Chapter Six

Managing high risk individuals ­ service development

Introduction

6.1    The Government has recognised that in many instances patients who pose (or have posed) a high risk to others are not receiving the most appropriate or effective care and treatment that they need and in some cases, are held in inappropriate levels of security. This section describes a number of changes already underway which are designed to meet these problems. The emphasis is on improving the evidence-base of 'what works' through research and expanding the range of services provided to better meet the needs of all patient groups. This section also sets out in detail the proposed changes to the organisation and delivery of services for the DSPD group over the next three years.

6.2    The clarification and enhancement of the legal provisions which enable the compulsory care and treatment of individuals with mental disorder who pose a risk of serious harm to others, described in Chapter Three, will not reduce the risk to the public on their own. In order effectively to protect the public and safeguard the rights of individual patients, it is essential that robust legal powers are balanced with the delivery of high quality specialist care and treatment, at the right level of security, to meet the needs of individuals and reduce the risk they pose to others.

Developing secure mental health services

Provision of high security psychiatric services

6.3    Section 4 of the NHS Act 1977 was amended by section 41 of the Health Act 1999 to allow high security psychiatric services to be provided by NHS trusts. The aim of this change was to allow the three Special Hospital Authorities (Broadmoor, Ashworth and Rampton) to form new organisations with existing mental health trusts, so that they become providers of high security psychiatric services within an integrated secure and general mental health services trust.

6.4    Plans for Broadmoor and Rampton Hospital Authorities to integrate with other NHS trusts providing a wider range of mental health services are already well advanced. Broadmoor Hospital Authority will be dissolved on 31 March 2001, with a new West London Mental Health NHS Trust, incorporating Broadmoor Hospital and Ealing, Hammersmith and Fulham Mental Health Trust, becoming operational on 1 April 2001. Rampton Hospital Authority will also be dissolved on 31 March 2001, with a new Nottinghamshire Healthcare NHS Trust, incorporating Rampton Hospital and the medium secure services within Trent Region, becoming operational on 1 April 2001.

6.5    The integration arrangements for Ashworth Hospital Authority are linked to the wider development of secure psychiatric services in the North West. In this respect, formal consultation has begun on the creation of a new Mersey Mental Health Trust, which is expected to be established from April 2001. The proposal being consulted upon envisages that the mental illness service provided by Ashworth Hospital will form part of the new trust at a later date. Options for the other services currently provided by Ashworth Hospital Authority are currently being considered.

6.6    The high security hospitals' professional and geographical isolation has undoubtedly been at the root of many of the difficulties they have experienced. The integration of each of the hospitals into NHS trusts providing a wider range of mental health services will considerably alleviate the isolation problem, and there are already indications that recruitment difficulties are improving. The distinction between high and medium secure services will be maintained by providing the services on separate sites but with the advantage of having a Trust Board which can take an overview of the provision of the whole range of services.

6.7    We are confident that the new investment in the high security hospitals, and the linked modernisation and mainstreaming of the hospitals, will achieve our twin objectives of securing the safety of the public, staff and patients whilst offering a high quality service to people who genuinely require care and treatment in a high security setting.

Commissioning secure mental health services

6.8    Regional Specialised Commissioning Groups, which this year took on full responsibility for the commissioning of high and medium secure psychiatric services, are providing a more focused mechanism for identifying the needs of their population and developing integrated local services. Devolution of the funding for high security services from the High Security Psychiatric Services Commissioning Team within the NHS Executive to Health Authorities has removed the perverse financial incentive for health authorities to take patients back once they no longer require conditions of high security, and will facilitate the movement of patients into the level of security which they genuinely need.

6.9    The following will be essential components of the new commissioning arrangements:

• the formulation of a regional strategy agreed by all the key stakeholders. This will encompass robust assessment of patient needs, definitions of patient categories and admission criteria, and staffing and service development requirements for the local population of patients needing all levels of secure services;

• the involvement and commitment of providers (managers and clinicians) in the development of a strategic plan, the commissioning process and the co-ordination of service development;

• the involvement of local authorities, criminal justice agencies, social care, voluntary agencies, the Prison Service, and user representatives in the co-ordination of strategic planning and commissioning;

• management of the interface between the commissioning arrangements for high and medium security services and the commissioning of general mental health services;

• management of local commissioning in the context of the national priorities for provision of high and medium secure services, including the provision of low volume specialist secure services (for example for people with learning disabilities, women and hearing impaired patients);

• national oversight of the process.

Review of security at the high security hospitals and reprovision of medium security services

6.10    In 1999, the Department of Health commissioned a review of security at the high security hospitals by a team led by Sir Richard Tilt, the former Director General of the Prison Service. Sir Richard's report,9 published earlier this year, made a number of recommendations for improvements to the perimeter and internal security of the hospitals, all of which we have accepted. We have made the necessary funding available and work is currently under way to implement those recommendations.

6.11    The Government has commissioned a review of medium security provision and forensic networks of care, which will identify gaps in capacity. The review will also encompass a survey of all types of secure beds, and the results will be shared with the appropriate agencies.

6.12    The Government has made an extra £25 million of recurrent revenue funding available, phased in over a three year period, specifically to address the problem of moving out patients when they no longer require treatment in conditions of high security. Significant capital funding is also being made available for this purpose over the three years 2001/04. The needs assessment work currently being undertaken will help inform the use of this funding, and women patients will be given high priority.

Developing secure women's services

6.13    The Department of Health commissioned work, supported by an expert group chaired by Dame Rennie Fritchie10, to look at strategic issues around women in the high security hospitals. The report of this group was published in March 1999.

6.14    This report is forming the basis of the development of a strategy, linked to additional funding, to ensure that priority is given to the discharge and movement out of the high secure hospitals of women patients who have been identified as not requiring the physical security that the three hospitals provide. The ultimate aim will be to provide safe, appropriate, and secure services that meet the needs of women patients. The strategy should be complete within 12 months.

6.15    However, it is likely that there will remain a very small number of women who present a high risk to the safety of others and who will continue to require a high level of physical security. The longer term needs of these women will be considered further by the National Oversight Group in policy and strategic developments around implementation of Sir Richard Tilt's report, and will also form part of policy considerations between the Department of Health and the Home Office around services for women who are DSPD. Consideration will be given to creating separate dedicated facilities for the small number of women who require high secure care.

Forensic child and adolescent mental health services

6.16    The Government recognises that action is required to bring fragmented and variable local services for children and adolescents with mental health problems up to an acceptable standard. Joint national targets for child and adolescent mental health services (CAMHS) for health and social care were introduced for the first time under the National Priorities Guidance 1999-2002, backed by additional investment from the NHS Modernisation Fund and the Mental Health Grant to local authorities.

6.17    We are working on the development of a strategy for forensic CAMHS. The intention is that this will cover all levels of need and service provision, including in-patient services and specialist community outreach teams. The need for additional CAMHS forensic secure units will be considered as part of our development strategy.

Prison mental health services

6.18    The Government recognises the need for, and is committed to delivering, reform of the health care services to prisoners, including young offenders. The report of a joint Prison Service/NHS Executive Working Group on the Future Organisation of Prison Health Care11, made a range of recommendations about how improvements should be taken forward on the basis of partnership between the Prison Service and the NHS including, in particular, meeting the needs of prisoners with mental health problems.

6.19    The Government has accepted the Report's recommendations and implementation has started in a number of areas. In particular:

• two new joint units ­ a Policy Unit and a Task Force ­ have been established to lead and co-ordinate the reform programme. The units, located in the Department of Health, came into being on 1 April 2000;

• work has also started at a local level, with prisons, young offender institutions and health authorities reviewing jointly the health needs of the local prisoner population. The aim is to develop local improvement plans to shape and focus local health services both inside and outside prison, so that the needs of prisoners and their throughcare are better met.

6.20    The NHS Plan recognises the high prevalence of mental health problems among the prison population. For example, recent surveys12 show that 9 out of 10 adult prisoners have one or more problems related to psychosis, neurosis, personality disorder and drug or alcohol abuse. Around 5000 prisoners at any one time are estimated to have a serious mental health problem requiring an active intervention. The NHS Plan, in keeping with recommendations of the Report on the Future Organisation of Prison Health Care, commits to the provisions of an extra 300 NHS staff to provide mental health in-reach services to prisoners, so that their mental health needs are met, and that they do not leave prison without a care plan.

6.21    The in-reach of multi-disciplinary community mental health teams can be expected greatly to improve the standards of care and treatment of mentally disordered prisoners, including those needing transfer to hospital and to facilitate continuity of care, when persons are received into custody, on transfer to hospital and back, and on release back to the community. Appropriately targeted funds will be made available to health authorities so that mental health services may reach in those prisons with mentally disordered offenders.

6.22    As part of the development of the in-reach of services, existing protocols will be reviewed and revised so that transparent referral and transfer arrangements are in place for those prisoners who need in-patient treatment for mental disorder in hospital or in a DSPD treatment centre. At present around 750 prisoners are transferred to hospital as restricted patients under the Mental Health Act 1983 each year. At any one time there will be a number of prisoner-patients waiting either to be assessed or transferred to hospital, and who are at present sometimes held in unsuitable conditions. The restructuring of the high security psychiatric service, improvements to the organisation of prison health services and in-reach of NHS specialist care will tackle the needs of a group of prisoner-patients who, though they may periodically need the support of a hospital environment, also need to receive more appropriate support and therapeutic intervention whilst in prison.

Developing specialist services for those who are dangerous and severely personality disordered

Introduction

6.23    The challenges posed by those who are DSPD cannot be solved by new legislative powers alone. Before new powers can be applied safely and ethically to those who are DSPD, new specialist assessment and treatment services must also be developed. In practice, many of those who are DSPD cannot safely be managed within mainstream high security psychiatric wards, even if there were capacity to accommodate them in existing services. More fundamentally, in common with many respondents to the consultation exercise and the Home Affairs Select Committee, the Government believes that where individuals are detained as a result of their mental disorder, they must be held in a therapeutic environment which is designed to address their needs effectively. This is not just a matter of new places ­ important though that is ­ but also properly trained staff, new approaches to assessment and treatment and a rigorous programme of research and evaluation. We believe that it is important to develop capacity in both the Prison Service and the NHS because, however services for this group are configured in the future, they will need to draw on the skills and expertise of both services. However, this service development phase is also an important opportunity to pilot new approaches to assessment and treatment and to develop a 'what works' evidence-base before taking final decisions about the structure of any new services and how the new powers be applied. The pilot period will also inform decisions about the precise kind of services required, the settings which are most appropriate, and how quickly services would need to be expanded. An important aspect of this work will also be to look at how best to provide specialist services for women who are DSPD.

6.24    The following sections set out our strategy for service development. All the initiatives in this section are being managed under the joint Home Office, Department of Health, Prison Service Programme that has already been described at paragraph 2.16.

New capacity

6.25    The Government has already announced an ambitious programme of service development in the Prison Service and the NHS. The first pilot assessment centre at HMP Whitemoor opened in September and Rampton High Security Hospital has now started piloting the assessment process on its current population of male personality disordered patients. Over the next three years, new approaches to assessment and treatment will be piloted and systematically evaluated in new facilities in both services. The results of this comprehensive programme will feed into decisions about further service development beyond the forthcoming Spending Review period.

Specialist DSPD places within the NHS

6.26    The NHS plan, published in July, announced the expansion of provision of specialist services for DSPD individuals over the next three years. £56m has been allocated to provide:

• 140 additional specialist secure places for the DSPD group by April 2004;

• 75 specialist rehabilitation hostel places by April 2004 to enable those personality disordered patients assessed as safe to be discharged into the community to move out of secure facilities more quickly and receive specialist help and support in the community.

Specialist DSPD facilities within the Prison Service

6.27    In the Prison Service, £70m has been allocated to provide:

• 80 refurbished places ­ to be fully operational by October 2001

• 100 places in newly built units to open in April 2003

6.28    Because we anticipate that far fewer women will be assessed as being DSPD than men, these facilities are for men only. Decisions on how best to pilot new approaches and provide services for women, will follow on from a detailed study over the next twelve months into their numbers and characteristics within existing services and consideration of how best new approaches to assessment and treatment can be developed and validated for use with women.

Towards a new 'whole system' service approach

6.29    As these new facilities come on stream they will be used to pilot new approaches to the assessment and treatment of those who are DSPD. Within the Prison Service, the pilot services will be used under present legislative powers for sentenced prisoners on a voluntary basis. Within the NHS, pilot sites will be used under current Mental Health Act powers from the beginning. However, not only will these pilots sites be used for the testing out and evaluation of new approaches, they will also provide the core of new services following the implementation of new mental health legislation. These pilot sites could also provide the core of a new 'third service' if, following a period of evaluation and review, the Government decides to proceed with that option. Although the Government has not yet decided whether new dedicated facilities will be required for women, any future powers and any organisational structures based in statute must apply equally to men and women.

6.30    This service development period also means that as new powers come into force the facilities are already in place to allow them to be used. Within the NHS, this transition should be relatively straightforward since any new facilities will already have been operating under mental health legislation. Within the Prison Service, the situation will be more complex because there will need to be a transition from voluntary pilot projects to new statutory arrangements. The Prison Service DSPD assessment facilities will be used to carry out assessments of sentenced prisoners, using the new power of the Home Secretary to direct a prisoner to undergo a specialist mental health assessment (see paragraph 4.11). Where following an assessment, no order is made under the Mental Health Act to transfer the prisoner to an NHS DSPD facility, the prisoner may, if appropriate, be transferred to a suitable Prison Service facility that provides prison service regimes and other interventions relating to the prisoner's identified needs.

Managing DSPD individuals across the Prison Service and the NHS

6.31    However, the Government is determined that any new capacity developed in existing services should not perpetuate a fragmented approach to the management of this group. New services will therefore be developed in a holistic way with partnership arrangements between new settings a fundamental prerequisite both for the identification of new sites and their day to day running. This will ensure that new approaches can consciously draw on the best in existing provision and that common standards are consistently applied in both settings. Practitioners will therefore be encouraged to work across the interface between the prison service and the NHS. For example, close links have already been developed between the Whitemoor Prison and Rampton Hospital pilots involving, for example, staff exchange.

6.32    Moving individuals between the two services according to their needs, and therefore altering the powers under which they are held, will require significant oversight especially in the early days. Individuals being assessed and those who are subsequently detained under powers in new mental health legislation will be detained in an appropriate therapeutic environment.

6.33    Offenders serving a prison sentence who require assessment for DSPD will be assessed in specialist DSPD assessment centres within the prison service. On the basis of the findings of such assessments it will be open to the Home Secretary to make a direction to transfer an offender to hospital if such a transfer is considered by him to be appropriate.

6.34    Offenders before the Courts may be assessed in a hospital whilst on remand. Courts will take into account the findings of such assessments in making sentencing decisions. If an offender is assessed as being DSPD it will be open to the Court to pass a prison sentence combined with a hospital direction or to make a disposal under new mental health legislation. In either case, the offender will be detained in a secure hospital.

6.35    Decisions on more detailed service planning will follow on from the evidence of the pilot projects as more information becomes available about the numbers and characteristics of those who are DSPD. But it is reasonable to anticipate that in the early days there may be problems matching supply to demand in different parts of the country, something that will be particularly important in planning provision for screening and full DSPD assessment.

6.36    Therefore, as part of the DSPD programme of work, before new legislation is implemented a small project team ­ including operational staff from the Prison Service and NHS ­ will be established. The team will work alongside existing management structures to:

• manage the transitional process from the pilot process to the application of new powers;

• manage the demand for screening assessments for individuals in the community in the early years of service development and places in the DSPD assessment centres in both prison and NHS;

• manage demand for places in DSPD treatment facilities in both the NHS and the prison service, given the restrictions on where some individuals can be held;

• act as a focal point for clinicians and staff working in both prison service and hospital facilities to ensure that all future decisions about service developments at a local level are taken within the context of the overall pilot and research programme;

• maintain links with other personality disorder services in the NHS and specialist regimes in the prison service eg HMP Grendon ­ to assist in the management of those individuals assessed as having a personality disorder but who fall below the criteria for entry into the specialist DSPD service.

6.37    In due course, depending on the outcomes of the first phase of the pilot programme, such a central coordinating unit could take on responsibility for the commissioning of specialist DSPD places in both the Prison Service and the NHS, as a further step in bringing the two services more closely together.

The assessment process

6.38    The consultation paper outlined the need for a systematic approach to the determination of whether an individual had a severe personality disorder and the level of risk posed to others. In addition, it would assess any treatment needs, and lead to a plan of care and management that took account of public safety and the full range interventions required. As part of the consultation process (see paragraph 2.9), a group chaired by Dr David Thornton (Head of the Offending Behaviour Programme Unit, Prison Service) developed the outline of such a process which has been further worked up and is now being piloted at Whitemoor Prison and Rampton Hospital. The process falls into two parts: the screening assessment and the full DSPD assessment.

The screening assessment

6.39    The screening assessment will take place in the Prison Service for those detained in prison, and in the NHS for those detained under mental health legislation or those living in the community. The purpose of the screening assessment is to establish whether there is sufficient evidence of someone being DSPD to justify a longer-term intensive assessment, and to establish whether the individual is sufficiently robust to undergo the full assessment.

6.40    As part of the screening assessment, an individual's history will be considered and there will be an interview with clinical staff to assess suitability and to screen out more immediate mental health or other needs e.g. treatment for substance misuse. The screening assessment will be evaluated alongside the full DSPD assessment.

6.41    In the early days, specialist teams will be trained in the screening process at the pilot sites. Following the implementation of the new legislation, regional teams will need to be established to provide access to screening assessments throughout the country.

The specialist DSPD assessment

6.42    The full specialist DSPD assessment will take place at a specialist assessment centre located in either the Prison Service high security estate, or a high security hospital. As presently designed, the assessment process lasts 12 weeks but this will be reviewed as part of the evaluation of the pilot projects.

6.43    As with the screening assessment, a multi-disciplinary team will conduct the assessment. The assessment process will include a range of risk assessments, and psychiatric, psychological, as well as behavioural and social observation. At the end of the process a case conference will identify whether the individual has a severe personality disorder, whether his or her level of risk is sufficiently high to justify being managed in a secure DSPD treatment setting, and whether the risk presented is linked to the personality disorder. It will also identify any specific treatment needs. The findings will be set out in a report which will cover the results of individual tools and instruments used and contain the actuarial and clinical data to substantiate its conclusions. These reports will be available to judges in informing sentencing decisions for those before the Courts, and to Mental Health Tribunals as part of civil proceedings for detention under new mental health legislation.

6.44    A psychiatrist will be a core member of any assessment team so that if either during, or as a result of, the assessment a person displays symptoms of a mental illness, appropriate services can quickly be identified. There will also be individuals who, after assessment, are found to pose a high risk to others, but who are not personality disordered. In the case of individuals who have been assessed on remand at the order of a Court, information from the assessment process may still be helpful to the Court when considering sentencing, the Prison Service in sentence planning and the Probation Service in supervising offenders in the community. Where the individual is not currently before the courts, information on the risk they pose will be used by local risk management panels to put in place a plan to manage the risk the individual poses (see paragraphs 5.4-5.6).

Assessment of women who may be DSPD

6.45    The DSPD assessment process being piloted at HMP Whitemoor and Rampton Hospital applies to men only. However, new legislative powers will apply equally to men and women and this will need to be supported by the provision of appropriate services. A separate project has therefore been established to identify and provide for the needs of women including plans for separate pilots of the assessment process and new approaches to treatment (see paragraphs 6.68 and 6.69).

Assessment of dangerousness and personality disorder in young people

6.46    Assessment of dangerousness in young people presents an even greater challenge than adults given the developmental factors involved. It is not currently known how to accurately identify those in adolescence who will be assessed as falling into the DSPD group once they reach adulthood (see paragraph 6.71).

6.47    Young people may be detained under the Mental Health Act for mental disorder or under section 25 of the Children Act, if they meet the relevant criteria defined in the Acts. Some are detained in young offenders institutions following conviction for a criminal offence. Further work will be required to address the legal transitions and the interface issues between services for young people and adult DSPD services to ensure that mechanisms are put in place to provide ongoing care and treatment for such young people once they reach 18 years. In a very small number of such cases it may be necessary to arrange for immediate assessment for compulsory care and treatment in a specialist adult DSPD service under mental health legislation.

Evaluation

6.48    Rigorous, independent analysis of the DSPD assessment process will be a key part of the service development process and a contract for the evaluation of the process has now been let. The evaluation will examine whether the assessment process:

• is valid, reliable and user friendly (including the impact on staff);

• is predictive of re-offending, quality of life, social integration, overall better functioning;

• identifies co-existing mental illness, learning disability, substance misuse, physical ill-health;

• is non-discriminatory, fair, culturally sensitive and takes account of the needs of those from ethnic minorities;

• identifies wider treatment needs e.g. health, social, educational, occupational and criminogenic.12 The Royal College of Psychiatrists Council Report CR 71 ­ Offenders with Personality Disorder.

Treatment

6.49    The DSPD assessment will provide information not only to inform the decisions of the courts and Mental Health Tribunals, but also to identify the care and treatment needs of the individuals concerned. It will be a requirement of any compulsory care and treatment order under the new legislation that, where compulsory powers are sought primarily because of the risk that the patient poses to others, a care plan is available that is considered necessary either directly to treat the underlying mental disorder, or to manage behaviours arising from mental disorder. Therefore new capacity for care and treatment and the development of new approaches is a fundamental part of the Government's service development strategy.

Therapeutic interventions

6.50    DSPD is a working definition rather than a single clinical diagnosis (see paragraph 2.18). We anticipate that any DSPD population will include a number of sub-groups i.e. individuals who pose a high risk to others as a result of a variety of different personality disorders. A number of therapies and approaches have been shown to be effective with particular groups and it is important to build on these in developing a comprehensive range of treatments. It will also be important to ensure that treatment regimes are sensitive to the needs of those from ethnic minorities. As part of the service development process, there will be two new treatment pilots within the Prison Service. The first of these at Whitemoor Prison will open in October 2001 and provide two new units each of 25 places. Within the NHS, new units for treating those who are DSPD will also be established.

6.51    Initially these pilots will be based on the best of current knowledge drawing on both the experience of existing NHS personality disorder services and work in the Prison Service. We will also be drawing on international practice and research. However, we will be considering whether recent innovative approaches can also be incorporated within the overall programme for example:

• programmes being developed in the Prison Service for those with "high Hare scores", previously found to be resistant to conventional approaches;

• Dialectical Behaviour Therapy;

• therapeutic regimes such as that at HMP Grendon;

• other cognitive behavioural therapies; and,

• community therapeutic programmes.

6.52    It is envisaged that any final treatment programme will be tailored to the individual patient. It is possible that there might be a core treatment programme for most of those who are DSPD, but most therapeutic interventions will be selected from a wider menu to meet individual treatment needs.

6.53    However, as the Royal College of Psychiatrists' Report on Offenders with Personality Disorder13 concluded, there is a need to define and refine current treatment goals for offenders with personality disorder and to undertake long term randomised trials with long-term follow up. The treatment approaches that are to be provided at the pilot sites will be evaluated in terms of a range of outcomes including levels of change in psychological state and reconviction. Where programmes have been shown to work they will be re-evaluated at regular intervals to monitor outcomes to check that standards have been maintained. The design of the evaluations will be robust. The strongest design for an evaluation is random allocation of subjects and this will be considered and chosen if possible (subject to ethical considerations).

6.54    At present little is known about effective treatment for female offenders suffering from personality disorder and who pose a risk to others. There is some evidence to suggest that therapeutic communities, cognitive-behavioural and dialectical behavioural therapies may be effective in treating some individuals. Work is currently underway to map out the therapeutic interventions currently available or suitable for high risk women in Prison and NHS settings. We intend to draw on this mapping exercise in devising and piloting a range of treatment interventions for women identified as DSPD.

Good Practice

Good Practice

Good Practice

Developing effective community services

Discharge and rehabilitation

6.55    Those who are DSPD need to be detained in an effective therapeutic environment both in order to ensure that they are managed safely and ethically but also to enable them to work towards successful re-integration into the community. However, when individuals are assessed as safe to be released or discharged into the community, it is likely that treatments delivered in a secure setting will need to be 'topped up' in the community. Some may also require some form of supported hostel accommodation to help them to make the transition to life in the community.

New provision for community rehabilitation hostels

6.56    There is a recognised lack of suitable community services into which those individuals with personality disorder who are currently in the high security hospitals, and who have been assessed as no longer presenting a high risk to others, can be moved. The NHS Plan announced the provision, by 2004, of 75 specialist rehabilitation hostel places which will enable those SPD patients being discharged into the community to move out of secure facilities more quickly and receive specialist help and support in the community.

Community supervision

6.57    Community supervision will also be important in managing the process of discharge. The Government's commitment to a 'joined-up' service approach extends into the community and we will be working with the Probation Service and health and social services to ensure that expertise is shared and that, as far as possible, common standards are developed irrespective of which service is responsible for statutory supervision on release or discharge into the community. In particular, the Probation Service already has considerable expertise in managing risk and in rehabilitating offenders with severe personality disorder and it will be essential that health and social services work closely with the probation service and build on this knowledge base.

Secondary prevention ­ preventing future dangerousness

6.58    A multi-disciplinary project team involving representatives from the police, probation and health and social services has been working closely with the range of services and agencies that come into contact with people with personality disorder, to identify the difficulties currently experienced in managing this group of people in the community and any gaps in service provision, and to highlight effective models of multi-disciplinary working. The findings of this work will be made available shortly and will used by the Department of Health and the Home Office to facilitate further service development and effective models of multi-disciplinary working in this area. This work includes effective provision for those being discharged from secure care, and services for those young adults who may develop high risk behaviour and require detention in hospital if they do not received appropriate interventions at an early stage.

Improving local risk management arrangements

6.59    Multi Agency Risk Panels (see paragraphs 5.4 ­ 5.6) will have a significant role to play in managing the risk posed by dangerous people with severe personality disorder both before and after detention in hospital. They are well placed to monitor the risk posed by individuals in the community and to coordinate agencies' efforts to reduce that risk. Where risk can no longer be effectively managed in the community, they will be able to refer an individual for assessment under new mental health legislation.

Staffing issues

6.60    The provision of new staff, new skills and new ways of working is an important part of our service development strategy. The Human Resources and Training Project has been established to identify and provide for this and to make recommendations about how best and how quickly services can be developed beyond the initial pilot period. The project will work closely with those responsible for human resources in existing services to ensure that any new services are not developed at their expense and that new services are not isolated from mainstream mental health services and criminal justice services.

6.61    Each of the pilot sites will employ a multi-disciplinary workforce. Although in the Prison Service, the majority of the staff will be Prison Officers and in the NHS the majority will be nursing staff, both will also include members of other professions including psychologists, psychiatrists, occupational therapists, probation officers and social workers.

6.62    The pilot site teams will also receive comprehensive specialist training and preparation, in addition to their core skills and knowledge, for working with this group. This will involve the development of team based skills and competency training programmes, and supervision skills training for managers. Recruitment and retention plans will also be developed to help address the difficulties and isolation that staff working with dangerous and severely personality disordered individuals often feel. It will also be important to ensure that new services do not become isolated from mainstream mental health and prison services and career pathways will need to enable staff to enter and leave DSPD services at different points in their careers. These plans will incorporate race equality issues both because of the Government's fundamental commitment to equality of opportunity and because an ethnically and culturally diverse workforce is needed if new services are to be fair, non-discriminatory and culturally sensitive.

6.63    Finally, strong leadership for staff working with DSPD individuals is vital. Training programmes for those who will be managing service delivery will be developed and there will be staff support and supervision training.

Research and international comparisons

6.64    An essential component of the DSPD service development strategy is to increase the evidence base. Findings from previous research studies both nationally and internationally have indicated potentially beneficial interventions for the DSPD group, but the results have limited value (Stein and Brown 199114,Davidson and Tyrer 199615, Linehan 199316). This is because of the methodology used, the way in which samples have been defined, because follow up has always been relatively short or because the interventions themselves have not yet been evaluated on the higher risk groups with personality disorder. These are factors, which along with previous under funding, have led to a low evidence base and problems in achieving a professional consensus about service development models (Royal College of Psychiatrists 199917, Cope 199318, Dolan and Coid 199319). This is the global position in respect of those countries where such services are being developed.

6.65    The service development and pilot approach that we have adopted incorporates a rigorous research programme. An essential component of this is the development and maintenance of international links to share knowledge, to learn from each other, and to carry out research together. Of the countries where we already have good links, for example The Netherlands and Canada, considerable thought is being given to taking forward similar evaluative work in respect of their own services. To this end, we are taking a new and innovative approach in establishing formal working links, building on existing international links, for example, the Anglo Dutch Accord (SHSA 199520).

6.66    Rigorous evaluation will be a fundamental part of the development of new services. The Government is determined that the future expansion of services and decisions about how best to structure and manage services for this group will be based on an evolving evidence-base. This will in part be provided by the evaluation of the pilot projects. But a wider research programme alongside this work is needed to fill other gaps in current knowledge. Substantial resources have been allocated to fund a comprehensive research programme ­ £2m in 2001/02 and comparable sums in the following two years. In addition to evaluating the pilot projects, the research programme will include:

• work to refine the numbers and characteristics of people who are DSPD;

• work to identify the causes of personality disorder in order to develop therapeutic interventions among those at risk of developing DSPD;

• cohort studies to assess the validity of the assessment process in predicting reconviction and aim to identify the risk factors associated with re-offending in this group;

• a long-term follow-up study of offenders with personality disorder in the community to assess the criminogenic needs of this group; and,

• work to ensure that every aspect of service development is non-discriminatory and culturally sensitive to the needs of those from ethnic minorities.

6.67    This research agenda has been agreed by an expert group of academics, clinicians and practitioners21. This expert group will monitor progress and will quality assure projects within the programme. The highest quality standards will apply and, where possible, research reports will be published and peer reviewed.

Services for women who are dangerous and severely personality disordered

6.68    A separate Women's Services Project has been established in order to give special attention to the needs of women who might be identified as DSPD. This is not intended to imply that new powers will apply any differently to women but rather to mainstream consideration of women's issues within the whole programme of service development. The basic principle underpinning this work is that the criteria that determine identification as DSPD should be the same for men and women. In practice, this means that:

• the level of risk posed must be comparable between men and women DSPDs, although the factors that give rise to the risk, and the ways in which that risk may be demonstrated may differ (e.g. in men: violent sexual acts, in women: life threatening arson);

• the tools used for assessment should be validated for use with men and women;

• the assessment process should be gender aware but not gender biased. For example, it should not deliberately exclude from the identification of DSPD factors that are unusual in men, but more prevalent in women, and are good indicators of high risk;

• treatment programmes for all DSPDs will need to be individually designed. There will be no 'off the shelf' set of interventions, but it likely that there will be a common 'pool' of interventions;

• the range of treatment programmes suitable for use with women may differ from the range available for men, but all will be designed to address the risk posed.

6.69    The Women's Services Project will therefore work alongside other projects to ensure that the needs of women who are DSPD are identified and that specialist services are developed accordingly.

Prevention strategies

6.70    Annex E of the consultation paper outlined a number of Government initiatives being taken forward across a wide range of Government departments and agencies which will help to reduce the numbers of children and adolescents who become severely personality disordered and dangerous by intervening with those children most at risk of developing personality disorder.

Primary prevention

6.71    Building on these initiatives, work on primary prevention will be an important part of the DSPD Research Programme. As a first step in developing a strategy to increase our knowledge of the specific causative and protective factors involved in the development of severe anti-social personality disorders, and what interventions are effective in childhood and adolescence in preventing severe personality disorder, the Department of Health and the Home Office commissioned the Policy Research Bureau to conduct a literature review of current knowledge about childhood risk factors for the development of severe personality disorder, and possible interventions. The report is due to be published early in the New Year and will help to inform future research and policy development. This work will be taken forward as part of the Research Strategy.

Conclusion

6.72    Many respondents to the DSPD consultation paper, commented on the need for new investment to develop new capacity, new approaches and the need to develop a strong research base for the future. This programme of work represents a substantial new investment of almost £126m over the next three years. It provides a unique opportunity to address the challenges posed by this group. Our approach is a pragmatic one. Public protection requires that the full range of new powers should be available as soon as possible and that specialist services should be available to allow those powers to be used. But decisions on the further development of those services, the speed of build-up, and their final organisational structure will depend on the expanding knowledge base that this investment will secure.