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In this study we demonstrate how the Health of the Nation Outcomes Scales for secure and forensic service users (HoNOS‐secure) tracks risk and recovery in men with mental illness and men with learning disability in a secure care pathway. Total and individual HoNOS‐secure item ratings made by multi‐disciplinary teams across the course of a period of admission (mean 15 months) for 180 men were examined. There was significant positive change on the clinical and risk‐related scales of HoNOS‐secure for patients in the learning disability care pathway (N = 48) between initial and final ratings. In the mental health care pathway (N = 132 patients) an apparent lack of change masked a more complex picture, where initial decline in HoNOS‐secure ratings was succeeded by significant improvement. Results suggest that it is challenging to measure clinical and risk‐related medium‐term clinical outcomes objectively for these patients, particularly in relation to core issues of treatment of mental disorder, and reduction of both problem behaviour and risk to others. However, it is important that practitioners continue to strive to demonstrate the benefits of care and treatment through appropriate outcomes measures.

The purpose of this paper is to report the experience and impact of paid staff who are employed to use their lived experience of mental health issues and service use within a secure mental health provider.

A qualitative approach using semi-structured interviews and thematic analysis was employed.

Results from this study suggest that employing lived experience workers (LEWs) in secure mental health settings is valuable to clinical staff, service users, the employing organisation and LEWs themselves. Findings emphasised the importance of support for LEWs to enable them to fulfil their role and maintain wellbeing, and the need to consider LEWs career progression within and beyond the role.

This study had a small sample size.

There is evidence to support LEWs in secure mental health settings and requirement for further understanding of their work in this environment. Specific recommendations include the need for training for clinical staff about the role of LEWs, specific LEWs role training, and regular supervision and mental health support for LEWs.

This is the first paper reporting the experience and impact of LEWs in a UK secure mental health service.

Inequalities can have a cumulative effect that leads to the presentation and subsequent progression of mental health difficulties. The detrimental effects can be compounded in the healthcare environment if staff lack an awareness of patients’' inequalities, and therefore, educating staff is of particular importance. The development of awareness training requires a deep understanding of staff perceptions of patient inequalities in a secure mental health care setting and the impact that this can have on mental illness.

The study was carried out using a qualitative design, where staff were asked to complete a 22-question survey from which the output is analysed using thematic analysis. In total, 100 patient-facing staff members working in a secure mental health facility completed the survey.

The results highlight that staff employed in a secure mental health care setting have an understanding of patient inequalities and how these can impact on patients in both the short and longer terms. The results highlighted the importance of awareness by staff and how an increase can have a significant benefit on the quality of the care provided within secure mental health facilities.

There is an increasing awareness of the impact of inequalities on mental health and how this can influence a patient’s journey. This study involving staff employed in a secure care mental health facility highlights the role of staff awareness of inequalities and also underlines the importance of understanding the key role of staff awareness in mental ill health.

The concept of inequality refers to being treated unfairly in society and its impact on mental illness has been explored primarily using a quantitative research approach. Patients’ lived experiences of inequalities prior to their admission to a secure care setting need to be addressed with a higher priority as they can serve to improve our understanding of the factors underlying the development of mental illness at a personal level. The aim of this study is to explore participant’s views on whether for them the experience of inequality is associated with the development of mental illness.

A qualitative study, using a thematic analytical approach, was carried out to explore patients’ lived experiences of inequalities. A total of 11 participants, who were receiving treatment in a UK secure mental health hospital, were recruited into this study. The concept of inequality was explored using semi-structured interviews.

Data showed that patients had experienced a variety of inequalities which had negative impact on their mental health. Four main themes were identified from thematic textual analysis – abuse and its impact, a lack of support, the issue of labelling and the importance of understanding.

Data showed that patients had experienced a variety of inequalities which had negative impact on their mental health. Four main themes were identified from thematic textual analysis – abuse and its impact, a lack of support, the issue of labelling and the importance of understanding.

This is the first study, to the best of the authors’ knowledge, to consider intersectionality and admission to mental health units by interviewing patients in secure mental health setting.

The more disadvantaged members of society generally experience poorer outcomes following the development of mental ill-health. The purpose of this paper is to scope the literature and synthesise findings on the inequalities and mental health within secure mental health settings.

Six electronic databases were searched to identify relevant studies. These were included if they examined the association between inequalities and mental health in women’s secure mental health settings.

Of the 608 studies reviewed, 14 met the inclusion criteria. In these papers, violence and/or abuse were described as the most prevalent inequalities. The second most frequent group of inequalities identified were socio-economic. Only three published studies researched the impact of ethnicities. Physical health, alcohol abuse and a dysfunctional family upbringing were only mentioned in one of the studies. Gender identity, transitioning and sexual orientation was not considered in any papers. These are areas, which require further investigation to determine their specific impact in this setting.

This review highlights the dearth of high-quality research-based evidence underpinning an understanding of the impact of inequalities on women in secure mental health settings. The existing studies suggest that inequalities have a very particular impact and that intersectionality plays a key role. Further research is required to further understand how inequalities impact the lives of women in secure mental health settings.

The inequalities that women experience in relation to mental health need to be further researched in the context of intersectionality. There are also research gaps in terms of gender identity, sexual orientation and socio-economic background. Further primary research using a more complex methodological paradigm is required to explore these factors and their impact on mental health service provision.

The role of inequalities should be considered as part of an overall care package, including the experiences of adverse childhood experiences and this should contribute towards the development of a trauma-based care approach.

To the best of the authors’ knowledge, this is the first study to scope literature about inequalities experienced in women’s secure psychiatric settings considering intersectionality.

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.

The concept of inequality can be described as not being treated equally to everyone else in society. While previous studies have explored the concept of inequality and its impact on mental illness, these have been primarily quantitative. The details of experiences and potential impacts of inequalities by patients prior to admission into secure care have not been investigated comprehensively using a qualitative approach, which will identify individualised factors that may contribute to the development of mental ill-health. This study aims to explore whether those with multiple disadvantages are at greater risk of developing mental illness.

A qualitative study of patients’ clinical notes upon admission to a secure in-patient facility was conducted using a thematic analytical approach to investigate the key inequalities reported by patients with mental health problems. The topic of inequality was examined by assessing the clinical notes of 21 patients who were under treatment at the time of the study.

The majority of patients experienced multiple inequalities which impacted negatively on their mental health status. Three main themes that were identified were – a disrupted living environment, disturbed childhood and the importance of support. The thematic analysis has shown that the majority of the patients were exposed to numerous societal disadvantages in association with challenging life events in their early years and these have impacted significantly on their subsequent well-being.

When assessing the background to mental illness, it is important to gain a deep understanding of many inequalities that patients have faced prior to them developing their condition and, in particular, how these have combined to initiate the clinical manifestation. The study highlights the importance of raising awareness of how being treated unfairly, whether based on protected or non-protected characteristics, can contribute towards people becoming disadvantaged in society and ultimately making them more vulnerable to the development of mental health difficulties. Results of the study may inform the future use of inequalities as an integral component in the development of trauma-informed care.

This is the first study, to the authors’ knowledge, to consider intersectionality and admission to mental health units by adopting qualitative approach, specifically by reviewing patients’ clinical notes.

The purpose of this paper is to understand service users’ experience of a new acceptance and commitment therapy (ACT)-based substance misuse programme. The programme is designed for people in secure mental health services, presenting with complex mental health difficulties and co-occurring substance misuse problems.

A qualitative approach informed an exploratory pilot of this novel intervention. Service users completing a 16-week ACT programme were invited to participate in the current study. Out of the nine individuals enroled on the programme, six opted to take part in the exploratory pilot and completed semi-structured interviews following part 1 of the programme (eight weeks). Four of these participants proceeded into part 2 of the programme (eight weeks) and completed a further semi-structured interview.

The thematic analysis identified five main themes: “Increased awareness of personal values and the impact of substance use on values”, “Taking committed action towards values”, “Coping skills and the application of skills to manage difficult thoughts and feelings”, “Personal development” and “Use of metaphors/analogies”.

A quantitative evaluation of clinical outcomes is recommended to gauge further programme effectiveness.

The findings provide preliminary support for the use of an ACT-based substance misuse programme in a secure mental health setting.

This study evaluates the use of a novel ACT-based substance misuse intervention with people in secure mental health care with co-occurring mental health and substance misuse difficulties. This paper provides an in-depth understanding of service users’ experience of participating in this new treatment programme.

There are high levels of psychiatric morbidity amongst people in prisons. In England and Wales, prisoners who present with the most acute mental health needs can be transferred to hospital urgently under part III of the Mental Health Act 1983. This project reviewed all such transfers within one region of England, with an emphasis on differences across levels of security.

Over a six-year period (2010–2016) within one region of England, 930 psychiatric referrals were received from seven male prisons. From these referrals, 173 (18.5%) secure hospital transfers were required. Diagnostic and basic demographic information were analysed, along with hospital security categorisation (high secure, medium secure, low secure, psychiatric intensive care unit and other) and total time to transfer in days.

There were substantial delays to urgent hospital transfer across all levels of hospital security. Prisoners were transferred to the following units: medium security (n = 98, 56.9%); psychiatric intensive care units (PICUs) (n = 34, 19.7%); low secure conditions (n = 20, 11.6%); high secure conditions (n = 12, 6.9%); other (n = 9, 5.2%). Mean transfer times were as follows: high secure = 159.6 days; other = 68.8 days; medium secure = 58.6 days; low secure = 54.8 days; and psychiatric intensive care = 16.1 days.

In keeping with the wider literature in this area, transfers of prisoners to hospital were very delayed across all levels of secure psychiatric hospital care. Mean transfer times were in breach of the national 14-day timescale, although transfers to PICUs were quicker than to other units. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved.

This paper extends the available literature on the topic of transferring prisoners with mental illness who require compulsory treatment. There is a small but developing literature in this area, and this paper largely confirms that delays to hospital transfer remain a serious problem in England and Wales. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved. This could include different referral and transfer models as a component of service-based and pathways research or combining referral pathways across units to improve their efficacy.