Picture of the State Hospital

Forensic Mental Health Services in Scotland

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Forensic mental health services specialise in the assessment, treatment and risk management of people with a mental disorder who are currently undergoing, or have previously undergone, court proceedings. Some people are managed by the forensic mental health service under civil legislation, such as the Mental Health (Care and Treatment) (Scotland) Act 2003, if they are considered to be at a high risk of harming others or in some cases themselves

In Scotland there are three levels of secure care:

  • High secure – this level of security is for patients who pose a grave and immediate danger to others if at large. In Scotland, this level of secure care for male patients is provided by the State Hospital in Carstairs. There are currently no high secure facilities for women in Scotland – women requiring this level of care are referred to Rampton Hospital in Nottinghamshire, England or managed in the medium secure estate.
  • Medium secure – this level of security if needed for patients who represent a serious but less immediate danger to others. This level of secure care is provided on a regional basis. With units based at Rohallion Clinic, Perth, Orchard Clinic, Edinburgh and Rowanbank Clinic, Glasgow.
  • Low secure – this level of security is needed for patients who present a less serious danger to others. Most mainland territorial boards provide low secure services. NHS Lothian does not currently have a low secure forensic unit and patients requiring this level of care are currently being managed in a medium secure setting.

Forensic community mental health teams are based in health boards

The Mental Welfare Commission, in January 2022,stated that of 503 patients in forensic settings and in forensic Intensive Psychiatric Care Units (IPCUs) and rehabilitation settings, the vast majority were male (92.3%) with an average age of 44 years.

Most people receiving care and treatment in forensic mental health services have a diagnosis of a mental illness (75.1%), followed by intellectual disability (15.5%). Two percent had a diagnosis of a personality disorder and for seven percent their diagnosis was unknown.

Forensic mental health services: independent review

In 2019, the Scottish Government announced a review of the way forensic mental health services are delivered. The report, published in February 2021, made 67 recommendations, including that:

“A new NHS Board should be created for forensic mental health services in Scotland”(Recommendation 1).

The Scottish Government established a short life working group to consider the options for a new governance, planning and collaboration approach for Forensic Mental Health Service. The result of the options appraisal exercise for establishing a new forensic service is expected in the very near future. A more detailed report on progress with implementing the recommendations and the planned programme of work over the next year and beyond is also expected.

High secure service for women

As noted above, there are currently no high secure facility for women in Scotland. The State Hospital had previously provided this but closed the service in 2007-08. Women requiring high secure care are currently referred to the Rampton Hospital in Nottinghamshire, England or cared for in the medium secure estate. The independent report recommended:

  • A high secure service for women should be opened in the State Hospital within nine months of the publication of the Review.
  • The Short Life Working Group set up in response to the Forensic Network’s report on the Women’s Service and Pathways should reform to complete its work related to women’s pathways across in medium secure, low secure and community forensic settings.

The working group for reforming women’s forensic services reformed in 2021 and the Director of Finance and e-health at the State Hospitals Board for Scotland recently told the Parliament that they are due to discuss this issue soon with the Minister for Social Care, Mental Wellbeing and Sport.

Mental health needs of the prison population

Not all prisoners with mental health problems are treated within forensic mental health services as this level of care would not be appropriate. There is a higher level of mental health illness in the general prison population compared with the general population. Suicide and self-harm are also more common in prisoners than the general population.

A recent Scottish Government report (September 2022) noted some groups of people, including young people and older adults, as well as those with physical or learning disabilities, are at a high risk of experiencing poor mental health while in prison.

Data on the mental health needs of people living in Scotland’s prisons is not routinely collected. The report used modelling to estimate the level of mental health need in Scotland’s prison population:

It is worth noting that the mental health needs of individuals in prison are often multiple and complex and people in prison often experience multiple co-occurring problems.

The report also looked at the services available for individuals in prison. It concluded:

“There is overwhelming evidence that individuals in prison are more likely to have a range of mental health needs, which are often multiple and complex. Existing provision to support the mental health of people in prison in Scotland does not adequately meet these needs and a change in approach is required”.

This view was echoed by Professor Colin McKay, a member of the Scottish Mental Health Law Review, who told the Criminal Justice Committee at its meeting on the 1 March 2023:

“One of the starkest things that we noticed was that, although there are fewer than 100 of those mental health disposals a year, there are thousands of people with a mental illness or a learning disability in the criminal justice system, and there is a lot of evidence that the system does not always meet their needs”.

The NHS has been responsible for the provision of health care in prisons since November 201, when it transferred from the Scottish Prison Service (SPS). The Mental Welfare Commission has reported on mental health support in Scotland’s prisons, following its earlier report in 2011. It stated:

“Our key messages of 2011 have not been realised and the anticipated improvements of health care responsibilities being transferred to NHS Scotland have not materialised”.

The 2022 report made ten recommendations including around:

  • workforce planning
  • training needs
  • screening processes
  • follow up assessments
  • the operation of multidisciplinary meetings and care planning processes
  • use of segregation
  • access to community mental health and social supports upon release
  • the review of current strategies.

It also recommended that the Scottish Government should monitor the delivery of the recommendations and work with SPS and NHS to:

“resource and deliver on better outcomes for people with mental health related conditions in prisons across Scotland”.

This is just one of the many reports over recent years that have made recommendations about forensic mental health services and mental health support for prisoners, including a report by the Session 5 Health and Sport Committee on Healthcare in Prisons.

As Professor Colin McKay told the Criminal Justice Committee:

“We might now be at the point when we need to stop reviewing stuff and start a systematic programme of change”.

Lizzy Burgess (Senior Researcher Health and Social Care, SPICe)

Featured image: Carstairs State Hospital – geograph.org.uk – 162159.jpg by Alan Stewart is licensed under CC BY-SA 2.0.