Person

• Carers Needs• Appropriate Services• Minimum Restriction• Child’s Welfare is

Paramount• Duty to Maintain Parental

Relationships• Social Inclusion

Legislation


Protection / RightsAdvocacy

• Duty to Inform Patient of Advocacy Services

• Duty to Take Steps to Arrange Advocacy Services

Legislation


Protection / RightsNamed Person

Nominated by a patient in accordance with the

provisions of the Act to act in their best interests.

The named person is entitled to receive certain

information about the patient and to act on behalf

of the patient in certain circumstances and at

certain times

Legislation


Protection / RightsAdvance Statement

A written, witnessed document made when the

patient is well, setting out how he or she would

prefer to be treated (or not treated) if they were

to become ill in the future

Legislation


Protection / RightsMental Welfare Commission• Monitor operation of act and promote best

practice• Patient visits; investigations; interviews and

medical examinations; inspect records• Publish information and guidance; give advice or

bring matters to the attention of others including services and government.

Legislation


Protection / RightsMental Health Tribunal Scotland

• New independent body to make decisions in relation to applications, reviews and appeals

• Legal Members, Medical Members and General Members

• Right of appeal against compulsory measures• Right of appeal against excessive security

Legislation


Definition of Mental Disorder• Mental Illness

• Learning Disability

• Personality Disorder

Exclude if only by reason of:Sexual orientation; sexual deviancy; transexualism; transvestism; dependence on or use of alcohol or drugs; behaviour that causes harassment, alarm or distress; acting as no prudent person would do

Legislation


Definition of Treatment

• Nursing

• Care

• Psychological Interventions

• Habilitation

• Rehabilitation

Legislation


Grounds for Compulsion

• Mental Disorder

• Treatment is Available

• Significant Risk to Health, Welfare or Safety

• (Significantly Impaired Decision Making)*

• Compulsion is Necessary

* Only applies in Civil Procedures

Legislation


Menu of Compulsory Powers

• Detention in Hospital

• Compulsory Treatment

• Attendance at Services

• Access for Service Providers

• Place of Residence

• Notification or Approval of Change of Address

Legislation


Requirements for Compulsory Powers

• Psychiatric Reports

• Mental Health Officer Reports

• Designated Responsible Medical Officer and

Mental Health Officer for all cases.

Legislation


Mental Health Officer

• Registered Social Worker

• Training in Mental Disorder and Mental

Health Law

• Appointed by the Local Government

Legislation


Care Plan

• Objectives of Treatment

• Details of Community Care Services

• Details of any other Treatment or Services

Legislation


Issues

• Number of Interim Orders and Tribunals

• Provision of Information to Named Person

• Managing Views of Victims

Legislation


Outcomes

• Fewer Emergency Orders

• Fewer episodes of compulsion

• Increasing use of community measures

• Successful appeals against security

Legislation


Use of Mental Health LegislationMH(S)A 1984 MH(C&T)(S)A 2003

1/4/05-4/10/05 5/10/05-1/4/06

Emergency 2410 920(62%)

Short term 1511 1666(10%)

Long term 773 528

Hospital 469

Community 59

Legislation


Mental Health Tribunal - good for patients?

“Patients feel they are being listened to by the panel members – that has to be a

good thing”

Carolyn Little, Chair

National Schizophrenia Fellowship

Legislation



Questions?

Legislation


Practice

MEL 1999 (5) Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland provides the basis for Forensic Mental Health Services in Scotland.

Policy


Practice

Mentally disordered offenders should be cared for: • with regard to quality of care and proper attention to

the needs of individuals• as far as possible in the community rather than in

institutional settings• under conditions of no greater security than is justified

by the degree of danger they present to themselves or to others

• in such a way as to maximise rehabilitation and their chances of sustaining an independent life

• as near as possible to their own homes or families if they have them

Guiding Principles of MEL 1999 (5)


Scottish Ministers call for new approach to FMHS

“.. to bring a pan-Scotland dimension to the planning process for services .. to support the development of local services .. and to secure protocols to ease the management of patients

through the system”

Mary Mulligan, MSPDeputy Health Minister, 2002

Practice


Context

• Population: 5 million

• Forensic inpatient population 500

• Under developed services in 15 health authorities

• Forensic Services within NHS – 1 small independent provider (24 beds)

Practice


Media

Practice


“Review the process for determining the right care for mentally disordered offenders”

“Consider wider issues surrounding patient pathways .. Including information systems,

education and training and strategic planning”

Scottish Executive Health Department, March 2003

Objectives

Practice


Forensic beds

High 240 Low

Currently

Planned

Low

Practice

500 BedsApproximate figures

Med 50

Low

High 140

Med 150

Low


“A key measure of success will be a smaller State Hospital … services can and should

be provided in other secure and community settings”

Malcolm Chisholm, MSP

Health Minister, 2003

Practice


Network Board

• Multi Agency – Health, Scottish Executive, Social Work, Police,

Prison, Local Government Housing, Carer agencies

• Regional Representation– North, South and East, West, Northern Ireland– Each circa 1.5m population

Practice


Principles

Practice

• Pan Scotland approach

• Strategic Planning

• Performance Management Frameworks

• Information Systems

• Education and Training


National High secure

Regional Structure

Practice

Local Low Secure

Local Low Secure

Local Low Secure

Local Low Secure

Local Low Secure

Local Low Secure

Local Low Secure

Medium Secure


Local Services – Low Secure

Regional – Medium Secure

National High secure

Community Services

Regional Structure

Practice


Appeals against excessive security• 66 applications

• 34 heard

• 24 upheld

• 8 declined

• 17 cancelled/withdrawn

Practice


“The Forensic Network is an excellent example of how we can bring together

national, regional and local perspective on the planning and delivery of services”

Hugh Henry, MSP

Justice Minister, 2005

Practice


Strategic Planning

• Definitions of Levels of Security– Obvious starting position– Matrix of security– Tool for audit of existing and planned services– Recommended development of Secure Care

Standards

Practice


• Secure Care Standards– Eleven standards– Three generic standards across all security

levels (1 assessment & care planning; 2 delivery of generic and specialist treatments, interventions and support for recovery; 3 teams, skills, staffing)

– Remaining eight specific to security level (maintenance of detention; suspension of detention; management of violence; excluded items; communication and technology; movement of personnel and contingencies)

Practice

Strategic Planning


• Services for Women

– Small patient-specific group

– No need for high secure beds

– Favour community based specialist services

– Small number of medium secure beds

Practice

Strategic Planning


• Services for Learning Disabilities– Small population

– Robust community based services

– Regional multi-agency risk management groups

– 12 high secure beds

– Separate services for LD, small regional units

Practice

Strategic Planning


• Personality Disorders– Significant population in NHS and Prisons

– “PD should not be a diagnosis of exclusion from forensic mental health services in Scotland”

– No change to current clinical in-patient practice

– Pilot work with criminal justice and prisons

Practice

Strategic Planning


• 2006 Policy and Guidance– Including conflict resolution and patient flows

• Care Programme Approach• Risk Management • Clinical Governance• School of Forensic Mental Health

Launch October 2007

Practice

Policy



Practice

Questions?


Education SoFMHSchool of Forensic Mental Health

School of Forensic Mental Health:

Teaching, Training & Research


The Three Graces



Venus de Milo



Knowledge and Understanding of the MH(C&T)(S)A 2003 within Trainee Psychiatrists

• Response Rate 93% (n=48)• Mean Total Score 22/61 (range 6-51)

- FY2 19- SHO 29- SpR 38- Principles: mean 2/10 (40% - 0)- Detention Criteria 2/5



Survey of Services for People with “Forensic” Personality Disorder

• 7 implicitly exclude people with a

primary PD Dx from admission

• 7 assess people with a primary

diagnosis of PD

• 8 use multidisciplinary and 10

comprehensive methods of

assessment

• 4 use structured clinical tools for

the assessment of PD

• 6 services did not accept people with a primary diagnosis of PD for specific intervention, treatment or management, 4 services did not accept people with a secondary dx

• No reliable figures

• Training requirements were identified in particular for developing case formulations and employing evidence based




Rationale“The Network provides the opportunity for

participating stakeholders to consider …. education and training . . . and the

commissioning of research to establish an evidence base for service development”

Scottish Executive Health DepartmentMarch 2003



Network Working Group• Multi-agency expert group• Objectives

– Review provision of forensic education and identify gaps

– Review recent research – Develop proposals and models for school of forensic

education and research (if required)

– Consider advantages and disadvantages– Consider resource and funding issues



Identifying needs• Two scoping exercises (including independent)

• Both highlight clear gaps• Complex nature of needs (risk, law, complex system & clients)

• No postgraduate provision• No forum for multidisciplinary training although clinicians

work on multidisciplinary basis• Limited forensic mental health training in non health

agencies• Research efforts are small and uncoordinated



Meeting the needsDevelop a Forensic School• Coordinating body (consortium)• Provider and Commissioner • Build on existing resources• Programme development• Training trainers• Teaching materials



Option Appraisal

• I Do nothing

• II Refer to a Coordinating Body

• III Establish a Virtual School

• IV Establish a Physical School



Business Case• Appraisal of options

• Advantages/disadvantages

• Costs

• Risk assessment

• Establish and weight benefits criteria



Option AppraisalScore

• I Do nothing 2.54• II Refer to a Coordinating Body 7.52• III Establish a Virtual School 16.03• IV Establish a Physical School 14.38

Affordability



Principles

• Practical Utility

• Inclusive

• Feasible

• Financially viable



Delivery (1)• All of Scotland• Links with educational institutions• Board – stakeholders• Administrative base• Use of existing materials• Development of new materials• NHS & educational interface



Delivery (2)• Multidisciplinary courses in forensic studies • Modular basis with clear assessment of

competences• Access to modules, diploma or MSc• Part-time• Distance learning• Multi-agency• Specific training



Sample Modules

• Law and Mentally Disordered Offenders

• Mental Disorder and Crime

• Risk Assessment and Management Treatment

of Mentally Disordered Offenders

• Services for Mentally Disordered Offenders



Support for the school

• Government Policy

• NHS Education Scotland

• Scottish Executive Health Department

• Forensic Network Associates

• Higher Education Institutions

• Further Education Institutions



New to Forensic

• Commissioned by NHS Education Scotland

• Designed for clinical and non clinical staff

• 6 month self directed learning programme

• Students supported by mentors

• Twelve chapters with case scenarios

• Delivery by network of trainers within services


Chapter 1 - Aims and Teaching Methods

Chapter 2 -Understanding Mental Disorder

Chapter 3 -Definitions, Principles and Policy

for Mentally Disordered Offenders

Chapter 4 -Civil Mental Health Legislation

Chapter 5 -Forensic Mental Health Services

Chapter 6 -Attitudes to Mentally Disordered

Offenders and ways of dealing

with personal emotions and

boundaries

Chapter 7 -Forensic Mental Health Services and the

Criminal Justice System: Understanding the

relationship

Chapter 8 -Psychiatric Defences and Legislation for

Mentally Disordered Offenders

Chapter 9 -Assessment, Treatment and Management

of Mentally Disordered

Offenders

Chapter 10 -Multidisciplinary Working, Communication

and Managing Difference

Chapter 11 -Safety of Staff, Patients and Public

including Risk Assessment and

Management

Chapter 12 -Taking Account of the Views of Users and

Carers


Content (1)


Content (2)

•Differential objectives

•A problem based learning approach

•Participants supported by experienced mentors

•Use of a reflective diary

•Case studies designed to challenge thinking

•Links to other learning materials throughout the programme




Mentor Mentor

Trainer

Trainer

Mentor Mentor

Trainer

Trainer

Mentor Mentor

Trainer

Trainer



Current Work

• Police Probation Training

• Strategic Change Grant

• Network of Trainers

• Risk Management Agenda

• Psychological Therapies Training


Education

SoFMHSchool of Forensic Mental Health

Come and see for yourself ……

IAFMHS 2009 Conference, Edinburgh

PracticeLegislation



[email protected]@[email protected]+ 44 1555 842018

The Forensic Network 1 A Study of Major Change: Legislation, Education & Practice.

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