A Review of Gatekeeping in Medium

Secure Services

Dr Paul GilluleyChair 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 bedsAverage cost of medium secure bed £172,000Total annual cost £0.5 billionLow volume high cost service1% efficiency saving would be £5 million

Quality, Innovation, Productivity and Prevention

National QIPP Programme for Medium Secure Services

AssessmentGatekeepingAdmissionSecure care pathwaysPayment by resultsDischargePatient experience

Gatekeeping

• 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?

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”.

Prison 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 (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

Current blocks

• 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

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