The impact of the Health and Social Care Act 2012 on forensic psychiatry

As a National Health Service forensic psychiatrist working on a newly commissioned low secure ward, the statement: ‘it is all too predictable that yet more patients will be pushed down forensic care pathways from which return to mainstream care will be difficult (p. 402)’ in Holloway's excellent November editorial ¹ struck a firm chord with me.

In the past year, I have overseen an expansion of both the low secure forensic estate and the out of area patient placements. Although there was some clinical and commissioning intent to introduce the low secure estate to allow transition out of the medium secure estate (and indeed this has happened to some extent), there has been quite a surge of patients coming from the general acute services and the community.

We also receive some prison transfers; these include general adult community patients with no prior forensic history who were missed in the community owing to (poorly resourced) service lapses. Such patients become ‘forensic’ because of a lack of adequate community psychiatric services rather than being appropriate referrals to the service. In any case, we are expanding.

Good news for forensic staff, but not so good for patient care. Earlier psychiatric intervention for them may have even saved them from being locked up in prison. This is low-income country psychiatry in a high-income country.

At a recent presentation by some Californian psychiatrists, I was very impressed by the vigour with which they grapple with often very difficult legal circumstances of psychiatric care in their jurisdiction. They noted that most of their state hospital beds were occupied by their forensic patients. There was very little available for non-forensic patients, either in hospital or in the community. I wonder whether here in England we are also heading in that direction.

Finally, it appears that in this evolving, risk-focused, forensic-heavy psychiatric care environment, the ‘forensic’ patient today is not the same forensic patient from 20 years ago. These days, not every forensic patient is a high secure step-down patient. Why is it then more difficult to discharge forensic patients into the community, and return them to mainstream services? At the very least, the expanding low secure estate ought to provide an easier interface within the psychiatric services than was the case in the past. This way we will have done our best for our patients while contending with the difficult care environment being planned for us by this government. Indeed, who else will?