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

2. 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

3. A study of major change
Legislation
Practice
Education

4. Mental Health (Care and Treatment) (Scotland) Act 2003
Legislation
Mental Health (Care and Treatment) (Scotland) Act 2003
“The best mental health legislation in the world?” Holyrood Magazine (7/5/07)

5. Background Legislation 20 years out of date?
Significant changes in mental health policy and service delivery
Human Rights
Millan Committee
MH Act Reference Group – Working Together
Be specific (significant change, community care)
Human Rights 1998 challenges all policies and legislations

6. MHA 2003 Legislation 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
Ok to say its badly written

7. (Care and Treatment) The Act Legislation Mental Health (Scotland)

8. Principles Legislation Take Account of Patients Wishes Carers Needs
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
Also apply to decisions that do not involve the act
Good point to counter the negative message about how it is written

9. Protection / Rights Advocacy
Legislation
Protection / Rights Advocacy
Duty to Inform Patient of Advocacy Services
Duty to Take Steps to Arrange Advocacy Services

10. Protection / Rights Named Person
Legislation
Protection / Rights Named 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

11. Protection / Rights Advance Statement
Legislation
Protection / Rights Advance 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

12. Protection / Rights Mental Welfare Commission
Legislation
Protection / Rights Mental 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.
Mental Welfare Commission for Scotland
Important for patient rights focus

13. Protection / Rights Mental Health Tribunal Scotland
Legislation
Protection / Rights Mental 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

14. Definition of Mental Disorder
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
Personality Disorder is interesting, AA will say more
Also Prudent Person & Drug and Alcohol

15. Definition of Treatment
Legislation
Definition of Treatment
Nursing
Care
Psychological Interventions
Habilitation
Rehabilitation

16. Grounds for Compulsion
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
Important to stress Welfare and Safety “to others”

17. Menu of Compulsory Powers
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

18. Requirements for Compulsory Powers
Legislation
Requirements for Compulsory Powers
Psychiatric Reports
Mental Health Officer Reports
Designated Responsible Medical Officer and Mental Health Officer for all cases.

19. Mental Health Officer Registered Social Worker
Legislation
Mental Health Officer
Registered Social Worker
Training in Mental Disorder and Mental Health Law
Appointed by the Local Government

20. Care Plan Objectives of Treatment Details of Community Care Services
Legislation
Care Plan
Objectives of Treatment
Details of Community Care Services
Details of any other Treatment or Services

21. Issues Number of Interim Orders and Tribunals
Legislation
Issues
Number of Interim Orders and Tribunals
Provision of Information to Named Person
Managing Views of Victims

22. Outcomes Fewer Emergency Orders Fewer episodes of compulsion
Legislation
Outcomes
Fewer Emergency Orders
Fewer episodes of compulsion
Increasing use of community measures
Successful appeals against security

23. Use of Mental Health Legislation
MH(S)A MH(C&T)(S)A 2003
1/4/05-4/10/05 5/10/05-1/4/06
Emergency (62%)
Short term (10%)
Long term
Hospital
Community 59

24. Mental Health Tribunal - good for patients?
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
Enormous opportunity costs but brings in views /participation of carers

25. Questions? A Study of Major Change: Legislation, Education & Practice

26. Practice
Policy
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.
Government policy in this area of practice goes back to 1999 and ….
Based on the Reed Report in England and Wales (1991) the policy set out some guiding principles.
But not costed and this has been a major stumbling block to service development

27. Guiding Principles of MEL 1999 (5)
Practice
Guiding Principles of MEL 1999 (5)
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
Nothing changed
Patients stuck in high security – Free £30m
1999 – 2002

28. Scottish Ministers call for new approach to FMHS
Practice
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, MSP
Deputy Health Minister, 2002
In early 2002 during the parliamentary debate on the Bill Ministers recognised lack of progress and asked me to lead a forensic network
Political backing important ++++

29. Context Population: 5 million Forensic inpatient population 500
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)
Small country
Small forensic population
In patients but of course prisons and in the community
Traditional problem of media excitement

30. Practice
Media
Care is provided in an environment of public rage and insatiable desire for the salacious stories, and so – developing services is a difficult task.
Political nervousness together with media interest misleads the public.

31. Practice
Objectives
“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
Back to the network objectives
Configuration of services +

32. Forensic beds Practice Currently Planned High 240 Med 50 Low Low
The Network is about redistribution of beds across the spectrum of security
Some issues:
Concentration on lower high secure
increased medium secure
Outstanding – long term care and community services
500 Beds
Approximate figures

33. Practice
“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
One year on, Politicians continued to back the network objectives in shifting the balance of care across levels of security

34. Network Board Multi Agency Regional Representation Practice
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
I decided that the network should develop regional planning as 15 Health Authorities – too few population

35. Principles Pan Scotland approach Strategic Planning
Practice
Principles
Pan Scotland approach
Strategic Planning
Performance Management Frameworks
Information Systems
Education and Training
Pan Scotland due to size of population
Strategic planning – how to do rather than what to do as set out in MEL 1999 (5)
Performance Management Systems – ensuring patients are not stuck in (free) high security 1/3 Glasgow, East
Sharing information cruicial between agencies
Developed into the School of Forensic Mental Health

36. Regional Structure Practice
Local Low Secure
Local Low Secure
Local Low Secure
National
High secure
Medium Secure
Local Low Secure
Local Low Secure
So going back to where we were in For me it was starting from scratch as there was no effective network of services
Basically high secure (remember free)
One MSU in the East, very underutilised, reasons of cost
Spattering of low secure all different across the 15 Health Authorities
Virtually no community services
Local Low Secure
Local Low Secure

37. Regional Structure Practice Local Services – Low Secure
Regional – Medium Secure
National
High secure
In saying that the Forensic Estate will stay about the same in number the cost will be in excess of £20m extra
TSH – reduce by 100 to 140
Regional MSUs for population of 1-2m 3 in number
East in operation since 2002
West next month 74 beds
North 32 beds 2012
The under use of the east unit has been recovered due mainly to appeals against excessive security and is now full.
Community Services

38. Appeals against excessive security
Practice
Appeals against excessive security
66 applications
34 heard
24 upheld
8 declined
17 cancelled/withdrawn
So a clear link to legislation driving practice
(since September 2006)

39. 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
Again continued Political Support

40. Strategic Planning Definitions of Levels of Security Practice
Obvious starting position
Matrix of security
Tool for audit of existing and planned services
Recommended development of Secure Care Standards
At the outset I recognised 3 gaps in progressing services in accordance to policy
What are the levels of security?
Small population of women and LD
And this is where we started

41. Strategic Planning Secure Care Standards Practice 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)
Started with Medium Secure small private unit had to be registered
Developed low and high secure standards so three generic standards 8 relating to security level

42. Strategic Planning Services for Women Practice
Small patient-specific group
No need for high secure beds
Favour community based specialist services
Small number of medium secure beds
30 or so in Scotland 21 beds in TSH and nothing designated elsewhere
Plan 30 or so, again redistribution across east and west, local. Close TSH by end of summer

43. Strategic Planning Services for Learning Disabilities Practice
Small population
Robust community based services
Regional multi-agency risk management groups
12 high secure beds
Separate services for LD, small regional units
26 TSH
Low secure – close supervision unity across the country
Plan 26 – 12 TSH
12 – 16 MSU

44. Strategic Planning Personality Disorders Practice
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
Current practice: Not routinely admitted
Proposing to work together with CJS and SPS in the assessment and management of offenders with PD.
One of the main recommendations

45. Policy Practice 2006 Policy and Guidance Care Programme Approach
Including conflict resolution and patient flows
Care Programme Approach
Risk Management
Clinical Governance
School of Forensic Mental Health
Launch October 2007
The work of the Network so far has been endorsed by Government, still to come is
New guidance on CPA for restricted patients
clinical governance arrangements and the formal academic establishment of the School

46. Questions? A Study of Major Change: Legislation, Education & Practice

47. School of Forensic Mental Health:
SoFMH
School of Forensic Mental Health
Education
School of Forensic Mental Health:
Teaching, Training & Research

48. SoFMH
School of Forensic Mental Health
Education
The Three Graces

49. SoFMH
School of Forensic Mental Health
Education
Venus de Milo

50. Mean Total Score 22/61 (range 6-51)
SoFMH
School of Forensic Mental Health
Education
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

51. Survey of Services for People with “Forensic” Personality Disorder
SoFMH
School of Forensic Mental Health
Education
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

52. SoFMH
School of Forensic Mental Health
Education
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 Department
March 2003

53. Network Working Group Education Multi-agency expert group Objectives
SoFMH
School of Forensic Mental Health
Education
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

54. Identifying needs Education
SoFMH
School of Forensic Mental Health
Education
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

55. Meeting the needs Education Develop a Forensic School
SoFMH
School of Forensic Mental Health
Education
Meeting the needs
Develop a Forensic School
Coordinating body (consortium)
Provider and Commissioner
Build on existing resources
Programme development
Training trainers
Teaching materials

56. Option Appraisal I Do nothing II Refer to a Coordinating Body
SoFMH
School of Forensic Mental Health
Education
Option Appraisal
I Do nothing
II Refer to a Coordinating Body
III Establish a Virtual School
IV Establish a Physical School

57. Business Case Appraisal of options Advantages/disadvantages Costs
SoFMH
School of Forensic Mental Health
Education
Business Case
Appraisal of options
Advantages/disadvantages
Costs
Risk assessment
Establish and weight benefits criteria

58. Option Appraisal Score I Do nothing 2.54
SoFMH
School of Forensic Mental Health
Education
Option Appraisal
Score
I Do nothing
II Refer to a Coordinating Body
III Establish a Virtual School 16.03
IV Establish a Physical School 14.38
Affordability

59. Principles Practical Utility Inclusive Feasible Financially viable
SoFMH
School of Forensic Mental Health
Education
Principles
Practical Utility
Inclusive
Feasible
Financially viable

60. Delivery (1) Education All of Scotland
SoFMH
School of Forensic Mental Health
Education
Delivery (1)
All of Scotland
Links with educational institutions
Board – stakeholders
Administrative base
Use of existing materials
Development of new materials
NHS & educational interface

61. Delivery (2) Education Multidisciplinary courses in forensic studies
SoFMH
School of Forensic Mental Health
Education
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

62. Sample Modules Education Law and Mentally Disordered Offenders
SoFMH
School of Forensic Mental Health
Education
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

63. Support for the school Education Government Policy
SoFMH
School of Forensic Mental Health
Education
Support for the school
Government Policy
NHS Education Scotland
Scottish Executive Health Department
Forensic Network Associates
Higher Education Institutions
Further Education Institutions

64. New to Forensic Education Commissioned by NHS Education Scotland
SoFMH
School of Forensic Mental Health
Education
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

65. Content (1) Education SoFMH
School of Forensic Mental Health
Education
Content (1)
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
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

66. Content (2) Education Differential objectives
SoFMH
School of Forensic Mental Health
Education
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
Emphasise Multi-disciplinary writing group

67. SoFMH
School of Forensic Mental Health
Education

68. Current Work Police Probation Training Strategic Change Grant
SoFMH
School of Forensic Mental Health
Education
Current Work
Police Probation Training
Strategic Change Grant
Network of Trainers
Risk Management Agenda
Psychological Therapies Training
Already couple of Psychological Therapy events: Anger and Sex Offending

69. SoFMH
School of Forensic Mental Health
Education

70. Come and see for yourself …… IAFMHS 2009 Conference, Edinburgh
SoFMH
School of Forensic Mental Health
Legislation
Practice
Education
Come and see for yourself ……
IAFMHS 2009 Conference, Edinburgh

71. A Study of Major Change: Legislation, Education & Practice lindsay
A Study of Major Change: Legislation, Education & Practice