A Review of Gatekeeping in Medium Secure Services Dr Paul Gilluley Chair of the Advisory Group
Introduction Background What is the gatekeeping process? What has been done so far? Outcomes so far Possible structures for the future
Background 64 medium secure services in England (60% provided by the NHS) Total of around 3,000 beds Average cost of medium secure bed 172,000 Total annual cost 0.5 billion Low volume high cost service 1% efficiency saving would be 5 million
Quality, Innovation, Productivity and Prevention National QIPP Programme for Medium Secure Services Assessment Gatekeeping Admission Secure care pathways Payment by results Discharge Patient experience
Establish current gatekeeping process that is presently in place Assessment models used How is level of security required assessed? Identify blocks and inefficiencies that exist Identify areas of good practice What is patient experience of the system? Gatekeeping
Method Questionnaire Sent to all units December 2010 Reminders in January and February 2011 Meetings with stakeholder Meetings with service user experts
Stakeholders Ministry of Justice High Secure hospital clinical directors Centre for Mental Health SCG forensic commissioners Services users experts
Service users Entry from high secure, prison and the community. Male and female. Generally complimentary regarding the treatment they received in hospital Praised staff and how they approached and respected them
High Secure transfer Doctors from the medium secure service came to see me every year. They kept saying I was not ready for transfer. They never told me what I had to do so that I would be ready for transfer.
When I got to hospital no one explained why I was there. When I asked how long I would be there they said forever. I was told there was no limit on how long I would be there. I asked the guy in the room next door who had been there five years what they expected you to do. No one explained anything to me Prison transfer
Prison transfer (2) Whilst in prison lots of doctors came to visit me but did not explain why. Was taken one day to Court and instead of going back to prison I went to hospital
Community transfer I was given no information about the unit and suddenly I was transferred there. My family were not told. I was put in with lots of women who had been transferred from prison. Although I had been in prison before I was surprised as I had done nothing wrong.
Questionnaire Over 40 responses Good geographical spread Both NHS and independent sector A few low secure but majority medium secure services
Referral, Assessment, Admission Some very detailed policies In some areas joint agreement between providers and commissioners with clearly defined timescales NHS provide gatekeeping (problems with independence) No consistent referral process Usual MDT assessment
Assessments tools Overall appeared to be dependent on clinical judgement Some use of actuarial tools although these tend to be used post admission Dundrum quartet Scales 1 & 2 are carried out at time of assessment Structured clinical judgement
Insufficient information at time of referral Lack of appropriate beds Poor communication with other agencies Delays in MoJ response Lack of community support Competence of staff assessing Funding problems Multiple referral to providers Current blocks
What works well? Single point of access to services Standarised referral form Commissioner involvement in process MDT involvement Clear care pathways Forensic Community teams available Quick response time to referral
Design the process Electronic database Centralised gatekeeping process Standardised assessment criteria Emergency bed availability Managed clinical network from time of arrest till return to general services Timely MoJ response
Possible future Stay the same Improve what is already there Separate commissioning of gatekeeping