Low secure LD care pathway and gate-keeping guidance and templates Dr Susan Johnston M.B., Ch.B., F.R.C.Psych. Dr Richard Lansdall-Welfare M.B., Ch.B., M.R.C.Psych. Ruth Sargent 1 Low secure LD care pathway and gate-keeping guidance and templates CONTENTS Section Page no. 1 Preface 4 2 Introduction 5 3 Care pathway 6 4 Referral and Gate-keeping process for low secure services 7 4.1 Referral pathway 7 4.2 Timescale 8 4.3 The Gate-keeping assessment 8 4.4 Key decision points in the gate-keeping process 9 4.5 The Gate-keeping report 11 5 Model pathway within low secure services 12 6 Equality impact assessment 14 7 Review date 16 8 Approval 16 APPENDICES 1 Description of high, medium and low secure services and locked rehabilitation services 17 2 The East Midlands learning disability community forensic service model 19 3 East Midlands clinical Gate-keepers – low secure 23 4 Assessment tools and outcome measures 25 5 Gate-keeping assessment template 37 6 Steering group attendees 41 2 Low secure LD care pathway and gate-keeping guidance and templates Population in the East Midlands East Midlands had one of the fastest growing populations between 2001 and 2009. Above average growth is projected to continue, with particularly large growth rates in older age groups. The population of the East Midlands was estimated to be 4.5 million in 2009, 8.6 per cent of the population of England. Population density was 290 residents per sq km, one of the lowest among the English regions. It varied from less than 80 residents per sq km in West Lindsey in Lincolnshire, to 4,200 in Leicester unitary authority. It is projected the region will have 5.2 million residents by 2028, 17 per cent more than in 2008. The projected increase for England is 15 per cent over the same time period. 3 Low secure LD care pathway and gate-keeping guidance and templates 1. Preface This document has been developed as part of the East Midlands Next Stage Review, Towards Excellence work programme. The East Midlands Next Stage Review identified the need to develop a forensic care pathway for people with learning disability. An element of the pathway that was causing considerable concern was low secure provision. Low secure services provide hospital care for people with complex needs, challenging behaviours and/or forensic needs. The concerns were threefold; firstly that people were placed inappropriately far from home, secondly that they may be staying longer than necessary in secure care, and finally that the costs of the placements were not adequately monitored or controlled by commissioners. With low secure commissioning moving to East Midlands Specialised Commissioning Group (EMSCG) in April 2009 it was agreed that EMSCG would lead this work alongside the low secure clinical lead, Richard Lansdall-Welfare, appointed in March 2009. The Chief Executive lead for the work-stream is John McIver, Chief Executive NHS Lincolnshire. The original milestones for the project concentrated on the handover of responsibility for commissioning low secure services from local PCTs to EMSCG, and for audits of provider units to be undertaken against Department of Health guidance. These were completed by June 2009. A steering group was formed in October 2009 to progress the work on the learning disabilities forensic care pathway, referral and gate-keeping processes for low secure care. Representatives from the 6 East Midlands NHS provider Trusts and from the 9 Primary Care Trusts were invited to join the steering group. A full list of invited organisations and attendees can be found at the back of the document. (Appendix 6) The authors of this document are grateful for the enthusiasm, hard work and commitment from the steering group attendees. A confirm and challenge event was held on 29th October 2010 to help finalise the document. Focus groups were also held with service users in 2 provider units. 4 Low secure LD care pathway and gate-keeping guidance and templates 2. Introduction Secure mental health and learning disability services are specialist, tertiary mental health services that provide for both mentally disordered offenders and those whose behaviour has led, or could lead to offending. They manage individuals who are a risk to others and require input from staff with specialist expertise and knowledge and provide a level of security for detained patients. Forensic/secure services serve the public and the criminal justice system by: “Providing secure services within a framework of clinical governance, specialised assessment, treatment and rehabilitation for offenders with mental health problems or those at risk of offending; Promoting better services through teaching, research and development; and Working closely with service users, carers, other health, local authority social services, nonstatutory and criminal justice agencies to reduce and manage risk.” (Jobbins, Abbott, Brammer, Doyle, McCann & McClean; 2007) The range of forensic and secure services currently within the UK are generally categorised by the level of security they provide. The term forensic and secure is often used interchangeably when discussing these services, but may describe different populations and services. A brief description of high, medium and low secure services is available in Appendix 1. This document seeks to describe the forensic care pathway for people with learning disabilities in the East Midlands, together with the gate-keeping process for low secure care. 5 Low secure LD care pathway and gate-keeping guidance and templates 3. Care Pathway An overview of the care pathway and current population of people with learning disabilities cared for by forensic services is set out below: East Midlands Regional Learning Disability Forensic Care Matrix Criminal Justice System COMMUNITY SERVICES Community LD Services Community Forensic Services Local Adult Mental Health Services PRISON CAT C Low Secure Services 40 CAT B/C CAT A/B Medium Secure Services Local 10 Locked Rehabilitation Service Regional 35 National High Secure Services 6 *The numbers denote East Midlands patients in services in May 2010. Meeting the needs of learning disabled forensic patients involves a multi agency response and a tiering of services in the overall learning disabilities service model. Individual care pathways may utilise several of the elements above. There is also an important relationship with the criminal justice system. Broadly speaking the category of prisons mirrors the tiering of health services. Community services patients may receive services from a range of organisations and services. They are the hardest population to quantify. The Steering Group agreed a model for a virtual community forensic team which will vary in it’s specific make-up in each area but retains the same function. This is outlined in Appendix 2. The diagram above implies a simplistic, linear process and system that does not always map well onto a complex set of services or reflect individual pathways. The aim is to assist in clarifying the pathway and processes, together with greater alignment of the entries and exits into and out of services. 6 Low secure LD care pathway and gate-keeping guidance and templates 4. Referral and Gate-Keeping Process for Low Secure Services Over the last 2 years the commissioning of low secure commissioning has transferred from Primary Care Trusts to East Midlands Specialised Commissioning Group. This has enabled a greater focus on patients with learning disabilities with these specialised needs. This section sets out clear arrangements for referral to, and clinical gate-keeping of low secure services which will be applied across the East Midlands to achieve consistency. 4.1. Referral Pathway LOW SECURE REFERRAL PATHWAY Medium Secure Services Prison In-Reach Teams/Courts/ Police/Probation Forensic and Low Secure Community Teams Adult Mental Health Services Learning Disability Services Local consideration of appropriateness for Low Secure bed (arrangements will vary by area) SINGLE POINT OF ACCESS Low Secure gate-keeping request via East Midlands Specialised Commissioning Group LOCAL CLINICAL GATE-KEEPER Assesses appropriateness of patient Emergency requires Low Secure bed EMSCG Case Manager proceeds with referral to Low Secure bed immediately-liaise with local commissioner Requires Low Secure bed Does not require Low Secure bed Case manager retrospectively informs panel due to urgency of placement LOCAL MULTI-AGENCY DECISION MAKING PANEL Monitoring of all requests for individual placements (the panel has EMSCG attendance) 7 Low secure LD care pathway and gate-keeping guidance and templates 4.2. Time scales The time scales below are taken from the Best Practice Guidance Specification for adult Medium secure services (Health Offender partnerships DH 2007) and should be considered as best practice for low secure gate keeping assessment and placement. The gate keeper should ascertain the urgency of the situation on receipt of the referral. “E3 For urgent referrals, an initial verbal response regarding the appropriateness of a referral should be made within 24 hours of receipt of the referral, and an initial multidisciplinary assessment within seven days. The outcome should be notified verbally within 24 hours of the assessment, and a formal written assessment should follow within seven days. E4 For routine referrals, an initial response as to whether a multidisciplinary team (MDT) assessment will be appropriate should be notified within 14 days and an initial MDT assessment within one month. A decision should be made within two weeks and a bed offered within a further six weeks.” The steering group has identified that good practice would suggest that the gate- keeping assessment is multidisciplinary, however clinicians will agree and produce a single report signed by the consultant. There are some circumstances where this might be difficult to achieve. If there is a single gate-keeper this should be a specialist learning disability consultant psychiatrist or an Approved clinician. A full list of identified gate-keeping assessors for the region is given in Appendix 4. Assessors will normally operate within their own locality. However, they can operate across County boundaries if required. 4.3 The Gate Keeping Assessment Clinicians working in an individual service are familiar with the role of deciding, as a result of informal and formal processes, which patients are accepted into a service. Whilst this may be considered a form of gate-keeping it differs from providing a gate-keeping role on behalf of commissioners of services. Most clinicians are familiar with: Providing an assessment and treatment service for a defined number of inpatient beds or occupied bed days(OBD) or contracted number of face to face contacts, outpatient(OPD) contacts Inpatient facilities under their own or a colleagues control 8 Low secure LD care pathway and gate-keeping guidance and templates Formal (and informal) operational practices and service strategy Staff & resource skills/deficits at any particular time Staff knowledge and strengths (e.g. autistic disorders, fire- setters etc) Bed management issues Existing inpatient populations & dynamics Knowledge or experience of managing a particular patient Independent Gate-keeping is a different process. Gate-keeping is the process of managing / making recommendations to access scarce and expert resources. It is reasonable to have clear structures and processes in place to ensure those most in need receive the appropriate services. Gate-keeping will be needed to enter a service and for any transition or exit from the service. It should provide early indications of necessary treatment and markers of progress, or risk milestones on a treatment plan. This should help an individual to maintain the achieved progress in more local / less secure / less structured/staffed / less costly services. 4.4 Key Decision Points in the Gate-keeping Process The decision points identified below are not altogether a linear process. They may be interactive and are key in identifying appropriate levels and the type of service provision for the individual. Decision point 1 Eligibility for access to specialised learning disability services should be ascertained noting that wherever possible, practicable and appropriate mainstream (including forensic) services with/without support should be accessed by all. On assessment does the individual have: known learning disability – this may require formal psychometric testing following the assessment to assist in this. recently assessed learning disability. additional complex cognitive impairments such that they require a specialised earning disability provision. Decision point 2 Almost without exception for individuals presenting with offences or offending like behaviour the first gate to be negotiated is:- 9 Low secure LD care pathway and gate-keeping guidance and templates Criminal Justice versus Healthcare provision, this is a very critical decision and may be more prominent following the implementation of the recommendations from the Bradley Report. Decision point 3 For those individuals whose “behaviours” if convicted would attract a non-custodial sentence the decision is: No additional health provision Community provision (including treatment as part of probation) Residential hospital provision informal / detained Decision point 4 For those individuals whose “behaviours” if convicted would attract a custodial sentence (or those who are serving prisoners) the decision is: Hospital versus Prison Note:Hospital provision can only be offered if the individual fulfils detention criteria under the Mental Health Act (2007), otherwise intervention should be offered as in-reach to prison. Decision point 5 If it is considered the individual should receive hospital provision the decision is: Locked rehabilitation services v low v medium v high secure services Note: For existing prisoners it is important to note that the security category of the detaining prison will have a bearing on the level of security for hospital provision that will be acceptable to the Ministry of Justice. To identify anticipated level of hospital security Security components need assessment to find best fit (consider use of structured tool e.g. The Security Needs Assessment Profile (SNAP)) Current risk assessment of violence, sexual offending, further offending, vulnerability (consider use of HCR-20, EPS, SVR-20, RSVP, etc) Principles Individuals should be placed in the least restrictive environment for their needs. 10 Low secure LD care pathway and gate-keeping guidance and templates There may be times when the complexity of intervention required may best be delivered where there is the appropriate skill resource and historical patterns indicate worsening patterns of behaviour when challenged. An individual in crisis in custody acting out in distress may improve and stabilise very quickly in the higher staffed hospital provision. Additional considerations At the time of assessment the treatment interventions likely to alleviate or prevent deterioration in mental health should be identified. Not only do these assist in the selection of the best fit placement but serve as initial care pathway targets and progress markers. Reference should be made to geographic or other variables impacting on the suitability of placement e.g. illicit drug free facility, geographically distant from victim. Respectful suggestions of services known to fulfil provision criteria may be made but referral to such remain the realm of the secure services commissioning team and acceptance to individual services will remain the decision of the specific service. 4.5 The Gate-keeping Report A single Gate-keeping report will provide a clinical picture of the individual and their possible management issues. It will clearly identify the level of security required to best meet the individual’s needs and the level of risk posed. The report should be based on a face to face interview with the person and take account of and make reference to any appropriate background documentation. Telephone calls to others involved with the person can assist in the assessment and should be referenced in the report. The report will identify the names and profession of assessors; with the final sign off by a psychiatrist in learning disability. This person should be able to hold the status of an Approved or Responsible Clinician. (NB only a medical practitioner can initiate detention). The template for the report is attached in Appendix 6. 11 Low secure LD care pathway and gate-keeping guidance and templates 5. Model Pathway within Low Secure Services The steps outlined are broadly sequential and are offered as guidance to commissioners and local clinicians monitoring placements. Based on average length of admission data it is anticipated that structured low secure admissions, with associated treatment and rehabilitation, may last up to 2 years duration (though this is dependent on the clinical rationale and individual circumstances). Lengths of stay beyond this timescale are a variance from this model and may require repeat gatekeeping to re-assess treatment need / risk assessment in conditions of low security, as requested by EMSCG case manager. 12 Low secure LD care pathway and gate-keeping guidance and templates Admission and Engagement Max Timeframe Preadmission Activity Baseline Measurement MDT assessment incorporating provisional care plans, risk management strategies. Identification of key named workers, RC and named nurse 1 week Familiarisation Health Action Plan Communication plan By first CPA 6-12 weeks after admission Information gathering from all agencies, including social history Clinical management of immediate risks Understanding the person – development of an initial clinical formulation Explore the needs and formulate joint actions for risk reduction and recovery Person centred plan Max Timeframe From initial CPA onwards to 18 months Intervention, Rehabilitation and Recovery Interventions and Outcomes After 18 months Implementation of CPA treatment plan, including accessible patient held version. Treatment interventions: Psychotropic treatment Insight related / mental health awareness work re psychosis Drug/Alcohol misuse related therapy Social problem solving skills Interpersonal violence – focus on impulsivity, anger control Development of social interaction / engagement, habilitation or rehabilitation, and educational / vocational opportunities (OT interventions) Psychological approaches such as CBT, DBT or CAT (where appropriate) Specific offence related therapy – sex offending, arson (where appropriate) Structured Personality disorder assessment (where appropriate) Risk assessment / management – graded risk testing linked to plans with clear targets (in terms of changes in observation status, patient access levels, nursing care plans and section 17 leave status) Development of a care pathway beyond low secure conditions Management of Transitional steps low to community Consider use of Keep safe model Ability to manage conflict Focus on functional skill development and maturational tasks Increasing independence and social integration Development of non-institutional routines and structure to time management Demonstration of acquired skills Treatment Resistant If likely clinical pathway trajectory is not towards step-down from low secure conditions imminently Treatment outcomes have not been achieved There is a lack of sufficient change Risk has not reduced sufficiently to progress There should be a re evaluation to assess the balance between treatment/change and quality of life After 5 years Cross area gate keeping from another area. Not the original gate keeper 13 Completion of gate-keeping assessment MDT have agreed admission plan Development of a CPA Treatment Plan which incorporates psychiatric, forensic nursing, psychological, OT, SALT and general medical treatment interventions or areas of ongoing need. This should interlink with risk assessment tools. Completion of HONOS Secure HCR-20 in preparation; where appropriate relevant consider other relevant risk assessment tools, e.g. SVR-20 or RSVP for sex offending; actuarial tools e.g. STATIC 99, RISK MATRIX 2000 Consideration of further assessment using tools. These may include formal assessment of intellectual functioning (such as WAIS) or others areas of functioning e.g. GAF, BPRS, PANSS, PASSAD, EPS Outcome Measurement Positive changes in Recovery Planning Tool Scores Evidence of linking between CPA, Recovery plan and PCP in accessible format and patient held Positive changes in pre and post Model of Human Occupation (MOHO) scores (when developed) Completion of Assessment of Motor and Process Skills (AMPS) HONOS Secure and HCR-20 ratings reflect reduced risk management strategies needed Successful transfer. No return within 1 year. At 18 months forensic case managers / throughcare clinicians should gather clinical evidence from provider and request a gate keeping assessment Consider quality of life indicators Maintenance and Risk Management Low secure LD care pathway and gate-keeping guidance and templates 6. Equality Impact Assessment EIA Initial Screening Template PLEASE ENSURE EACH BOX IS COMPLETED OTHERWISE THE SCREENING PROCESS WILL NOT BE VALIDATED Directorate East Midlands Specialised Commissioning Group Department Mental Health Name of ‘activity’ being assessed Name of document Person completing this form Ruth Sargent Head of Specialised Mental Health and Learning Difficulties Please indicate ( ) whether activity is Proposed or Existing Step One: Brief overview of aims and objectives of the Activity Aim: To improve patient experience and quality and cost of service Objective: (intended benefits or outcomes) Care closer to home. Reduce length of stay. Step Two: Details of Consultation/Involvement – during the development of this activity? All provider trusts and 9 PCTs have been involved in developing the guidance. Confirm and Challenge Event 29th October 2010. Step Three: Policy/Service Content: (A) SERVICE USERS For each of the following checks is this ‘Activity’ sensitive to people of different age, ethnicity, gender, disability, religion or belief, sexual orientation & transgender? The checklists below will help you to identify any strength and / or highlight improvements required to ensure that the activity is compliant with equality legislation. (A) Check for DIRECT/INDIRECT discrimination against any minority group of SERVICE USERS: Does your ‘Activity’ adversely impact people from using the services : Response Yes No 1.0 Age 1.1 Gender (Male, Female) 1.2 Sexual Orientation (Gay, lesbian) 14 Please justify your response for each area and action to be undertaken Low secure LD care pathway and gate-keeping guidance and templates 1.3 Transsexual/transgender 1.4 Disability including Learning Disability, Mental Health, Sensory Impairment, Physical or other (Check this link for further) 1.5 Race or Ethnicity 1.6 Religion or Belief (including other belief) 1.7 Gypsy/Roma/Traveller 1.8 Dependants/Family/Carers 1.9 Offenders and Ex offenders Guidance covers all adults requiring assessment for low secure care Summary of actions required to remedy any adverse impact(s) identified above. Action Lead Target date Summary of actions required to remedy any adverse impact(s) identified above. Action Lead Target date Number of ‘Yes’ answers for Service users (A) Number of ‘Yes’ answers for Employees. (B) Step Five: DETERMINATION QUESTIONS Yes/ No Is there any evidence that some groups are affected differently? No Is there a need for external or user consultation? No If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 15 Comments (mandatory) All current service users and carers are currently being consulted Low secure LD care pathway and gate-keeping guidance and templates Is the impact likely to be negative? Can we reduce the impact by taking different action? IMPACT(Please Tick) High Medium Low Step Six: Send copy of EIA Assessment to EIA Team Attach any procedural document/s when submitted to the EDHR Team for validation. If you have answered “Yes” to any of the questions in step five it is likely the function/activity will need a full EIA. However if the action/s identified in step three mitigate the impact/s this will reduce likelihood of a full EIA. It may be reasonable to review the activity in 12 months to determine the overall outcome of the agreed actions. The EDHR team will be more than happy to discuss any concerns in this regard Signatures author/reviewer of activity Date for next review 7. 2 Review Date 2 years following approval 8. Approval Approval will be sought from EMSCG Board. 16 0 1 Low secure LD care pathway and gate-keeping guidance and templates Appendix 1 Description of high, medium and low secure services and locked rehabilitation services High Secure Services High secure provision provides a care and treatment environment for those individuals who would pose a grave and immediate danger to others if at large. Security arrangements should be capable of preventing even the most determined escape attempt or absconder. The comprehensive range of services, both recreational and clinical, acknowledges the severe limitations for access to community services and facilities. Medium Secure Services Medium secure provision provides a care and treatment environment for individuals who present a serious but less immediate danger to others. Physical security with security protocols and procedures, supported by high levels of staff should be sufficient to deter all but the most determined to escape or abscond. These environments should meet the needs of those who are not yet ready for leave into the community, but with an emphasis on graduated use of community facilities when possible. As described in the Best Practice Guidance: Specification for adult medium secure services. Health Offender Partnerships 2007 (DOH). Low Secure Services Low secure provision provides a care and treatment environment for individuals who present a less physical danger to others. Security arrangements should impede rather than completely prevent those who wish either to escape or abscond. Low secure provisions will have a greater reliance on staff observation and support rather than physical security measures. Low Secure Services are not Psychiatric Intensive Care Units. Low Secure services should emphasise access to community services, and promote a philosophy of community integration. (The National Minimum Standards Low Secure Units (DH, 2002) should be consulted for more detailed guidance) Each secure mental health provider will ensure, though the Care Programme Approach process that each individual patient will receive high-quality care and treatment which meets their needs and supports their recovery. Locked and Unlocked Rehabilitation Services Locked & Unlocked Hospital Rehabilitation (Psychiatric & Learning Disabilities) Service is a whole systems approach to recovery from mental illness that maximises an individual’s quality of life and social inclusion by enhancing skills, promoting independence and autonomy in order to give them real opportunity for the future that may lead to successful community living through appropriate support “ 17 Low secure LD care pathway and gate-keeping guidance and templates The service provides high levels of therapeutic care underpinned by evidence-based practice in keeping with industry norms, where this is published or is custom and practice. This will include a comprehensive assessment of the needs of the individual in order to devise an individualised treatment programme that will address social, physical, intellectual and mental health needs within a specific and measurable care plan, regularly collated and reviewed through the CPA framework. The maintenance of a safe, sound and secure environment for all is paramount. It is expected that the level of security will be based on individual patient need, the responsibility to protect others, and/or prevention of harm to self. Service delivery will take account of patient diversity, meeting the needs of gender, cultural and religious diversity through policies and practices that positively respect the patient’s gender, cultural, religious and spiritual preferences (Taken from the regional specification for rehabilitation services) 18 Low secure LD care pathway and gate-keeping guidance and templates Appendix 2 The East Midlands Learning Disabilities Community Forensic Service Model Introduction This document outlines the aims, objectives and functions of a learning disability (LD) community forensic team, which will be virtual in nature and will be purely advisory at this stage. It is anticipated that each of the counties in the East Midlands will give strong consideration to enabling the development of such a team. Across the East Midland’s health communities the level of activity required is thought to be low, hence there is little or no critical mass indicating the need for dedicated teams. This has resulted in a gap in service with no specialist LD forensic service in place in the community for offenders with LD. As part of the Towards Excellence LD low secure work stream an opportunity arose for the development of a service model for this group of service users. Survey work in Leicestershire indicated the following: 1. The community teams in learning disability services had a significant caseload of people with forensic issues. 2. The community teams did not always have the necessary skills to an appropriate level to manage this client group. 3. There was very little peer support and supervision could be enhanced in this area of practice 4. There is difficulty in accessing the right service for these individuals. The virtual team The virtual community forensic learning disability team would consist of appropriately experienced staff currently working within LD services. They are likely to come from various professional backgrounds including psychology, psychiatry and nursing. Aim To provide an advisory community forensic services for people with learning disabilities in the East Midlands. 19 Low secure LD care pathway and gate-keeping guidance and templates Objectives 1. To provide a community LD forensic service as a virtual team with no structural facilities. 2. To provide advice, supervision and training for community teams in managing service users with LD and forensic risks and to undertake assessments and inform management strategies where needed. 3. To provide advice, supervision and training for in-patient services (including locked rehabilitation) staff in managing service users with LD and forensic risks and to undertake assessments and inform management strategies where needed. 4. To undertake gate-keeping assessments locally and regionally, working in close partnership with East Midlands Secure Commissioning Group (EMSCG) and other regional gate-keepers to facilitate smooth transition of service users who step-down into low secure, locked rehab facilities or to the community by supporting the relevant community teams. 5. To establish and maintain links with stakeholders in the clinical network such as, general adult forensic services, the Criminal Justice System (police, prison, probation services, courts, crown prosecution service) and to work in partnership to provide a LD forensic service for individuals with LD who come into contact with other parts of the clinical network and vice versa. 6. To consider developing an expert witness team service for the Legal Services Commission. 7. To consider developing and providing adapted treatment programmes (sex offending and arson) in addition to providing a forensic angle to existing treatment strategies like anger management, relationship work and stop and think groups. The Virtual forensic team and its skill mix The Core (virtual) team will consist of professionals with forensic experience working in LD services drawn from the following disciplines: psychiatry nursing psychology speech and language therapy occupational therapy social work The core team’s skills, in addition to basic competencies, will include expert assessment and management of forensic risks, working with other professionals in the clinical network, 20 Low secure LD care pathway and gate-keeping guidance and templates administration of risk assessment scales relevant to the type of offence and providing support and training for community teams. The core team should be linked to clinical networks which consist of identified individuals from relevant stakeholder organisations. Eligibility Principles to follow in assessing eligibility to service 1. To be as inclusive as possible. The team will also be involved in support, advice and signposting. 2. The service user should have a learning disability as defined by the British Psychological Society in 2001. 3. There should be an identified forensic issue. Possible care pathway An example of the care pathway that has been developed in Leicestershire detailed overleaf. 21 Low secure LD care pathway and gate-keeping guidance and templates Leicestershire Forensic Care Pathway (Process Map) Primary Care Trusts / Local Authorities LLR Community Forensic services (General and LD / Local, Regional & National) East Midlands Secure Commissioning Group Criminal Justice System (Prison, Probation, Police, MAPPA, LSC, CPS) Community LD Teams Community LD Forensic Team Triage Red = Immediate Amber = 2-3 Weeks Red LDGreen Forensic Panel meeting = 5-6 Weeks Fast track Assessment Advice / Signposting / training / peer support / supervision / involvement in multiagency approach In complex cases, full involvement in intervention and discharge procedures 22 Gate-Keeping report Expert witness report Low secure LD care pathway and gate-keeping guidance and templates As can be seen from the above, these teams are a focussing and consolidation of the existing expertise within local services, and do not entail additional resources for setting up. Consideration of their training and developmental needs, however, should be undertaken by local services. Authors John Devapriam Richard Lansdall-Welfare Ruth Sargent October 2010 Appendix 3 23 Low secure LD care pathway and gate-keeping guidance and templates Current East Midlands Clinical Gate-Keepers – Low Secure Learning Disability (Dec 2010) For a more recent list of Gate-keepers please contact EMSCG 0116 295 0898 Nottinghamshire Derbyshire Leicestershire Northamptonshire Lincolnshire Identified Gatekeepers Email Address Dr Niraj Singh Niraj.Singh@nottshc.nhs.uk Dr Tapati Mukherjee Tapati.mukherjee@nottshc.nhs.uk John Robertson John.Robertson@nottshc.nhs.uk Dr Muhammad Qureshi Muhammad.Qureshi@DerbysMHServices.nhs.uk Pat Robinson Pat.Robinson@DerbysMHServices.nhs.uk Gaynor Ward Gaynor.Ward@DerbysMHServices.nhs.uk Rani Gosal Rani.Gosal@DerbysMHServices.nhs.uk Emma Hazel Emma.Hazel@derbyshirecountyPCT.nhs.uk Tania Moss taniamoss@nhs.net Jayne Stapleton Jayne.Stapleton@derbyshirecountypct.nhs.uk Dr Subash Mathews Subash.mathews@derbyshirecountypct.nhs.uk Sandra Twigg Sandra.Twigg@derbyshirecountypct.nhs.uk Dr John Devapriam John.Devapriam@leicspart.nhs.uk Lynne Moore Lynne.moore@leicspart.nhs.uk Dr Satheesh Kumar Satheesh.kumar@leicspart.nhs.uk Dr Raza Kiani Raza.kiani@leicspart.nhs.uk Dr Tonye Sikabofori tonye.sikabofori@nht.northants.nhs.uk Pily Maden pily.maden@nht.northants.nhs.uk Dr Peter Speight Peter.Speight@lpt.nhs.uk Dr Talib Abbas Talib.Abbas@lpft.nhs.uk Dr Enrique Bonell Enrique.BonellPascual@lpft.nhs.uk Dr Nicky Taylor nickytaylor@nhs.net Catherine Keay Catherine.Keay@lpft.nhs.uk Appendix 4 24 Low secure LD care pathway and gate-keeping guidance and templates For Reference. Assessment Tools and Outcome Measures 1. The Risk for Sexual Violence Protocol RSVP These factors relate to past information about an Sexual Violence History individual and their previous behaviour. They are not amenable to reduction. Chronicity of Sexual violence Early onset of sexual offending is a poor prognostic factor and a reliable indicator of future offending: Diversity of sexual violence Range of victim selection and nature of assaults: Greater diversity associated with increased risk: Escalation of sexual violence: Refers to sexual violence which increases in severity, frequency or diversity over time; e.g. more direct contact with victims, more serious coercion, includes all activity not only those resulting in arrest or conviction Physical coercion in sexual violence: refers to actual, attempted or threatened physical harm that arises in the course of sexual violence or that is intended to further the commission of sexual violence. Psychological coercion in sexual violence: acts during the course of or to further the commission of sexual violence that involve threatened loss or promised gain of 25 Low secure LD care pathway and gate-keeping guidance and templates status, privilege, power or affection. Includes grooming, breach of trust, abuse of power or entitlement. Not causal but reflect presence of attitudes condoning sexual violence, self awareness difficulty and sexual deviation. Psychological Adjustment Factors reflecting adjustment that have strong and relatively specific conceptual link with decisions to engage in sexual violence Extreme minimisation or denial of sexual violence: involves failure to admit or accept responsibility for acts of sexual violence and the consequences for those acts. Includes displacement or projection of responsibility and victim blaming Attitudes that support or condone sexual political, violence: include cultural, socio- sub-cultural personal, attitudes or belief systems and patterns of behaviour that directly or indirectly encourage or excuse coercive, violent sexual acts or sex with minors (Andrews & Bonta 2003, Krug et al 2003 Mann & Beech 2003) Problems with self awareness refers to reasonable understanding and evaluation of mental processes, reactions, self knowledge (English & English 1958) Perception of own risk believed to correlate with recidivism (Hanson & Harris 2000) Problems with stress or coping: linked empirically with overall risk of 26 Low secure LD care pathway and gate-keeping guidance and templates violence. violence In relation to sexual some evidence that stressful events precipitate deviant sexual fantasies that may, in turn, lead to the acting out of these fantasies. Problems resulting from child abuse: empirical evidence suggests child abuse is a general risk factor for criminality, non-sexual violence and sexual violence. It has been reported that child abuse may lead to the development of sexual deviation or empathy problems and in turn, to the increased risk of perpetrating sexual violence. Mental Disorder Factors reflecting psychopathology. fluctuating in presence preference or arousal or behaviour that involves a focus on inappropriate persons or objects (those that fall outside the realm of what is considered legal or conventional in consenting sexual relationships) Psychopathic personality disorder: as assessed using a standardised assessment schedule such as PCL-R (Hare 1991, 2003) or PCL-SV Hart et al 1995) Specifically associated with diverse sexual violence and increased risk of nonsexual violence 27 significant All the factors are dynamic nature symptmatology over time Sexual deviance: sexual interest, of and severity of Low secure LD care pathway and gate-keeping guidance and templates Major Mental Illness: refers to presence of mental illness and “mental retardation” which may lead to impulsive or irrational decisions to act on a sexually violent manner or interfere with the ability or motivation to comply with treatment or supervision Problems with substance abuse: may lead to impulsive or irrational decisions to act in a sexually violent manner. Some people with serious sexual deviance deliberately use substances to dis-inhibit themselves when they are considering sexual violence. Substance abuse may also interfere with the ability or motivation to comply with treatment and supervision Violent or suicidal ideation: reflects experience of thoughts, impulses or fantasies about causing or attempting to cause physical harm to self or others. Social Adjustment Reflect problems relating to people and fulfilling social roles and obligations. dynamic in nature Problems with intimate relationships: involve the failure to establish or maintain stable romantic or sexual relationships with ageappropriate partners, whether due to lack of desire, ability or opportunity. Includes terms and concepts of intimacy problems, poor dating skills, and attachment difficulties. 28 Factors are all Low secure LD care pathway and gate-keeping guidance and templates Problems with relationships: non-intimate the failure to establish or maintain positive social support network, regardless of desire, ability or opportunity Includes isolation, alienation, incompetence or poor social skills Problems with unemployment, employment: educational or vocational impairments. Associated with risk of criminality and general violence. Non sexual criminality Marker of presence of other risk factors. May cause negative mood and interpersonal conflicts Manageability Reflect problems managing violence in the community. risk of sexual Associated more generally with risk of violence and criminality, rather than specific sexual violence.. role in perpetration of sexual violence Problems with planning: considers making and implementing prosocial life plans; poor self management, unrealistic goals, impulsivity and inability to delay gratification.. Problems with treatment: reflects failure to benefit from rehabilitative services designed to address identified deficits in the individuals psychosocial adjustment Problem with supervision: reflect failure to benefit from services designed to make it more difficult for the individual to engage in further sexual violence. Also relevant are 29 Indirect Low secure LD care pathway and gate-keeping guidance and templates uncooperative, oppositional or antiauthority attitudes. Other considerations Evidence 30 Low secure LD care pathway and gate-keeping guidance and templates 2. HCR-20 The HCR-20 (Webster, Douglas, Eaves & Hart, 1997) is a structured guide that is designed to assess risk for violence in those with mental or personality disorders. Violence is defined as actual, attempted or threatened physical harm that is deliberate and non-consenting. The HCR-20 facilitates the formation of informed decisions about an individual’s release plans and community supervision based on a constellation of actuarial and clinical risk factors. These factors include the individual’s past history (H), current clinical risk (C), and future risk (R). Support for the validity of the HCR-20 in predicting general violence has been found in samples of civil and forensic psychiatric patients and prison inmates (Douglas & Hart, 1996). Historical Items These factors relate to past information about an individual and their previous behaviour. They are not amenable to reduction. HCR-20 Historic Item Evidence H1 Previous Violence: The scoring scheme for this item is intended to capture the density of previous violence. Therefore the number of past violent acts is combined with their severity to differentiate between a 2/1 score. A 1 score would be given if there were one or two acts of moderately severe violence. Moderately severe violence would include slapping, pushing, and other behaviours unlikely to cause serious or permanent injury to victims. A 2 score would be given for three or more acts of serious previous violence, or any acts of severe violence. Acts of severe violence includes, but is not limited to, those that cause death or serious injury to or maiming of the victim. All violence up to and including the time of the assessment is included as “previous violence.” This would include the index offence, violence during incarceration or hospitalisation, or violence directed at the assessor during interview. A NO would indicate no previous acts of violence. H2 Young age of first violence: Age is established by considering the date of the first known violent incident, which is not necessarily the index offence. If there are no known acts of violence, or the patient was 40 years and older at first known violent act, a 0 score is allotted. Between 20 and 39 a 1, and under 20 a 2 score is allotted. H3 Relational Instability: This refers only to “romantic,” intimate, or non-platonic partnerships, and does not include 31 Low secure LD care pathway and gate-keeping guidance and templates relationships with friends or family. This item is geared toward whether the individual is able to form and maintain long-term, stable relationships given the opportunity. “Instability” would include many short-term relationships; absence of any relationships or presence of conflict within a long-term relationship. A 0 score would indicate a relatively stable and conflict-free relationship pattern, a 1 possible/less serious unstable and/or conflictual relationship pattern, and a 2 score where there is evidence of definite/serious unstable and/or conflictual relationship pattern or the absence of a relationships. H4 Employment Problems: Individuals who warrant a 2 score on this item may refuse to seek legitimate employment, have a history of many short-term jobs, or of frequently being sacked or quitting. A 1 score is given for possible/less serious employment problems; a reduction from 2 to 1 may be warranted if economic, physical, or mental problems preclude employment but caution is recommended as the item focuses on employment problems rather than employability. Institutional work programmes may be considered. A 0 should be given if there is no evidence of employment problems. H5 Substance Misuse Problems: : Included in this item is the misuse of prescription drugs and glue or solvents. Whilst psychiatric diagnosis of substance abuse ought to be taken seriously their mere presence does not warrant a 2 score without corroboration. Focus on whether there exists impairment of functioning in areas such as health, employment, recreation or interpersonal relationships that are attributable to substances. Examples would include, (but are not limited to): being late for work; irate with others; being severely hung over; an inability to concentrate whilst working or driving or doing so whilst under the influence; substance related arrests; having difficulties within interpersonal relationships; and denying problems despite strong evidence to the contrary. A 1 score should be given for possible/less serious substance use problems and a 0 for no substance use problems. H6 Major Mental Illness: A diagnosis of major mental illness should conform to an official nosological system such as DSM-IV or ICD-10. The item is scored on the basis of past history and is unaffected by whether the disorder is currently active or in remission. A 2 score would be given when the evidence of major mental illness is unequivocal; if the evidence is equivocal (e.g., course or severity is unclear), then a 1 score is appropriate. Less serious mental illnesses, such as anxiety disorders, somatoform disorders, paraphilias or sleep disorders should be coded 0 32 Low secure LD care pathway and gate-keeping guidance and templates H7 Psychopathy: : It must be stressed that this rating is to be made on the basis of an informed and trained psychopathy assessment using the PCL-R or PCL:SV. The item is not to be used until such a rating is available. The item is scored according to the British Rating Scale as follows: 0 for a score of 14 or less, 1 for a score between 15 and 24 and YES for a score equal to, or greater than 25. H8 Early Maladjustment: Violence can be predicted through childhood victimisation as well as through being a childhood victimiser or delinquent. A 2 score should be given if maladjustment has occurred in at least two of the three domains of home, school, and community. If the maladjustment was very severe in one domain (e.g., severe and prolonged childhood abuse), then a 2 score is also justified. A 1 score should be given if there is evidence of possible/less serious maladjustment. No early maladjustment is coded 0 H9 Personality Disorder: A diagnosis of personality disorder should conform to an official nosological system such as DSM-IV or ICD-10; this is scored on the basis of past history and is unaffected by whether the disorder is currently active or in remission. A 2 score would be given when the evidence of personality disorder is unequivocal; A 1 score should be given if there is a diagnosis of personality disorder traits but the full criteria have not been met. 0 is given to indicate no personality disorder. H10 Prior Supervision Failure: Failures during any institutional or community placement are relevant here. A 2 score is given if the act resulted in (re-) apprehension, (re-) institutionalisation by a correctional or mental health agency, escape from a correctional facility, elopement from a maximum secure hospital, abscondance whilst on an escorted official visit (e.g., funeral/hospital attendance), re-offence during probation, revocation of parole, or failure to attend for psychiatric treatment as ordered by a court or tribunal. A 1 score is given for less serious failures such as returning late when released on pass, causing a disturbance, failing to take medication as prescribed, or using alcohol or drugs whilst prohibited. A 0 is given if the individual has never had a period of institutional, or community supervision or if there are no prior supervision failures. 33 Low secure LD care pathway and gate-keeping guidance and templates Clinical Items These items relate to the current clinical presentation, including reference to the existing therapeutic, remedial or activity programmes in place as well as general functioning. Clinical Items Evidence C1 Lack of Insight: This item refers to the degree to which the patient fails to acknowledge and comprehend his or her mental disorder and its effect on others. This lack of insight can be expressed in many ways. Some patients may have clearly evident signs of a major mental illness but are unable, or unwilling, to acknowledge that they may act in a violent manner without regular use of prescribed medication. Others may have difficulty realizing the importance that a well-structured support group may have in averting violence. Yet others may have little insight into their, generally, high levels of anger and dangerousness. A score of 2 should be given for definite/serious lack of insight, a 1 for a possible/less serious lack of insight and a 0 for no lack of insight. C2 Negative Attitudes: This item refers to recent evidence of pro-criminal and antisocial attitudes connected to a higher propensity for violence. Most people could be said to have negative attitudes of some kind but this item is present to elucidate entrenched antisocial attitudes and beliefs. Sadistic, homicidal, or paranoid attitudes which do not stem from mental illness may be counted under this item as can evidence of remorselessness, a current unwillingness to abide by rules and regulations, evidence of splitting behaviour, boundary pushing, callousness and lack of empathy. A 2 score is given for definite/ serious negative attitudes, a 1 for possible/less serious negative attitudes and a 0 given for no negative attitudes. C3 Active Symptoms of Major Mental Illness: Assessors should follow an official nosological system such as the DSM-IV or ICD-10 for definitions of psychotic symptoms. 2 should be given for definite/serious active symptoms of major mental illness, 1 for possible/less serious active symptoms of major mental illness, no active symptoms of major mental illness should be coded 0. C4 Impulsivity: Impulsivity refers to dramatic day-to-day, hourto-hour fluctuations in mood or presentation. It is an inability to remain composed and directed when under the pressure to act. Impulsive people are quick to (over-) react to real, or imagined slights, insults and disappointments, when they do their action may appear to be 34 Low secure LD care pathway and gate-keeping guidance and templates exaggerated or overdone. The item, therefore, measures behavioural and affective instability and should be scored 2 in the case of definite/serious impulsivity, 1 for possible/less serious impulsivity and 0 for no impulsivity. C5 Unresponsive to Treatment: This item refers to any . treatment designed to ameliorate criminal, psychiatric, psychological, social, or vocational problems. It is vital to know if the individual has sought help and accepted it, rejected it out of hand, or agreed to it merely to speed their transfer or “look good” to a court, Mental Health Review Tribunal or other authority. A 2 score is given to individuals who respond poorly, or not at all, to treatment attempts. They may lack motivation to begin or continue with treatment or merely pay lip service to treatment or complete treatment but fail to benefit from it. A 1 score is given if there is possible/less serious unresponsiveness to treatment and if the patient is responsive to treatment the item should be coded 0.. Risk Managed Items The risk management section considers how individuals will adjust to future circumstances. The intention is to stimulate the development of appropriate risk management plans. The assessment of risk will depend heavily upon the context within which the subject is placed. The following comments reflect the possibility of Mr ……….. being freed from detention in the near future. Risk Management Items Evidence R1 Plans Lack Feasibility: Lack of feasibility may be due to the fact that community agencies/RSU’s are unwilling (due to the patient’s behaviour) or unable (due to lack of resources) to provide assistance. Alternatively, the patient may have played no role in making plans or be uninvolved with peers or family. Finally, family and peers may be unable or unwilling to help. Score 2 for a high probability that plans will not succeed, 1 for a moderate probability that plans will not succeed and a 0 indicates that there is a low probability that plans will not succeed. R2 Exposure to Destabilizers: This term appertains to risk increasing factors. In the majority of cases the patient may be exposed to destabilizers because of inadequate professional supervision. Assessors should consider whether the patient would be attending specialized support programmes such as alcohol or substance use sessions for assistance with abstaining from destabilizers. A 2 score should be given if there is a high probability of 35 Low secure LD care pathway and gate-keeping guidance and templates exposure to destabilizers a 1 for a moderate probability and a 0 indicates that there is a low probability of exposure to destabilizers. R3 Lack of Personal Support: A 2 score on this item would appertain to an individual who would lack emotional, financial, or physical support from friends or family, or if such support is available but the individual is unwilling to accept it. It is important to look beyond “good intentions” of friends and family and ensure that they are not just being “used” to secure release. A 1 score is given if there is a moderate probability of lack of personal support and a 0 should indicate that the individual will have appropriate support. R4 Non-Compliance with Remediation Attempts: This item should be construed broadly to include remediation attempts in both therapeutic and supervision/management realms. A 2 score on this item should be given to individuals who it is felt have little motivation to succeed and unwillingness to comply with medication or therapy, or refuse to follow rules in the future. A 1 score should be given if the probability of non-compliance with remediation attempts is judged to be moderate and a 0 indicates that there is a low probability of noncompliance with remediation attempts. R5 Stress: This item can be coded as 2 if the individual is likely to be exposed to serious stressors, or if the individual has been judged to cope poorly with stressful situations. A 1 score would indicate a moderate probability of stress, and a 0 indicates a low probability of stress. 3. HoNOS Information relating to HoNOS, HoNOS secure and HoNOS LD is available at the following: http://www.rcpsych.ac.uk/quality/honos/secure.aspx 36 Low secure LD care pathway and gate-keeping guidance and templates Appendix 5 Gate Keeping Assessment Template Front sheet NHS number: Name: 1 DOB: Current Placement: R.C: Date of Assessment: Place of Assessment: Referral Source:2 Referral Date: Legal Status: 3 Mental Health Act Section: 4 Differential Diagnoses: 5 Index Offence/Behaviour: Previous Convictions: 1 Include any known aliases. 2 Name of case manager at East Midlands Specialised Commissioning Team. 3 Include stage of the legal process. 4 Give details of Mental Health Act section currently applicable. 5 Please give current and previous diagnosis. 37 First Report Return to secure service New Problem Low secure LD care pathway and gate-keeping guidance and templates Assessed by: 1. 2. MAPPA Links: Sources of information:6 1 Introduction 2 Summary and Opinion 7 3. Recommendations Low secure yes/no Treatment needs Progress markers 6 Interview persons present, location, duration; records; reports; files; documents. 7 Include risks, clinical opinion and a brief rationale for recommendation. 38 Low secure LD care pathway and gate-keeping guidance and templates 4. Patient History Personal History: Pre-morbid Personality: Intellectual and Adaptive Functioning (inc Education & Employment): Psychosexual History: Family History: Substance & Alcohol Use:8 Physical Health: Current medication: Behavioural & Forensic History:9 5. At Interview: Presentation: Mental state examination: Areas of Need: 8 Give details of use of illicit substances and use of alcohol. 9 Give details of circumstances of and attitude to index offence/behaviour, progress in hospital/custody, circumstances leading to admission. 39 Low secure LD care pathway and gate-keeping guidance and templates Therapeutic Issues identified: Behavioural issues identified: Attitude to treatment: Recommendations re Medication: 6. Clinical Opinion on Risk 7. Consideration for Low Secure Services10 Background Information Appendices Previous reports11 In preparing this report I read and considered the following reports. Note: Risk Considerations:12 Consideration has been given to the risks presented by Mr …………… using the frameworks for structured clinical risk judgements provided for violent and sexual offending using both the “Risk of Sexual Violence Protocol” (RSVP) and “HCR20” schedules, which identify and describe factors associated with the repetition of sexual or violent offending respectively and indicate areas of potential intervention which might manage the behaviour and/or modify any perceived risks. Each of these frameworks examines the chronicity, diversity, escalation and historical pattern of key 10 Additional Placement Considerations Reference should be made to geographic or other variables impacting on the suitability of placement e.g. illicit drug-free facility media / local interest geographically distant from victim Interventions likely to alleviate or prevent deterioration in mental health and reduce risk should be identified. Initial care pathway targets and progress markers. 11 Please state authors and dates. 12 If you have used a structured clinical framework you could consider using the following text. 40 Low secure LD care pathway and gate-keeping guidance and templates criminogenic factors of the identified behaviours to date, considers current interactions and attitudes which contribute to the assessment of anticipated motivation, engagement and compliance with intervention strategies to reduce further risks of re-offending. Each of the risk factors is rated on a three-point assignment of ‘0’, ‘1’, ‘2’ or ‘no’, ‘maybe’, ‘yes’. A rating of ‘0’ or ‘no’ indicates that the item is definitely absent; a rating of ‘1’ or ‘maybe’ indicates that the item is possibly present or present in a less serious form; a rating of ‘2’ or ‘yes’ indicates that the item is definitely present in a more pervasive or serious form. These “values” are not additive and do not give a “risk score”. Risk for future offending and the development of plans to manage this risk are based on the risk factors identified as relevant for each individual. Clinical and Risk factors are dynamic, situation specific subject to change and therefore should be reviewed on a regular basis. RSVP, SNAP and HCR20 available at Appendix 4. 41 Low secure LD care pathway and gate-keeping guidance and templates Appendix 6– Steering Group Attendees Lisa Cresswell Derby City PCT David Gardner Derbyshire County PCT Diane Smith Derbyshire County PCT Dr Edward De Saram Derbyshire County PCT Gaynor Ward Derbyshire Mental Health Services NHS Trust Dr Muhammad Qureshi Derbyshire Mental Health Services NHS Trust Ruth Sargent East Midlands Specialised Commissioning Group Dr Sateesh Kumar Leicestershire Partnership NHS Trust Dr John Devapriam Leicestershire Partnership NHS Trust Lynne Moore Leicestershire Partnership NHS Trust Dr Peter Speight Lincolnshire Partnership NHS Foundation Trust Pily Maden Northamptonshire Healthcare NHS Trust Dr Tonye Sikabofori Northamptonshire Healthcare NHS Trust Gregory Payne Nottingham City NHS Nick Judge Nottingham City PCT Dr Jaspreet Phull Nottinghamshire Healthcare NHS Trust Dr Adarsh Kaul Nottinghamshire Healthcare NHS Trust Dr Mark Taylor Nottinghamshire Healthcare NHS Trust Martine Lascelles Nottinghamshire Healthcare NHS Trust Dr Richard Lansdall-Welfare Nottinghamshire Healthcare NHS Trust Dr Sue Johnston Nottinghamshire Healthcare NHS Trust 42