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Women’s secure hospital care pathways in practice: a qualitative analysis of clinicians views in England and Wales
© Somers and Bartlett; licensee BioMed Central Ltd. 2014
Received: 21 November 2013
Accepted: 18 September 2014
Published: 1 October 2014
In England and Wales women form a small but significant group within the wider, largely male, secure hospital population. Secure hospitals are designed to assess and treat individuals with both mental health problems and significant criminal behaviour. The theoretical approach to the care of secure hospital women is increasingly informed by a grasp of gender-specific issues. However, there is a lack of evidence on the adequacy of current structures and processes of care delivery.
This qualitative study explores the nature and quality of care pathways for women in low and medium secure hospital beds by eliciting participants’ views of factors enhancing or impeding care. Beds are publicly funded and provided either by the National Health Service (NHS) or the Independent Sector (IS). Participants from both sectors were local experts (40 Consultant Psychiatrists, 7 Service Managers) who were well placed to describe their immediate health environment.
Evidence from the study indicates that participants were focused on the physical relocation of women to less secure conditions, even though many women do not readily achieve this.
Participants were alert to potential conflicts between ideal care and affordable care. Ideal care was compromised by the absence of suitable local services (beds or community placements), curtailed episodes of care and changes of care team. It was promoted by an awareness of the specific needs of women, continuity of care and support for teams unfamiliar with women’s needs.
Future service design must address these challenges in care delivery, incorporating a better understanding of and response to the ways the system can echo women’s experiences of trauma and their negative attachment histories. Specifically, critical transitions in care must not be allowed to further reinforce the discontinuity, failure and rejection experienced by individual women earlier in their lives.
KeywordsWomen Mentally Disordered Offenders Pathways of care Continuity Transition Cost of care
Regional and local secure hospital services in England and Wales for mentally disordered offenders have been developed since 1975 [1, 2] based primarily on the needs of men [3–6]. Recent guidelines for medium and low secure services aim to ensure national standards of care are met [7–9], but lack a gender dimension. Theoretical insights into the relevance of gender-specific issues (trauma histories and attachment styles) to the care of women in secure care has slowly emerged [5, 10–14]. However there is a dearth of evidence; outcome studies are small scale for example  or limited to recidivism . The delivery of care via the current national system which utilises some 1625 women’s beds  is poorly described.
Caring for mentally disordered offenders, of both genders, involves movement through a multi-organisational system that includes the criminal justice system (police, court diversion schemes, prison), secure hospital care, step down and community (e.g. 24-hour supported accommodation) facilities . In England and Wales, the National Health Service (NHS) and the Independent Sector (IS) (private and charity run organisations) provide secure services, which are purchased by NHS Commissioners. Routes in and out of secure care are complex and interdependent  and can be slow [19, 20].
The current qualitative study reports local, informed views of the nature and quality of pathways of care in women’s secure services. It adds to the existing literature by characterising problems encountered at transition points in care and contextualises these findings in the resources allocated to these high cost, low volume services. The data presented here represent part of the full analysis of interviews that revealed the nature of caring for women and women’s secure care pathways in practice. The current paper describes the latter, an understanding of the women’s care pathway in secure hospitals, which may differ from other health arenas. The study’s immediate practical significance is to inform the UK national service specification for these services, following the introduction of new commissioning structures in health and social care .
This paper reports interview data from the national service evaluation of women’s secure care pathways [17, 19]. Service evaluation status was confirmed by the National Research Ethics Service and South West and St George’s Mental Health NHS Trust. Each participating NHS Trust approved the study through their audit or R&D departments.
Participants were drawn from units identified in a wider study of secure hospital services to women in England and Wales (see [17, 19] for additional detail on units) and involved 96 of the 99 (19 of the 21 NHS and 40 of the 41 IS low secure units (LSU) and the 23 NHS and 14 IS medium secure units (MSU)) that took part in the national service evaluation . All services were informed about the interviews when they agreed to take part in the study. We were able to obtain at least one interview, at the relevant security levels, for each NHS region. Nine IS providers were represented by at least one interview, five (of which four were not participating), all providing low secure beds, are not represented by an interview. Forty-seven interviews were conducted that represent 45 forensic services responsible for 56 (of a possible 99) secure units; 26 medium secure units (17 NHS, 9 IS) and 30 low secure units (15 NHS, 15 IS) and two Women’s Enhanced Medium Secure Services (a higher staff patient ratio than other medium secure services). Some services had both levels of security and eleven interviewees completed one interview for both tiers of security. In two units two interviews were completed for each unit.
Interviews were conducted with Consultant Psychiatrists, or Service Managers where they felt they had a fuller view of the clinical and business workings of the service or where the Consultant Psychiatrist was not available. This method is known as “elite interviewing” (, p105) where interviewees are picked for their experience and expertise, in this case knowledge of both patients and services; forty Consultant Psychiatrists and seven Service Managers or Nurse Directors took part.
The interviews were developed by the research team (Additional file 1), which included two Consultant Forensic Psychiatrists and two forensic mental health researchers . Semi-structured interviews were conducted by asking respondents what were the Service’s strengths, weaknesses, opportunities and threats (SWOT framework) in four areas: clinical approach, care pathways, commissioning and financial issues. A SWOT framework was used as it is a helpful tool for understanding and planning services. SWOT comes from the field of management and business strategy, “…it invites decision makers to consider important aspects of their organisation’s environment and helps them organise their thoughts” (, p8). It is a tool to identify the positive and negative aspects, of an organisation, be they internal or external [24, 25].
In addition to the four topics to be discussed within the SWOT framework, three specific, open questions were added in anticipation of the national commissioning changes and to ensure the imposed framework did not limit responses: i) How does your local service fit into the national picture? ii) What would you change about your local service? iii) What would you change about the national picture?
Participants were given the interview framework (Additional file 1) in advance, at which point they were able to nominate a more suitable respondent if necessary. Due to the large numbers of interviews we aimed to collect, with participants from all over England and Wales, all interviews were conducted over the telephone by a Research Worker (NS) (n = 35) and a Forensic Psychiatrist (n = 12). Interviewers conferred about the level of prompting, which was kept to a minimum. The interviews were transcribed by the interviewer as they were being conducted, hence some quotes appear in a short hand form. The transcriptions were returned to the interviewee to review and amend if they wished. No major revisions were made to the transcripts. Interviews lasted between 20 minutes and one hour, with all respondents answering all questions. Interview subjects were assured of personal anonymity as well as anonymity of region and provider. Participants seemed engaged and eager to discuss issues relating to women in secure care.
A thematic analysis was conducted as described by Braun and Clarke  following the six phases of: familiarising oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report. The software programme NVivo  was used to aid and track manual analysis and features such as word frequency and other data examination facilities utilised. The analysis was conducted in the main by a research worker (NS) who was new to the field of forensic psychiatry, in order to minimise subjectivity. Initial coding on a subset of interviews was conducted independently by two Consultant Forensic Psychiatrists (one of whom, AB, is an experienced qualitative researcher) and finalised by consensus; the codes were expanded as additional data was examined and altered as iterative examination of the data developed by the research worker created a comprehensive analytic framework. Codes were categorised and, in turn, themes were allowed to emerge from the data. Codes and themes were not restricted to the SWOT framework and links across and between this interview framework were considered. As the analysis progressed a further sample of interviews were explored and cross-referenced by members of the research team and emerging themes discussed and considered.
Results and discussion
Overarching themes and subthemes within “Pathways in practice”
The Nature of the “Secure Care Pathway”
Movement of women through tiers of security or out of services
- Discharge facilitate
Cost-quality of care conflict
The cost of caring for women
- Nature of care is expensive
- Cost is gender relevant
- Determinants of bed purchase
The false economy of rapid discharge
- Discharge driven by cost
- The negative effect of early discharge on recovery
The peril of repatriation
- Premature and disruptive discharge
- Financially driven
Availability of Services
Gaps and blockages
- Lack of service provision
- Placements far from home
- Provision of appropriate care in inappropriate security; continuity
Access to community placements
- Lack of step-down facilities and supported accommodation
- Support and involvement in the community to prevent relapse
- Broad conceptualisation of community (See Lists 2 & 3)
Attitudes to Care
Competing concepts of continuity
- Continuity of treatment
- Continuity of responsibility
Fear and reluctance in receiving Teams
- Stigma of women in secure services
- Anxiety about receiving women from secure services
- Outreach and supportive relationships
The nature of the “Secure Care Pathway”
Participants’ descriptions of care pathways were understood in narrow terms and distinct from the commonly accepted, formal meaning. For them, care pathways meant the physical relocation of patients, not necessarily care delivery. In contrast, a care pathway, also referred to as integrated care pathways, within the NHS, is defined as:
“An integrated care pathway determines locally agreed multidisciplinary practice, based on guidelines and evidence where available for a specific patient/client group. It forms all or part of the clinical record, documents the care given, and facilitates the evaluation of outcomes for continuous quality improvement” (, p4).
A care pathway in the NHS is the set of defined activities and processes involved in a discrete aspect of care [29, 30]. For example, referral, assessment, intervention (usually aligned with National Institute of Clinical Excellence (NICE) guidelines) and discharge for a particular condition within a particular population. Emphasis may be on assessment and intervention phases as key processes involved in care.
Participants knew the study focused on the “care pathways of women mentally disordered offenders” but this was not defined for them. A handful of Consultant Psychiatrists enquired what this meant; they were asked to explain what it meant to them. One Consultant Psychiatrist held firmly that “pathways of care” was an unhelpful term, with no real meaning. Respondents were asked to describe a unit’s intended pathways of care. They were preoccupied with the physical movement of women out of their services, not assessment or intervention. Of the 50 responses to this question, only seven Consultant Psychiatrists said something about what treatment options and structure were within the service, of which all but one were based in the Independent Sector. Five more referred to their assessment process or acknowledged different care plans for those with personality disorders and mental illness. Without fail, every respondent described the source of admission and intended place of discharge.
Clinicians’ descriptions of care pathways suggested they were both linear and to lower rather than higher, or the same level of security. There was little acknowledgement that, in reality, patients move to higher security, for example from low to medium . Clinicians were however describing intended pathways of care. This is at odds with the reality that a third of women are discharged to units of the same security level (ibid).
“Offering no thrills but fits in with QIPP; so we are keeping them moving into lower security. We focus on reducing risk and moving them on in timely fashion.” (IS)
Respondents focused on the point of discharge throughout the interviews; how discharge was facilitated or blocked. The next sections reveal how financial costs, attitudes to care and actual availability of services affected care pathways in practice.
Cost-quality of care conflict
The cost of caring for women
“Expensive to run service and high level of observations. Very challenging, higher than average sickness rates and demand for staff for observations. So resource intensive.” (NHS)
“They [commissioners] don’t build in observations into budget and so problematic when increased” (NHS)
“We have a much reduced budget and how do we maintain quality standards when service is very resource intensive?” (NHS)
“Not acknowledging their special needs e.g. the new PD service is for men only. Hospital managers do not recognize complexity of women.” (NHS)
“Not investing enough in service. And treating like general service; underestimating staff input needs.” (NHS)
“They don’t commission services separately and so lose the essence of women’s service.” (NHS)
“commissioners looking for cheapest providers, moving out of Private to NHS for money not clinical reasons; when we are not sufficiently staffed has implications for other patients.” (NHS)
“Commissioners need to look at outcomes more rather than cost. This emphasis on cheap service is a potential false economy.” (IS)
“Things are generally tight, which is a threat to patient care. E.g. [we] used to have art and drama therapy. Want more for less.” (IS)
In several units art and drama therapy were reported to be he first services to be cut (arguably essential in a population that may not be able to engage with traditional verbal psychological therapies). One unit could no longer continue their DBT (dialectical behavioural therapy for personality disorder) due to redundancies.
The false economy of rapid discharge
“financial situation- commissioning target reduces length of stay and so we need low secure service or step down that we can use. Commissioners are moving to a one in one out way rather than expanding.” (NHS)
“In the current financial climate there is a push for reducing length of stay. Women are high cost so pushing discharge too quickly; they [women] may not have all skills so ends in re-admission. Length of stay is captured but not looking at re-admission rates or community survival rates.” (NHS)
“The current climate is worrying due to the reduction in beds, length of stay and reduction of assertive outreach provision in general psychiatric service, resulting in quick and premature discharge before they are properly treated.
This results in relapsing with long-term consequence of treatment resistance etc. with increased re-admission rates and high need for rehabilitation, e.g. the referrals to x have increased…” (NHS)
“We provide a secure base then discharge suddenly: how can we manage that better. Outreach is constrained by funding.” (NHS)
“Three month disengagement package; we keep a bed for three months in case. Visit weekly for the first month. Helps the accepting team.” (NHS)
They emphasised the importance of a definite transition period, citing it as a major strength when available.
The peril of repatriation
“Frustrating when they are moved in the middle of a placement when they have established relationships.” (IS)
“Premature discharge can derail treatment and rehab. Particularly with PD [personality disorder].” (IS)
“Sometimes patients are taken back by the referrers to their local areas half way through their recovery. This decision is understandably mainly financially driven but it does have an impact on the patients’ journey to recovery” (IS)
“At times patients who are progressing well with treatment but do not require MSU are moved away by commissioners to other local LSUs, where treatment cannot be continued” (IS)
There was a sense of frustration from the Independent Sector, which provides 75% of women’s low secure beds . Several Independent Sector providers were able to provide more than one level of the care pathway (a combination of or all of medium, low, step-down services) either on the same site or in close proximity and with good relationships between services. The IS lamented that they were rarely able to move women along what they considered to be faster or more streamlined, pathways. In addition, the IS, which collectively considered one of its main strengths as adapting quickly to the market and filling gaps in provision, was aware of a need for step-down and supported accommodation (discussed later) but felt rates of repatriation made the financial viability of such services questionable.
Availability of services
Gaps and blockages
“There is growth in medium secure units but not matched in low secure units.” (NHS)
“Some localities do not have dedicated LSU and patients need to be placed in out of area placements further away from home areas.” (NHS)
“Length of admission; women do get stuck longer than need to. Difficult to identify what care pathway, squeeze into what is available because of the lack of [low secure] provision.”(IS)
“NHS needs to wake up and provide local services for women. They are now OATs (out of area treatments).” (NHS)
For some regions, where low secure provision was absent, there was a sense that OATs were unavoidable. There was tension between women being placed far from home versus the potential benefits of receiving more specialised care.
“Not enough low [secure] step up, so women are moving from PICU (psychiatric intensive care unit) straight to medium. Low [secure] provision needs assessing. Women in higher levels of security than is required for their needs, because there are not enough low secure beds.” (NHS)
“Patients stay in medium until supported tenancy as changing service would not be better” (NHS)
“Unique as it [the unit] offers long term stay on medium security levels but it functions as a low secure unit, through very robust relational security, creating a calm and safe environment.” (NHS)
“Medium can serve rehab function dealing with long term-why would there be a need to step down. Idea of linear pathways is absurd, but should keep [MDOs] in least level of security.” (NHS)
“Longer length of stay because not going to low secure so in higher security, but avoids destabilizing change.” (NHS)
The tension between achieving continuity of care and women being detained in undesirably high levels of security is conceptually important for how women’s secure care pathways are thought about and planned. It has long been a tenet of forensic practice that detention in the lowest level of security possible, bearing in mind the need to manage risk safely, is preferable . Continuity of care, also judged to be a service design imperative, is, to judge from this data, both hard to achieve and, at times, privileged over this principle of minimal restriction. This reflects the de facto situation but cannot be assumed to have been as widely considered in service planning as is desirable.
Access to community placements
“The only issue would be to enhance the pathway downstream to move people out and take more patients in.” (NHS)
“We are restricted in where we can send women; limit in what is available for complex women.” (NHS)
“Identifying a placement is an issue; there are small numbers of female only rehab placements-causes delays in low secure.” (IS)
Two major issues were highlighted. There was not enough supported accommodation and it was insufficiently varied to match women’s different capabilities. For example, there were several calls for partially supported and “homely” women-only accommodation, with staff who understood emotional crisis and self-harm. Respondents also wanted support for women in the community that would help them avoid readmission e.g. day centres that could act as crisis points, with well trained and supported staff.
“Community”, as invoked by participants was a broad concept related to the transition out of secure services (List 2). It not only referred to receiving mental health teams and supported and step-down accommodation on leaving secure services but also the need to access the community whilst in secure services, in order to acclimatise them to life outside and aid rehabilitation. This could be leave (sometimes difficult to obtain) and/or voluntary work projects (a result of local links and innovative practice). Accessing the community was a key consideration in moving women out of secure care but relied on a separate funding stream. As a result, respondents were keen to emphasise things that could be done to improve access to the community and thus the long-term rehabilitation of women leaving secure pathways. List 3 highlights these suggestions.
List 2 Understanding “The Community”
Accommodation and supported accommodation/step down services.
General mental health services and teams.
Community access/participation: section 17 leave, volunteering, projects such as market stalls.
List 3 Accessing the “The Community”
Filling gaps in accommodation provision; type and availability.
Easily accessible information about available accommodation and services.
Forensic outreach: support for MDO and receiving teams.
Education of and support for local services.
Commissioners funding “transitional pathway” for up to 6 months.
Clear lines of responsibility for and access to funding streams.
Attitudes to care
Fear and reluctance in receiving teams
“PCTs won’t accept because of self-harm, women difficult to manage so try and support placements where they go.” (NHS)
“Change people’s perceptions of it being so difficult. People don’t realize they move on and get better even though they are in secure, so when next present to acute there is stigma. (NHS)
“anxiety of the receiving team, focus on how they were rather than how the patient is now.” (NHS)
“Will offer receiving teams advice. Go out twice in first month to check women, on existing budget.” (NHS)
“We have good links with step down services and work with those teams when the patients experience anxieties.” (NHS)
The IS reported difficulties with communication and relationships with receiving teams. IS units rely on commissioner case managers to identify and maintain contact with receiving units that are geographically distant; this input varies both individually and by region.
Competing concepts of continuity
“[We] do not use agency staff and have internal bank cover but still these staff would not know patients very well and there is at times disruption to continuity of care.” (IS)
“[We have] continuity of care as I also work in the community. Good relationships with community teams mean it is easier to transfer out.” (NHS)
“Have fairly self-contained levels and units within the service. Same staff looking after transition phases. Gives patients a lot of incentive to move on and continuity of care.” (IS)
“[We have a] range of services on one site. We can take acute phases of illness and move through the service into rehab and being prepared for discharge into community.” (IS)
“pre discharge very helpful; we can say to the community they have been living in open environment.” (NHS)
The desire to have all sections of the pathway to hand or to create a sense of progress (pre-discharge wards) points not only to the need to have treatment continuity but also to the wish of units to retain clinical responsibility. This did not necessarily mean the care team remained the same, although when it was available, it was cited as a major strength. Rather, continued responsibility means a provider (NHS and IS) can move women on without having to engage with outside teams, gatekeeping, funding issues, bed waits and can control transitions. Maintenance of responsibility contributes to continuity of care by enabling relationships between internal units and staff and swift communication.
“Commissioning care pathways rather than care spells. Following all the way through to community; if maintain women in same environment it allows them to change. Commission right into community.” (NHS)
“How commissioners purchase beds rather pathways of care. Would give patient and us stability.” (IS)
Women trying to escape difficult situations related to family, relationships and substance abuse may need to leave their home region. Acquiring rehabilitation funding from “home” PCTs to these new communities was described as “notoriously difficult”. The IS, with a national intake, reported this more frequently than the NHS.
The aim of the present study was to provide a nuanced overview of how women’s secure care pathways should, could and do work. Its national remit meant sacrificing a degree of depth that might have been achieved in longer face to face data collection. Telephone interviewing did enable us to reach a large number of geographically disparate respondents. A limitation, compared to face-to-face interviews, was the unavailability of some visual, social cues, which facilitate clarification, prompting and a greater understanding of the context of the service. We were also unable to record the interviews and some information or meaning may have been lost in the immediate transcription, as the interviewer simultaneously processed several types of information. The current study used respondent validation (review, amendment and approval of interview transcripts) before text analysis for this reason. The study would have been enhanced by respondents’ review of themes emerging from the data but this was incompatible with the project’s resource management. This is only one of several ways to check credibility; we did use peer examination, which was conducted throughout the analysis process .
Health funding in the UK is being severely reduced [36, 37]. Respondents reported a tension between moving women out of long term, expensive, secure hospital care and the clinical need to ensure consistent, high quality and resource intensive care that might facilitate successful, long-term rehabilitation. Clinicians’ concepts of a pathway concerned moving women out of services. They described several factors that delay transfer and some that speed it up. Rapid discharge or repatriation from the independent sector to the NHS was considered to disrupt treatment and, in the long term, to result in avoidable readmission.
Respondents’ insights have revealed a conflict between the actual and the preferred, clinical pathway. Continuity of care was jeopardised by the reality of the care system. Without service user views on the subjective importance of continuity of care and the pros and cons of specific elements of the pathway, the significance of this finding cannot be fully assessed. However, the system as described is not functioning as intended. Further research is also required to go beyond the current qualitative work and elucidate the extent to which the pathway is not functioning in the described ways and the associated impact on psychological and reoffending outcomes.
The individual histories of women in secure hospital services are characterised by early trauma and pathological attachment structures [38–40] rendering them particularly sensitive to feelings of abandonment and rejection, encapsulated in high levels of borderline pathology in this population . The discharge of some women from these services appears overly driven by financial and commissioning pressures. If the respondents’ views are well founded, the recommended, gendered approach [12, 13] to this population’s clinical needs of continuity of care (within a service and of individual staff) is compromised. Sudden and/or premature discharge combined with insufficient and changeable staffing, may resonate with women’s individual experiences which, if ignored, may undermine their progress. Potentially self-punitive perceptions, born of chronically low self–esteem, may stem from remaining in unnecessarily high levels of security. Concomitant, limited opportunities to gain confidence and responsibility in the community may jeopardise long term rehabilitation in the community. This theoretically plausible understanding needs greater empirical exploration. However, future service design cannot be oblivious to this analysis of the system of care [41, 42].
aPCTs were abolished by the Health and Social Care Act 2012. Their function of commissioning local general health care in a small geographical area has been taken over by a Clinical Commissioning Group.
Nadia Somers: Research Worker SGUL (Current role: Trainee Clinical Psychologist, Royal Holloway University of London).
Annie Bartlett: Reader and Honorary Consultant in Forensic Psychiatry SGUL & Clinical Director (Jnt) Offender Care Central North West London NHS Foundation Trust.
The authors are extremely grateful to Dr Matthew Fiander for comments on questionnaires and drafts of this paper, to Dr Mari Harty for contributions to questionnaire development and to Dr Doreen Attard for assistance conducting interviews.
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