A Study of Major Change: Legislation, Education

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
Mental Health (Care and Treatment) (Scotland) Act
2003
Legislation

• The best mental health legislation in the
  world? Holyrood
  Magazine (7/5/07)

5
Background
Legislation

• 20 years out of date?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
MHA 2003
Legislation

• 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
The Act
Legislation

• Mental Health
• (Care and Treatment)
• (Scotland)
• Act 2003

8
Principles
Legislation

• 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
• Childs Welfare is Paramount
• Duty to Maintain Parental Relationships
• Social Inclusion

9
Protection / RightsAdvocacy
Legislation

• Duty to Inform Patient of Advocacy Services
• Duty to Take Steps to Arrange Advocacy Services

10
Protection / RightsNamed Person
Legislation

• 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
Protection / RightsAdvance Statement
Legislation

• 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
Protection / RightsMental Welfare Commission
Legislation

• 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
Protection / RightsMental Health Tribunal
Scotland
Legislation

• 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
Definition of Mental Disorder
Legislation

• 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
Definition of Treatment
Legislation

• Nursing
• Care
• Psychological Interventions
• Habilitation
• Rehabilitation

16
Grounds for Compulsion
Legislation

• 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
Menu of Compulsory Powers
Legislation

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

18
Requirements for Compulsory Powers
Legislation

• Psychiatric Reports
• Mental Health Officer Reports
• Designated Responsible Medical Officer and Mental
  Health Officer for all cases.

19
Mental Health Officer
Legislation

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

20
Care Plan
Legislation

• Objectives of Treatment
• Details of Community Care Services
• Details of any other Treatment or Services

21
Issues
Legislation

• Number of Interim Orders and Tribunals
• Provision of Information to Named Person
• Managing Views of Victims

22
Outcomes
Legislation

• Fewer Emergency Orders
• Fewer episodes of compulsion
• Increasing use of community measures
• Successful appeals against security

23
Use of Mental Health Legislation
Legislation

• MH(S)A 1984 MH(CT)(S)A 2003
• 1/4/05-4/10/05 5/10/05-1/4/06
• Emergency 2410 920 (62?)
• Short term 1511 1666 (10?)
• Long term 773 528
• Hospital 469
• Community 59

24
Mental Health Tribunal - good for patients?
Legislation

• 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(CT)(S)A
2003 within Trainee Psychiatrists
SoFMH School of Forensic Mental Health
Education

• Response Rate 93 (n48)
• Mean Total Score 22/61 (range 6-51)
• FY2 19
• SHO 29
• SpR 38
• Principles mean 2/10 (40 - 0)
• Detention Criteria 2/5

51
Survey of Services for People with Forensic
Personality Disorder
SoFMH School of Forensic Mental Health
Education

• 7 implicitly exclude people with a primary PD Dx
  from admission
• 7 assess people with a primary diagnosis of PD
• 8 use multidisciplinary and 10 comprehensive
  methods of assessment
• 4 use structured clinical tools for the
  assessment of PD

• 6 services did not accept people with a primary
  diagnosis of PD for specific intervention,
  treatment or management, 4 services did not
  accept people with a secondary dx
• No reliable figures
• Training requirements were identified in
  particular for developing case formulations and
  employing evidence based

52
Rationale
SoFMH School of Forensic Mental Health
Education

• The Network provides the opportunity for
  participating stakeholders to consider .
  education and training . . . and the
  commissioning of research to establish an
  evidence base for service development
• Scottish Executive Health Department
• March 2003

53
Network Working Group
SoFMH School of Forensic Mental Health
Education

• Multi-agency expert group
• Objectives
• Review provision of forensic education and
  identify gaps
• Review recent research
• Develop proposals and models for school of
  forensic education and research (if required)
• Consider advantages and disadvantages
• Consider resource and funding issues

54
Identifying needs
SoFMH School of Forensic Mental Health
Education

• Two scoping exercises (including independent)
• Both highlight clear gaps
• Complex nature of needs (risk, law, complex
  system clients)
• No postgraduate provision
• No forum for multidisciplinary training although
  clinicians work on multidisciplinary basis
• Limited forensic mental health training in non
  health agencies
• Research efforts are small and uncoordinated

55
Meeting the needs
SoFMH School of Forensic Mental Health
Education

• Develop a Forensic School
• Coordinating body (consortium)
• Provider and Commissioner
• Build on existing resources
• Programme development
• Training trainers
• Teaching materials

56
Option Appraisal
SoFMH School of Forensic Mental Health
Education

• I Do nothing
• II Refer to a Coordinating Body
• III Establish a Virtual School
• IV Establish a Physical School

57
Business Case
SoFMH School of Forensic Mental Health
Education

• Appraisal of options
• Advantages/disadvantages
• Costs
• Risk assessment
• Establish and weight benefits criteria

58
Option Appraisal
SoFMH School of Forensic Mental Health
Education

• Score
• I Do nothing 2.54
• II Refer to a Coordinating Body 7.52
• III Establish a Virtual School 16.03
• IV Establish a Physical School 14.38
• Affordability

59
Principles
SoFMH School of Forensic Mental Health
Education

• Practical Utility
• Inclusive
• Feasible
• Financially viable

60
Delivery (1)
SoFMH School of Forensic Mental Health
Education

• All of Scotland
• Links with educational institutions
• Board stakeholders
• Administrative base
• Use of existing materials
• Development of new materials
• NHS educational interface

61
Delivery (2)
SoFMH School of Forensic Mental Health
Education

• Multidisciplinary courses in forensic studies
• Modular basis with clear assessment of
  competences
• Access to modules, diploma or MSc
• Part-time
• Distance learning
• Multi-agency
• Specific training

62
Sample Modules
SoFMH School of Forensic Mental Health
Education

• Law and Mentally Disordered Offenders
• Mental Disorder and Crime
• Risk Assessment and Management Treatment of
  Mentally Disordered Offenders
• Services for Mentally Disordered Offenders

63
Support for the school
SoFMH School of Forensic Mental Health
Education

• Government Policy
• NHS Education Scotland
• Scottish Executive Health Department
• Forensic Network Associates
• Higher Education Institutions
• Further Education Institutions

64
New to Forensic
SoFMH School of Forensic Mental Health
Education

• Commissioned by NHS Education Scotland
• Designed for clinical and non clinical staff
• 6 month self directed learning programme
• Students supported by mentors
• Twelve chapters with case scenarios
• Delivery by network of trainers within services

65
SoFMH School of Forensic Mental Health
Education
Content (1)
Chapter 7 - Forensic Mental Health Services and
the Criminal Justice System Understanding
the relationship Chapter 8 - Psychiatric
Defences and Legislation for Mentally Disordered
Offenders Chapter 9 - Assessment, Treatment and
Management of Mentally Disordered
Offenders Chapter 10 -Multidisciplinary Working,
Communication and Managing Difference Chapter
11 -Safety of Staff, Patients and Public
including Risk Assessment and Management Chapter
12 -Taking Account of the Views of Users
and Carers
Chapter 1 - Aims and Teaching Methods Chapter 2
- Understanding Mental Disorder Chapter 3
- Definitions, Principles and Policy for
Mentally Disordered Offenders Chapter 4 - Civil
Mental Health Legislation Chapter 5 - Forensic
Mental Health Services Chapter 6 - Attitudes to
Mentally Disordered Offenders and ways of
dealing with personal emotions and boundaries
66
SoFMH School of Forensic Mental Health
Education
Content (2)

• Differential objectives
• A problem based learning approach
• Participants supported by experienced mentors
• Use of a reflective diary
• Case studies designed to challenge thinking
• Links to other learning materials throughout the
  programme

67
SoFMH School of Forensic Mental Health
Education
68
Current Work
SoFMH School of Forensic Mental Health
Education

• Police Probation Training
• Strategic Change Grant
• Network of Trainers
• Risk Management Agenda
• Psychological Therapies Training

69
SoFMH School of Forensic Mental Health
Education
70
SoFMH School of Forensic Mental Health
Practice
Legislation
Education

• Come and see for yourself
• IAFMHS 2009 Conference, Edinburgh

71
A Study of Major Change Legislation, Education
Practicelindsay.thomson_at_tsh.scot.nhs.ukandrea
na.adamson_at_tsh.scot.nhs.uked.finlayson_at_tsh.scot.n
hs.uk 44 1555 842018