"We will publish an audit document that will help all agencies identify their role in the care and custody of this group and identify and gaps in current provision."
Our National Health: a plan for action, a plan for change, December 2000.
Background/Definitions
1. The objective of this care pathway document is to describe for agencies what needs to be in place, where, when and provided by whom to ensure seamless provision of services and accommodation for mentally disordered offenders. This document specifies the different elements and links required to monitor and audit the service system and identify any gaps and variances in provision.
2. It is important to establish agreed criteria for access to specialist expertise, treatment and care at, Local, Supra Local and National levels. In these terms this document provides a pathway through a service system (rather than diagnosis specific). This document does not describe a pathway for all people with a mental health problem or learning disability, the focus is on people with a mental disorder who either come to the attention of the criminal justice system (CJS) or whose behaviour poses a risk of such contact.
3. In this document the terms, Local, Supra Local and National describe the different levels of service according to the population bases served:
Defining features
4. Four defining features, inform the care pathway document for this client group. Each recognises that the complex needs of the client group cannot be met by one agency alone;
(i) Routes
5. This document describes both the structures, services and accommodation needed for those with a mental disorder who come to the attention of the Criminal Justice System (CJS), those at risk of contact with the CJS and those in prison, the State Hospital or elsewhere in the care or custody system.
(ii) Heterogeneity
6. The range of needs and risks presented can be distinguished along a number of dimensions each requiring different service responses:
Degree/severity/nature of mental disorder ie, mental illness, learning disability;
Socio-demographic characteristics: sex, ethnicity, age, and first language;
Impairments/complex needs eg, sensory impairment;
Past history of psychiatric/psychological disorder/offending;
Nature and severity of offending behaviour;
Presumed link between mental disorder and offending behaviour (culpability); and
Nature and severity of risk.
(iii) Assessment/service response
7. The important dimensions to assessment and service response include individual need and risk and the requirements of the criminal justice process.
(iv) Service Imperatives
8. The different (and potentially) competing service priorities within and between agencies are recognised in the pathway. These may be between models based on individual welfare and treatment, and others based on public interest, due process, sentence management. In addition the care pathway acknowledges the inter-dependence between professionals and agencies.
Care Pathway Document
9. This document is based on the routes into, through and out of the CJS. Each stage along the ‘pathway’ describes the network of services and supports which need to be in place to provide the quality of service set out in NHS, MEL(1999)5.
10. This document therefore comprises 4 elements:
(i) A pathway or route structured primarily by the criminal justice process, but with access points to specialist services at Local, Supra Local and National level for those set out at paragraph 5 above.
(ii) A structure to enable assessment of the individual in order to assess individual needs and the risks presented (to themselves and others) and to inform criminal justice decision-making.
(iii) A network of services and supports at Local, Supra Local and National level, both specialist and mainstream, in response to the assessed needs of the individual and the risks they present.
(iv) Longer term planning, based on a network of links and connections including monitoring of individuals, where appropriate.
11. These elements are presented in the diagram attached at Appendix 1.
Stages along and within the Care Pathway
12. Although overlapping there are eight key stages in the "journey";
(i) People with mental health problems or learning disabilities at risk of coming to the attention of the criminal justice system. People in prison or elsewhere in the care/custody system.
(ii) Police Contact: no offence; no charge; possible mental disorder.
(iii) Police Contact: alleged offence; possible mental disorder.
(iv) Report to the Procurator Fiscal.
(v) Pre-Trial Committal.
(vi) Court Proceedings:
Assessment of mental disorder
Assessment of fitness to plead/state of mind at the time of the alleged offence.
(vii) Found Guilty/finding that the person did the act or made the omission constituting the offence: pre-disposal.
(viii) Disposal:
(a) Community disposal
(b) Hospital disposal
(c) Prison disposal.
Key Points
13. Not all those coming to the attention of the CJS will travel the length of the ‘pathway’ from Stages 2 to 8 of Appendix 1. At each point some may be diverted out; formally detained in hospital under the extant legislation; informally admitted to hospital; or supported in the community. Individuals may also be transferred out of the criminal justice system or discharged from a service, they may also re-enter the pathway later.
14. Movement in and out of the pathway reinforces the need for information sharing and mechanisms for ensuring continuity of care. In this regard consideration on the development of information sharing and systems integration continues through the NHS Information Management and Technology Board, the Confidentiality and Security Advisory Group for Scotland and the Social Work Information Review Group.
15. No individual will necessarily require the full range of mental health, learning disability, social work, social care, housing and community resource options. The objective is to ensure the broad availability and appropriateness of resources to meet the individual needs and risks presented.
16. No single agency will be in a position to provide the full range of services to respond to assessed needs. The objective is to identify on a cross-agency basis the range of services and supports required and to agree which agency at Local, Supra Local or National level should respond to the service and individual needs identified. Thereafter, it is a matter of ensuring access arrangements and links are in place.
17. A checklist of community based, secondary, and tertiary care services is recommended to assist multi-agency access to a range of service components. A model checklist is attached at Appendix 2.
18. The links between and within agencies and professionals are of equal importance. Development and implementation at local level requires clearly defined links and connections within and across health, social work, housing agencies and with criminal justice services. This includes links with local mechanisms for monitoring sex offenders.
19. Appendix 3 illustrates the range of links and connections (and their complexity).
20. Appendix 4 (1-8c) describes what is happening and what needs to be in place at each ‘stage’ of the pathway. These are intended for illustrative purposes only and allow for local variation, where appropriate. Examples of the organisational requirements needed for efficient operation of the service system are provided with each diagram. Some are stage specific, others underpin every stage and form the infrastructure of the pathway. This will, by implication, help identify gaps in service provision.
21. Agreed criteria are required to ensure the appropriate use of, and access to, specialist services (at an appropriate level of security) to meet an individual’s needs and the risks presented. At Local level criteria need to be established for access to, and discharge from, Local level specialist services.
22. Each stage of this document builds in the opportunity for longer term care planning. Consideration is needed to ensure the safe transition of individuals in all cases but particularly those with complex needs between different elements of the service system, referred to here as an ‘augmented Care Programme Approach’ (CPA). Both the mechanism and the criteria that would inform the user need to be agreed. The outcome guidance of Scottish Executive Discharge Protocol Working Group for patients being discharged (or transferred with a view to discharge) from the State Hospital will need to be integrated into all local procedures. At Local level there is scope for consideration of the criteria for the use of the Care Programme Approach and Personal Life plans for people with less complex needs.
23. At assessment, and at the point of service delivery, mechanisms need to be in place to ensure the identification of, and responses to, specific needs, including age, sex, people with learning disabilities, people from black and ethnic minority communities, people with sensory impairments or for whom English is not their first language.
24. At individual client or patient level, specific monitoring mechanisms need to be built in locally to enable identification of the route taken, and variations from the pathway.