Guidance for commissioners of forensic mental health services

Guidance for commissioners of forensic mental health servicesThis guide is about the commissioning of high, medium, and low secure forensic mental health services for working-age adults.

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These services will be commissioned by NHS England, with commissioning decisions being based upon a set of service specifications developed by an appointed Clinical Reference Group. These service specifications were consulted on in January 2013 can be found at

This guide does not aim to repeat these specifications, but instead attempts to achieve three complementary objectives:

  1. to take into account these service specifications
  2. to make recommendations which ‘go beyond’ these service specifications in terms of their aspirations for high-quality, recovery-focused and secure care
  3. to provide an ‘overview introduction’ for new and existing commissioners to allow them to understand and start planning an integrated care pathway for forensic mental health care which includes:
    • high, medium, and low inpatient forensic mental health services
    • community forensic mental health services (as commissioned at a local level by Clinical Commissioning Groups)
    • prison health services and probation services (which are respectively commissioned at a national level by NHS England, and also by the National Offender Management Service)
    • police and court ‘liaison and diversion’ services (as commissioned at a national level by NHS England
    • providers of all levels of forensic mental health services (including the NHS, independent sector, Local Authorities, social care and voluntary sector).

While it is not possible to provide an exhaustive guide to commissioning all parts of this integrated care pathway, this document provides a starting point for different commissioners and providers to design or redesign such an initiative.

Importantly, several members of the Clinical Reference Group appointed by NHS England have also been involved in writing this guide. This has helped ensure that it (a) builds upon the published service specifications (which are intended to cover commissioning decisions in the next 12 months only), and (b) encourages commissioners to start planning the development of high quality forensic services over a longer time period of three to five years.

Ten key messages for commissioners

1. Forensic mental health services are provided for (a) individuals with a mental disorder (including neurodevelopmental disorders) who (b) pose, or have posed, risks to others and (c) where that risk is usually related to their mental disorder. They may be placed in:

  • hospitals (particularly secure hospitals)
  • the community
  • or prison.

Forensic mental health services work collaboratively with:

  • other mental health professionals, General Practitioners (GPs) and social care staff
  • agencies working in the criminal justice system. Forensic services are able to demonstrate effectiveness in reducing serious reoffending in individuals discharged from secure inpatient services.

2. Patients must be at the centre of the care provided by forensic mental health services. There should be a dual emphasis on promoting and enabling individual recovery and independence, while also ensuring the protection of the public. Critically, these are not mutually exclusive aims or outcomes, because high quality care will result in improved protection of the public.

3. Forensic mental health services are ‘low volume and high cost’ services (i.e. they work with a smaller number of individuals with typically more complex needs and consequently higher related care costs). It is essential therefore that they are commissioned in a way which ensures that:

  • patients should make progress through the care pathway according to their risk to others and the stability of their mental health
  • forensic services are flexible enough to meet the complex needs of all individuals within the service, regardless of whether this is a secure hospital, in the community, or a prison
  • administrative barriers which could block an individual’s progress along the care pathway, and also any interfaces between one commissioning body and another, are kept to an absolute minimum
  • mental health care in prisons is equivalent to the care provided to individuals in the community.

4. Commissioners should ensure that security measures promote a safe environment which enables therapeutic work to be undertaken to meet an individual’s needs. Commissioners should be aware that safe care is provided through a combination of physical, relational and procedural elements. It is well recognised that an over reliance on physical security can have a negative impact on the therapeutic environment of secure hospitals.

5. Commissioners should commission integrated pathways of care rather than individual packages of care – doing otherwise will create administrative delays at each interface. A significant challenge to the development of the integrated forensic mental health pathway is the:

  • number of service interfaces (which often cross different health, social care and criminal justice agency boundaries)
  • different commissioning streams operating within the health and social care sectors
  • need for a range of government departments to work collaboratively (this includes the Department of Health and the Ministry of Justice, which commissions the National Offender Management Services – NOMS).

6. The future commissioning of an integrated forensic mental health care pathway will be the responsibility of several different departments of NHS England and Clinical Commissioning Groups (CCGs). It is therefore essential that the various commissioning streams are coordinated to ensure that there are no gaps or administrative delays because of the different commissioning streams responsible for the components of an integrated pathway.

7. It is essential to include the commissioning of effective mental health services in prisons, with this being based on the ‘equivalence of care’ principle. This will require an equal provision of care between those health services provided in prison, compared to those available in community settings. In addition, commissioners also should take into account the specific needs of:

  • women
  • individuals with a learning disability
  • young people
  • individuals with comorbid substance misuse problems
  • individuals with personality disorders.

The mental health of individuals in prison would be improved significantly with the implementation of the Offender Mental Healthcare Pathway, published by the Department of Health in 20052.

8. Commissioners should ensure that all forensic services are part of the Quality Network for Forensic Mental Health Services (QNFMHS). The QNFMHS have been successful in improving standards in medium secure services ( qnfmhs) largely due to the support given by commissioners to this initiative. It is essential that the same level of support is given to the extension of the QNFMHS to low secure services, and also the new QNFMHS networks for community forensic services and prison in-reach mental health services.

9. Commissioners should ensure that the forensic mental health care pathway takes account of the recommendations of the 2009 Bradley report. The Bradley report addressed the need to divert more offenders with severe mental health problems away from prison and into more appropriate facilities. It included recommendations relevant to the design of the offender pathway including:

  • early intervention, arrest and prosecution
  • the court process
  • prison, community sentences and resettlement
  • delivering change through partnership.

The most significant recommendation was the development of Criminal Justice Mental Health Teams. Commissioners need to ensure that services operate in an integrated way with these teams. In its response, the Government committed to the full implementation of the Bradley report recommendations by 2014.

10. The time of highest risk for individuals is during the transition between different parts of the pathway – it is essential this transition is managed safely and effectively. This is particularly the case for the transition from the security and support in the institutional setting to increased independence and responsibility in the community. It is essential that this transition is managed safely and effectively by clinicians who are familiar with the individual and with whom the individual has already developed and built a positive and trusting therapeutic relationship.