Pathways into medium secure psychiatric provision

David Melzer and Brian Tom for: The Mental Healthcare Policy Research Group

Key words: medium secure psychiatric units, mentally disordered offenders

In 1998, the Department of Health in England commissioned a series of research studies on medium secure psychiatric units (MSPUs). The Epidemiology for Policy Group played a leading role in the national study of routes into medium secure provision.

In the study reports, we summarised:

  • data on the characteristics of units and patients assessed for admission to virtually all medium secure provision, during 1999
  • the results of a qualitative study of clinical decision-making about admission.

Other linked studies include

  • The follow-up of mentally disordered offenders in prisons (The longitudinal study of psychiatric morbidity among prisoners in England and Wales, Mental Healthcare Policy Research Group, 2000) See: David Melzer, Brian D.M. Tom, Traolach Brugha, Tom Fryers, Adrian Grounds, Tony Johnson, Howard Meltzer and Nicola Singleton. Prisoners with Psychosis in England and Wales: A One-Year National Follow-Up Study. The Howard Journal of Criminal Justice, Volume 41, Issue 1, pages 01-13, February 2002.
  • the study of pathways out of MSUs (led by Prof Maden).

Brief outline of the ‘Pathways in’ study

The overall aim of the ‘Pathways in’ project was to gather nationally representative information on medium secure units and on the patients assessed with a view to admission. The study was designed to inform policy development and management of these services.

This study was undertaken by the academic Mental Healthcare Policy Research Group in collaboration with the Social Surveys Division of the Office for National Statistics (ONS). While ONS participated in the design and undertook the fieldwork on this study, the Research Group has led the analysis and reporting. The views set out in this Summary are those of the Research Group and do not necessarily reflect those of ONS.

Conclusions of the studies

Nearly all Medium Secure beds within England and Wales were successfully included in the study, with detailed data collected on 94% of the sampled assessments. It should be remembered though that most of the data were collected during interviews with the assessors in the Medium Secure Units, and no data are available directly from those that referred patients, or from the patients themselves. A qualitative study of admission decision making was also undertaken.

The study results raise a large number of issues:

  • The patients being assessed for admission tended to have long psychiatric histories and previous criminal convictions. Features of personality disorders are very common in those assessed for medium secure units, although personality disorders as primary diagnoses are uncommon. Levels of dangerousness are high. Three findings may justify further policy analysis:
    • Problems with drugs and alcohol were common, with 37% of those assessed having marked or incapacitating social or health problems due to alcohol or drugs;
    • Non compliance with treatment was also common, with 38% having a history of persistent non-compliance with community treatment;
    • Patients with primary diagnoses other than mental illness are commonly excluded from medium secure units by admission policies.
  • Although treatment non-compliance was an issue, there was little evidence of use of official arrangements related to supervision: during the previous two years, only 8% of the sample had been placed on a supervision register and 2% on supervised discharge arrangements. The development of aftercare services that are capable of supporting people with dual diagnosis and / or treatment non-compliance may have to be a more prominent part of the development of forensic services.
  • It has been suggested that admissions from prisons into medium secure units were less likely than from NHS settings, but in fact the opposite was the case. There is evidence that the admission decision was oriented to accepting those with psychotic conditions, with risk of dangerousness playing a smaller role.
  • Both at unit level and at follow-up four weeks after assessment there was evidence of long delays in admission to Medium Secure Units for those put on waiting lists. For example, of the 34 people in prisons on the waiting lists, 62% were still in prison waiting to be admitted to MSUs four weeks later.
  • We estimate that a total of approximately 500 assessments of people in prisons were undertaken in the entire MSU system in England and Wales in the first half of 1999, adjusting for the assessments and units that were not included in the sample survey. Of these, approximately 210 prisoners were admitted and 175 put on a waiting list. The 500 assessments of prisoners over 6 months (83 monthly) can be compared to the estimated 2,800 severely mentally ill prisoners held in England and Wales at the time of the ONS Psychiatric Morbidity Survey of Prisoners (See report of the Longitudinal Study of Psychiatric Morbidity among Prisoners in England and Wales). 870 prisoners with ‘severe mental illness’ (31% of the 2,800) were held for violent or sexual offences.
  • The data suggest that assessed patients have a wide range of unmeetable needs, within current care resources. Longer term secure care (for more than 2 years) emerged as an important need, with 13% of those assessed regarded as needing long term medium secure care, and 4% as needing long term low security care. There were also significant unmeetable needs for specific treatments or forms of care, including for example, cognitive and behavioural therapy and occupational rehabilitation.
  • A possible problem in the flow of information was evident in that although assessors had received corroboration about histories of violence in almost all cases, assessors did not know the effects of the violence on victims in 30 out of 133 cases (22%).
  • There was limited evidence of a ‘revolving door’ pattern, in that 17% of patients assessed in prisons had been psychiatric inpatients during the previous two years.
  • There was some evidence of delay in referral from prisons, with assessors saying that 38% of those facing criminal proceedings should have been referred earlier from remand prisons. For the 40 sentenced patients in prisons, assessors felt that half should have been transferred earlier to hospitals, under the Mental Health Act of 1983.

Outputs

David Melzer, Brian D.M. Tom, Traolach Brugha, Tom Fryers, Adrian Grounds, Tony Johnson, Howard Meltzer and Nicola Singleton. Prisoners with Psychosis in England and Wales: A One-Year National Follow-Up Study. The Howard Journal of Criminal Justice. 2002 Feb;41(1):1-13.

Brugha T, Singleton N, Meltzer H, Bebbington P, Farrell M, Jenkins R, Coid J, Fryers T, Melzer D, Lewis G. Psychosis in the community and in prisons: a report from the British National Survey of psychiatric morbidity. Am J Psychiatry. 2005 Apr;162(4):774-80.
PMID: 15800152

Pathways into medium secure

Grounds A, Melzer D, Fryers T, Brugha T. What determines access to medium secure psychiatric provision? Journal of Forensic Psychiatry & Psychology. 2004;15(1):1-6. [Editorial]

Melzer D, Tom B, Brugha T, Fryers T, Gatward R, Grounds A, Johnson T, Meltzer H. Access to medium secure psychiatric care in England and Wales. 1: A national survey of admission assessments. Journal of Forensic Psychiatry & Psychology. 2004;15(1):7-31.

Grounds A, Gelsthorpe L, Howes M, Melzer D, Tom B, Brugha T, Fryers T ,Gatward R, Meltzer H. Access to medium secure psychiatric care in England and Wales. 2: A qualitative study of admission decision-making. Journal of Forensic Psychiatry and Psychology. 2004;15(1):32-49.

Melzer D, Tom B, Brugha T, Fryers T, Gatward R, Grounds A, Johnson T, Meltzer H. Access to medium secure psychiatric care in England and Wales. 3: The clinical needs of assessed patients. Journal of Forensic Psychiatry and Psychology. 2004;15(1):50-65.