CLINICAL PSYCHIATRY
Community care for mentally ill offenders John Parry RGN, RMN, is Assistant Director of Nursing Services. Regional Forensic Psychiatry Service. Mersey Region.
Perhaps no group ofpatients needs skilled support on discharge back into the community more than mentally disturbed offenders. John Parry describes the community nursing input to the Regional Forensic Psychiatry Service in Merseyside, and emphasises the need for a co-ordinated and planned approach to help solve the multiple and complex problems of this group.
Following the recommendations of the Report of the Committee on mentally abnor mal offenders’ (1) almost every regional health authority in England now provides secure unit beds for offender patients. Some regions have a single regional secure unit and others have peripheral units. Many have not yet hit the target bed provision of 20 beds per million population. In addition to recommending the setting up of regional secure units, the Butler report also recommended the development of regio nal forensic psychiatry services. There is little mention of nursing involvement either in the Butler report or in subsequent reports about supervision and aftercare of offenders. How ever, in the author’s experience, the type of patients discharged require a high input of supervision and aftercare by health service staff in order to maintain their wellbeing and reduce the risk of offending as a result of deterioration in their mental condition. This is seen not as an addition to the supervision required, but as a complementary service, working in liaison with the probation service, social services, other community psychiatric nurse (CPN) teams and agencies within the community. The phrase 'nursing within controlled environments’ includes treatment and care both in hospital, eg special hospitals, regional secure units (RSUs) and local psychiatric hospitals, and the community where there are restrictions on the patients’ treatment and supervision. We are all aware of the 'revolving door' syndrome where patients move from prison to hospital to community and back to either prison or hospital, mainly due to a relapse in their mental health while in the community which has not been picked up early enough, resulting in either reoffending or admission to hospital.
The aim of the service is to break this circle by providing adequate support, treatment and preventative nursing intervention. The moni toring of maintenance medication and patient/family support is essential for all psychiatric patients, but is particularly important in the care of offender patients. The development of the RSU programme should ideally be integrated with the local NHS services throughout the region. Because of the large caseloads of most CPNs, together with the need for a high input to the supervision and aftercare in the community for offender patients, it has been found necessary to provide a parallel service for a small group of clients who pose particularly difficult problems. We have been fortunate in the geographical size of the region which is considerably smaller than most, with concentrated areas of population. The secure unit is sited reasonably central to the region and although the catchment area encompasses some ten health districts, the travelling distance is not too great. Initial fears about distances have proved unfounded, in that the majority of patients are discharged to inner city areas where accom modation is most readily available.
Genericism/specialism The arguments for specialism are twofold. First, RSUs are politically sensitive and at tract sensational media attention. However successful the rehabilitation of offenders into the community, one serious reoffence can undermine both the confidence of the sup porting team and also the local community. Regional and district health authorities are also particularly sensitive to problems arising from regional secure unit clientele. Second, the majority of patients admitted to regional secure units and subsequently discharged into the community are suffering from schizophrenia and the importance of maintenance medication is essential in the prevention of deterioration and possible re offence. Local community services are often unable and sometimes reluctant to provide the high input required for this group of patients. The interim secure unit opened in August
February 27/Volume 5/Number 23 1991 Nursing Standard 29
CLINICAL PSYCHIATRY
'M /y>.
W.
**•/
H’i,
m '^VCs.
RSU development The regional secure unit opened in August 1983 and a full-time community nurse was appointed the following month. The com munity caseload at the time was about 20 patients and as the unit developed a staff nurse was attached to the community team. Two more full-time posts were developed within the next two years. Currently we have three full-time CPNs based at the unit. Of the total number of patients discharged about 20 per cent arc followed up by the forensic psychiatry service. The remainder are either transferred to other catchment area teams within the region or are returned to special hospital or prison. The patients who are followed up tend to be serious offenders 30 Nursing Standard February 27/Volume 5/Number 23 1991
who have been detained under a hospital order. Their discharge is conditional upon residence at a given address, attendance at outpatient clinics and receiving medication. Other conditions may also be imposed as part of the aftercare package. This is, in practice, compulsory treatment in the community which is fully understood by the patient and works extremely well. The community nursing team consists of a team leader, one charge nurse and one sister. Female patients in the community tend to be followed up by female staff, but this will depend upon the patient’s preference and deployment of caseload. There are three con sultant forensic psychiatrists and the CPNs attend the clinical team meetings on the unit each week. While it would be logical for the CPNs to be consultant attached, this is not always possible because of the geographical location of patients discharged to various parts of the region. Generally there is considerable overlap between the CPNs and their clients which also makes for better communication. The concept of multidisciplinary team work is very strong, and as well as managing a caseload of patients in the community, there is considerable involvement by the CPNs w'ith inpatients who are preparing for discharge. They necessarily need to work very closely with the social workers who are based at the clinic and the ward staff as well as other members of the clinical team. Each week a predischarge meeting is held involving all representatives of the team to discuss those patients who are looking forward to discharge within a reasonable length of time. This is extremely helpful in ensuring an adequate preparation of the discharge treat ment plan and package where allocation of supervision in the community is required. The importance of early liaison between nursing staff and other agencies such as the probation service, social services, hostel staff and relatives is essential for smooth discharge to be effected. The total caseload at the end of 1989 was 78 patients. These include those patients who have received inpatient treat ment and have been discharged to the com munity, outpatients who are offenders being treated within the community who have not had inpatient treatment, clients in the cluster flat schemes, patients on trial leave and inpatients preparing for imminent discharge. Future projections of increasing caseload esti mate an addition of up to ten new cases per year, inclusive of those transferred off the coascload to other teams and new patients joining the caseload.
JL1JA ROBINSON
I
1976 and during the early days it quickly became apparent that with a philosophy of assessment, treatment and rehabilitation towards either local hospital or community, we were in the ‘high-risk business'. For mentally disordered offenders, the interface between hospital treatment and community care is a particularly difficult area, and patients who had spent a long time in institutions, either prisons or special hospi tals, reacted quite differently when faced with the prospect of living in the community. The psychological security of the institu tion was a major factor to be addressed in the patients' rehabilitation. Some patients found the integrated care and ‘liberalism’ of secure units quite threatening and the task of devel oping independence and self-care was particu larly difficult. It was realised rapidly that unless there was adequate support, aftercare and supervision within the community, treat ment in hospital, however successful, was doomed to failure. Consequently, in addition to the 14bedded unit, a ten-bed pre-discharge ward was opened where nursing staff became in creasingly involved in preparation for com munity care and the follow-up of discharged patients. Initially this was successful, but as the number of patients in the community increased, the nursing staff were faced with conflicting priorities between patients on the ward and patients in the community. The needs of the ward took priority and this led to a subsequent reduction in adequate aftercare. In planning the RSU we resolved to have full-time community nursing staff at tached to the clinic who would be able to concentrate their efforts on providing the support and treatment the patients in the community required.
t
I
CLINICAL PSYCHIATRY An analysis of the community caseload shows almost 40 per cent of the new patients are conditionally discharged (Section 37/41), the majority of whom have a probation officer as statutory supervisor. The previous offences of patients on the community caseload include homicide (15 per cent), assault of various degrees (68 per cent), arson (10 per cent), and sex offences (7 per cent). The system developed for case reviews includes a progress report each week at the clinical team meetings held on the unit which are attended by members of the community psychiatric nursing team and regular monthly reviews held at the outpatient department in the city centre. These monthly reviews will include all those persons involved in the patient’s after care, eg medical, nursing, probation, social work, hostel staff, etc.
Crisis intervention from the early days of the interim secure unit the need for a crisis intervention service was identified. Initially, a core of nursing staff who were willing to respond to crisis interven tion calls were drawn up. This was on an ad hoc basis with nobody officially on call. As the RSU developed and the CPN team increased, the need for an on-call system was essential. In order to spread the workload, one of the CPNs is on call alternate weeks and is paid an on call allowance. At first this necessitated the on call nurse to be close to a telephone while on call for the week. Now a radio page system has been introduced which allows the nurse on call to have some freedom of movement within the catchment area while still remaining in con tact with the clinic. The crisis intervention team operates a 24-hour, seven-day-week service, and the usual procedure is for calls either from patients themselves, relatives, social workers, pro bation staff, or any other agency to initially contact the clinic direct. The CPN on call is then paged and the nature of the crisis discussed. If any further members of the team are required to participate in the intervention they will be contacted. A back-up list of staff is available. The CPN will either be accompanied by one of the clinic staff or a member of the back-up team. Usually the members of the team would be able to attend the crisis within an hour of being called, depending on the geographical location of the patient within the region. The crisis intervention team responds only to those patients who are currently being followed up by the community nursing team.
Other crises, for example, emergency referrals, are responded to by the medical and nursing staff and others from the relevant clinical teams. For this purpose the catchment area is divided into three, each consultant having a responsibility for receiving referrals from a specific geographical area within the region. When the community nursing team at tends a crisis, usually at night or at weekends, an assessment is made of the situation and the crisis is resolved if possible without readmiss ion. However, if the patient requires admis sion and agrees to come in, he or she will be brought to the clinic and the consultant on call informed. It is essential that the judgement of the community nursing staff is sound and respec ted by their medical colleagues. If the patient is not willing to be readmitted, he or she can be recalled if on a conditional discharge or detained under an emergency section of the Mental Health Act, which will require the attendance of an approved social worker. A written report is made of each crisis call. There are approximately 30 to 40 emerg ency crisis intervention calls per year with only a small percentage of these requiring admission. It is often practice if readmission is required for restricted patients, that the patients are brought in informally with their consent, or detained under Section 2 rather than being recalled. The Home Office is informed of the readmission and a report given of the circumstances and reasons for readmiss ion or detention. The patients themselves would prefer this procedure rather than hav ing to be recalled with consequent delay in discharge, although if there is obvious serious risk to the public recall may be necessary. It is interesting that many of the conditionally discharged patients on the community caseload are willing to be followed up by the community staff long after absolute dis charge. This is mainly due to the relationship which has been built up between the staff and patient both during their admission period and aftercare in the community. The difficulty in finding adequate accom modation in the community for offender patients has presented serious problems in maintaining a throughput of patients to the regional secure unit and has caused delays in discharge arrangements. Many of the patients who go through a regional secure unit have previous offences involving members of the family. Often the family is unwilling to have the patient back or it is unwise for the patient to be returned to the environment for a variety of reasons. This
February 27/Volume 5/Number 23 1991 Nursing Standard 31
CLINICAL PSYCHIATRY S3 \\
)|
«
I
U
'/
\
c
ff
k
m m,
k m
i
I m 'Learning to fit back into the community.’
n
1
gran tmimimmiw/s: has presented major difficulties in accommo dating patients outside their original area leading to considerable problems with hous ing departments and local social services. In order to resolve these difficulties ap proaches were made several years ago to a local housing trust and a ‘cluster flat scheme’ was developed. The philosophy of this scheme was to provide permanent tenancy for discharged patients from all areas of the region with a tripartite management group involving Liver pool Housing Trust, Liverpool Association of Mental Health (MIND) and the regional forensic psychiatry service. The first scheme was opened in 1985 and consisted of a large three-storey Georgian building, converted into six self-contained flats near Liverpool city centre. Several sites were considered, including a small hotel, which for various reasons did not meet requirements. The first group of patients to occupy the cluster flats included five male patients and one female patient. The manage ment group met monthly and support services included a representative from the housing trust, a member of MIND, a probation officer responsible for the statutory supervision of several of the clients, a social worker and community nursing staff. Initially the input to the clients included daily visits and these were gradually reduced. Although the flats were self-contained and had no communal facilities the group members were very supportive to each other and the male patients
32 Nursing Standard February 27/Volume 5/Number 23 1991
very protective of the female resident. A pay phone was installed within the flats so that the clients could contact the clinic in an emerg ency. This resolved the problem of trying to find a public phone which was working within the locality. During the first year there was a fire within one of the flats and the patient was returned to the clinic. The patient has since been dischar ged to hostel accommodation. Despite this setback the project has been very successful so far and, based on the experience of this scheme, a second scheme was opened in April 1988. The second scheme has six self-contained, purpose built flats and a communal lounge. It is sited on the outskirts of Liverpool. All the residents are male. As with the first scheme, a decision was made by the management team, after much debate, to treat the scheme as a group of private flats and not to have prior discussion with local resident groups regarding the purpose of the scheme and the nature of the residents. This approach has worked well and clients have integrated well into the local community. The major drawback of cluster flat schemes is that because clients have permanent tenan cies, unless they move onto other accommo dation, the flats become permanently filled and further accommodation needs to be sought for new clients. Hopefully, over the next few years, further schemes will be developed with at least one scheme having resident staff available on a 24-hour basis.
The drop-in centre Merseyside has a particularly high unem ployment problem and it is unlikely that many patients discharged will be able to obtain full-time employment. While patients may be successfully discharged to appropriate accommodation, we had to address the prob lem of providing useful activities for them in their daily lives. Attendance at day centres where patients can remain active and develop a social life is an important aspect of their discharge plan. Various day centre facilities are used throughout the region but unfor tunately some areas are less well off than others. We have found that most day centres are willing to accept our patients providing there is adequate support, advice and follow up available from the community team. If good support is forthcoming then day centre staff tend to welcome further clients from the forensic psychiatry service. Day centre staff are aware that if there is a problem regarding one
CLINICAL PSYCHIATRY
Further reading DHSS (1987) ‘Supervision and aftercare of conditionally discharged restricted patients’. London, HMSO. DoH and Welsh Office (1989) 'Code of Practice’ - Mental Health Act Commission. London, HMSO. Weller M, Weller B (1988) ’Crime and mental illness’ Medicine, Science and the Law. 2,38-46. Hogg C (1986) ‘Patients' Charter: guidelines to good practice’. London, Association of Community Health Councils. Reference 1. DHSS (1975) ’Report of the Committee on mentally abnormal offenders’. (Butler report), CMCD 6244. London, HMSO.
of the clients they can contact the clinic and very quickly receive the support they need. Because day centre facilities are not always available and there are gaps in the services provided by various districts within the region, it was felt that we should provide some facilities for some of our own patients/clients where they could attend on an informal basis and have access to members of the forensic team, eg medical, nursing, psychology and social work staff. A drop-in centre was established several years ago in the basement of the outpatient department in Liverpool city centre. This facility includes a central meeting/activity room, kitchenette and billiard room. Access is available without going through the outpa tient department itself. At present, sessions are provided on three days a week and the drop-in centre is managed by the CPN staff. While patients attend the drop-in centre they can receive medication, attend out patient appointments and have general coun selling and support. There is no obligation to attend, but because it is informal the atten dance has escalated, so much so that space is now becoming scarce. It is intended to increase the numbers of sessions to five days a week but this has obvious staffing impli cations. Patients who attend have the opportunity of cooking a meal for the group and engaging in discussions or indoor activities. Regular outings are held to various places of interest including camping trips to Wales and the Lake District. The Probation Service has centres where outdoor activities such as canoe ing, horse riding, abseiling, rock climbing, orienteering and other pursuits are available for use by our client group. One of the major advantages of the drop-in centre is that inpatients preparing for discharge from the regional secure unit attend with staff from the clinic and are able to mix socially with patients who have already been discharged. This enables them to gain a useful insight into the problems and experience that patients have in setting up accommodation in the community. Pre-discharge groups are ar ranged and programmes developed to prepare the group for life in the community, includ ing such skills as dealing with DSS benefits, form filling, coping with bills and demands, and other difficulties associated with setting up on their own. Formal sessions have been introduced with input from various members of the team and outside agencies to come and talk to patients about problems of daily living. These sessions include input from psychology staff, social
workers, housing officers, probation staff, voluntary agencies, education staff and others who will be able to offer advice and support to the clients. Future developments There is now a thriving forensic service within the region and a stage has been reached where further developments and consequent staffing and financial impli cations have to be considered. The questions now being raised are: have we reached satu ration point; is there a limit to the number of persons on the caseload; and how do we cope with future demand? There is a fine balance between maintaining adequate support for patients in the community and reducing their dependence upon the health care services. At what stage do we transfer patients over to other teams and what are the patients' wishes about their future aftercare?
Less than expected Interestingly, the demand for inpatient beds is less than expected and the demand for support and aftercare is more than antici pated. In the outpatient department 300-400 new patients are seen each year who are ex-offenders requiring treatment but not ad mission. We currently have approximately 60 admissions per year to the regional secure unit which represents about 15 per cent of men tally ill offenders within the region. It looks likely that some of the resources available for regional secure units will need to be re-direc ted towards the community with a consequent reduction of operational beds and more flexi bility in staffing to cater for the future demands of care in the community. Like most RSUs, Scott Clinic is on the site of a large psychiatric hospital which is being closed. There is some pessimism about the care that will be provided for the 'difficult-tomanage' group of patients within local dis tricts and this is bound to have implications for future forensic psychiatry services. While ideally RSUs should be part of an integrated service, the pressure on community nursing teams as a result of closures and early discharge is increasing and there is less and less commitment from local services to take on clients with a history of offence. It is now recognised that there must be provision for those psychiatric patients who do not require the facility of a regional secure unit and who do not fall within the category of community care schemes. The experience gained by RSU teams with this complicated client group is a major resource in consultation with local district health authorities for future provision of care.
February 27/Volume 5/Number 23 1991 Nursing Standard 33
Community care for mentally ill offenders John Parry RGN, RMN, is Assistant Director of Nursing Services. Regional Forensic Psychiatry Service. Mersey Region.
Perhaps no group ofpatients needs skilled support on discharge back into the community more than mentally disturbed offenders. John Parry describes the community nursing input to the Regional Forensic Psychiatry Service in Merseyside, and emphasises the need for a co-ordinated and planned approach to help solve the multiple and complex problems of this group.
Following the recommendations of the Report of the Committee on mentally abnor mal offenders’ (1) almost every regional health authority in England now provides secure unit beds for offender patients. Some regions have a single regional secure unit and others have peripheral units. Many have not yet hit the target bed provision of 20 beds per million population. In addition to recommending the setting up of regional secure units, the Butler report also recommended the development of regio nal forensic psychiatry services. There is little mention of nursing involvement either in the Butler report or in subsequent reports about supervision and aftercare of offenders. How ever, in the author’s experience, the type of patients discharged require a high input of supervision and aftercare by health service staff in order to maintain their wellbeing and reduce the risk of offending as a result of deterioration in their mental condition. This is seen not as an addition to the supervision required, but as a complementary service, working in liaison with the probation service, social services, other community psychiatric nurse (CPN) teams and agencies within the community. The phrase 'nursing within controlled environments’ includes treatment and care both in hospital, eg special hospitals, regional secure units (RSUs) and local psychiatric hospitals, and the community where there are restrictions on the patients’ treatment and supervision. We are all aware of the 'revolving door' syndrome where patients move from prison to hospital to community and back to either prison or hospital, mainly due to a relapse in their mental health while in the community which has not been picked up early enough, resulting in either reoffending or admission to hospital.
The aim of the service is to break this circle by providing adequate support, treatment and preventative nursing intervention. The moni toring of maintenance medication and patient/family support is essential for all psychiatric patients, but is particularly important in the care of offender patients. The development of the RSU programme should ideally be integrated with the local NHS services throughout the region. Because of the large caseloads of most CPNs, together with the need for a high input to the supervision and aftercare in the community for offender patients, it has been found necessary to provide a parallel service for a small group of clients who pose particularly difficult problems. We have been fortunate in the geographical size of the region which is considerably smaller than most, with concentrated areas of population. The secure unit is sited reasonably central to the region and although the catchment area encompasses some ten health districts, the travelling distance is not too great. Initial fears about distances have proved unfounded, in that the majority of patients are discharged to inner city areas where accom modation is most readily available.
Genericism/specialism The arguments for specialism are twofold. First, RSUs are politically sensitive and at tract sensational media attention. However successful the rehabilitation of offenders into the community, one serious reoffence can undermine both the confidence of the sup porting team and also the local community. Regional and district health authorities are also particularly sensitive to problems arising from regional secure unit clientele. Second, the majority of patients admitted to regional secure units and subsequently discharged into the community are suffering from schizophrenia and the importance of maintenance medication is essential in the prevention of deterioration and possible re offence. Local community services are often unable and sometimes reluctant to provide the high input required for this group of patients. The interim secure unit opened in August
February 27/Volume 5/Number 23 1991 Nursing Standard 29
CLINICAL PSYCHIATRY
'M /y>.
W.
**•/
H’i,
m '^VCs.
RSU development The regional secure unit opened in August 1983 and a full-time community nurse was appointed the following month. The com munity caseload at the time was about 20 patients and as the unit developed a staff nurse was attached to the community team. Two more full-time posts were developed within the next two years. Currently we have three full-time CPNs based at the unit. Of the total number of patients discharged about 20 per cent arc followed up by the forensic psychiatry service. The remainder are either transferred to other catchment area teams within the region or are returned to special hospital or prison. The patients who are followed up tend to be serious offenders 30 Nursing Standard February 27/Volume 5/Number 23 1991
who have been detained under a hospital order. Their discharge is conditional upon residence at a given address, attendance at outpatient clinics and receiving medication. Other conditions may also be imposed as part of the aftercare package. This is, in practice, compulsory treatment in the community which is fully understood by the patient and works extremely well. The community nursing team consists of a team leader, one charge nurse and one sister. Female patients in the community tend to be followed up by female staff, but this will depend upon the patient’s preference and deployment of caseload. There are three con sultant forensic psychiatrists and the CPNs attend the clinical team meetings on the unit each week. While it would be logical for the CPNs to be consultant attached, this is not always possible because of the geographical location of patients discharged to various parts of the region. Generally there is considerable overlap between the CPNs and their clients which also makes for better communication. The concept of multidisciplinary team work is very strong, and as well as managing a caseload of patients in the community, there is considerable involvement by the CPNs w'ith inpatients who are preparing for discharge. They necessarily need to work very closely with the social workers who are based at the clinic and the ward staff as well as other members of the clinical team. Each week a predischarge meeting is held involving all representatives of the team to discuss those patients who are looking forward to discharge within a reasonable length of time. This is extremely helpful in ensuring an adequate preparation of the discharge treat ment plan and package where allocation of supervision in the community is required. The importance of early liaison between nursing staff and other agencies such as the probation service, social services, hostel staff and relatives is essential for smooth discharge to be effected. The total caseload at the end of 1989 was 78 patients. These include those patients who have received inpatient treat ment and have been discharged to the com munity, outpatients who are offenders being treated within the community who have not had inpatient treatment, clients in the cluster flat schemes, patients on trial leave and inpatients preparing for imminent discharge. Future projections of increasing caseload esti mate an addition of up to ten new cases per year, inclusive of those transferred off the coascload to other teams and new patients joining the caseload.
JL1JA ROBINSON
I
1976 and during the early days it quickly became apparent that with a philosophy of assessment, treatment and rehabilitation towards either local hospital or community, we were in the ‘high-risk business'. For mentally disordered offenders, the interface between hospital treatment and community care is a particularly difficult area, and patients who had spent a long time in institutions, either prisons or special hospi tals, reacted quite differently when faced with the prospect of living in the community. The psychological security of the institu tion was a major factor to be addressed in the patients' rehabilitation. Some patients found the integrated care and ‘liberalism’ of secure units quite threatening and the task of devel oping independence and self-care was particu larly difficult. It was realised rapidly that unless there was adequate support, aftercare and supervision within the community, treat ment in hospital, however successful, was doomed to failure. Consequently, in addition to the 14bedded unit, a ten-bed pre-discharge ward was opened where nursing staff became in creasingly involved in preparation for com munity care and the follow-up of discharged patients. Initially this was successful, but as the number of patients in the community increased, the nursing staff were faced with conflicting priorities between patients on the ward and patients in the community. The needs of the ward took priority and this led to a subsequent reduction in adequate aftercare. In planning the RSU we resolved to have full-time community nursing staff at tached to the clinic who would be able to concentrate their efforts on providing the support and treatment the patients in the community required.
t
I
CLINICAL PSYCHIATRY An analysis of the community caseload shows almost 40 per cent of the new patients are conditionally discharged (Section 37/41), the majority of whom have a probation officer as statutory supervisor. The previous offences of patients on the community caseload include homicide (15 per cent), assault of various degrees (68 per cent), arson (10 per cent), and sex offences (7 per cent). The system developed for case reviews includes a progress report each week at the clinical team meetings held on the unit which are attended by members of the community psychiatric nursing team and regular monthly reviews held at the outpatient department in the city centre. These monthly reviews will include all those persons involved in the patient’s after care, eg medical, nursing, probation, social work, hostel staff, etc.
Crisis intervention from the early days of the interim secure unit the need for a crisis intervention service was identified. Initially, a core of nursing staff who were willing to respond to crisis interven tion calls were drawn up. This was on an ad hoc basis with nobody officially on call. As the RSU developed and the CPN team increased, the need for an on-call system was essential. In order to spread the workload, one of the CPNs is on call alternate weeks and is paid an on call allowance. At first this necessitated the on call nurse to be close to a telephone while on call for the week. Now a radio page system has been introduced which allows the nurse on call to have some freedom of movement within the catchment area while still remaining in con tact with the clinic. The crisis intervention team operates a 24-hour, seven-day-week service, and the usual procedure is for calls either from patients themselves, relatives, social workers, pro bation staff, or any other agency to initially contact the clinic direct. The CPN on call is then paged and the nature of the crisis discussed. If any further members of the team are required to participate in the intervention they will be contacted. A back-up list of staff is available. The CPN will either be accompanied by one of the clinic staff or a member of the back-up team. Usually the members of the team would be able to attend the crisis within an hour of being called, depending on the geographical location of the patient within the region. The crisis intervention team responds only to those patients who are currently being followed up by the community nursing team.
Other crises, for example, emergency referrals, are responded to by the medical and nursing staff and others from the relevant clinical teams. For this purpose the catchment area is divided into three, each consultant having a responsibility for receiving referrals from a specific geographical area within the region. When the community nursing team at tends a crisis, usually at night or at weekends, an assessment is made of the situation and the crisis is resolved if possible without readmiss ion. However, if the patient requires admis sion and agrees to come in, he or she will be brought to the clinic and the consultant on call informed. It is essential that the judgement of the community nursing staff is sound and respec ted by their medical colleagues. If the patient is not willing to be readmitted, he or she can be recalled if on a conditional discharge or detained under an emergency section of the Mental Health Act, which will require the attendance of an approved social worker. A written report is made of each crisis call. There are approximately 30 to 40 emerg ency crisis intervention calls per year with only a small percentage of these requiring admission. It is often practice if readmission is required for restricted patients, that the patients are brought in informally with their consent, or detained under Section 2 rather than being recalled. The Home Office is informed of the readmission and a report given of the circumstances and reasons for readmiss ion or detention. The patients themselves would prefer this procedure rather than hav ing to be recalled with consequent delay in discharge, although if there is obvious serious risk to the public recall may be necessary. It is interesting that many of the conditionally discharged patients on the community caseload are willing to be followed up by the community staff long after absolute dis charge. This is mainly due to the relationship which has been built up between the staff and patient both during their admission period and aftercare in the community. The difficulty in finding adequate accom modation in the community for offender patients has presented serious problems in maintaining a throughput of patients to the regional secure unit and has caused delays in discharge arrangements. Many of the patients who go through a regional secure unit have previous offences involving members of the family. Often the family is unwilling to have the patient back or it is unwise for the patient to be returned to the environment for a variety of reasons. This
February 27/Volume 5/Number 23 1991 Nursing Standard 31
CLINICAL PSYCHIATRY S3 \\
)|
«
I
U
'/
\
c
ff
k
m m,
k m
i
I m 'Learning to fit back into the community.’
n
1
gran tmimimmiw/s: has presented major difficulties in accommo dating patients outside their original area leading to considerable problems with hous ing departments and local social services. In order to resolve these difficulties ap proaches were made several years ago to a local housing trust and a ‘cluster flat scheme’ was developed. The philosophy of this scheme was to provide permanent tenancy for discharged patients from all areas of the region with a tripartite management group involving Liver pool Housing Trust, Liverpool Association of Mental Health (MIND) and the regional forensic psychiatry service. The first scheme was opened in 1985 and consisted of a large three-storey Georgian building, converted into six self-contained flats near Liverpool city centre. Several sites were considered, including a small hotel, which for various reasons did not meet requirements. The first group of patients to occupy the cluster flats included five male patients and one female patient. The manage ment group met monthly and support services included a representative from the housing trust, a member of MIND, a probation officer responsible for the statutory supervision of several of the clients, a social worker and community nursing staff. Initially the input to the clients included daily visits and these were gradually reduced. Although the flats were self-contained and had no communal facilities the group members were very supportive to each other and the male patients
32 Nursing Standard February 27/Volume 5/Number 23 1991
very protective of the female resident. A pay phone was installed within the flats so that the clients could contact the clinic in an emerg ency. This resolved the problem of trying to find a public phone which was working within the locality. During the first year there was a fire within one of the flats and the patient was returned to the clinic. The patient has since been dischar ged to hostel accommodation. Despite this setback the project has been very successful so far and, based on the experience of this scheme, a second scheme was opened in April 1988. The second scheme has six self-contained, purpose built flats and a communal lounge. It is sited on the outskirts of Liverpool. All the residents are male. As with the first scheme, a decision was made by the management team, after much debate, to treat the scheme as a group of private flats and not to have prior discussion with local resident groups regarding the purpose of the scheme and the nature of the residents. This approach has worked well and clients have integrated well into the local community. The major drawback of cluster flat schemes is that because clients have permanent tenan cies, unless they move onto other accommo dation, the flats become permanently filled and further accommodation needs to be sought for new clients. Hopefully, over the next few years, further schemes will be developed with at least one scheme having resident staff available on a 24-hour basis.
The drop-in centre Merseyside has a particularly high unem ployment problem and it is unlikely that many patients discharged will be able to obtain full-time employment. While patients may be successfully discharged to appropriate accommodation, we had to address the prob lem of providing useful activities for them in their daily lives. Attendance at day centres where patients can remain active and develop a social life is an important aspect of their discharge plan. Various day centre facilities are used throughout the region but unfor tunately some areas are less well off than others. We have found that most day centres are willing to accept our patients providing there is adequate support, advice and follow up available from the community team. If good support is forthcoming then day centre staff tend to welcome further clients from the forensic psychiatry service. Day centre staff are aware that if there is a problem regarding one
CLINICAL PSYCHIATRY
Further reading DHSS (1987) ‘Supervision and aftercare of conditionally discharged restricted patients’. London, HMSO. DoH and Welsh Office (1989) 'Code of Practice’ - Mental Health Act Commission. London, HMSO. Weller M, Weller B (1988) ’Crime and mental illness’ Medicine, Science and the Law. 2,38-46. Hogg C (1986) ‘Patients' Charter: guidelines to good practice’. London, Association of Community Health Councils. Reference 1. DHSS (1975) ’Report of the Committee on mentally abnormal offenders’. (Butler report), CMCD 6244. London, HMSO.
of the clients they can contact the clinic and very quickly receive the support they need. Because day centre facilities are not always available and there are gaps in the services provided by various districts within the region, it was felt that we should provide some facilities for some of our own patients/clients where they could attend on an informal basis and have access to members of the forensic team, eg medical, nursing, psychology and social work staff. A drop-in centre was established several years ago in the basement of the outpatient department in Liverpool city centre. This facility includes a central meeting/activity room, kitchenette and billiard room. Access is available without going through the outpa tient department itself. At present, sessions are provided on three days a week and the drop-in centre is managed by the CPN staff. While patients attend the drop-in centre they can receive medication, attend out patient appointments and have general coun selling and support. There is no obligation to attend, but because it is informal the atten dance has escalated, so much so that space is now becoming scarce. It is intended to increase the numbers of sessions to five days a week but this has obvious staffing impli cations. Patients who attend have the opportunity of cooking a meal for the group and engaging in discussions or indoor activities. Regular outings are held to various places of interest including camping trips to Wales and the Lake District. The Probation Service has centres where outdoor activities such as canoe ing, horse riding, abseiling, rock climbing, orienteering and other pursuits are available for use by our client group. One of the major advantages of the drop-in centre is that inpatients preparing for discharge from the regional secure unit attend with staff from the clinic and are able to mix socially with patients who have already been discharged. This enables them to gain a useful insight into the problems and experience that patients have in setting up accommodation in the community. Pre-discharge groups are ar ranged and programmes developed to prepare the group for life in the community, includ ing such skills as dealing with DSS benefits, form filling, coping with bills and demands, and other difficulties associated with setting up on their own. Formal sessions have been introduced with input from various members of the team and outside agencies to come and talk to patients about problems of daily living. These sessions include input from psychology staff, social
workers, housing officers, probation staff, voluntary agencies, education staff and others who will be able to offer advice and support to the clients. Future developments There is now a thriving forensic service within the region and a stage has been reached where further developments and consequent staffing and financial impli cations have to be considered. The questions now being raised are: have we reached satu ration point; is there a limit to the number of persons on the caseload; and how do we cope with future demand? There is a fine balance between maintaining adequate support for patients in the community and reducing their dependence upon the health care services. At what stage do we transfer patients over to other teams and what are the patients' wishes about their future aftercare?
Less than expected Interestingly, the demand for inpatient beds is less than expected and the demand for support and aftercare is more than antici pated. In the outpatient department 300-400 new patients are seen each year who are ex-offenders requiring treatment but not ad mission. We currently have approximately 60 admissions per year to the regional secure unit which represents about 15 per cent of men tally ill offenders within the region. It looks likely that some of the resources available for regional secure units will need to be re-direc ted towards the community with a consequent reduction of operational beds and more flexi bility in staffing to cater for the future demands of care in the community. Like most RSUs, Scott Clinic is on the site of a large psychiatric hospital which is being closed. There is some pessimism about the care that will be provided for the 'difficult-tomanage' group of patients within local dis tricts and this is bound to have implications for future forensic psychiatry services. While ideally RSUs should be part of an integrated service, the pressure on community nursing teams as a result of closures and early discharge is increasing and there is less and less commitment from local services to take on clients with a history of offence. It is now recognised that there must be provision for those psychiatric patients who do not require the facility of a regional secure unit and who do not fall within the category of community care schemes. The experience gained by RSU teams with this complicated client group is a major resource in consultation with local district health authorities for future provision of care.
February 27/Volume 5/Number 23 1991 Nursing Standard 33
