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      A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

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          Abstract

          Background

          Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay.

          Objectives

          To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay.

          Design

          A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4).

          Setting

          All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England.

          Participants

          Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4).

          Results

          Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain. Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group.

          Limitations

          We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients.

          Conclusions

          The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain.

          Future work

          To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients.

          Study registration

          The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376.

          Funding

          The NIHR Health Services and Delivery Research programme.

          Related collections

          Most cited references92

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          Telling Stories: Narrative Approaches in Qualitative Research

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            The labelling theory of mental illness.

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              Is Open Access

              Patient outcomes following discharge from secure psychiatric hospitals: systematic review and meta-analysis

              Background Secure hospitals are a high-cost, low-volume service consuming around a fifth of the overall mental health budget in England and Wales. Aims A systematic review and meta-analysis of adverse outcomes after discharge along with a comparison with rates in other clinical and forensic groups in order to inform public health and policy. Method We searched for primary studies that followed patients discharged from a secure hospital, and reported mortality, readmissions or reconvictions. We determined crude rates for all adverse outcomes. Results In total, 35 studies from 10 countries were included, involving 12 056 patients out of which 53% were violent offenders. The crude death rate for all-cause mortality was 1538 per 100 000 person-years (95% CI 1175–1901). For suicide, the crude death rate was 325 per 100 000 person-years (95% CI 235–415). The readmission rate was 7208 per 100 000 person-years (95% CI 5916–8500). Crude reoffending rates were 4484 per 100 000 person-years (95% CI 3679–5287), with lower rates in more recent studies. Conclusions There is some evidence that patients discharged from forensic psychiatric services have lower offending outcomes than many comparative groups. Services could consider improving interventions aimed at reducing premature mortality, particularly suicide, in discharged patients.
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                Author and article information

                Journal
                Health Services and Delivery Research
                Health Serv Deliv Res
                National Institute for Health Research
                2050-4349
                2050-4357
                February 2017
                February 2017
                : 5
                : 11
                : 1-234
                Affiliations
                [1 ]Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
                [2 ]Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
                [3 ]Department of Mental Health, Social Work and Interprofessional Learning, Middlesex University, London, UK
                [4 ]Partnerships in Care, Nottingham, UK
                [5 ]Manchester Business School, University of Manchester, Manchester, UK
                Article
                10.3310/hsdr05110
                26c034b8-1a75-474b-beb2-d70dbe14e693
                © 2017

                Free to read

                http://www.nationalarchives.gov.uk/doc/non-commercial-government-licence/non-commercial-government-licence.htm

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