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This article describes a process undertaken to develop a set of commissioning principles to support the commissioning of secure learning disability services across England. The principles, shaped around the 11 competencies laid down in the World Class Commissioning competencies framework (Department of Health, 2008a), were produced following a scoping exercise that looked at provision and commissioning of secure learning disability services within each strategic health authority (SHA) area in England. Specific details were collected about types of services provided, including detailed service specification, quality indicators, how these (specialist) services link with local services (secure and non secure) and cost of services. Information collected about commissioning concentrated on strategic vision, practical commissioning arrangements, how the quality of services was monitored, how access to services was controlled and how ‘secure’ service users are reintegrated back into local (non secure) services and communities. This scoping exercise was augmented by qualitative data obtained from interview with a group of former service users. Themes generated through the interviews were integrated within the general guidance. A quality assurance framework based on the World Class Commissioning Competencies is proposed, against which specialist and local commissioners can benchmark their current commissioning arrangements.

There is growing awareness in New Zealand (NZ) of the impact that Autistic Spectrum Disorder (ASD) has on individuals and their families and the ability to engage in health services. Although it is a relatively rare condition, approximately 1 per cent of the population will have ASD, directly affecting approximately 40,000 individuals in NZ. The purpose of this paper is to provide some reflections and questions on what we can learn from a NZ perspective. This is based on an overview of the limited literature around ASD and offending and the author’s experience in the UK working in a medium secure unit.

Through a past site visit as part of the annual international conference on the Care and Treatment of Offenders with an Intellectual and/or Developmental Disability in the United Kingdom (UK), the author became aware of the medium secure forensic unit for male patients with ASD at the Roseberry Park Hospital (UK’s Tees, Esk and Wear Valleys NHS Foundation Trust). During the author’s advanced training in forensic psychiatry with the Royal Australian and New Zealand College of Psychiatrists the author was privileged to be able to apply and be accepted for a four-month sabbatical training position at this hospital.

Outlined is background information about ASD and review findings from the limited literature on ASD and offending. Also outlined is the author’s learning as a trainee working in medium secure unit for people with ASD who have offended, and finally how this experience may help in the development of services in NZ, given that at this stage such services are under-developed.

To be able to share the valuable experience and learning opportunity the author was able to have, as well as raise the awareness of ASD generally, and specifically the need for specialist services for the small number of people with ASD who come into contact with Justice Services.

The purpose of this paper is to develop an understanding of the experience of secure care from the patients’ perspective.

A systematic review of qualitative literature was conducted. The data was sourced from the electronic databases: PsychINFO, CINAHL, Medline and the Web of Science Core Collection using pre-defined search terms. A total of 17 studies, conducted in various countries worldwide and covering high, medium and low secure inpatient settings, were included for review. The analysis involved integrating findings from across the literature and was guided by thematic synthesis.

A total of eight themes were generated from the data, three of which provided an understanding of the experience of forensic secure care, and the remaining five themes provided an understanding of the factors which may influence the experience of secure care.

Developing understanding of patient experience can lead to service improvements, potentially impacting patients’ motivation and engagement and thus reducing admission times, potential recalls and recidivism.

To the best of the authors’ knowledge, this is the first systematic review to date to exclusively explore the broad topic of the patient experience of secure mental health care.

Low security is a poorly understood concept, particularly in relation to people with an intellectual disability. Characteristics of patients offered an admission to low secure intellectual disability settings have not been robustly demonstrated. The same applies to staff perceptions of low security. The aims of the study were to ascertain the characteristics of patients referred to a low secure intellectual disability unit which lead to an offer of admission, identify the views of staff working on the unit on the concept of low security, and use both sets of data to discuss low secure provision for people with intellectual disability. A case‐controlled study was carried out for 33 patients referred to the unit over 42 months. The characteristics of 18 patients offered an admission were compared with those of 15 patients not offered an admission, and five of the staff working on the unit were interviewed about the concept of low security. Patients offered an admission were more able than those not offered an admission, posed more risks and were more complex diagnostically. Staff working on the unit agreed that their patients were complex, but felt that they were appropriately placed overall. The challenges of low secure provision were discussed by staff. Patients sampled were complex and heterogeneous, but not necessarily ‘forensic’. Their complexity requires sophisticated care plans and management strategies. This study has implications for referrers, staff, patients and managers, and highlights areas for future research.

The first NHS forensic low secure unit for adolescents, the Westwood centre, opened in 2004. This paper seeks to focus on service utilisation and initial outcomes for the young people admitted in the first 45 months compared with young people accessing a neighbouring open adolescent unit.

In order to understand service utilisation and initial outcomes, the clinical profiles of young people admitted in the first 45 months were evaluated. This included demographics, locality, admission status, length of stay, medication use, presenting problem, diagnosis, previous and discharge destination. The profiles of young people accessing the low secure unit were then compared with young people accessing a neighbouring open adolescent unit. Clinical profiles were ascertained from available healthcare records and service data. These were inspected and analysed using descriptive statistics.

Thirty (54 per cent) of the 56 Westwood young people were male, the mean age at admission was 16.3 years and mean length of stay was 202 days. Twenty‐five (44 per cent) young people had a discharge diagnosis related to psychosis, the remainder having primary problems relating to emotional and/or conduct problems. 26 (47 per cent) were discharged to another hospital setting and 20 (35 per cent) returned to their home of origin. Young people accessing the low secure unit were significantly older at admission and there was a trend for a higher proportion of females to be admitted to the open setting. In addition, the low secure unit had a greater proportion of young people with psychotic disorders and longer lengths of stay. Case examples illustrate a pilot of initial outcomes.

There were time differences in comparison of low secure and open unit and retrospective use of health care records.

Clinical profiling is useful as a basis to consider clinical outcomes, pathways, utilization of a service, service/training needs and development. Comparisons between inpatient units provide further evidence to the areas above and help dispel myths that may otherwise guide decisions, e.g. about which diagnoses or gender affecting length of stay. Most young people progress positively from the low secure service onto open or community settings. Improving future outcomes for young people include such as through diversion from custody, length of admission, reduced symptoms/risks and planned progress to suitable community placements or home.

The paper provides a clinical profile of young people accessing a low secure setting in comparison to an open unit. This has relevance to other secure and inpatient adolescent units and is important in considering pathways and outcomes.

The topic of offender rehabilitation has been subject to much research over the past decade. Numerous meta‐analytic reviews of offender treatment, particularly group treatment based on cognitive behavioural principles, have been reported. Together with the ‘triad of principles’ — risk, need and responsivity — they have formed the foundation upon which most offending behaviour interventions have developed. However, outcome data from existing programmes provides mixed evidence, and evidence for interventions for those in forensic mental health settings are still in their infancy. This paper critically considers the current evidence for the treatment of offending behaviour, and its application in forensic mental health settings, in order to inform development of such treatments in low secure mental health care. Most of the research focuses on non‐mental health settings, and is largely what will be considered here. The paper concludes that low secure interventions need to capitalise on the evidence of ‘what works’ while revisiting key concepts such as ‘dose’ and responsivity in order to design appropriate treatments. Individual outcome evaluation needs to form part of development in this area.

Standard one of the national service framework for mental health (DH, 1999) requires health and social services to promote social inclusion for all. Users of secure services are, arguably, the most excluded of all those in the care of mental health services and thus the most in need of active social inclusion. Yet they are the least able to participate in the community‐based programmes that would help them re‐engage with ordinary living following discharge. In this article Rachel Wakefield and colleagues describe the obstacles they had to overcome to introduce a socially inclusive resettlement programme for service users in the low secure unit where they work.

The purpose of this paper is to present the arguments for sustaining a clinical database, assess its feasibility in a low-secure service, examine the data that can be captured and discuss what this means for practice implications and service development. The paper aims to demonstrate how a clinical database can provide information on three key areas: what patients are like before admission, what is done with them whilst they are in hospital and what happens to them when they are discharged. The paper also aims to examine the practical, legal and ethical implications of building such a database.

This is conducted in the form of a feasibility study charting the development and implementation of an inpatient clinical database for a low-secure inpatient service.

The feasibility of creating and maintaining a clinical database in a low-secure service has been assessed and the paper has found that they are an invaluable source of data that all mental health services should strive to develop. They will enable services to track their own outcome measures and tailor their service and interventions according to the needs of service users. However, ethical and legal issues surrounding building clinical databases are complex and require careful consideration.

This is a small-scale study that captured the experience of one service. Ideally this research should be expanded with nationwide clinical database development.

This paper includes implications for the implementation of a clinical database, the resources needed for the running of this and the development of standardised outcome measures for mental health services.

This is potentially an innovative way of developing a clinical database for a low-secure unit and some of the first research into the feasibility of a database for this population. Its practical application is relatively new and potentially innovative in how it is applied.

The restrictive nature of low secure mental health settings and the issues associated with risk management and safe practice raise numerous challenges which need to be overcome for individuals to engage in community-based programmes. The paper aims to discuss these issues.

Two community-based schemes are described. The first uses the natural environment as a medium in which to deliver opportunities to develop vocational skills. The second provides exercise-based activity to promote healthier living. This paper aims to explore the acceptability, feasibility and sustainability of the projects along with the views and achievements of participants.

Both schemes were well-attended with positive views from participants and others. Planned positive risk taking enabled individuals to participate in a safe and structured way. Initial evaluation of the projects suggest that they were viewed as acceptable by the service and valued by participants. Participation led to some individuals engaging in new opportunities for vocational and leisure activities.

Fostering access to community-based occupational opportunities for those in low secure mental health services can be achieved safely and with numerous apparent benefits. Research is now needed to determine further the nature and extent of the gains made through such activity.

This is the first known study of its kind utilising inter-agency collaboration to address the needs of those residing in a low secure mental health facility. Within the forensic mental health population, the standards of care recommend a comprehensive, recovery-focused approach aimed at building resilience and preventing relapse, with the need for thorough intervention for physical health needs. This study supports these recommendations by providing opportunities for planned positive risk taking, opportunities for social inclusion, skills development, increased access to physical exercise to address overall wellbeing.

There are few reliable psychometric measures of the psychopathology of offenders with intellectual disabilities (ID). However, previous research has indicated that the emotional problems scale (EPS) is useful in identifying a range of treatment needs and in predicting risk to self and others. The purpose of this paper is to compare the severity of the emotional and behavioural problems of a small sample of offenders with ID in medium and low secure services, as assessed by EPS. Additionally, the data are tentatively compared with those reported in previous research to precipitate discussion regarding the changes in clinical populations in secure care over time.

The study collected demographic and EPS data for patients with ID (n=25) on medium secure and a low secure wards. Data were collected as part of routine clinical practice, with EPS forms being completed by nursing and other multi-disciplinary staff.

It was found that there was no statistically significant difference in EPS scores between medium and low secure patients with ID. The authors also highlight differences between the current sample and the normative data collected by previous research.

The data regarding the psychopathology of medium and low secure patients with ID provide insight into the ever changing resourcing needs and risk profiles of this complex patient group. In addition, there is a dearth of empirical research that comments on the clinical differences observed over time in forensic populations. As the current data differ from pre-existing normative data, the potential shift in populations and also implications for the accuracy of clinical decision making based on the assessment are discussed.