Dr Tom WhiteFormer 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 BenchmarkingNo of Restricted Patients/100/000

No of CPA/ 100,000

MMD beds/100,000

North 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 Assessment6. 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 Kyle of Lochalsh looking towards Skye Schiehallio

n and Loch Rannoch, Perthshire

St Ninian’s Isle, Main Land Shetland

Loch Ness, Inverness-shire

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 real-

time tracking to avoid unmanaged bottle-necks”

• 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 & Inter-

Regional 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