A Study of Major Change: Legislation, Education & Practice

1. A Study of Major Change: Legislation, Education & Practice

2. Lindsay Thomson, MD, Medical Director, The State Hospital/Forensic Network/ Edinburgh University (Chair) Andreana Adamson, BSc (Econ) MBA, Chief Executive, The State Hospital/Forensic Network Ed Finlayson, CQSW, DipSW, Head of Social Work, South Lanarkshire Council/The State Hospital

3. A study of major change Legislation Practice Education

4. Legislation Mental Health (Care and Treatment) (Scotland) Act 2003 “The best mental health legislation in the world?” Holyrood Magazine (7/5/07)

5. Legislation Background • 20 years out of date? • Significant changes in mental health policy and service delivery • Human Rights • Millan Committee • MH Act Reference Group – Working Together

6. Legislation MHA 2003 • Royal Assent 25 April 2003 • Preparing for Implementation Programme • Act Implemented 5th October 2005 • 23 parts with over 300 sections • Code of Practice, 3 Volumes

7. Legislation The Act Mental Health (Care and Treatment) (Scotland) Act 2003

8. Take Account of Patients Wishes Maximise Participation Provide Maximum Benefit Non Discriminatory Practice Take Account of Views of Named Person Carers Needs Appropriate Services Minimum Restriction Child’s Welfare is Paramount Duty to Maintain Parental Relationships Social Inclusion Legislation Principles

9. Legislation Protection / RightsAdvocacy • Duty to Inform Patient of Advocacy Services • Duty to Take Steps to Arrange Advocacy Services

10. Legislation Protection / RightsNamed Person Nominated by a patient in accordance with the provisions of the Act to act in their best interests. The named person is entitled to receive certain information about the patient and to act on behalf of the patient in certain circumstances and at certain times

11. Legislation Protection / RightsAdvance Statement A written, witnessed document made when the patient is well, setting out how he or she would prefer to be treated (or not treated) if they were to become ill in the future

12. Legislation Protection / RightsMental Welfare Commission • Monitor operation of act and promote best practice • Patient visits; investigations; interviews and medical examinations; inspect records • Publish information and guidance; give advice or bring matters to the attention of others including services and government.

13. Legislation Protection / RightsMental Health Tribunal Scotland • New independent body to make decisions in relation to applications, reviews and appeals • Legal Members, Medical Members and General Members • Right of appeal against compulsory measures • Right of appeal against excessive security

14. Legislation Definition of Mental Disorder • Mental Illness • Learning Disability • Personality Disorder Exclude if only by reason of: Sexual orientation; sexual deviancy; transexualism; transvestism; dependence on or use of alcohol or drugs; behaviour that causes harassment, alarm or distress; acting as no prudent person would do

15. Legislation Definition of Treatment • Nursing • Care • Psychological Interventions • Habilitation • Rehabilitation

16. Legislation Grounds for Compulsion • Mental Disorder • Treatment is Available • Significant Risk to Health, Welfare or Safety • (Significantly Impaired Decision Making)* • Compulsion is Necessary * Only applies in Civil Procedures

17. Legislation Menu of Compulsory Powers • Detention in Hospital • Compulsory Treatment • Attendance at Services • Access for Service Providers • Place of Residence • Notification or Approval of Change of Address

18. Legislation Requirements for Compulsory Powers • Psychiatric Reports • Mental Health Officer Reports • Designated Responsible Medical Officer and Mental Health Officer for all cases.

19. Legislation Mental Health Officer • Registered Social Worker • Training in Mental Disorder and Mental Health Law • Appointed by the Local Government

20. Legislation Care Plan • Objectives of Treatment • Details of Community Care Services • Details of any other Treatment or Services

21. Legislation Issues • Number of Interim Orders and Tribunals • Provision of Information to Named Person • Managing Views of Victims

22. Legislation Outcomes • Fewer Emergency Orders • Fewer episodes of compulsion • Increasing use of community measures • Successful appeals against security

23. Legislation Use of Mental Health Legislation MH(S)A 1984 MH(C&T)(S)A 2003 1/4/05-4/10/055/10/05-1/4/06 Emergency 2410 920 (62%) Short term 1511 1666 (10%) Long term 773 528 Hospital 469 Community 59

24. Legislation Mental Health Tribunal - good for patients? “Patients feel they are being listened to by the panel members – that has to be a good thing” Carolyn Little, Chair National Schizophrenia Fellowship

25. Legislation Questions? A Study of Major Change: Legislation, Education & Practice

26. Policy Practice MEL 1999 (5) Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland provides the basis for Forensic Mental Health Services in Scotland.

27. Guiding Principles of MEL 1999 (5) Practice Mentally disordered offenders should be cared for:   • with regard to quality of care and proper attention to the needs of individuals • as far as possible in the community rather than in institutional settings • under conditions of no greater security than is justified by the degree of danger they present to themselves or to others • in such a way as to maximise rehabilitation and their chances of sustaining an independent life • as near as possible to their own homes or families if they have them

28. Scottish Ministers call for new approach to FMHS Practice “.. to bring a pan-Scotland dimension to the planning process for services .. to support the development of local services .. and to secure protocols to ease the management of patients through the system” Mary Mulligan, MSP Deputy Health Minister, 2002

29. Context Practice • Population: 5 million • Forensic inpatient population 500 • Under developed services in 15 health authorities • Forensic Services within NHS • 1 small independent provider (24 beds)

30. Media Practice

31. Objectives Practice “Review the process for determining the right care for mentally disordered offenders” “Consider wider issues surrounding patient pathways .. Including information systems, education and training and strategic planning” Scottish Executive Health Department, March 2003

32. Forensic beds Practice Currently High 240 Med 50 Low Low Planned High 140 Med 150 Low Low 500 Beds Approximate figures

33. Practice “A key measure of success will be a smaller State Hospital … services can and should be provided in other secure and community settings” Malcolm Chisholm, MSP Health Minister, 2003

34. Network Board Practice • Multi Agency • Health, Scottish Executive, Social Work, Police, Prison, Local Government Housing, Carer agencies • Regional Representation • North, South and East, West, Northern Ireland • Each circa 1.5m population

35. Principles Practice • Pan Scotland approach • Strategic Planning • Performance Management Frameworks • Information Systems • Education and Training

36. Practice Regional Structure Local Low Secure Local Low Secure Local Low Secure National High secure Medium Secure Local Low Secure Local Low Secure Local Low Secure Local Low Secure

37. Practice Regional Structure Local Services – Low Secure Regional – Medium Secure National High secure Community Services

38. Appeals against excessive security Practice • 66 applications • 34 heard • 24 upheld • 8 declined • 17 cancelled/withdrawn

39. Practice “The Forensic Network is an excellent example of how we can bring together national, regional and local perspective on the planning and delivery of services” Hugh Henry, MSP Justice Minister, 2005

40. Strategic Planning Practice • Definitions of Levels of Security • Obvious starting position • Matrix of security • Tool for audit of existing and planned services • Recommended development of Secure Care Standards

41. Practice Strategic Planning • Secure Care Standards • Eleven standards • Three generic standards across all security levels (1 assessment & care planning; 2 delivery of generic and specialist treatments, interventions and support for recovery; 3 teams, skills, staffing) • Remaining eight specific to security level (maintenance of detention; suspension of detention; management of violence; excluded items; communication and technology; movement of personnel and contingencies)

42. Practice Strategic Planning • Services for Women • Small patient-specific group • No need for high secure beds • Favour community based specialist services • Small number of medium secure beds

43. Practice Strategic Planning • Services for Learning Disabilities • Small population • Robust community based services • Regional multi-agency risk management groups • 12 high secure beds • Separate services for LD, small regional units

44. Practice Strategic Planning • Personality Disorders • Significant population in NHS and Prisons • “PD should not be a diagnosis of exclusion from forensic mental health services in Scotland” • No change to current clinical in-patient practice • Pilot work with criminal justice and prisons

45. Policy Practice • 2006 Policy and Guidance • Including conflict resolution and patient flows • Care Programme Approach • Risk Management • Clinical Governance • School of Forensic Mental Health Launch October 2007

46. Practice Questions? A Study of Major Change: Legislation, Education & Practice

47. SoFMH School of Forensic Mental Health Education School of Forensic Mental Health: Teaching, Training & Research

48. The Three Graces SoFMH School of Forensic Mental Health Education

49. Venus de Milo SoFMH School of Forensic Mental Health Education

50. Knowledge and Understanding of the MH(C&T)(S)A 2003 within Trainee Psychiatrists SoFMH School of Forensic Mental Health Education • Response Rate 93% (n=48) • Mean Total Score 22/61 (range 6-51) • FY2 19 • SHO 29 • SpR 38 • Principles: mean 2/10 (40% - 0) • Detention Criteria 2/5