Abstract
Aims and method
To assess the need for the provision of low secure care in Northern Ireland. A survey of the providers of healthcare in Northern Ireland was conducted using a study tool based on Royal College of Psychiatrists Low Secure Network Standards admission criteria.
Results
A total of 105 patients were assessed as needing low secure care including 93 patients currently admitted to hospital in the region and 12 patients admitted to hospital outside of the region.
Clinical Implications
The results of this study are similar to previous estimates of need for the provision of low secure care in the UK. The results provide information likely to be of assistance in the commissioning of low secure services.
Declaration of Interest
None
It is self evident that what is needed in one part of a service will depend on the provision in other parts of the service. Mental Health Services in Northern Ireland have undergone substantial change in the past ten years through the implementation of the Bamford Review and Transforming Your Care.1, 2, 3 A significant consequence has been a change in the provision of inpatient care. A reduction in average available mental health beds by 35% over the past 5 years combined with high occupancy rates (90%) and a 19% reduced length of stay reflect a reduction in inpatient bed availability.4
A regional network of forensic mental health services has been developing including the opening of the first medium secure unit, Shannon Clinic, in 2005, the development of community forensic mental health teams, and mental health services in prison.
There are plans for the closure of long stay wards over the next few years.4 The Bamford Adult Implementation Group is chaired by commissioners and is tasked with planning the provision of low secure care. Low secure units provide rehabilitation for patients who need to be detained to hospital under mental health legislation. The criteria for detention to hospital are that the person suffers from a mental illness and failure to detain them would create a substantial risk of serious physical harm to self or others.
The secure component of care consists of physical security, such as locked doors and fences, procedural security, such as control of various items coming into the ward, and relational security, which involves fostering therapeutic relationships through an in depth knowledge of the patient's illness and behaviour. Low secure rehabilitation aims to reintegrate the patient back into society through multidisciplinary treatment of their illness and a reduction in the risk of harm that led to their detention.
This survey aimed to assess the current need for the provision low secure services in the region. Unlike other parts of the UK, there is no private sector provision of secure mental healthcare in Northern Ireland.
METHOD
A study tool was designed based on Royal College of Psychiatrists Low Secure Network Standards admission criteria.5 The Associate Medical Director or equivalent and Director of Mental Health (or their nominee) for each Health and Social Care Trust were surveyed and sent the study tool in order to ascertain the number of patients in the Trust area who needed low secure care. The Public Health Agency was also surveyed to assess the low secure need of those patients currently being cared for in other parts of the UK.
STUDY TOOL
Inclusion criteria
May be detained under mental health order (not necessarily presently detained)
Clinical risk or legal requirement for secure care
M&F > 18 years old
May benefit from rehabilitation
Offending with low levels of violence
Patient does not require medium or high secure care
Exclusion criteria
<18 years old
Primary substance misuse without mental illness
Complex needs that can be managed in PICU or open ward.
| Patient Location | Number of patients |
|---|---|
| Low secure/locked rehabilitation ward | |
| Open rehabilitation ward | |
| Acute inpatient ward | |
| PICU | |
| Other | |
| Total |
RESULTS
All of the five HSC Trusts and the Public Health Agency responded to the survey and provided the following data
Of the 105 patients, 43 were in low secure or locked rehabilitation wards, 3 were in PICU, 18 were in acute inpatient wards, 8 were in a medium secure unit and 4 in a neurorehabiliation unit. 17 patients were in distributed across acute inpatient units, PICU and locked rehabilitation. Provision of low secure or locked rehabilitation wards in a Trust area appeared to be associated with fewer patients in acute inpatient wards identified as needing low secure care.
DISCUSSION
Northern Ireland has some significant differences in the provision of secure hospital care in comparison with the rest of the UK and Ireland, most notably that there is no provision of private sector secure hospital care or provision of high secure care. The result of this study that 105 patients require low secure care in a population of 1.8 million fits comfortably with the low secure prevalence of 4.6 per 100,000 in England.6
The results of this study provide guidance for the commissioning of low secure services in Northern Ireland which will be conducted in line with the Bamford Review plan for secure rehabilitation for those patients who require treatment under the auspices of mental health legislation.
The strengths of the study were the 100% response rate from the providers and commissioners of care, and the use of a study tool based on Royal College of Psychiatrists Quality Network Standards. In addition, rather than using a point sample or past trends, the methodology measured the current need for low secure services.
A limitation of the study was the service level rather than individual assessment of need. The methodology also includes only those patients known to local psychiatric services. Patients not known to local psychiatric services may also require low secure care but we expect that most needing low secure would be known to services.
A decision was taken not to include prisoners in the methodology of this study due to pending changes in mental health legislation. High levels of psychiatric morbidity exist in prisons, with 90% of prisoners suffering from at least one of: neurosis, psychosis, personality disorder, alcohol abuse or drug dependence.7 Comorbidity of multiple diagnoses of mental disorders is also common and has been estimated at 40-90%.8 It would be reasonable to expect that some prisoners may need treatment in a low secure unit, either through a court diversion scheme or by transfer from prison to hospital.
ACKNOWLEDGEMENTS
We would like to thank all who responded to the survey, Dr Stephen Bergin, and the Bamford Adult Mental Health Implementation Group for their contributions. We would also like to thank the referee for their helpful comments.
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