Dr Tom White Former Lead Clinician – Secure Care Project

1. 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

2. Agenda • Route to Rohallion (Medium Secure) • A new Clinical Model • NoS Network – embedding the new Regional MSU within Regional Low Secure Services

3. 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

4. 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

5. What is Medium Security? Architectural, procedural and relational components outlined in: • Levels of Security Report (2006) • Department of Health (2009)

6. 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

7. North of Scotland Benchmarking

10. September 2010 - preparing the ground Works progressing - Jan 2011

11. Rohallion Admin Block – Jan 2012 Varra Ward – April 2012

12. What is a Forensic Psychiatry Service? “Focus on systematic assessment and management of risk” “Ability to deliver offence-related interventions” Tom Fahy

13. A New Clinical Model

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Unique Features of Rohallion (2) • Focus on modifiable risk factors for cardiovascular disease especially “Metabolic Syndrome” • Delivery of Level 2 SPJ Risk Assessment • Psychological formulation of offending (RMA) (MATRIX) • Integrated Care Pathway focusing on adequacy of assessment and enhanced CPA

21. Unique Features of Rohallion (3) • Delivering psychological therapies • Assessment of need Focusing on Matrix Priorities • Anger • “Coping with mental illness” • Drug & Alcohol Misuse • Matched tiered approach

22. Developing a Regional Network

23. North of Scotland Planning Group Area

24. Kyle of Lochalsh looking towards Skye Orkney Isles Schiehallion and Loch Rannoch, Perthshire St Ninian’s Isle, Main Land Shetland Loch Ness, Inverness-shire River Dee, Aberdeenshire

25. The Right Place – The Right Time May 2000Managed 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

26. Regional MCNsNHS 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.

27. 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.

28. 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

29. 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

30. 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

31. 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)

32. 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

33. Stairway glazing in Rohallion Medium Secure Ward Courtyard

34. View from Medium Secure Garden