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Review Of Forensic Services Signals Way Forward

Timely Review Of Forensic Services Signals Way Forward

Dr Janice Wilson, Ministry of Health Deputy Director-General of Mental Health released today the report on services for people with mental illness in the justice system.

"It is timely that a review of the current framework for mental health services for people in the justice system has happened as it is 10 years since the regional forensic services were first set up", said Dr Wilson.

"At the heart of the revised framework is the role of Adult Mental Health community teams as the hub of community provision supported by the specialist community forensic services".

"We do have forensic mental health services that are internationally recognised, but that does not mean that we cannot improve them. The purpose of the review has been to identify where improvements can be made".

"The overall aim for people with mental illness in the justice system is to provide a level of general mental health service similar that which would be provided to anyone with a mental illness. However within the population in the justice system there will always be a small group who will also require on-going secure care or specialist oversight through forensic mental health services".

"The report released today both revises the current framework and identifies the key areas requiring increased levels of service provision. New or enhanced services are specified for prison teams and assertive community teams. Increases to forensic inpatient beds and court liaison services are also identified. Quality improvements will also be required in adult community mental health teams, acute inpatient wards, and services for Maori in all areas".

"The purchasing of these new services has already begun in line with the way forward. A detailed national implementation plan supported by four regional plans will also be developed. A steering group, set up to support the implementation phase, will be led by the Ministry of Health in partnership with District Health Boards. This group will also involve a range of key organisations including the Department of Corrections, NZ Police and the Department for Courts."

"The implementation plans will cover areas such as; how Heath and Corrections will work together around their respective responsibilities, workforce development, effective participation of Maori and Pacific Islands peoples and enhancement of adult mental health services".

"Funding for the developments and enhancements will be met from within the money available to the Ministry of Health for implementing the Mental Health Commission's Blueprint for Mental Health Services in New Zealand."

"The way forward will result in both improved community mental health services and specialist forensic mental health services".

End

For more information contact: Gerard Vaughan, Communications Manager, Mental Health and Disability Issues ph: 04-496-2064 or 025-402965

16 March 2001

Questions and Answers sheet

"Services for People with Mental Illness in the Justice system - Framework for Forensic Mental Health Services"

- Why has this review of mental health services for people in the justice system been done?

The national mental health strategy required the Ministry to set population benchmarks for access to forensic mental health services.

In 1999 the Department of Corrections published the National Study of Psychiatric Morbidity in New Zealand Prisons, which established the number of people in prison with a mental illness. This report also projected an increase in inmate numbers that will impact on forensic mental health services.

Given this, and the fact it is 10 years since the regional forensic services were set up, it was timely for the Ministry of Health to review the current framework in which forensic and other mental health services are being delivered to people in the justice system and to identify ways to further develop the framework.

Has additional funding gone into forensic services since the National Study of Psychiatric Morbidity was completed in 1999?

Approximately $9.2 million (GST exclusive) of additional funding has either gone into or been budgeted for forensic mental health services between 1998/1999 and 2001/02. This is an increase of approximately 19% i.e. from a total forensic budget of $48 million in 1998/1999 to $57.2 million in 2001/02.

What additional bed numbers have been funded through this extra money?

The increased bed numbers include both intensive treatment services in inpatient and step down facilities. (A step down facility provides a service for people who are in transition from long-term inpatient settings and who need to develop community living skills prior to moving to a community residential service). By 2003 we will have increased inpatient and step down bed numbers by 31 beds, from 192 beds in 1999 to 223 beds in 2003.

What other forensic services have been or will be funded?

There will be further development of prison forensic teams, court liaison teams and community assertive treatment teams through adult mental health services. By 2003 we aim to have nationally the following full time equivalent numbers:

Service Area Staff FTE Forensic Community Teams 17 FTE's Court liaison teams 19.2 FTE's Adult Mental Health Community Assertive Treatment Teams 40 FTE's Prison Teams 46.5 FTE's

It is difficult to calculate the increase of this requirement over current FTE's in these areas, as these services are currently configured in different ways around the country. The three-year implementation phase of the Framework will require some re-configuration of how these services are currently delivered. Additional funding may be required to achieve these 2003 targets.

What other things will be happening as a result of the Framework?

As well as developing a detailed three-year implementation plan a steering group will also be set up to support the implementation phase. The steering group will involve a range of key organisations including the Ministry of Corrections, NZ Police and the Department for Courts.

The implementation plan will also cover key areas of clarifying roles and responsibilities of Heath and Corrections, workforce development, effective participation of Maori and Pacific Islands peoples and enhancement of adult mental health services.

What was the scope of the review?

The terms of reference for the review were to:

· establish benchmarks for levels of service for forensic mental health clients · clarify responsibilities of forensic services through identification and resolution of interface issues between health and criminal justice services · identify current and future resource requirements · develop a comprehensive best possible model for forensic health services.

What areas does the Framework identify as needing additional resourcing?

The Framework identifies that increases are required in forensic inpatient beds and court liaison services. New or enhanced services are also specified for prison teams, assertive community teams, and community mental health teams. Quality improvements will also be required in adult community mental health teams, acute inpatient wards, and services for Mäori in all areas. The Framework also proposed national benchmarks to guide resource allocation.

Where will the funding come from to implement the Framework?

Funding for the needed developments and enhancements will be met from funding available to the Ministry of Health for implementing the Mental Health Commission's Blueprint for Mental Health Services in New Zealand.

Who will be involved in implementation of the Framework?

To fully implement the findings of the Framework both the Ministry of Health and the Department of Corrections will need to continue to work together around their respective responsibilities. For Heath key areas for further development will be around acute services for assessement and treatment, as well as structured rehabilitation for defined periods of time and extended rehabilitation for those who need continual care and rehabilitation in a secure environment for a long period of time.

The Department of Corrections prison health service will continue to be responsible for primary mental health care of inmates. This includes assessment to enable diagnosis, referrals and intervention and this role will be supported by the forensic mental health team in a consultation/liaison fashion.

How will the Framework benefit people with mental illness who are currently in the Justice system?

The aim is to provide a level of general mental health service to people in the justice system similar to that which would be provided to anyone with a mental illness. This includes services available through primary care and specialist mental health services available through forensic services. Of the population in the justice system there will always be a small group who will also require on-going secure care through specialist forensic mental health services. The Framework, when implemented, will result in both improved primary care and specialist mental health services.

What are forensic mental health services?

Forensic mental health services is an area of mental health that specialise in providing assessment, treatment and rehabilitation to people with a mental illness who have also committed crimes or who are at risk of committing crimes. These services were established on a regional basis following the 1989 Mason Report. Regional Forensic Services provide 'outpatient' services (assessment and treatment) plus secure treatment facilities for those requiring intensive treatment.

How do people in prison access forensic mental health services?

Prison staff have the responsibility for referring inmates who may have a mental illness to the prison medical services. Those services may in turn refer on to the forensic psychiatric services if the person requires this specialist service.The service is carried out by a multi-disciplinary team providing assessment and treatment for people who are acutely ill, as well as those not acutely ill. The forensic team will assess whether an individual needs to be transferred to a forensic inpatient unit for ongoing assessment and treatment, or whether such an individual can be assessed and treated within the prison environment.

What percentage are forensic services of the total mental health budget?

The 1999/2000 Budget for mental health services was $596 million. Forensic mental health services are approximately 9% of this total budget.

"Services for People with Mental Illness in the Justice System - Framework for Forensic Mental Health Services"

Executive Summary The 1988 Mason report established the model around which forensic services are structured and delivered today. Since then, community-based services for all mental health patients have developed considerably, driven largely by the national mental health strategy (Looking Forward 1994) and increased funding for mental health development. Although the Mason report proposed their development, it did not anticipate the present configuration of community services.

This review is intended to enhance provision of both corrections and forensic services, including services to prisons and courts. It was conducted in the wider context of health services.

The terms of reference for this review are to:

1. establish benchmarks for levels of service to forensic clients

2. clarify responsibilities of forensic services by identifying and resolving interface issues between health and criminal justice sectors

3. identify current and future resource requirements

4. develop a comprehensive 'best possible' model for forensic services.

The resulting proposals clarify the purpose and target population of forensic services, and emphasise community mental health over specialist services. They aim to improve services as much as possible for the consumer, with as little disruption as possible for service providers and clients.

Review findings

The review used a census and qualitative surveys to gather up-to-date data. The Review Findings companion document presents results in full.

The census shows: · forensic services treat only a few people overall (189 inpatients and 256 outpatients) · court and prison liaison staff of regional forensic services assess about 2500 people at court and 4500 prison inmates per annum · the vast majority of inpatients and outpatients are male · a disproportionately high number of Mäori are forensic service consumers · many forensic service consumers are diagnosed with schizophrenia or another serious mental illness, most of whom are required to receive care under legislation · for most inpatients and outpatients, index offences are 'serious' (ie, violent or sexual) offences.

>From qualitative feedback, overall consensus was that the current model of forensic services is appropriate. Predominant themes among responses were liaison and integration of forensic services and adult mental health services (AMHS). Concern was expressed about: · inadequacy of forensic facilities for women and long-term patients · inappropriateness of forensic care for people with an intellectual disability, with behaviour problems associated with head injuries, or with challenging high-risk behaviours · workforce and resources, in view of increasing demand and shortages of Mäori and Pacific staff · screening for mental illness in prisons · the lack of step-down or community-based residential facilities for forensic clients.

The Mäori review highlighted: · lack of effective Mäori participation at all forensic service levels · lack of Mäori frameworks and infrastructures to integrate Mäori into mainstream services in many regions · issues for Mäori mental health professionals and traditional practitioners · the high proportion of Mäori in the forensic population, including high rates diagnosed with schizophrenia.

Issues

The lack of clarity about the target population could create more forensic consumers than necessary. Possible consequences are more forensic institutions, service delivery inefficiencies and, for many people, inappropriate care as well as unnecessary criminalisation and stigmatisation.

Blurred boundaries between forensic service providers and associated services illustrate a need for more integrated services and greater continuity for the consumer.

The need to gather information for the review, and consequent difficulties, indicate major problems in data collection and information systems.

Model of service

A comprehensive, integrated community approach is proposed. It builds on the community care principle at the heart of modern mental health services, aiming for the least restrictive level of care in the most 'normal' environment possible. It also enhances the current model of corrections and forensic services.

Under the model the forensic services will continue to be a specialist service, but greater focus is given to their role of working with AMHS in a supportive partnership. AMHS will have an enhanced (and supported) role in providing community services to people who are discharged from prisons or forensic inpatient services.

Specialist forensic teams in the community and inpatient service will support AMHS and provide a consultation liaison service, as well as provide (direct) ongoing oversight of a small number of individuals. Expanded forensic court liaison and prison teams will enhance services to people referred by court or a prison.

Reallocation of funding as well as increased funding may be considered, so that AMHS can strengthen their capacity for both community and inpatient care.

There should be greater Mäori participation at all forensic service levels. This result may be achieved through additional Mäori staff or kaupapa Mäori services in the mainstream environment, or by establishing separate kaupapa Mäori services.

Services have clear responsibilities under the new arrangements. Part of the implementation process is to ensure there are appropriate incentives (eg, a review process) to meet those responsibilities.

National benchmarks have been developed for forensic services under this model. These benchmarks are intended to guide rather than determine resource allocation.

Resource requirements under the proposed model include: · more resources for forensic inpatient beds and court liaison services · new or enhanced services for prison, assertive treatment and community mental health teams · quality improvements in AMHS community teams, acute inpatient wards, and services for Mäori in all areas · skilled, competent staff ? with further work needed to determine training and education needs, and ways to meet them effectively · information services to support community teams and, more generally, the proposed model.

Together these changes should lead to responsive, quality services delivered in the least restrictive and least stigmatising environment.

Implementation

Implementation will be planned in the context of current changes in the health sector. It is envisaged that establishing the enhanced role for AMHS is a medium- to long-term goal, probably taking four to five years.

Future work

Further study is needed on the needs of children and youth, which this review did not address.

It is proposed that people in prison receive services on the same basis as people in the community. Within the prison setting it is not possible to provide compulsory treatment. There is a need for extensive debate over the suggestion to change this situation.

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