Service innovations: the Orchard Clinic: Scotland's first medium secure unit

The development of forensic psychiatry provision in Scotland lags behind that in other parts of the United Kingdom. Until recently, there were no medium secure units in the country and mentally disordered offenders (MDOs) requiring such care had to be managed in intensive psychiatric care unit (IPCU) settings. In November 2000, The Orchard Clinic, a medium secure unit sited at the Royal Edinburgh Hospital, was opened. This paper discusses the background to this development, the government policies setting out plans for the care, services and support of MDOs in Scotland, progress and work of the new unit to date and plans for developments in other parts of Scotland.

Forensic psychiatry in England and Wales

The sub-speciality of forensic psychiatry has expanded greatly over the past 15 to 20 years. In 1970, there were only two forensic psychiatrists in England, there were no medium secure units and, outside of ordinary psychiatric hospitals, MDOs were either treated in special hospitals or in prison. Two reports (Department of Health and Social Security, 1974; Home Office/Department of Health and Social Secuity, 1975) recommended the development of medium secure units in each health authority region and the latter suggested that 1000 beds would be required in England. A further report (Department of Health/Home Office, 1992) highlighted the need for MDOs to be cared for in a hospital setting rather than within the criminal justice system. This report found that there were 602 beds in medium secure units in England, considerably less than the 1500 beds it recommended.

Services in Scotland

The Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland policy document (Scottish Office, 1999) was the subject of extensive consultations between April and August 1998 and set out the policy for the best care, services and support for MDOs in Scotland. It stated that health boards and local authorities should enter service-level agreements with the criminal justice agencies to provide effective local arrangements for the assessment and treatment of people who appear to be mentally disordered.

The policy acknowledged the increasing tension between the needs of MDOs and those requiring acute/intensive care. As the State Hospital at Carstairs, Lanark, is the only designated secure provision in Scotland, individuals who do not require this level of security are at times treated there because of the lack of alternatives. Patients may be kept at the State Hospital for longer than their clinical condition would dictate because local services are unable to accept them back. In April 1999, there were 21 patients who had been waiting between 3 and 12 months for transfer and three who had waited for over a year (Mental Welfare Commission, 1999).

The Framework for Mental Health Services in Scotland (Scottish Office, 1997) stated that health boards should organise a range of short- and long-term forensic in-patient facilities and a range of community options. This would not only provide placements for returning State Hospital patients, but also services to local prisons, courts and general psychiatry units. The units should be located throughout Scotland, employ an appropriate range of clinical staff and be commissioned for multiples of around 12 patients. The Scottish Office was of the opinion that four or five such units would be required in Scotland.

A review of the implementation of the policy (Scottish Development Centre for Mental Health, 2001) was carried out nationally between January and September 2000. Services were found to be sub-optimal compared with government policy. Many areas did not have an agreed definition of the specific needs of this client group and few areas had established formal service-level agreements for the provision of services for MDOs. There was great variation in access arrangements to health and social work for the police service and courts and there were limited alternatives to remand in hospital or prison. Services for some individuals, such as those with borderline learning disability, Asperger syndrome and acquired brain injury, were particularly poor.

The Scottish Executive (2001) response to the review document aimed to help all agencies determine their roles in the care of this group of individuals and identify gaps in provision. To help facilitate this, all health boards are now required to submit a local progress report each September.

Recent developments in Edinburgh

Scotland's first medium secure unit, The Orchard Clinic, situated in the grounds of the Royal Edinburgh Hospital, was officially opened in November 2000. After completion of a full option appraisal, this 50-bed unit was chosen as the preferred option. The initial proposal for the unit was made in early 1987 by the lead forensic clinician. Its development has been a major component of the health board's longer-term plans for the expansion of services for offenders. Before pursuing the project, the trust consulted widely within the locality, including the neighbouring private school, and a number of public meetings were held to try to reduce anxieties.

The unit was sized at 50 beds with one 25-bed acute assessment ward and two rehabilitation wards. It serves a population of 1.5 million in Lothian, Fife, Forth Valley and the Borders. The number of beds was based on comparisons with England and Wales and took into account the inappropriate use of the State Hospital. Initially, the unit was due to come into operation in early 2000 with a phased build-up to full occupancy over a one-year period.

The unit was designed carefully in order to provide a safe, secure and attractive environment for patients and staff, with adequate rehabilitation facilities. It incorporates numerous security details, including reversible door hinges to prevent patients barricading themselves inside a room. An internal garden and courtyard areas allow patients access to fresh air without compromising security. There are CCTV cameras and a pinpoint security alarm system. There is no perimeter security fence, although there are sensor alarms in the ground surrounding the unit. One feature particular to this unit are the windows that have been designed with ‘window trays’ to prevent items being passed in or out. The unit is well-provided with occupational therapy rooms, exercise facilities, a therapeutic kitchen and an art room. This is also the first unit in the hospital to operate a system of computerised case notes.

Each patient belongs to one of three clinical teams, each with a full complement of medical staff, occupational therapists (and assistants) and social workers. There is psychology, pharmacy, physiotherapy and dietician input to each team. At present, there are two fulltime psychologists with a third being recruited. It is hoped to secure another two or three sessions of dietician time but other than that, input from paramedical staff is felt to be adequate. In August 2001, there were 25 in-patients. Of these, one was an out-of-area referral, with another in the process of transfer to the unit. Currently (April 2002), the unit is running almost at capacity with only one or two free beds per ward at any time.

Unfortunately, the provision of community forensic services remains underdeveloped. There is a shortage of streamlined, well-resourced community provision which, in turn, is likely to lead to delayed discharges. There is only one community psychiatric nurse for the unit.

There have been some initial operational difficulties with the unit. It finally came into operation 4 months later than planned because of a number of practical and technical problems. This led to a backlog of referrals and there have also been financial implications as staff had already been recruited.

Building costs were initially estimated at approximately £4.1 million, with a final cost on completion of £5.1 million. The annual running costs, which mainly comprise staff salaries, approximate the building costs.

Proposed developments in other parts of Scotland

The development of medium secure facilities in Glasgow has been less straightforward. In January 2000, after 5 months of debate and discussion, Greater Glasgow Health Board reaffirmed its earlier decision that the proposed secure unit should be sited at Stobhill Hospital. Despite the fact that the creation of this unit would actually increase public safety by ensuring that those with mental disorders who have offended will receive treatment in a more appropriate setting with specialist care, the public have been opposed to the plans and a petition of 10 000 signatures has been presented to the Scottish Parliament's Public Petitions Committee. Concerns have focused mostly on issues of public safety, as the site is in the middle of a housing scheme and adjacent to a park and three primary schools. There have also been concerns that this development may compromise the future of the general hospital. There were criticisms that the public had not been consulted adequately. There is no doubt that the process has been made more difficult by the stigma toward those suffering from a mental illness. This is partly due to ignorance that breeds fear. The Royal College of Psychiatrists is very aware of this, and has already undertaken a campaign to help address the issue.

In 2001, a second consultation exercise was ordered and at the end of January 2002, plans to build the secure unit were given the first seal of approval. The unit will cost approximately £12.5 million. Campaigners have, however, sent a second petition to the Scottish Parliament asking it to intervene.

The experiences of the development of medium secure facilities in Edinburgh and Glasgow have therefore been quite different. It is possible that this is at least partly because the Royal Edinburgh Hospital is long established and has had an intensive care/forensic unit for a considerable period.

There are a number of reasons why development of these facilities in Scotland has been so slow. These include generous provision of maximum-security beds at The State Hospital with a lower threshold for admission compared with England. Currently, health boards do not have to pay for their patients who are detained in the State Hospital, which may be a disincentive for the further development of medium secure units. The rate of closure of the old psychiatric hospitals has been slower than in England and, therefore, potentially more beds have been available for long-stay forensic type patients. There was little push for change from the, then, Scottish Office, coupled perhaps with a feeling of anxiety among the Scottish psychiatric establishment regarding the development of medium secure units.

It is vital that this development of forensic services continues, as currently available facilities are inadequate and fall well behind those in England. The lack of medium secure in-patient facilities has resulted in MDOs remaining inappropriately in prison and the State Hospital. This cannot be justified from a human rights point of view. The development of these units on their own is not enough and it must be complemented by an increase in community provision, including accommodation and support services.