A survey of medium-secure units for mentally disordered patients reveals wide variations in staff-to-patient ratios. James Rooney considers the implications

The current inquiry into the service and the level of security provided in the personality disorder unit at Ashworth Hospital highlights yet again the problems that appear to exist within the maximum-secure special hospitals. Much will be written about the Ashworth inquiry in the next few months. But the special hospitals do not exist in isolation, and many of the patients admitted to and discharged from these hospitals also use the medium-secure unit (MSU) network. The maximum-secure hospitals and medium-secure services together constitute what are traditionally known as the forensic services, providing care to mentally disordered patients who require treatment in conditions of greater security than can be provided in open mental health units.

Although the medium-secure network forms an important part of an integrated, comprehensive mental health service, remarkably little has been written recently about its organisation, composition and effectiveness and the problems it faces.

Special hospitals have been around since the 1850s. MSUs date from the Butler report of 1975.1 There are approximately 25 medium-secure inpatient and community services that serve multi-district areas within England and Wales. But 21 years on, some of the key recommendations in the Butler report have still not been carried through. Despite the recommendations that, for instance, a secure hospital unit would be built in each regional health authority, and that this provision would be financed by a direct allocation of central government funds, numbers of secure beds are still not adequate.

The London purchasing authorities remain highly dependent on medium-secure services in the independent sector, and have seen expenditure on secure services in London more than double in the three years since 1993.2 The inadequate implementation of this key recommendation is also shown by the fact that North Wales has only recently received the finance to build a specialist MSU with a completion date of October 1998.

A second key recommendation of the Butler report was that,'the running costs as well as the capital costs for the regional secure hospital units should be met from central funds'.

Although this recommendation was not fully implemented, most of our colleagues who work in generic mental health services have a perception that all medium-secure services have developed uniformly. In some respects they have.

Most medium-secure services will provide pre-admission assessments, inpatient services, and either phased or total aftercare and all or some of the following: diversion schemes, sex offender/violent offender treatment, training and advice/consultancy.

But there are major variations between services in relation to philosophy and staffing. These variations may be the result of the service meeting local need, but more likely reflect the beliefs of the key stakeholders driving the development of the medium-secure service in each area.

A survey carried out by the North Wales service across 18 medium-secure services highlights this diversity. The units surveyed ranged in size from 13 to 77 beds, and covered catchment areas of between 700,000 and 5.2 million people. The ratio of nurses per bed ranged from 1.6 to 2.7, with the qualified nurse staffing level ranging from 52 to 90 per cent. The impact of this variation needs to be seen in the context of the provision of treatment and security.

All the secure units surveyed highlighted the intensity of the care delivered within a maximum two-year time frame. In addition, it is recognised that the security provided by the secure unit has more to do with the number of staff and their skill in forming therapeutic relationships and carrying out effective treatment and observation than with the physical security of the units.

While acknowledging that all disciplines working within the service contribute to both treatment and security, nurses not only form the largest group of staff, but are also the only group who work across a 24-hour period, seven days a week. Therefore it can be assumed that they would have a greater impact on the day-to-day therapy and security provided within the service. With such a wide variation evident in nurse staffing, it would be interesting to compare the effect of this variation in numbers and grades not only on the value for money provided, but potentially on the effectiveness of the treatment implemented and the security provided. Similar variations were also evident in other disciplines.

The table highlights the numbers of beds per discipline. As can be seen, the number of beds per consultant psychiatrist ranged from 6.5 to 30, which implies a major difference in the level of workload undertaken. All the services surveyed had junior medical staff who are not included in these figures, but the numbers were remarkably consistent across services. In relation to the psychology department, most services were funded on either 'A' or 'B' grades, but some services also employed psychological assistants. Psychological assistants are not included within the figures provided, which show that the number of beds per qualified psychology staff range from 4.3 to 30. For the purposes of the survey, we also combined the numbers of social workers and probation officers working in each service. These ranged from one to eight in total, depending on the size of the unit surveyed. The numbers of beds per social worker/probation officer ranged from 5.4 to 30. As can be seen, the range from minimum to maximum is comparable across these three disciplines.

It was evident from these figures that if the unit surveyed had high staffing numbers in one discipline it had high staffing numbers in all disciplines, irrespective of the size of the unit or its location. There is no evidence that an MSU placed in an urban area is better staffed than one in a rural area, or that there is a north/south divide. However, in units where the staffing figures in the disciplines were poor in comparison with other services, the staffing levels for occupational therapy did not fit this pattern. Most services employed both qualified and technical occupational therapy staff, and the number of beds per all occupational therapists ranges from 4.3 to 14. It would appear that where there were poor staffing levels in nursing, psychiatry and psychology, managers had decided to increase the numbers of occupational therapy staff to offset these figures and to ensure that therapeutic activity was maintained.

The survey results appear to indicate that aftercare provision had a high priority. But two of the 18 services surveyed did not employ community psychiatric nurses. Among the others, the number of CPNs per unit ranged from one to seven, and the numbers employed appeared to relate not to the size of the unit, but to the population served. Ten of the units surveyed had some funding for patient education, which ranged from a half day per week for one unit to a whole-time equivalent for another. Visiting therapists were also employed in most services, eg art, drama, speech and physiotherapy.

It is impossible, without further research, to determine how decisions were made. But it appears obvious that all of the medium-secure services surveyed have developed independently, depending on patient need, available funding and the philosophies, values and beliefs of the major stakeholders and drivers behind each service. It is often said that medium security is provided not by locked doors and windows, but by the staffing levels and the relations the staff have with their patients. If this is true, these figures suggest that the level of security is applied with great variation across the different services in England and Wales.

On the face of it, one might in essence argue that some units are providing a higher level of security than others, and that the quality and intensity of service delivered differs. However, as little research has taken place on the efficacy of medium-secure services, these statements are hard to substantiate. Indeed, one of the most disappointing aspects highlighted by the survey is that a third major recommendation of the Butler report that, 'more research in connection with mentally disordered offenders and the importance of planning evaluative studies to be built into any new regime or form of treatment' has not been implemented either.

This is particularly disappointing when one considers that in England and Wales, unlike in many other countries, there is a network of purpose- built centres dealing with a similar group of clients who are usually followed up over a long period of time. This would appear an ideal basis for collaboration and inter-service research. It is hoped that this missed opportunity will be taken up in the near future.

It is fair to say that the High Security Psychiatric Services Commissioning Board has tendered for some research to be undertaken. But there remain too many questions unanswered about the efficacy and cost-effectiveness of different treatment methods, different staffing levels and different organisational and management structures in determining the short and long-term outcomes for the clients entering the MSU network.

Butler also identified the difficulties of finding sufficient suitable staff who will work in these units. His report noted: 'financial recognition for these nurses had been negotiated so that it would encourage many of them to accept the specialised and demanding work'.

Many of the units contacted are still having difficulty appointing up to their established levels in most disciplines, particularly in nursing and occupational therapy. To compound this, the advent of trusts and local pay bargaining has meant that the 'forensic lead' for all nursing staff, particularly unqualified nursing staff, has now become a talking point and could be abolished in the near future. This, in addition to the low numbers of qualified nurses available in the market, the increased competition for staff and the arguments for a generic worker, could make staffing these services more difficult in the future, which would have an impact on public safety and patient therapy.

Although forensic services have had a high profile for the past few years, this has not always been for the best reasons. It is imperative that the services have good leadership so that we can get our message across at local and national level, a more coherent plan and follow-through on the future of these services occurs, and gaps and missed opportunities are rectified in the near future.