The National High Secure
Services for Women
Rampton Hospital
Dr Sue Elcock
Consultant Forensic Psychiatrist
1
Positive about integrated healthcare
2
3
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
4
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
5
6
7
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
8
9
10
NHSHSW
50 beds
 Emerald A
 Emerald B
6 Beds
6 Beds
 Topaz
12 Beds -PD Admission/Treatment Ward
 Ruby
14 Beds -PD Treatment Ward
 Jade
12 Beds -Mental Health Ward
-Learning Disability Unit
-Intensive Care Unit
 Diamond Resource Centre -Day care services for women
11
De-escalation
Quiet Rooms
Low Stimulus
Seclusion
12
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 by
Senior
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
13
Referrals
2008
2009
2010
2011
2012
2013
TOTALS
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
14
Admissions
2008
2009
2010
2011
2012
2013
TOTALS
20082013
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
15
Conversion Rates
○
○
○
○
○
○
2008
2009
2010
2011
2012
2013
5 admitted from 13 referrals
8 admitted from 23 referrals
7 admitted from 17 referrals
9 admitted from 20 referrals
7 admitted from 14 referrals
9 admitted from 20 referrals
38.5%
35%
41%
45%
50%
45%
16
Discharges
2008
2009
2010
2011
2012
2013
TOTALS
20082013
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
17
The Population
18
MHA (2012)
MHA Section
Number of Patients
37/41
22
47/49
7
41(5)
7
3
5
37
3
Total
44
19
Length of Stay (2012)
years
0-1
Number of Patients
7
1-2
4
2 -5
22
5 - 10
7
10 - 15
3
15 - 20
Total
1
44
20
Challenges
21
 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
22
 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 staff
5% 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)
23
 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 approa
to self injury
 Specialist supervision
 Post Incident Defusing and Debriefing (NICE)
 Promote staff well being: OH, physio, sickness policy
24
Integrated Care Pathway
25
Women’s Service Pathway: Assessment stage (incorporating early treatment and engagement)
MDT Assessments (6 months)
LEARNING
DISABILITY
STREAM
MENTAL HEALTH
STREAM
PERSONALITY
DISORDER
STREAM
INTENSIVE CARE
STREAM
MDT MEETING:
MDT ASSESSMENT PLAN
(1)
CARE STREAM
SPECIALIST ASSESSMENTS
(3)
CORE ASSESSMENT SET
(2)
REFERRAL OUT
OF SERVICE
(6)
Assessment Stage:
Interventions & Activity
Concurrent Pathways
Link to ICP Map 4
TASI PROGRAMME
SOCIAL CARE
PATHWAY
COMPLETION OF
DISTRESS SIGNATURE
(7)
TED
PATHWAY
MEANINGFUL DAY PLAN
(8)
PHYSICAL HEALTH
PATHWAY
INITIAL MDT FORMULATION
(4)
HEALTHY LIFESTYLES
PATHWAY
6 MONTH CPA MEETING
(5)
SECURITY PATHWAY
CPA CARE PLAN
Link to CPA Pathway
LINK TO ICP MAP 5:
GENERIC ACTIVITY
MDT MEETINGS
NAMED NURSE
INTERVENTIONS
PATHWAY
ENDS
OUTCOMES FOR ASSESSMENT
STAGE
(9)
THERAPEUTIC MILIEU
26
Women’s Service Pathway: Foundation Stage - Early Treatment and Engagement (6 -12 months)
Core Foundation Interventions
SERVICE CORE INTERVENTION:
TASI PROGRAMME
(1)
Foundation Interventions
Concurrent Activity
Concurrent Pathways
Link to ICP Map 4
DIRECTLY WORKING WITH
ANGER AND AGGRESSION
(7)
RECOVERY PLANNING
(9)
CPA PATHWAY
COMMUNICATION SKILLS
GROUP
(8)
MEANINGFUL DAY PLAN
(10)
TED
PATHWAY
SERVICE CORE INTERVENTION:
DIALECTICAL BEHAVIOURAL
THERAPY
(2)
LEARNING DISABILITY
CARE STREAM:
FOUNDATION INTERVENTIONS
(3)
LINK TO ICP MAP 5
GENERIC ACTIVITY
SOCIAL CARE
PATHWAY
MDT CLINICAL MEETINGS
MENTAL HEALTH
CARE STREAM:
NAMED NURSE INTERVENTIONS
THERAPEUTIC MILIEU
FOUNDATION INTERVENTIONS
(4)
PHYSICAL HEALTH
PATHWAY
ACCESS TO LEGAL SUPPORT AND
ADVOCACY
PERSONALITY DISORDER
CARE STREAM:
HEALTHY LIFESTYLES
PATHWAY
FOUNDATION INTERVENTIONS
(5)
INTENSIVE
CARE STREAM:
SECURITY
PATHWAY
FOUNDATION INTERVENTIONS
(6)
OUTCOMES FOR FOUNDATION STAGE
(11)
27
Women’s Service Pathway: Treatment Stages
Core Interventions
LEARNING
DISABILITY
CARE STREAM
(1)
MENTAL HEALTH
CARE STREAM
(2)
Individual Risk and Offence
Focused Work
PERSONALITY
DISORDER
CARE STREAM
(3)
TASI PROGRAMME:
(4)
SUBSTANCE MISUSE
AWARENESS GROUP
(5)
INDIVIDUAL VIOLENCE /
ANGER MANAGEMENT
(6)
ARSON TREATMENT GROUP
(ALSO INDIVIDUAL)
(7)
SUBSTANCE MISUSE
TREATMENT PROGRAMME
(8)
Concurrent Pathways
and Activity
CASE MANAGEMENT
CONCURRENT PATHWAYS
LINK TO ICP MAP 4
LINK TO ICP MAP 5
GENERIC ACTIVITY
MDT CLINICAL MEETINGS
PHYSICAL HEALTH & WELLBEING
NAMED NURSE INTERVENTIONS
Link to Primary Healthcare /
Healthy Lifestyles Pathway
THERAPEUTIC MILIEU
BEHAVIOURAL ANALYSIS
(LD STREAM)
(9)
ACCESS TO LEGAL SUPPORT AND
ADVOCACY
OCCUPATIONAL & ARTS
THERAPIES
Link to TED Pathway
OUTCOMES FOR TREATMENT STAGES
(10)
28
Women’s Service Pathway: Consolidation Stage
Consolidation Stage
LEARNING
DISABILITY
CARE STREAM
MENTAL HEALTH
CARE STREAM
DISCHARGE PATHWAY PLAN
(5)
SELF MANAGED
RECOVERY & RELAPSE
PREVENTION PLANS
(1)
RECOVERY & RELAPSE
PREVENTION PLANS
(6)
DISTRESS SIGNATURE
(2)
PROVIDER IN-REACH
(SOCIAL CARE PATHWAY)
PROMOTING INDEPENDENCE
(3)
MEANINGFUL DAY PLAN
(4)
NO
PERSONALITY
DISORDER
CARE STREAM
MDT REVIEWS / CPA REVIEWS
YES
DECISION TO TRANSFER OR
DISCHARGE
YES
MINISTRY OF JUSTICE
NOT SUITABLE
REFORMULATION AND
RETURN TO PATHWAY
RETURN TO PRISON
29
Women’s experiences of
self injury and trauma
30
The Background

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
NICE Guidance Self-Harm: longer-term management
(133) Nov 2011
The key priorities for implementation when working with people who selfharm 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
The National High Secure Healthcare Service for Women
Trauma and Self Injury Programme
33
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 Approaches
to 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
34
Level 1: Proactive Approaches
Wellbeing
groups
Skincare and
Camouflage
Training
Patient Rep group
Enhancing capacity
Proactive approaches
Self help packs
Trauma education
groups
Staff Training
Patient involvement
Wound care pack
and training
35
Level 2: Interactive Approaches
Champions
Staff/patients
Adapted approach to
Reducing harm
Sensory signatures
Ward milieu
Individualised
Distress signatures
Shared formulation
Guide to aid helpful
responses
36
Level 3: Therapy Interventions
Dialectical Behaviour
Therapy
DBT
Cognitive Analytic
therapy
CAT
Therapy Options
Individual/Group
Eye Movement
Desensitisation and
Reprocessing
EMDR
Cognitive Behavioural
Therapy
CBT
37
39
‘It gives me a framework as a nurse to gain
understanding of what the woman is
experiencing from her own view”
‘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 now understand the difference
between when I am impulsive and
when I am spontaneous’
‘It gives me something that’s just
about me , not what I’ve done’
‘The most helpful thing was
learning about the vicious
cycles I didn’t realise that
avoidance doesn’t help.’
‘opportunity to look at what helps reduce distress
It is what I should be doing as a nurse, this aids
recovery’
‘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’
‘I would like to share what I have learnt
with my mum I think she will
understand me better.’
40
Ap
r-0
9
Ju
n0
Au 9
g09
O
ct09
De
c09
Fe
b10
Ap
r-1
0
Ju
n10
Au
g10
O
ct10
De
c10
Fe
b11
Ap
r-1
1
Ju
n11
Au
g11
O
ct11
De
c11
Fe
b12
Ap
r-1
2
Ju
n1
Au 2
g12
O
ct12
De
c12
Fe
b13
Ap
r-1
3
Ju
n1
Au 3
g13
O
ct13
De
c13
No. of Incidents
No of incidents of Self Harm in Women's Service
1 Apr 2009 to 31 Dec 2013
90
80
70
60
50
40
30
20
10
0
41
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
42
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
43
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
44
Eye Movement Desensitisation and
Reprocessing
 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
45
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
46
Contact details: [email protected]
47