Characteristics and needs of long-stay patients in high and medium secure forensic-psychiatric care: Implications for service organization

Written by Prof. Birgit Völlm,
Clinical Professor and Readerin Forensic Psychiatry, Faculty of Medicine & Health Sciences, University of Nottingham


This report summarises the research progress we have made on ‘Characteristics and needs of long-stay patients in high and medium secure forensic-psychiatric care: Implications for service organisation’. The National Institute of Health Research (NIHR) UK has funded this 3-year study, which we are two thirds through, as of the recent quarterly meeting – the ‘Project Management Group and Service User Reference Group meeting’ – which took place in mid-January.

In our project we collect simple administrative data (age, gender, ethnicity, type of detention, date of admission) of a representative sample of 40% of the entire forensic-psychiatric population (Work package 1). We then identify, from those patients, those that fulfil our criteria for ‘long-stay patients’ (the criteria depends on the level of forensic psychiatric care: If in medium-security care, more than 5 years residence; if in high-security care, more than 10 years residence; or, if in a mixture of high and medium security settings, more than 15 years residence), and conduct detailed reviews of the long stay patients’ files, covering offending and psychiatric history, current and past treatment, incidents within institutions, etc. (Work package 2). We then interview approximately 20 of the long term patients from different settings, questioning them about their experiences of long-stay forensic psychiatric care (Work package 3). Finally, we conduct interviews with a range of senior clinicians, commissioners and policy makers, based both locally and abroad, to identify how our findings can inform forensic psychiatric service organisations (Work package 4).

During the quarterly meeting, it was confirmed that all data for Work package 1 has been collected and is now ready to be analysed. Within this sample, we have information on 1573 patients: 326 of these are long-stay patients, i.e. just under 21% of the total. Our initial analysis indicates that long-stay patients differ from non-long-stay patients in terms of age (long-stay patients are older) and ethnicity (there are more Caucasian British patients in the long-stay patient group), but not on gender. Long-stay patients are disproportionately more likely to be detained in the independent sector institutions (compared to if they were in the NHS) indicating a service gap within the NHS for this patient group. Differences in the legal status of the two patient groups were identified, with additional restrictions imposed on the long-stay patient group. We speculate that these additional restrictions, identified, could impede the long stay patients’ pathway through the system, keeping them in the system for longer.

Data collection proformas are now available for over 80% of the Work package 2 data – this data has been cleaned and entered into the system for analysis. Prior to statistical analysis, our initial observations of the data suggest the existence of a group of patients who are relatively settled in care service organisation; This group is not engaged in any formal treatment and are not in a process of being referred on to less secure services. A large proportion of patients appear to have engaged in institutional violence, which in some cases appears to be more severe than the offences that brought them in to the institution in the first place. Some patients do not have an index offence – they are being detained in forensic-psychiatric care for a long time without a conviction by a court. We also observed that a number of patients, despite being classified as a long-stay care patient at our cut-off point in 2013, have nevertheless since moved on, predominately in the ‘right direction’, i.e. to less secure service institutions. On a further positive note, the majority of patients are in contact with friends and family.

We discussed at length the sampling framework for patient interviews, especially the suitability of the questions to be asked. During these discussions, our Service User Reference Group was particularly helpful, suggesting methods of engaging patients and making them feel at ease during the interviews, and also suggesting questions we might include in the interviews. One line of questioning, decided upon, will consider the desirability of long-stay units in the UK. It will be most useful to her from long term patients themselves in this regard. As well as discussing lines of questioning, we recognised the need to educate long term patients during the interviews as well, e.g. to provide examples of Quality of Life initiatives that are being employed in other countries, as awareness of initiatives, other than those they themselves have been exposed to, is likely to be low. There are low security initiatives in service organisations overseas, e.g. to engage in paid work or have unsupervised contact with their spouse while an in-patient, that long term patients here in the UK may consider desirable.

At this quarterly meeting, we only touched on Work Package 4, as the interviews that have been done so far are still awaiting write-up at present. The interviewees, so far, have all been based in the UK but have included a broad range of forensic psychiatric care, including senior clinicians, commissioners and forensic psychiatric care policy makers. More time will be allocated to discussing progress of Work Package 4 at future meetings.

To know more about this project, click here.


Funding Acknowledgement:

This project was funded by the National Institute for Health Research HS&DR Project: 11/1024/06


Department of Health Disclaimer:

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Project, NIHR, NHS or the Department of Health.