Exploration of adverse patterns of placement of young people in secure care: The unwanted child?

BACKGROUND: Emerging evidence suggests that distant placements and multiple moves may be detrimental to young people in care settings. Less is known about the characteristics of young people in secure care most affected by these processes. AIMS: This study examined distance from home and number of previous placements in English young people detained in secure care and their relationships with organisational and individual characteristics. METHODS: Data were derived from the (2016) cross-sectional National Adolescent Study census of English young people in secure care, which included 1322 young people across secure mental health, welfare and Youth Justice establishments. Associations were described with odds ratios/95% confidence intervals (OR/CI). RESULTS: Overall, 285 young people (26.4%) were in secure placements over 100 miles from their family/local authority while 54 (5.6%) had 10 or more previous placements. These rates were higher in secure welfare than other settings (73.8%; OR (CI) = 9.62 (5.72, 16.18), 12.7%; OR (CI) = 2.76 (1.29, 5.91) respectively), and there was significant overlap between long-distance placement and multiple placements (n = 22; OR (CI) = 2.26 (1.27, 4.04)). Younger age and presence of neurodevelopmental disorder were also associated with long-distance placements while psychiatric diagnosis, previous secure placement, and previous service contact were linked to multiple placements. CONCLUSIONS: Distant and/or multiple placements in young people in secure care appear common, particularly for those who are placed in secure welfare and who are younger and/or present with a psychiatric disorder. Multi-agency evaluations that capture the longitudinal experience of these vulnerable young people are needed to understand how undesirable patterns of placement in secure care occur and prevent future instances.

Mental health, welfare or justice: An introductory global overview of differences between countries in the scale and approach to secure placements of children and young people.

BACKGROUND: Estimates suggest that over a million children per year are deprived of their liberty across the world. Little is known about the types, ethos or distribution of secure beds in which they are detained. AIM: This study aims to provide quantitative data with background information, to explore similarities and differences across jurisdictions, and to inform critical inquiry into key concepts and practices. METHODS: Data was obtained using an opportunistic sample of affluent countries, derived from an emerging academic/practice network of senior professionals. Depending on jurisdiction, data was already in the public domain or specifically requested. Data requests were related to the nature and size of health, welfare and criminal justice elements of secure beds and recent occupancy. Key professionals working in child secure settings, within jurisdictions, provided commentary on local approaches. RESULTS: Data was incomplete but allowed for comparisons between 10 jurisdictions. The proportions of the populations of children and young people detained varied by jurisdiction as did their distribution across variations of secure settings. Not all jurisdictions had all three kinds of secure settings. Definitions of secure beds varied depending on the use of relational, procedural or physical security. CONCLUSION: Findings are tentative but suggestion solely considering numerical descriptions of children's detention is misleading; our study highlights ways in which comparative studies may be improved. Within reported jurisdictions, the framework of health, welfare and justice was meaningful but this may not hold true with a wider international application of this method. Open interrogation of this data would be enhanced by the inclusion of children's perspectives.

Young men and young women in secure care: gender differences in the placement of those with mental health needs.

BACKGROUND: The system of secure care for young people in England and Wales comprises youth justice, welfare and mental health facilities. Empirical studies have failed to investigate the system as a whole. The National Adolescent Study in 2016 was the first to provide comprehensive system wide information. This paper, derived from that data set, addresses equity of service provision for young men and women in secure care who have mental health problems. METHODS: The detained census population of English young people in 2016 was 1322 and detailed data were available on 93% of this population, including 983 young men and 290 young women. The descriptive census data were interrogated to identify associations between gender, other sociodemographic and clinical variables, using Chi-square and Fisher's exact tests. RESULTS: Numerically more young men in secure care than young women in secure care warrant a psychiatric diagnosis but young women had a 9 fold increase in the odds of having a diagnosis compared with the young men. The pattern of mental health diagnoses differed significantly by gender as did the legislative framework under which females and males were placed. This different pattern of secure care placement continued to differ by gender when the nature of the mental health diagnosis was taken into account. CONCLUSIONS: No definitive explanation is evident for the significantly different placement patterns of young men and young women with the same mental health diagnoses, but the anticipated consequences for some, young men and some young women are important. Proper explanation demands an examination of process variables outwith the remit of this study. The lack of routine scrutiny and transparent processes across secure settings could be responsible for the development of these differential placement practices; these practices seem at odds with the duty placed on public services by the Equality Act.

Challenges and mental health needs of women in prison.

The world population of women and girls in prison is increasing. Evidence points to high rates of mental health problems. Approaches to these problems vary and include both psychiatric epidemiology and gender-sensitive understanding and intervention. Prison environments and women prisoners' needs are complex and demand gender-aware care in view of women's vulnerability and histories of trauma. Declaration of interest A.B. was a clinical director of the offender care services at Central and North West London National Health Service (NHS) Foundation Trust until August 2016, with responsibility for several women's prison healthcare services in London and the South East, and is currently clinical director of NHS England London Health in Justice Clinical Network, paid as a salary one day a week.

Public mental health crisis management and Section 136 of the Mental Health Act.

The interface between mental health services and the criminal justice system presents challenges both for professionals and patients. Both systems are stressed and inherently complex. Section 136 of the Mental Health Act is unusual being both an aspect of the Mental Health Act and a power of arrest. It has a long and controversial history related to concerns about who has been detained and how the section was applied. More recently, Section 136 has had a public profile stemming from the use of police cells as places of safety for young, mentally disturbed individuals. This paper explores the current state of health of this piece of legislation. Specifically, we consider whether alternative approaches are more suitable for those individuals in crisis and/or distress who come into contact with the police. This requires careful thought as to the proper role of both health and criminal justice professionals who are daily grappling with an ethically contentious domain of multiagency work.

Characteristics of women in a prison mental health assessment unit in England and Wales (2008-2010).

BACKGROUND: The high prevalence of mental disorders among women in prison is recognised worldwide. In England and Wales, successive governments and independent reports have argued that the equivalent of community care in prisons is acceptable but that some mental health assessment units (MHAUs), staffed by professional clinicians, should remain. These have not been researched. AIMS: This paper aimed to explore patterns of use of a MHAU in a women's prison in England and to test the hypothesis that it was being used only, as intended--to hold women pending transfer to a health service hospital or in a bona fide crisis. METHODS: Anonymised data on all women transferred to one MHAU between 1 January 2008 and 31 August 2010 were obtained from the prison files and subjected to descriptive analysis. RESULTS: Less than a third of these women were transferred to an outside hospital; this group stayed longest in the unit. An overlapping group of 52% of the women was under a special assessment, care in custody and teamwork protocol because of suicide or serious self-harm risk. Thus, 188 (68%) admissions fulfilled national protocol criteria for MHAU admissions. Two in five women admitted were released or returned to ordinary prison locations. Nevertheless, over 80% of the women were known to external mental health services, and 64 (30%) were so unwell on arrival in prison that they were transferred directly to the MHAU. Over a third of admissions were of women admitted more than once during the 32 months of study, and this was significantly more likely after release from prison directly to the community. CONCLUSIONS: Our hypothesis was not sustained, and it seems unlikely that this prison MHAU is unique in being used outside its strict remit. A shift from studying the epidemiology of mental disorder in prisons to the epidemiology of mental health needs could benefit this vulnerable group and the wider community alike.

Pathways of care of women in secure hospitals: which women go where and why.

BACKGROUND: Care pathways for women needing expensive, secure hospital care are poorly understood. AIMS: To characterise women in low and medium security hospitals in England and Wales and to compare populations by security and service provider type. METHOD: Census data from all specialist commissioning areas. Sociodemographic, clinical, medico-legal, criminological and placement needs data were requested on all women in low and medium secure hospital beds. Parametric tests were used for continuous data and chi-square or Fisher's exact tests for categorical data. Thematic analysis was used for free text data. RESULTS: The independent sector is the main service provider. A third of all women (n = 1149) were placed outside their home region despite spare local National Health Service (NHS) capacity. The independent sector provides for women with relatively rare disorders, including intellectual disability. The NHS admits most serious offenders. One in 20 are detained because of self-harm alone. CONCLUSIONS: Patient-specific factors (notably the diagnosis of personality disorder) and organisational inadequacy (commissioner and service provider) contribute to placements that compromise rehabilitation. Responses should include local solutions for women whose main risk is self-harm and a national approach to women with highly specialist needs.

Women's secure hospital care pathways in practice: a qualitative analysis of clinicians views in England and Wales.

BACKGROUND: In England and Wales women form a small but significant group within the wider, largely male, secure hospital population. Secure hospitals are designed to assess and treat individuals with both mental health problems and significant criminal behaviour. The theoretical approach to the care of secure hospital women is increasingly informed by a grasp of gender-specific issues. However, there is a lack of evidence on the adequacy of current structures and processes of care delivery. METHODS: This qualitative study explores the nature and quality of care pathways for women in low and medium secure hospital beds by eliciting participants' views of factors enhancing or impeding care. Beds are publicly funded and provided either by the National Health Service (NHS) or the Independent Sector (IS). Participants from both sectors were local experts (40 Consultant Psychiatrists, 7 Service Managers) who were well placed to describe their immediate health environment. RESULTS: Evidence from the study indicates that participants were focused on the physical relocation of women to less secure conditions, even though many women do not readily achieve this.Participants were alert to potential conflicts between ideal care and affordable care. Ideal care was compromised by the absence of suitable local services (beds or community placements), curtailed episodes of care and changes of care team. It was promoted by an awareness of the specific needs of women, continuity of care and support for teams unfamiliar with women's needs. CONCLUSION: Future service design must address these challenges in care delivery, incorporating a better understanding of and response to the ways the system can echo women's experiences of trauma and their negative attachment histories. Specifically, critical transitions in care must not be allowed to further reinforce the discontinuity, failure and rejection experienced by individual women earlier in their lives.

Language, foreign nationality and ethnicity in an English prison: implications for the quality of health and social research.

BACKGROUND: More than one in 10 of all prisoners in England and Wales are Foreign Nationals. This article discusses whether the research applications to one London prison are aimed at understanding a prisoner population characterised by significant multinational and multilingual complexity. METHODS: We studied all accessible documents relating to research undertaken at a women's prison between 2005 and 2009 to assess the involvement of Foreign National prisoners and women with limited English. The source of information was prison research applications and protocols. We also looked at available final research reports and journal articles. RESULTS: Two key findings emerged from this study. First, studies at this prison frequently excluded Foreign National prisoners and women with limited English. Second, Foreign National prisoners were often clustered as a homogeneous category in the research reports reviewed. This is despite their diverse cultural backgrounds, their variable immigration status and their differing competence in English, all of which affect their lives. CONCLUSIONS: The failure to include and/or identify social subgroups of the population can undermine the value of research, including, in the case of the study prison, funded health research. This can compromise associated needs assessments and service delivery, particularly important in already disadvantaged populations; this may encourage and/or perpetuate a range of health inequalities. There is a pressing need to examine cultural exclusion in other health and criminal justice settings, to assess the ways in which-and the extent to which-such exclusion may compromise the merit of proposed and completed health and social research.

The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation.

BACKGROUND: we know very little about mental health practitioners' views on treatments to change sexual orientation. Our aim was to survey a representative sample of professional members of the main United Kingdom psychotherapy and psychiatric organisations about their views and practices concerning such treatments. METHODS: We sent postal questions to mental health professionals who were members of British Psychological Society, the British Association for Counselling and Psychotherapy, the United Kingdom Council for Psychotherapy and the Royal College of Psychiatrists. Participants were asked to give their views about treatments to change homosexual desires and describe up to five patients each, whom they has treated in this way. RESULTS: Of 1848 practitioners contacted, 1406 questionnaires were returned and 1328 could be analysed. Although only 55 (4%) of therapists reported that they would attempt to change a client's sexual orientation if one consulted asking for such therapy, 222 (17%) reported having assisted at least one client/patient to reduce or change his or her homosexual or lesbian feelings. 413 patients were described by these 222 therapists: 213 (52%) were seen in private practice and 117 (28%) were not followed up beyond the period of treatment. Counselling was the commonest (66%) treatment offered and there was no sign of a decline in treatments in recent years. 159 (72%) of the 222 therapists who had provided such treatment considered that a service should be available for people who want to change their sexual orientation. Client/patient distress and client/patient autonomy were seen as reasons for intervention; therapists paid attention to religious, cultural and moral values causing internal conflict. CONCLUSION: A significant minority of mental health professionals are attempting to help lesbian, gay and bisexual clients to become heterosexual. Given lack of evidence for the efficacy of such treatments, this is likely to be unwise or even harmful.

What same sex civil partnerships may mean for health.

A growing number of countries have introduced a form of marriage or civil partnership registration for same sex couples. Marriage confers health benefits on heterosexual men and women and similar benefits could arise from same sex civil unions. The authors argue that legal and social recognition of same sex relationships may reduce discrimination, increase the stability of same sex relationships, and lead to better physical and mental health for gay and lesbian people.

Assaults by Mentally Disordered Offenders in Prison: Equity and Equivalence.

Managing the violent behaviour of mentally disordered offenders (MDO) is challenging in all jurisdictions. We describe the ethical framework and practical management of MDOs in England and Wales in the context of the move to equivalence of healthcare between hospital and prison. We consider the similarities and differences between prison and hospital management of the violent and challenging behaviours of MDOs. We argue that both types of institution can learn from each other and that equivalence of care should extend to equivalence of criminal proceedings in court and prisons for MDOs. We argue that any adjudication process in prison for MDOs is enhanced by the relevant involvement of mental health professionals and the articulation of the ethical principles underpinning health and criminal justice practices.

Potential implications of interleukin-7 in chronic wound healing.

Methods of identifying chronic wounds that will heal in a timely, coordinated fashion and those that will not, together with novel therapeutic strategies, are vital for progression in the field of wound healing. Interleukin (IL)-7 has been associated with various biological and pathological processes. The present study explored the potential role of IL-7 in wound healing. IL-7 expression levels were examined in a clinical cohort of chronic wounds using reverse transcription-quantitative polymerase chain reaction and immunohistochemical staining analysis. The impact of recombinant human IL-7 (rhIL-7) on the growth and migrational rates of HaCaT keratinocyte cells was subsequently examined using in vitro growth and electric cell-substrate impedance sensing functional assays. The mRNA expression levels of IL-7 were increased in the healed chronic wound tissue samples, compared with non-healed chronic wound tissue samples, although the difference was not statistically significant. Similarly, immunohistochemical analysis revealed a greater staining intensity of IL-7 in the healed chronic wound tissue sections compared with the non-healed tissue sections. Treatment with rhIL-7 did not affect HaCaT cell growth rates, but was shown to enhance cell migration, an effect that could be further enhanced through the addition of inhibitors of neuronal Wiskott-Aldrich syndrome protein and protein kinase B. The data of the present study suggest that the expression levels of IL-7 may be increased in healing chronic wounds, and thus IL-7 may have a role in this process, potentially through its effects on the cellular migration of keratinocytes.

Perioperative dexamethasone administration in tonsillectomy patients: A three-cycle audit showing improvement using printed theatre lists.

Dexamethasone administration prior to tonsillectomy has been shown to reduce morbidity and is part of SIGN guideline 117. We conducted a three-cycle audit of 149 patients to ascertain how well guidelines were being met and introduce a sustainable method to improve compliance. A 3-month audit was conducted to ascertain how many tonsillectomy patients didn't receive pre-operative dexamethasone. ENT secretaries were requested to add 'Dex Please' to tonsillectomy theatre lists. A 3-month re-audit was conducted; the intervention was only implemented in half of cases and so a reminding tool for the secretarial staff was administered before a third cycle. Initially, there was 73% compliance to SIGN guidelines, this improved to 87% in the second cycle. After the second intervention, all tonsillectomy theatre lists had the 'Dex Please' note and compliance to SIGN guidelines was 100%. There were five readmissions in the first cycle, three in the second and two in the third cycle. All readmissions were underdosed according to guidelines. Understanding there are regular staff rotations throughout many U.K. hospitals, we implemented a reliable method to increase compliance to guidelines which helped reduce post-operative readmission after tonsillectomy. This can be easily introduced to other institutions and for other perioperative requirements.

Intellectual disability screening in women prisoners: preliminary evaluation.

PURPOSE: - The purpose of this paper is to evaluate a new Intellectual Disability (ID) screening service within a women's prison in England. DESIGN/METHODOLOGY/APPROACH: - Analysis of prisoner records was carried out to establish characteristics of women entering the prison, rates of screening completion and time intervals for all stages of the assessment pathway. FINDINGS: - In total 198 women were received into prison and underwent 202 ID screens. Nine out of ten women completed a screen, almost all on arrival or very soon afterwards. There were 23 referrals for secondary assessment but only four were completed. Most of the women identified for additional screening left the prison before this could be achieved. ORIGINALITY/VALUE: - This evaluation is the first to show that preliminary screening for ID is feasible in prison. This screening alone is useful for prisons to make the kind of reasonable adjustment required of public bodies by the Equality Act. However, its value is constrained unless resources are also dedicated to the kind of additional screening which might lead to definitive diagnosis and care planning for intellectual disability. This model of assessment would be of considerable value in establishing prisoners at risk by virtue of different levels of intellectual disability and could be used to provide more reliable and routine estimates of prevalence contributing to overall better service planning.

A 'bittersweet pill to swallow': learning from mental health service users' responses to compulsory community care in England.

Two forms of compulsory mental healthcare and supervision in the community are provided within the Mental Health Act 1983: Supervised Discharge Orders (SDOs) and guardianship. At a time when the Government are proposing to extend powers of supervision over people with severe mental illness in the community, it is appropriate that service users' experiences of existing legislation are examined and reported. Despite a range of literature that presents mental health service users' views and experiences, it remains unclear how service users respond to compulsory community mental healthcare in England. The present paper presents the findings of a qualitative investigation into service users' perceptions and experiences of living with SDOs. In the interviews, service users communicated their understanding of why mental health professionals placed them on the order and how their lives have been affected. Individual service users are capable of seemingly contradictory responses, simultaneously accepting and resisting the orders. This paper presents a typology of the range of responses. These responses are fatalism and resignation, dependency, ownership, bargaining, cooperation, resistance, and rejection. The study provides a model with which we can begin to understand how service users respond to compulsory community care where their options are legally constrained.

Women's secure hospital services: national bed numbers and distribution.

A mapping exercise as part of a pathway study of women in secure psychiatric services in the England and Wales was conducted. It aimed to (i) establish the extent and range of secure service provision for women nationally and (ii) establish the present and future care needs and pathways of care of women mentally disordered offenders (MDO) currently in low, medium and enhanced medium secure care. The study identified 589 medium secure beds, 46 enhanced medium secure beds (WEMSS) and 990 low secure beds for women nationally. Of the 589 medium secure beds, the majority (309, 52%) are in the NHS and under half (280, 48%) are in the independent sector (IS). The distribution of low secure beds is in the opposite direction, the majority (745, 75%) being in the IS and 254 (25%) in the NHS. Medium secure provision for women has grown over the past decade, but comparative data for low secure provision are not available. Most women are now in single sex facilities although a small number of mixed sex units remain. The findings have implications for the future commissioning of secure services for women.