The latest specifications for housing patients in medium secure care clarify the rules and include welcome proposals to improve life in locked wards. Rebecca Norris reports

In February the first of 89 service users are set to move into a newly built medium secure unit at South London and the Maudsley foundation trust's Bethlem Royal Hospital in Beckenham, Kent.

In moving to the purpose built unit some will be leaving a unit that had once been the face of all things modern about locked wards. A picture of the hospital's Denis Hill unit features on the front cover of a 1993 NHS design guide. The guide served as the chief rule book on how to house offenders in secure hospitals until it was superseded in July by a new Department of Health specification for medium secure units.

'The specification is not a national service framework,' says DoH head of medium secure policy Karen Howell, 'but it is recommended best practice and designed to support the commissioning of these services. Providers and commissioners across the piece were all saying: "Please define medium secure services."'

With record numbers of service users living in medium secure settings, the specification's 187 quality principles have been welcomed for not just tightly defining physical security requirements but also setting out minimum care standards. They state that it is as important for units to provide patients with at least 25 hours a week of structured activity as it is to stay behind a 5.2m perimeter fence.

DoH officials are now talking to the Healthcare Commission, the Mental Health Act Commission and foundation trust regulator Monitor about how they incorporate the standards into future checks so a national picture on the current state of medium secure units can be painted for the first time.

In the meantime, commissioners will use the specification to ensure consistent practice across units and weed out unfit providers.

East Midlands medium secure commissioner and co-author of the specification Lee Brammer says: 'Historically some providers - in the independent sector as well as the NHS - have marketed themselves as medium security, when actually the service environment provided for patients falls well short [of this specification]. We were also very clear that there had to be equity for patients, whether it was for male patients with mental health problems, people with a personality disorder or a learning disability, or female patients.

'If we are going to deny patients their liberty, we also need to ensure we're not detaining them in a higher level of security than their needs demand. Providers should not have an expectation of revenue if they are not providing a service that meets a specification, or commissioner or population requirements.'

Growing need

High and medium secure units are now home to a record number of patients - 3,723 in July - according to figures revealed by the Sainsbury Centre for Mental Health in September. Numbers have risen by 45 per cent since 1996.

This is partly explained by medium secure services taking on 400 new patients that the 2000 Tilt report found had previously been kept inappropriately in high security beds. The growth of prison inreach mental health teams has also unearthed many prisoners with unmet psychiatric needs.

'The guidance quite rightly highlights the inter-relationship of physical, procedural and relational security in this setting,' says Phil Garnham, Oxleas foundation trust joint head of nursing and RCN forensic nursing forum chair.

Relational security uses the therapeutic relationship between staff and patients and structured activities to reduce risk.

'For quite a lot of service users, a therapeutic relationship between them and staff members may be the first significant relationship they have had. They usually have not had a consistent upbringing, or engaged in school. We also concentrate on structure through work opportunities with gradually increased opportunities to gain skills. Most medium secure service users have no employment history,' says Mr Garnham.

'This patient group is one of the most socially isolated you would come across. We're pleased the guidance recognises the importance of staff treating them with respect and dignity. If they don't, then patients are not going to be able to go into the community and offer the same respect and dignity to people they are then living with.'

Public health standards outlined in the guidance are also welcome, given the level of undetected physical problems, such as sexually transmitted diseases, in the predominantly male population of medium secure units.

'If patients are hiding such problems, the embarrassment and physical pain could be contributing to some of their attitudes and reactions,' adds Mr Garnham.

The forensic sector acknowledges it is relatively better funded and staffed than general inpatient psychiatric services. But some units are likely to find improving the patient's day 'challenging', says John O'Grady, a consultant psychiatrist at Hampshire Partnership trust's medium secure unit Ravenswood House and chair of the Royal College of Psychiatrists forensic faculty.

Staff shortages and limited room space can prevent patients receiving a full range of therapies, according to a pilot project launched by the college's quality network for forensic mental health services. The eight providers that inspected each other also found most units failed to give nurses at least one hour's clinical supervision each month.

The Mental Health Act Commission is also concerned about the quality of the patient day.

'A common problem we encounter during our visits - not just particular to medium secure care, but to general psychiatric inpatients as well - is a lack of meaningful activity for patients,' says Phil Wales, one of the commission's four regional directors. 'We don't want care plans in theory that aren't put into practice for any one of a number of reasons on any given day.'

Other units may struggle to meet the specification's physical security standards. Mr Brammer says an audit of his region's five medium secure providers - two NHS, three independent - shows one virtually meets all of them, one faces significant challenges, two need to improve their policies and procedures and one may not meet standards at all.

'There are some threats there for some services because of the level of investment they may have to make and also whether they will gain planning consents for changes,' he says. 'We have been very open with providers, so they are aware of the direction of travel.

'We are now working out an agreed action plan of compliance. I'm looking for 1 April 2008 as the target date unless there are clear derogations bilaterally agreed. If providers then still say they can't meet them, my view is I wouldn't have a mandate to commission from them.'

On the fence

NHS medium secure units are covered within the generic annual health checks of mental health trusts, with the Healthcare Commission registering private settings, largely guided by the old design guide.

Commission mental health strategy head Anthony Deery recalls only one case of refused registration; the provider's perimeter was not high enough and could not be compensated for by procedural or relational security measures.

The fence has been a sticking point,' he says: 'In the 1993 design guide, the NHS stated it should be 5.8m or 5.9m high. They then said this was an error but they didn't issue an erratum, so there was a lot of confusion and debate about whether you needed a fence all the way around or could you use the building as an integral part of the perimeter. I think the latest guidance clears that up.'

Mr Deery suggests the specification will become a subcomponent NHS and independent sector registration. But he also calls for the DoH to compel the independent sector to supply more data and to participate in the national patient survey, in line with NHS reporting. 'Roughly 80 to 90 per cent of patients in independent mental health hospitals are publicly funded but we do not have the same kind of information about them as we do from the NHS on detail such as length of stay, ethnic coding and age.'

The guidance will not be mandatory; regional commissioners will performance manage providers not meeting the standards, says Ms Howell. Regional audits in January did not indicate commissioners had great concerns, she says.

Until an independent report from a regulator confirms this, the national state of medium secure provision is largely a guessing game. What is not contested is concern about how quickly service users can access medium secure care.

At the end of each quarter of 2006, the Sainsbury Centre for Mental Health found over 40 prisoners had waited more than three months for their transfer to a medium or high secure unit. The Home Office has also criticised the NHS: 'The failure to identify need and provide support, at an early stage is the reason why some people offend in the first place,' it said in an October report.

The criminal justice system 'to a degree ties your hands as to how timely you can discharge those patients who are subject to restriction orders', says Mr Garnham.

Sainsbury Centre prisons and criminal justice director Sean Duggan, who 20 years ago was a charge nurse at the Denis Hill unit, notes the DoH is trialling 14 pilots to achieve maximum 28-day transfers. But he hopes the government might also consider mental health courts, where the judge is also a psychologist and practitioners are on hand to immediately advocate and assess patients.

'The courts can have pre-arranged contracts or agreements with forensic services so patients can go straight in to mental health care or diversion schemes, rather than have to go into prison and wait for assessment,' he says.

Meanwhile, observers warn medium secure settings cannot be seen in isolation from the rest of the care pathway.

'Psychiatric intensive care units and other units sometimes called low security are not suitable for long-term care, they are designed for short-term interventions and general psychiatry. What is missing is low-stream rehabilitation in a secure environment,' says Dr O'Grady.

'If you want to reduce offending, you should return people to adequate housing, employment, and education in low crime, low drug-using areas of the country,' he says. But he adds 'To be fair to the DoH, I think they are well aware of the problem and the next piece of work may well need to be on what constitutes low security.'

Commissioning issues: medium secure units

Commissioning of medium secure units is undertaken regionally with pooled primary care trust budgets under arrangements introduced in the 2006 Carter review.

National spending on the sector equates to around£0.5bn or£150,000 per patient per year. An uneven geographical spread of units often requires patients to be placed out of area, at great cost, with the independent sector providing around half of NHS-funded places.

In October care services minister Ivan Lewis revealed the need for an extra 699 medium secure beds by 2011. Projections are based on historical bed use, changes to mental health legislation, court sentencing trends, prison transfer rates and the needs of specific offender groups such as people with learning disabilities or personality disorders.

Mr Lewis said the NHS was 'on course' to meet this expansion, so long as regional commissioning was co-ordinated and delivered good value for money.

Commissioners often face fierce public opposition to new builds. In one case in Birmingham, local Labour MP Roger Godsiff warned the House of Commons a planned 80-bed medium secure unit on the site of a defunct hospital was 'totally wrong' when residents had previously been promised housing, education and general health facilities on the grounds.

Despite the cost and controversy, latest figures show only two per cent of patients discharged from secure units reoffend within two years with violent or sexual offences, compared with 46 per cent and 27 per cent respectively by people released from prison.

Five years of development - and some controversy: south London's new unit

'It is going to be a landmark,' enthuses Jane Wearne, project director at South London and Maudsley foundation trust for the organisation's 89-bed medium secure unit, which is due to open in February.

The£35.5m River House unit has been five years coming and has not been without controversy. Planning consent was only granted on appeal by the then office of the deputy prime minister in 2003.

Funded under the Department of Health's ProCure21 framework agreement and built by the trust's chief supply chain partner Interserve Health, the scheme was signed off by the finance director at the former South East London strategic health authority. Despite losing his post in the last NHS shake-up, he felt strongly enough to turn up to the unit's recent naming ceremony.

Ms Wearne praises the scheme's architects for an 'inspired' design that makes the most of the 250 acres of former estate land in which the unit is sited.

'When you approach the building there is nowhere you can see the whole of the building. It is not until you go past the administration building and staff areas that it opens up into a village of interconnecting wards, all grouped around a courtyard,' she says.

The unit includes individual gardens outside the accommodation and what Ms Wearne calls 'an incredibly high standard of therapeutic facilitates', including occupational therapy and activity areas, a fitness suite and gym.

Consultant psychiatrist and trust lead clinician for forensic services Andrew Johns says half of the unit's 89 patients will be repatriated from out-of-area care, including as far away as York.

'As well as avoiding costly placements the new unit should help us to link discharge planning into local care pathways and other services,' says Dr Johns.

River House will include women-only accommodation, separate intensive care and personality disorder wards and three flats for more independent living. Patients had input into the design.

'We are bringing together 14 or 15 men who may not have known each other before. We also have to double up on staffing for those patients moving from within the trust,' add Dr Johns.