a review of gatekeeping in medium secure services 2.pdf · a review of gatekeeping in medium secure...
TRANSCRIPT
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A Review of Gatekeeping in Medium
Secure Services
Dr Paul GilluleyChair of the Advisory Group
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Introduction
Background
What is the gatekeeping process?
What has been done so far?
Outcomes so far
Possible structures for the future
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Background
64 medium secure services in England (60% provided by the NHS)Total of around 3,000 bedsAverage cost of medium secure bed £172,000Total annual cost £0.5 billionLow volume high cost service1% efficiency saving would be £5 million
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Quality, Innovation, Productivity and Prevention
National QIPP Programme for Medium Secure Services
AssessmentGatekeepingAdmissionSecure care pathwaysPayment by resultsDischargePatient experience
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Gatekeeping
• Establish current gatekeeping process that is presently in place
• Assessment models used
• How is level of security required assessed?
• Identify blocks and inefficiencies that exist
• Identify areas of good practice
• What is patient experience of the system?
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Method
• Questionnaire
• Sent to all units
December 2010
• Reminders in January
and February 2011
• Meetings with
stakeholder
• Meetings with service
user experts
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Stakeholders
• Ministry of Justice
• High Secure hospital
clinical directors
• Centre for Mental
Health
• SCG forensic
commissioners
• Services users
experts
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Service users
• Entry from high secure,
prison and the
community. Male and
female.
• Generally complimentary
regarding the treatment
they received in hospital
• Praised staff and how
they approached and
respected them
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High Secure transfer
• “Doctors from the
medium secure
service came to see
me every year. They
kept saying I was not
ready for transfer.
They never told me
what I had to do so
that I would be ready
for transfer”.
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Prison transfer
• “When I got to hospital no one explained why I was there. When I asked how long I would be there they said “forever”. I was told there was no limit on how long I would be there. I asked the guy in the room next door who had been there five years what they expected you to do. No one explained anything to me”
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Prison transfer (2)
• “Whilst in prison lots
of doctors came to
visit me but did not
explain why. Was
taken one day to
Court and instead of
going back to prison I
went to hospital”
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Community transfer
• “I was given no
information about the unit
and suddenly I was
transferred there. My
family were not told. I
was put in with lots of
women who had been
transferred from prison.
Although I had been in
prison before I was
surprised as I had done
nothing wrong.
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Questionnaire
• Over 40 responses
• Good geographical
spread
• Both NHS and
independent sector
• A few low secure but
majority medium
secure services
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Referral, Assessment, Admission
• Some very detailed policies
• In some areas joint agreement between providers and commissioners with clearly defined timescales
• NHS provide gatekeeping (problems with independence)
• No consistent referral process
• Usual MDT assessment
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Assessments tools
• Overall appeared to be dependent on clinical judgement
• Some use of actuarial tools although these tend to be used post admission
• Dundrum quartet
• Scales 1 & 2 are carried out at time of assessment
• Structured clinical judgement
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Current blocks
• Insufficient information at time of referral
• Lack of appropriate beds
• Poor communication with other agencies
• Delays in MoJ response
• Lack of community support
• Competence of staff assessing
• Funding problems
• Multiple referral to providers
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What works well?
• Single point of access to services
• Standarised referral form
• Commissioner involvement in process
• MDT involvement
• Clear care pathways
• Forensic Community teams available
• Quick response time to referral
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Design the process
• Electronic database
• Centralised gatekeeping
process
• Standardised assessment
criteria
• Emergency bed
availability
• Managed clinical network
from time of arrest till
return to general services
• Timely MoJ response
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Possible future
• Stay the same
• Improve what is
already there
• Separate
commissioning of
gatekeeping