The British Journal of Psychiatry (2015) 206, 252–254
Correspondence Edited by Kiriakos Xenitidis and Colin Campbell
3
Bowers L, Brennan G, Ransom S, Winship G, Theodoridou C. The Nursing Observed Illness Intensity Scale (NOIIS). J Psychiatr Ment Health Nurs 2011; 18: 28–34.
4
Dix R, Pereira S, Chaudry K, Dale C, Halliwell J. A PICU/LSU environment assessment inventory. J Psychiatr Intensive Care 2005; 1: 65–9.
5
Ulrich RS, Bogren L, Lundin S. Towards a design theory for reducing aggression in psychiatric facilities. Presented at Arch 12: Architecture, Research, Care, Health in Gothenburg, Sweden, 13 November 2012. Chalmers University (http://conferences.chalmers.se/index.php/ARCH/ arch12/paper/download/426/67).
Contents &
The psychiatric ward as a therapeutic space
&
Discharges to prison from medium secure psychiatric units
Oliver Jenkins, ST6 in General Adult Psychiatry, Norfolk and Suffolk NHS Foundation Trust. Email: [email protected] doi: 10.1192/bjp.206.3.252
The psychiatric ward as a therapeutic space Papoulias et al1 have added a great deal to our understanding of the research exploring the effects of ward design on both patients and staff. They highlight the breadth of study designs but also the varying quality of both patient and environmental measures. A further inherent limitation in many of the studies seems to be the difficulty in controlling for confounding factors such as staffing and patient characteristics. Given these observations, it was unfortunate that our recent study2 was not, at the time, ready for inclusion in this systematic review, as it adds to the body of work identified and also addresses some of the criticisms. Our work aimed to assess the impact of a changed ward environment on the levels of in-patient agitation and conflict on an NHS psychiatric intensive care unit (PICU). Taking advantage of a PICU moving from an old, temporary building to a new, purpose-built ward, we were able to analyse routinely collected patient data that were markers of agitation and conflict, including number of seclusion episodes, duration of close observation, number of aggressive incidents and data from the Nursing Observed Illness Intensity Scale.3 We also had an evidence-based, objective, before-and-after measure of the ward environment: the Environment Assessment Inventory (EAI).4 This methodology, reviewing data before and after a ward change, enabled us to control for many of the important confounding factors that were highlighted by Papoulias et al,1 as patient profiles, ward staffing and policies remained largely unchanged. The results showed that the key measures of agitation and conflict were reduced on the new ward, and the EAI enabled us to identify quantifiable improvements and highlight critical design elements that had been improved upon. Like many of the studies in the systematic review, ours suggested that the physical environment of the psychiatric ward had a significant effect on patient behaviours. Some of the critical changes included better visibility, increased space for therapeutic activities and more privacy in the form of single rooms. Papoulias et al1 highlighted the common idea that improved privacy was a key environmental factor in reducing violence on psychiatric wards, and we too would make this interpretation. In the context of recent work by Ulrich et al,5 we concluded that it might be because patient privacy fosters a sense of control that reduces stress levels and in turn agitation and conflict, which are closely linked to violence. We hope that our findings can be set alongside the work to date and provide further evidence for optimising patient care by using evidence-based and objective standards to improve the environment of psychiatric wards.
252
1
Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry 2014; 205: 171–6.
2
Jenkins O, Dye S, Foy C. A study of agitation, conflict and containment in association with change in ward physical environment. J Psychiatr Intensive Care 2014; doi:10.1017/S1742646414000065.
The systematic review by Papoulias et al1 on the psychiatric ward as a therapeutic space reminds us of the important effects of environmental factors on in-patients. The physical environment is likely, however, to be particularly significant in settings where length of stay is long, whether in or out of hospital. The 1995 book by Halpern2 describes the mental health effects of the built environment on residents of a housing estate, and the concerns of Papoulias et al should be explored in residential mental health facilities in the community. For psychiatric in-patients, patient characteristics (including diagnosis) and psychosocial environmental factors are powerful determinants of what happens in the hospital, including behaviour disturbances, service user opinions and also, sometimes, illness outcomes.3,4 Clark5 was one of those who showed that different wards for different varieties of patient should have different sorts of environment, drawing on the extensive previous research in this field (e.g. Stanton & Schwartz6). A major problem with today’s in-patient wards is that everyone has to be admitted to, and as like as not, stay in, the same environment, whether or not it suits them and their illness. This might remind clinicians with long memories of the features of the old observations wards, to which anyone putatively mentally ill could be admitted, primarily for triage and transfer to the setting which suited them best. Today there is, in these terms, only the triage. 1
Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry 2014; 205: 171–6
2
Halpern D. Mental Health and the Built Environment: More than Bricks and Mortar? Taylor & Francis, 1995.
3
Bouras N, Trauer T, Watson JP. Ward environment and disturbed behaviour. Psychol Med 1982; 12: 309–19.
4
Watson JP, Bouras N. Psychiatric ward environments and their effects on patients. In Recent Advances in Clinical Psychiatry – 6 (ed. K Granville-Grossman). Churchill Livingston, 1988: 135–60.
5
Clark D. Administrative Therapy. Tavistock, 1964.
6
Stanton AH, Schwartz MS. The Mental Hospital. Basic Books, 1954.
Nick Bouras, Emeritus Professor, King’s College London, Institute of Psychiatry, Psychology and Neurosciences; Jim Watson, Emeritus Professor, Guy’s and St Thomas’ Hospitals. Email: [email protected] doi: 10.1192/bjp.206.3.252a
Author’s reply: We are pleased to have received such commendations of our review on psychiatric ward design.1 We believe, as the other commentators do, that this is a long-neglected area that needs more research to inform future investment – including the UK government’s recently promised increase in in-patient wards for younger people. The physical environment of healthcare facilities does affect the patient experience and their satisfaction and is recognised as
Correspondence
an integral part of care delivery.2 The study mentioned in Dr Jenkins’ letter strengthens the evidence base for the contribution of ward privacy to violence reduction.3 As that letter also indicates, measures have largely remained focused on clinical outcomes and any research can only hint at the key design components that drive these changes. Our review emphasised the need for patient-focused outcomes and their involvement in ward design. We have developed some novel methodology that can highlight positive and negative issues in current design from the patient perspective and have also developed measures to monitor the effects of changes in ward design. We hope that tools enabling robust, patient-centred evaluation of in-patient facilities might contribute to the recognition of the complex contribution of the material environment – in its physical and psychosocial dimensions – to patient outcomes. 1
Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. Design in mind: the psychiatric ward as therapeutic space: a systematic review. Br J Psychiatry 2014; 205: 171–6.
2
Department of Health. Health Building Note 03-01: Adult Acute Mental Health Units. The Stationery Office, 2013.
3
Jenkins O, Dye S, Foy C. A study of agitation, conflict and containment in association with change in ward physical environment. J Psychiatr Intensive Care 2014; 1: 1–9.
Emese Csipke, Institute of Psychiatry, King’s College London. Email: [email protected] doi: 10.1192/bjp.206.3.252b
Discharges to prison from medium secure psychiatric units The percentage of patients being discharged to prison from medium secure units has nearly doubled to 20% in just over a decade. The research captures a significant change in the practice of forensic psychiatry in England and Wales. When this area was discussed within the London region several years ago, colleagues who said that they were not doing this looked into the matter and found that they were. Doyle et al1 do not report any variation in practice, which suggests there has been a uniform change (across the relevant services). In considering why this has happened, the authors present a rather negative picture of sending back still-symptomatic, higher-risk people to prison, with inadequate aftercare. An alternative view is that this represents a new realism in forensic psychiatry. Medium secure provision has greatly expanded in the last 25 years but, as shown by the paper, the system is risk averse to community discharges. Such patients have low symptoms and stay longer in hospital. It is unlikely that more money will be allocated to forensic services and we have to make the best use of the resources we have. In East London, appropriately transferring patients back to prison, alongside an improved rate of community discharge and the consistency of an admissions panel, has helped to manage demand. The service has gone from a waiting list of 25 patients to having beds quickly available for people presenting as acutely psychotic in prison. This is despite only sending people to the independent sector in exceptional cases and having no expansion in relevant beds over the time period. The research is consistent with a change in the model that forensic psychiatrists have about prisoners. In the past, sending people with a diagnosis of psychotic mental illness back to prison was generally seen as inappropriate. Forensic psychiatry saw itself as having redeeming and containing roles, through identifying the
mentally ill in prison, transferring them to medium security, providing treatment, and then either discharging to the community or providing longer-term secure care if the person’s risk and/or illness could not be satisfactory managed. The model now seems to regard prison as a form of ‘community’, to which some prisoners will be returned after being treated in hospital. It is logical that the relevant groups should be those for whom safe and effective ordinary discharge is unlikely. They may have a primary diagnosis of mental illness, but this might not be the primary problem for a significant group (e.g. career criminals and those who committed serious offences unrelated to mental illness). It is acknowledged that some practitioners will not welcome this philosophical and practice shift. The fate of those returning to prison is an issue for both commissioning and service provision. NHS forensic and/or general adult services should follow up all those who are returned to prison. They should remain in the care programme approach (CPA) process, with 6-monthly CPA reviews and a local care coordinator who keeps in regular contact with them. This would assist with monitoring, management of relapses and aftercare. In East London, we have a consultant and community nurse with prison roles that include helping to manage returned prisoners. Although mental health prison in-reach is variable, such arrangements help provide a framework for prison aftercare. In respect of the idea of a prison hospital, as advanced in the paper, this is the approach in South Australia (and elsewhere). Other than for patients found unfit or insane, most patients have the master status of prisoner, whether on remand or sentenced. At the end of their prison sentence, or if their remand ends, they have to be released from the forensic hospital, but can ordinarily be detained in a non-forensic mental health unit. This system has the disadvantage that there are no hospital orders. A combination approach has merit. Hospital orders could be used for those who require a hospital care pathway and the court could still order people to hospital otherwise (e.g. for a trial of treatment). Mentally ill prisoners would receive more prompt treatment in a hospital within the prison estate. Each major metropolitan area or part of England and Wales could have such a prison hospital (regulated as usual by the Care Quality Commission). Prisoners could be informal patients, whereas currently they are being denied the ‘least restrictive’ approach enshrined within the Mental Health Act 1983. This would bring prison psychiatry in line with ordinary adult psychiatry practice. The underused hybrid order could be resuscitated for intermediate cases. It is therefore to be hoped that this paper will promote active consideration of the best way to manage patients presenting in prison. I note that, unfortunately, the seminal study by Coid et al of half the secure units in England and Wales,2 which showed marked variation in the practice of forensic psychiatry, was not presented and discussed at an annual forensic conference. As a specialty we should not miss the opportunity to discuss this highly relevant piece of research. 1
Doyle M, Coid J, Archer-Power L, Dewa L, Hunter-Didrichsen A, Stevenson R, et al. Discharges to prison from medium secure psychiatric units in England and Wales. Br J Psychiatry 2014; 205: 177–82.
2
Coid J, Kahtan N, Gault S, Cook A, Jarman B. Medium secure forensic psychiatry services: comparison of seven English health regions. Br J Psychiatry 2001; 178: 55–61.
Neil Boast, Consultant Forensic Psychiatrist, London. Email: [email protected] doi: 10.1192/bjp.206.3.253
253
Correspondence
Authors’ reply: Dr Boast is quite correct to highlight the probable variation in practice across different services. Similarly, we know there are wide variations in practice across prison mental health services and post-release aftercare.1,2 Although this is not surprising, it is important to note as any future policy in this area will need to ensure that best practice is shared, so that offenders with mental health problems have access to safe and effective care equivalent to that offered in NHS and healthcare settings. Dr Boast suggests that we paint a negative picture of services and current practice, but we do in fact acknowledge that some discharges back to prison are entirely appropriate, especially for those patients without a serious mental illness where long-term treatment is not required. Time spent in medium secure units would generally be positive for those admitted from prison, but in some cases any benefits will be lost once the patient returns to prison. We wanted to emphasise that there is currently very little evidence to suggest that the quality of care in prison is equivalent to that in medium secure services and we know that many prisoners will, for a number of reasons, discontinue their treatment while in prison or after release. Tragedies recently reported in the media involving mentally ill people soon after their release from prison highlight the importance of effective community care and treatment and on-going support and supervision. This is particularly true for those released with psychotic illness.3 In response to this need, we are currently investigating what happens to patients once they return to prison from medium secure units and we hope to have preliminary findings by the summer of 2015. We are aware that the burden of providing care and treatment to released prisoners is frequently placed on already hard-pressed primary care teams and mainstream mental health services, even though more intensive and specialist interventions are often required.
254
We concur with the proposal for new prison hospital services and we commend the model described by Dr Boast, which is currently operating in East London. New service models and the suggestion for wider use of hybrid orders are of real interest and warrant further consideration from a policy, clinical and legal perspective. Although the return to prison of an increasing number of patients from medium security may be inevitable to prevent bed blocking and maintain the throughput of patients in an expensive in-patient service, we currently do not know the full cost or consequences of this policy. This includes risks of further relapse and readmission and possible risk to public safety due to what is, in effect, a bed-management policy. To conclude, we hope our article, Dr Boast’s letter and our response continue to generate discussion in this important area, so that the availability, configuration and quality of services provided to mentally disordered offenders remains high on the commissioning and regulatory agenda. 1
Lennox C, Senior J, King C, Hassan L, Clayton R, Thornicroft G, et al. The management of released prisoners with severe and enduring mental illness. J Forens Psychiatry Psychology 2012; 23: 67–75.
2
Shaw J, Senior J, Thornicroft G, Birmingham L, Kendall K, Brooker C. A National Evaluation of Prison Mental Health In-Reach Services. A Report to the National Institute of Health Research. The Offender Health Research Network, 2009 (http://www.ohrn.nhs.uk/resource/Research/Inreach.pdf).
3
Keers R, Ullrich S, DeStavola B, Coid J. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry 2014; 171: 332–9.
Michael Doyle, Jeremy Coid, Jenny Shaw, Forensic Psychiatry Research Unit, St Bartholomew’s Hospital, London. Email: [email protected] doi: 10.1192/bjp.206.3.254
The psychiatric ward as a therapeutic space
Nick Bouras and Jim Watson BJP 2015, 206:252. Access the most recent version at DOI: 10.1192/bjp.206.3.252a
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 2 articles, 1 of which you can access for free at: http://bjp.rcpsych.org/content/206/3/252.2#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;206/3/252-a http://bjp.rcpsych.org/ on December 6, 2015 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
Correspondence Edited by Kiriakos Xenitidis and Colin Campbell
3
Bowers L, Brennan G, Ransom S, Winship G, Theodoridou C. The Nursing Observed Illness Intensity Scale (NOIIS). J Psychiatr Ment Health Nurs 2011; 18: 28–34.
4
Dix R, Pereira S, Chaudry K, Dale C, Halliwell J. A PICU/LSU environment assessment inventory. J Psychiatr Intensive Care 2005; 1: 65–9.
5
Ulrich RS, Bogren L, Lundin S. Towards a design theory for reducing aggression in psychiatric facilities. Presented at Arch 12: Architecture, Research, Care, Health in Gothenburg, Sweden, 13 November 2012. Chalmers University (http://conferences.chalmers.se/index.php/ARCH/ arch12/paper/download/426/67).
Contents &
The psychiatric ward as a therapeutic space
&
Discharges to prison from medium secure psychiatric units
Oliver Jenkins, ST6 in General Adult Psychiatry, Norfolk and Suffolk NHS Foundation Trust. Email: [email protected] doi: 10.1192/bjp.206.3.252
The psychiatric ward as a therapeutic space Papoulias et al1 have added a great deal to our understanding of the research exploring the effects of ward design on both patients and staff. They highlight the breadth of study designs but also the varying quality of both patient and environmental measures. A further inherent limitation in many of the studies seems to be the difficulty in controlling for confounding factors such as staffing and patient characteristics. Given these observations, it was unfortunate that our recent study2 was not, at the time, ready for inclusion in this systematic review, as it adds to the body of work identified and also addresses some of the criticisms. Our work aimed to assess the impact of a changed ward environment on the levels of in-patient agitation and conflict on an NHS psychiatric intensive care unit (PICU). Taking advantage of a PICU moving from an old, temporary building to a new, purpose-built ward, we were able to analyse routinely collected patient data that were markers of agitation and conflict, including number of seclusion episodes, duration of close observation, number of aggressive incidents and data from the Nursing Observed Illness Intensity Scale.3 We also had an evidence-based, objective, before-and-after measure of the ward environment: the Environment Assessment Inventory (EAI).4 This methodology, reviewing data before and after a ward change, enabled us to control for many of the important confounding factors that were highlighted by Papoulias et al,1 as patient profiles, ward staffing and policies remained largely unchanged. The results showed that the key measures of agitation and conflict were reduced on the new ward, and the EAI enabled us to identify quantifiable improvements and highlight critical design elements that had been improved upon. Like many of the studies in the systematic review, ours suggested that the physical environment of the psychiatric ward had a significant effect on patient behaviours. Some of the critical changes included better visibility, increased space for therapeutic activities and more privacy in the form of single rooms. Papoulias et al1 highlighted the common idea that improved privacy was a key environmental factor in reducing violence on psychiatric wards, and we too would make this interpretation. In the context of recent work by Ulrich et al,5 we concluded that it might be because patient privacy fosters a sense of control that reduces stress levels and in turn agitation and conflict, which are closely linked to violence. We hope that our findings can be set alongside the work to date and provide further evidence for optimising patient care by using evidence-based and objective standards to improve the environment of psychiatric wards.
252
1
Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry 2014; 205: 171–6.
2
Jenkins O, Dye S, Foy C. A study of agitation, conflict and containment in association with change in ward physical environment. J Psychiatr Intensive Care 2014; doi:10.1017/S1742646414000065.
The systematic review by Papoulias et al1 on the psychiatric ward as a therapeutic space reminds us of the important effects of environmental factors on in-patients. The physical environment is likely, however, to be particularly significant in settings where length of stay is long, whether in or out of hospital. The 1995 book by Halpern2 describes the mental health effects of the built environment on residents of a housing estate, and the concerns of Papoulias et al should be explored in residential mental health facilities in the community. For psychiatric in-patients, patient characteristics (including diagnosis) and psychosocial environmental factors are powerful determinants of what happens in the hospital, including behaviour disturbances, service user opinions and also, sometimes, illness outcomes.3,4 Clark5 was one of those who showed that different wards for different varieties of patient should have different sorts of environment, drawing on the extensive previous research in this field (e.g. Stanton & Schwartz6). A major problem with today’s in-patient wards is that everyone has to be admitted to, and as like as not, stay in, the same environment, whether or not it suits them and their illness. This might remind clinicians with long memories of the features of the old observations wards, to which anyone putatively mentally ill could be admitted, primarily for triage and transfer to the setting which suited them best. Today there is, in these terms, only the triage. 1
Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. The psychiatric ward as a therapeutic space: systematic review. Br J Psychiatry 2014; 205: 171–6
2
Halpern D. Mental Health and the Built Environment: More than Bricks and Mortar? Taylor & Francis, 1995.
3
Bouras N, Trauer T, Watson JP. Ward environment and disturbed behaviour. Psychol Med 1982; 12: 309–19.
4
Watson JP, Bouras N. Psychiatric ward environments and their effects on patients. In Recent Advances in Clinical Psychiatry – 6 (ed. K Granville-Grossman). Churchill Livingston, 1988: 135–60.
5
Clark D. Administrative Therapy. Tavistock, 1964.
6
Stanton AH, Schwartz MS. The Mental Hospital. Basic Books, 1954.
Nick Bouras, Emeritus Professor, King’s College London, Institute of Psychiatry, Psychology and Neurosciences; Jim Watson, Emeritus Professor, Guy’s and St Thomas’ Hospitals. Email: [email protected] doi: 10.1192/bjp.206.3.252a
Author’s reply: We are pleased to have received such commendations of our review on psychiatric ward design.1 We believe, as the other commentators do, that this is a long-neglected area that needs more research to inform future investment – including the UK government’s recently promised increase in in-patient wards for younger people. The physical environment of healthcare facilities does affect the patient experience and their satisfaction and is recognised as
Correspondence
an integral part of care delivery.2 The study mentioned in Dr Jenkins’ letter strengthens the evidence base for the contribution of ward privacy to violence reduction.3 As that letter also indicates, measures have largely remained focused on clinical outcomes and any research can only hint at the key design components that drive these changes. Our review emphasised the need for patient-focused outcomes and their involvement in ward design. We have developed some novel methodology that can highlight positive and negative issues in current design from the patient perspective and have also developed measures to monitor the effects of changes in ward design. We hope that tools enabling robust, patient-centred evaluation of in-patient facilities might contribute to the recognition of the complex contribution of the material environment – in its physical and psychosocial dimensions – to patient outcomes. 1
Papoulias C, Csipke E, Rose D, McKellar S, Wykes T. Design in mind: the psychiatric ward as therapeutic space: a systematic review. Br J Psychiatry 2014; 205: 171–6.
2
Department of Health. Health Building Note 03-01: Adult Acute Mental Health Units. The Stationery Office, 2013.
3
Jenkins O, Dye S, Foy C. A study of agitation, conflict and containment in association with change in ward physical environment. J Psychiatr Intensive Care 2014; 1: 1–9.
Emese Csipke, Institute of Psychiatry, King’s College London. Email: [email protected] doi: 10.1192/bjp.206.3.252b
Discharges to prison from medium secure psychiatric units The percentage of patients being discharged to prison from medium secure units has nearly doubled to 20% in just over a decade. The research captures a significant change in the practice of forensic psychiatry in England and Wales. When this area was discussed within the London region several years ago, colleagues who said that they were not doing this looked into the matter and found that they were. Doyle et al1 do not report any variation in practice, which suggests there has been a uniform change (across the relevant services). In considering why this has happened, the authors present a rather negative picture of sending back still-symptomatic, higher-risk people to prison, with inadequate aftercare. An alternative view is that this represents a new realism in forensic psychiatry. Medium secure provision has greatly expanded in the last 25 years but, as shown by the paper, the system is risk averse to community discharges. Such patients have low symptoms and stay longer in hospital. It is unlikely that more money will be allocated to forensic services and we have to make the best use of the resources we have. In East London, appropriately transferring patients back to prison, alongside an improved rate of community discharge and the consistency of an admissions panel, has helped to manage demand. The service has gone from a waiting list of 25 patients to having beds quickly available for people presenting as acutely psychotic in prison. This is despite only sending people to the independent sector in exceptional cases and having no expansion in relevant beds over the time period. The research is consistent with a change in the model that forensic psychiatrists have about prisoners. In the past, sending people with a diagnosis of psychotic mental illness back to prison was generally seen as inappropriate. Forensic psychiatry saw itself as having redeeming and containing roles, through identifying the
mentally ill in prison, transferring them to medium security, providing treatment, and then either discharging to the community or providing longer-term secure care if the person’s risk and/or illness could not be satisfactory managed. The model now seems to regard prison as a form of ‘community’, to which some prisoners will be returned after being treated in hospital. It is logical that the relevant groups should be those for whom safe and effective ordinary discharge is unlikely. They may have a primary diagnosis of mental illness, but this might not be the primary problem for a significant group (e.g. career criminals and those who committed serious offences unrelated to mental illness). It is acknowledged that some practitioners will not welcome this philosophical and practice shift. The fate of those returning to prison is an issue for both commissioning and service provision. NHS forensic and/or general adult services should follow up all those who are returned to prison. They should remain in the care programme approach (CPA) process, with 6-monthly CPA reviews and a local care coordinator who keeps in regular contact with them. This would assist with monitoring, management of relapses and aftercare. In East London, we have a consultant and community nurse with prison roles that include helping to manage returned prisoners. Although mental health prison in-reach is variable, such arrangements help provide a framework for prison aftercare. In respect of the idea of a prison hospital, as advanced in the paper, this is the approach in South Australia (and elsewhere). Other than for patients found unfit or insane, most patients have the master status of prisoner, whether on remand or sentenced. At the end of their prison sentence, or if their remand ends, they have to be released from the forensic hospital, but can ordinarily be detained in a non-forensic mental health unit. This system has the disadvantage that there are no hospital orders. A combination approach has merit. Hospital orders could be used for those who require a hospital care pathway and the court could still order people to hospital otherwise (e.g. for a trial of treatment). Mentally ill prisoners would receive more prompt treatment in a hospital within the prison estate. Each major metropolitan area or part of England and Wales could have such a prison hospital (regulated as usual by the Care Quality Commission). Prisoners could be informal patients, whereas currently they are being denied the ‘least restrictive’ approach enshrined within the Mental Health Act 1983. This would bring prison psychiatry in line with ordinary adult psychiatry practice. The underused hybrid order could be resuscitated for intermediate cases. It is therefore to be hoped that this paper will promote active consideration of the best way to manage patients presenting in prison. I note that, unfortunately, the seminal study by Coid et al of half the secure units in England and Wales,2 which showed marked variation in the practice of forensic psychiatry, was not presented and discussed at an annual forensic conference. As a specialty we should not miss the opportunity to discuss this highly relevant piece of research. 1
Doyle M, Coid J, Archer-Power L, Dewa L, Hunter-Didrichsen A, Stevenson R, et al. Discharges to prison from medium secure psychiatric units in England and Wales. Br J Psychiatry 2014; 205: 177–82.
2
Coid J, Kahtan N, Gault S, Cook A, Jarman B. Medium secure forensic psychiatry services: comparison of seven English health regions. Br J Psychiatry 2001; 178: 55–61.
Neil Boast, Consultant Forensic Psychiatrist, London. Email: [email protected] doi: 10.1192/bjp.206.3.253
253
Correspondence
Authors’ reply: Dr Boast is quite correct to highlight the probable variation in practice across different services. Similarly, we know there are wide variations in practice across prison mental health services and post-release aftercare.1,2 Although this is not surprising, it is important to note as any future policy in this area will need to ensure that best practice is shared, so that offenders with mental health problems have access to safe and effective care equivalent to that offered in NHS and healthcare settings. Dr Boast suggests that we paint a negative picture of services and current practice, but we do in fact acknowledge that some discharges back to prison are entirely appropriate, especially for those patients without a serious mental illness where long-term treatment is not required. Time spent in medium secure units would generally be positive for those admitted from prison, but in some cases any benefits will be lost once the patient returns to prison. We wanted to emphasise that there is currently very little evidence to suggest that the quality of care in prison is equivalent to that in medium secure services and we know that many prisoners will, for a number of reasons, discontinue their treatment while in prison or after release. Tragedies recently reported in the media involving mentally ill people soon after their release from prison highlight the importance of effective community care and treatment and on-going support and supervision. This is particularly true for those released with psychotic illness.3 In response to this need, we are currently investigating what happens to patients once they return to prison from medium secure units and we hope to have preliminary findings by the summer of 2015. We are aware that the burden of providing care and treatment to released prisoners is frequently placed on already hard-pressed primary care teams and mainstream mental health services, even though more intensive and specialist interventions are often required.
254
We concur with the proposal for new prison hospital services and we commend the model described by Dr Boast, which is currently operating in East London. New service models and the suggestion for wider use of hybrid orders are of real interest and warrant further consideration from a policy, clinical and legal perspective. Although the return to prison of an increasing number of patients from medium security may be inevitable to prevent bed blocking and maintain the throughput of patients in an expensive in-patient service, we currently do not know the full cost or consequences of this policy. This includes risks of further relapse and readmission and possible risk to public safety due to what is, in effect, a bed-management policy. To conclude, we hope our article, Dr Boast’s letter and our response continue to generate discussion in this important area, so that the availability, configuration and quality of services provided to mentally disordered offenders remains high on the commissioning and regulatory agenda. 1
Lennox C, Senior J, King C, Hassan L, Clayton R, Thornicroft G, et al. The management of released prisoners with severe and enduring mental illness. J Forens Psychiatry Psychology 2012; 23: 67–75.
2
Shaw J, Senior J, Thornicroft G, Birmingham L, Kendall K, Brooker C. A National Evaluation of Prison Mental Health In-Reach Services. A Report to the National Institute of Health Research. The Offender Health Research Network, 2009 (http://www.ohrn.nhs.uk/resource/Research/Inreach.pdf).
3
Keers R, Ullrich S, DeStavola B, Coid J. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry 2014; 171: 332–9.
Michael Doyle, Jeremy Coid, Jenny Shaw, Forensic Psychiatry Research Unit, St Bartholomew’s Hospital, London. Email: [email protected] doi: 10.1192/bjp.206.3.254
The psychiatric ward as a therapeutic space
Nick Bouras and Jim Watson BJP 2015, 206:252. Access the most recent version at DOI: 10.1192/bjp.206.3.252a
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 2 articles, 1 of which you can access for free at: http://bjp.rcpsych.org/content/206/3/252.2#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;206/3/252-a http://bjp.rcpsych.org/ on December 6, 2015 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
