Dr Tom White
Former Lead Clinician –
Secure Care Project
“The Way Forward: a New Build, a New Model,
a Network”
Presentation to NHS Grampian Research
Interest Group/Forensic Network
4 October 2012
Agenda
1. Route to Rohallion (Medium Secure)
2. A new Clinical Model
3. NoS Network – embedding the new
Regional MSU within Regional Low
Secure Services
Journey to Rohallion
• Butler Report (1975) “Interim Secure Units”
• MEL (99) 5 proposed a single national high
secure service, 3-4 regional MSU and local low
secure services.
• Mental Health (Care & Treatment) Act 2003 –
Section 264 Appeal against detention in
excessive security
• Outline Business Case – June 2006
• NHS CEL (48) 2006 : 3 regional medium secure
units – 30 beds for NoS
• Full Business Case – April 2011
• Building Due Opened – 17 September 2012
Implications for NOS
• High secure estate 240 –> 140 beds.
•
Need to develop 32 regional MSU beds.
• Continue low secure units in Tayside and Grampian
for male MDO and learning disability patients.
•
Work with Regional planners to access to
– high, medium and low secure female services
– medium secure LD services
What is Medium Security?
Architectural, procedural and relational
components outlined in:
• Levels of Security Report (2006)
• Department of Health (2009)
What is the Patient Population?
Nationally agreed admission criteria in
Scotland to High & Medium Secure Estate.
• Diagnostically complex – mental illness,
substance misuse and personality disorder
• Offence threshold
• Persistence of aggression/inappropriate
sexual behaviour/arson/stalking in lower
security
North of Scotland Benchmarking
No of CPA/ MMD beds/
100,000
100,000
North
No of
Restricted
Patients/
100/000
3.67
6.3
2.5
East
2.34
6.1
2.0
West
3.00
4.8
2.6
September 2010 - preparing the ground
Works progressing - Jan 2011
Rohallion Admin Block – Jan 2012
Varra Ward – April 2012
What is a Forensic Psychiatry
Service?
“Focus on systematic assessment and
management of risk”
“Ability to deliver offence-related
interventions”
Tom Fahy
A New Clinical Model
L & M Enquiry (2006)
•
•
•
•
•
Failure to assess risk
No shared risk management plan
No contingency plan
Poor documentation & supervision
Limited specialist training for non-medical
members of team
NHS Tayside Low Secure Service
• Limited capacity to deliver structured risk
assessment
• Psychology input only available in
community
• Limited development of nursing staff skills
to deliver psychological approaches
• In 2006, CPA not routinely used
NHS Tayside Low Secure Services
• Very good at monitoring metabolic
syndrome
• Able to engage patients over long periods
• Day care available to manage transition
from hospital to outpatient care
New Clinical Model (for Low &
Medium Secure)
• Developed in consultation with regional
partners at Regional Governance Group
• Discussed regularly with Executive Project
Board
• Approved by NoS Medical Directors on 23
November 2012
New Clinical Model (for Low &
Medium Secure) (contd)
• Development and implementation made
possible by appointment of Clinical
Service Manager
• Supported by Senior Practice
Development Nurse
• Facilitated by move to Forensic
Directorate
Clinical Model (Summary)
1. Nursing Assessment (BEST INDEX)
measures symptoms, functional ability and
risk
2. Developed NoS drug & alcohol
assessment instrument (& CBT based
intervention)
3. Tiered but systematic approach to
assessment of personality disorder
Unique Features of Rohallion (2)
4. Focus on modifiable risk factors for
cardiovascular disease especially
“Metabolic Syndrome”
5. Delivery of Level 2 SPJ Risk Assessment
6. Psychological formulation of offending
(RMA) (MATRIX)
7. Integrated Care Pathway focusing on
adequacy of assessment and enhanced
CPA
Unique Features of Rohallion (3)
8. Delivering psychological therapies
 Assessment of need
Focusing on Matrix Priorities
 Anger
 “Coping with mental illness”
 Drug & Alcohol Misuse
 Matched tiered approach
Developing a Regional Network
North of Scotland Planning Group
Area
Orkney Isles
St Ninian’s Isle,
Main Land
Shetland
Kyle of Lochalsh
looking towards
Skye
Loch Ness,
Inverness-shire
Schiehallion
and Loch
Rannoch,
Perthshire
River Dee,
Aberdeenshire
The Right Place – The Right
Time May 2000
Managed Clinical Network
• “to create and sustain a robust MCN across
Scotland”
• “Comprehensive database to provide realtime tracking to avoid unmanaged bottlenecks”
• Agree definitions of high, medium and low
secure
• Patients journey supported by ICP
• Protocols for key stages – admission,
assessment, transfer and discharge
Regional MCNs
NHS
HDL(2007)21
• The aim of all Regional Networks is to
clarify and support the development of
patient pathways across Board areas
when the service cannot be provided in
one Board area alone. They are,
therefore, focused on common
protocols, training & audit. MCNs’
strengths lie in the promotion of
consistency and quality of
service throughout the care pathway.
NHS HDL (2006) 48
• Establish forensic subgroups within 3
regional planning groups.
• Develop regional services.
• Monitor patient flow.
• Commissioning arrangements for OAT.
• Forward Regional Clinical Governance.
Developing Regional Services
• Male Mental Illness MSU
• Created capacity to assess risk (HCR20,
SVR-20)
• Training in “risk management plans”
(RMA)
• Training in “Drug and Alcohol Assessment
& Treatment”
• Training in CBT, anger assessment &
coping with Mental Illness Group
Monitor Patient Flow
• Monitor all Sec 264 Appeals
• Input to Conflict Resolution Group
• Complete NoS OOA list (State Hospital,
Orchard Clinic, England)
• Review every 3 months at Regional
Governance Group
• Negotiated admission pathway to
Rohallion
Regional Governance/Planning
Structure
• First met on 11 September 2008
• Strong links to National Network & InterRegional Leads
• Membership – Senior Planners & Practitioners
from mainland HB areas, MHO/SW input
• Minutes to Orkney HB, Shetland HB, Northern &
Tayside CJA
• Annual report to NoS Chairs & Chief Executives
Commissioning Arrangements for
OAT
• Contributed to Risk Share Agreement for
Medium Secure Learning Disability
Services
• In dialogue with both Orchard Clinic &
Rowanbank re Female Forensic Service
• In dialogue with NSD and other Regional
Planners to create NHS Scotland
specialist provision (head injury, ADHD,
autistic spectrum)
Regional Clinical Governance
•
•
•
•
Audit of Enhanced CPA
Audit of Discharge Pathway
Shared Policies & Procedures
Membership of Royal College of
Psychiatrist Medium Secure Quality
Improvement Group
Stairway glazing in Rohallion
Medium Secure Ward Courtyard
View from Medium Secure Garden