Title: Characteristics and needs of long-stay patients in high and medium secure forensic-psychiatric care: Implications for service organisation
Funder: Department of Health (England)

Abstract: •Work package (WP) 1 – Length of stay in secure care (months 1 – 6): cross-sectional design Sample: All patients currently resident in high secure care and a representative sample of medium secure units (MSUs) will be included following stratification by Strategic Health region sector (NHS/independent) size and specialisation (eg. patient group designated purpose). Our sampling strategy resulted in inclusion of 26 MSUs (16 NHS 10 independent) providing care for just under 2000 patients out of the total of 57 MSUs (34 NHS 23 independent). See full protocol for details on sampling strategy. Data collection: Basic patient characteristics (date of birth gender ethnicity admission source date of admission Mental Health Act section) and details of current ward will be collected through medical records departments. Data analysis: We will provide LoS (admission to current setting to census date) profiles for high and medium secure services and identify how many patients have been resident in secure care for excessive amounts of time using simple descriptive statistics applying our definitions for long-stay (see above). We will estimate the total number of long-stay patients in England.•WP 2 - Characteristics and needs of long stay patients (months 7 – 22): file reviews and interviews with responsible clinicians (RCs)Sample: The sample will be all long stay patients in the selected units from WP 1 approx. 120 in high and 380 in medium secure care. As individual RCs will potentially be responsible for the care of more than one long-stay patient it is expected that the number of RCs to be interviewed will be about a third of the sample.Data collection: Two fully trained researchers will collect data by review of patient files and interviews with RCs (or their deputies). Data collected from files will include date of admission to secure care movements between forensic services diagnoses offending history risk violent incidents and seclusions since admission treatments referrals Mental Health Review Tribunals and outcomes. RC interviews will capture security dependency treatment and political needs according to Shaw et al. [7] and RCs’ views on current and future service needs including life-long secure care and problems preventing transfer or discharge. Data analysis: We will report descriptive data on characteristics (eg. clinical risk etc.) of the long-stay patient group potential risk factors for long-stay using comparisons between subgroups stratified according to LoS differences between patients according to security need and consultants’ views on need for life-long secure care (chi-square association tests) factors identified from the literature and our own work predictive of level of security needed and need for life-long secure care (logistic regression) milestones in patients’ pathways using pathway diagrams and categorisation of long-stay patients with different characteristics and needs using structural equation modelling.•WP 3 – Patient experience of long-stay (months 19 – 30) - qualitative interviews Sample: Long-stay patients identified in earlier WPs will be interviewed using a sampling frame including gender current location and category of long-stay. Purposive sampling will be used to select participants representing different criteria of the sampling frame. Number of interviews will depend on data saturation but is expected to be around 30 in total.Data collection: Semi-structured interviews will be conducted using topic lists drafted after literature review and review of our own findings in collaboration with service user representatives covering eg. patients’ perspectives on long-stay and strengths and weaknesses of current service provision. Interviews will be conducted by trained service users in order to maximise respondents’ engagement. Interviewers will be free to vary the order and wording of questions will be required to also use probes and follow-up questions and be responsive to issues emerging from respondents’ accounts. All interviews will be tape recorded and verbatim transcripts made. Data analysis: Interview transcripts will be downloaded to NVivo. Thematic coding frameworks will be constructed allocating codes to themes and issues emerging from the data thereby facilitating the identification and organisation of emergent themes and issues. A sample of transcripts will be independently re-coded by a second researcher (TW) who will be blind to the original coding.•WP 4 – Service innovation (Months 1 – 33): qualitative and quantitative methods (Expert interviews workshops Delphi exerciseExpert interviews (yrs 1 and 2) will be conducted with (a) senior managers of long-stay institutions outside the UK (covering key elements best practice and challenges of long-stay forensic care) (b) senior commissioners and policy makers within the UK (covering perceptions of problem of long-stay strategies to address this and views on international models) (c) senior clinicians in high and medium secure settings (covering experience in the care of long-stay patients view on and resistance to potential new service models). All interviews will be recorded verbatim transcribed and analysed using NVivo (see above). Workshops (yr 2) will be conducted to explore some pertinent issues (eg. legal and ethical issues possible service models) in more detail in smaller groups. All relevant stakeholders will be invited. A Delphi exercise (yr 3) will be conducted to agree on essential and desirable elements of long-stay forensic psychiatric care in the UK context. It will be conducted electronically and include 100 experts from a range of backgrounds. Round 1 – description of features of appropriate services for long-stay patients in secure forensic settings. Data from Round 1 will be collated into a list of items for Round 2. Participants will be asked to rate their agreement with each item. Items that have > 80% agreement will be used in the final recommendations from this project.Findings from WP 4 will be used to formulate a report on service models and recommendations for their implementation including how to overcome hindrances.


Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH