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 Restricted Patients/ 100/000 No of CPA/ 100,000 MMD beds/ 100,000 North East West September 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 Kyle of Lochalsh looking towards Skye Schiehallion and Loch Rannoch, Perthshire St Ninians 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