Long-stay in high and medium secure forensic psychiatric care – Prevalence, patient characteristics and pathways in England

Introduction

Forensic psychiatric services are costly and highly restrictive for patients. Clinical experience and the limited research available indicate some patients stay for too long in these settings. A proportion of patients may, however, require long-term (potentially life-long) secure forensic psychiatric care but their needs may not be met by existing service provision designed for faster throughput.

Objectives

We conducted a national, multi-centre, cross sectional study exploring the prevalence of long-stay and characteristics of long-stayers in high and medium secure forensic psychiatric care in England.

Aims

(1) Estimate the prevalence of long-stay in secure settings in England (length of stay over 5 years in medium secure care or 10 years in high secure care); (2) describe the characteristics, needs and care pathways of long-stay patients. Develop recommendations following the exploration of international models for this patient group.

Methods

We employed a mixed-methods approach including the analysis of administrative data, case file reviews, patient interviews, consultant questionnaires, interviews with clinicians and commissioners and a Delphi survey.

Results

Twenty-five percent (n = 401) of our sample were experiencing long-stay. This patient group has a heterogeneous set of characteristics and needs relating to their diagnosis, offending history, risk and therapeutic need and have experienced a variety of care pathways through secure care.

Conclusions

We found a greater number of long-stay patients than originally estimated with a set of characteristics and needs that are arguably different to that of the general forensic population, therefore calling for a specific care pathway and service provision for this patient group with a greater focus on autonomy and quality of life.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Patient characteristics and outcome measurement in a low secure forensic hospital

BACKGROUND

Health services are increasingly required to measure outcomes after treatment, which can be reported to the funding body and may be scrutinised by the public. Extensive high-quality measurements are time consuming. Routinely collected clinical data might, if anonymised, provide good enough evidence of useful change consequent on service received.

RESEARCH QUESTION

Do the Health of the Nation Scale and the 20-item Historical, Clinical, Risk structured professional judgement tool scores provide evidence of clinical and risk change among low security hospital patients at 6 and 12 months after admission?

METHODS

One hundred and eight men were either resident on the unit on 1 January 2011 or new admissions to the census date of 31 May 2013. Their routinely collected data were added to an outcome register following each patient's Care Programme Approach clinical review meeting and analysed using repeated measures t-tests with Bonferroni corrections.

RESULTS

Most of the men, mean age 34.3 years, were single (93%), White British (71%) and with a primary diagnosis of schizophrenia (62%). There were significant reductions in the 11-item Health of the Nation Scale (excluding the community living condition scale) scores between baseline and 6 months and between 6 and 12 months, but no change on its additional 7-item secure subscale. Individual effect sizes indicated that 39% of the men had better social function, although 18% had deteriorated at 6 months. There was little overall change in the 20-item Historical, Clinical, Risk; individual effect sizes indicated that 11 men (15%) were rated as being at lower risk level and 10 (14%) at higher after 6 months in the study.

CONCLUSIONS/IMPLICATIONS FOR CLINICAL PRACTICE

Standard clinical measures are promising as indicators of change in low security hospital patients. Risk ratings may be conservative, but at this stage of a secure hospital admission, higher scores may be as likely to indicate progress in identifying and quantifying risks as apparent increase in risk. Copyright © 2017 John Wiley & Sons, Ltd.

Characteristics and Pathways of Long-Stay Patients in High and Medium Secure Settings in England; A Secondary Publication From a Large Mixed-Methods Study

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood. Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England. Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings. Results: 22% of patients in high security and 18% in medium security met the definition for "long-stay," with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample. Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

Background

Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay.

Objectives

To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay.

Design

A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4).

Setting

All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England.

Participants

Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4).

Results

Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain.Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group.

Limitations

We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients.

Conclusions

The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain.

Future work

To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients.

Study registration

The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376.

Funding

The NIHR Health Services and Delivery Research programme.

Inpatient forensic-psychiatric care: Legal frameworks and service provision in three European countries

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long-established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population.