Medium secure provision for women has been inadequate, but services tailored to their needs are now being provided. Emma Dent reports

When Avon and Wiltshire Mental Health Partnership trust opened a new, purpose-built, secure unit in Bristol late last year, for the first time in almost 20 years it was able to offer a women's medium secure service.

The creation of Fromeside reflected a growing trend in mental health services to provide this type of care in house after decades of reliance on the private sector for its provision.

Secure services constitute a relatively small but crucial part of mental health inpatient services, offering enhanced levels of security to those who may present a risk to themselves or others.

Category B is high security is provided only in former special hospitals; other services are rated either medium or low.

The reduction in high secure settings has meant the provision of more care in medium secure facilities - which effectively did not even exist until around 30 years ago.

Service managers admit that provision for women in this area has been inadequate.

Between eight and 12 per cent of all medium-secure patients nationally are women, but NHS provision of this type of care has not reflected need.

Women in secure settings pose particular challenges. Self-harm - up to 90 per cent of women in high secure and 70 per cent in medium secure facilities are estimated to have self-harmed - and fire starting are two common behaviours. Women are likely to have a history of abuse and/or self-harm but are less likely than men to have committed a violent or sexual offence, hence the limited need for high secure services.

Sue Waterhouse is regional lead for gender and women's mental health at Care Service Improvement Partnership south east development centre, and head of women's services at Sussex Partnership trust. She explains that it is because they present such behaviours and diagnoses that women often end up in secure settings. They tend to 'float' up the psychiatric system because the way they behave is considered unacceptable in a standard acute psychiatric inpatient unit.

'Services are provided around men,' she says. 'Women needing this kind of service often have horrific backgrounds - histories of abuse and domestic violence. They display their reactions to this in ways that society does not accept. It is not considered acceptable for women to show their rage and so they are considered difficult to manage,' she says.

'A lot of what has been done in the past has retraumatised women. Some women need women-only services.'

Blurred boundaries

Secure patients may also come from the criminal justice system, whether prison or a court referral scheme.

Kent and Medway trust acting director of forensic services Kevin Halpin says the two groups - those coming through the psychiatric system and those arriving via the criminal justice system - are not necessarily mutually exclusive.

'One of the consequences of the closure of the old large mental hospitals was that some patients who had spent a lot of time in them found themselves drifting to the only other institution left open to them: prison,' he explains.

The particular care needs of women in such circumstances were outlined in a 2002 Department of Health policy document Women's Mental Health: into the mainstream and its implementation guidance Mainstreaming Gender and Women's Mental Health.

Secure care for women had been regularly criticised by bodies, including the Mental Health Act Commission, Commons health select committees and support group WISH (formerly known as Women in Secure Hospitals).

Into the Mainstream recognised that only a small number of women need high secure care and outlined a model of care for a secure service specifically for women. This included the physical design of the facilities, staffing, organisation of activities and therapies and policies on the mixing of men and women.

Before this, a large proportion of independent sector provision had emerged as a direct result of the private sector stepping in to provide beds when the NHS felt unable to do so. The independent sector remains a provider of women-only settings and, as a result, some primary care trusts still commission private care.

Earlier this year, Nottingham City PCT was lead commissioner on a deal with Partnerships in Care to provide medium secure beds for women in Nottingham for 119 PCTs.

The right pathway

'Commissioning services in this way guarantees a clinical pathway for the service and provides a guaranteed price for the next three years,' says Partnerships in Care director of women's mental health services Dara Ni Ghadra.

Safety concerns had led many trusts to withdraw from provision of medium secure care for women but, prompted by Into the Mainstream, an increasing number are now providing it in house again.

'We decided we could not offer a medium secure service to women in 1987,' says Avon and Wiltshire Mental Health Partnership trust's clinical service manager for women's services Les Petrie.

'In the 1980s, secure units were mixed sex. It was felt all patients could be looked after on the same wards. But we could have sexual offenders on the same ward as women who were victims of abuse. It is easier to move women out than men because there are fewer of them in such services. So we started to place women with a preferred partner, but when they did not have any room a client would have to go wherever a place could be found,' he says.

The trust opened Fromeside, in Blackberry Hill, Bristol, last December, after previously providing only a 27-bed men-only unit. The 12-bedded women's unit at Fromeside opened in February, with many clients brought back from out-of-area placements.

There is a similar story at Kent and Medway NHS and Social Care Partnership trust, where a newly built 10-bedded unit for women at the Trevor Gibbens unit in Maidstone began receiving patients last October.

'We had stopped taking referrals for women a few years ago because a mixed environment was inappropriate and might have left them vulnerable. Most of our current patients were brought back from out-of-area placements and it took just two or three weeks to be full,' says Mr Halpin.

In East Sussex, before local services were amalgamated into Sussex Partnership trust through a recent merger, work had already begun on developing secure and forensic services across the county to provide everything from rehabilitation to medium secure services for men and women. Much of the proposed investment of£8.8m will come from costs recouped from bringing patients back from out-of-area placements.

In the women's medium secure service provided by the trust, an independent way of life is encouraged. There are no domestic staff and all the clients do their own cooking and cleaning.

'We want to avoid institutionalisation and develop the women's social skills to give them a better chance in the community,' says Ms Waterhouse.

Being prepared for life in the community raises the question of how much contact with men should be included. It is thought inappropriate for men and women to share bedroom and bathroom areas, and sleeping and recreational areas are kept completely separate.

However, secure service managers say it is vital to provide patients with positive male role models by employing some male staff. Fromeside, for example, employs a 70/30 mix of female and male staff, as suggested by WISH.

But mixing with men, including service users, must be controlled. Fromeside holds no social events and patients never mix for sports or therapy groups.

Mr Halpin points out that when women first come to a secure service they will often feel scared, and it is important to be able to reassure them that the environment is safe and secure.

As treatment progresses, some leisure activities are mixed sex, although a swimming lesson for example would always be female only.

'It's a fine line,' says Mr Petrie. 'Mixed groups are not the norm here. But, say, we have one male and one female who want to learn to speak French but only one session is available. They will learn together, if a risk assessment says that is appropriate. Safety is the first priority.'

Fine balance

Staff skills need to be finely balanced. In the past, the behaviour demonstrated by women in secure settings has often led to difficult relationships with staff who have looked after them, and who have been upset or annoyed by it.

'We have weekly reflective practice and psychoanalytical supervision to ensure that we remain balanced in terms of the care we provide. And we have a busy activities and therapy programme. Our expectation is that patients should be engaged all day. If they are occupied, then boredom and stress is reduced, which in turn reduces self-harm and the need for observations,' says Mr Petrie.

Future admissions are expected to come from the criminal justice system, psychiatric services, and, to a lesser extent, out-of-area placements. New referrals from high secure settings are less likely.

From next year, high secure services for women across the NHS will be based at a new 60-bed unit at high secure Rampton Hospital, in Nottinghamshire.

Ashworth, another former secure hospital, no longer has a women's service and Broadmoor will cease to provide one from 2007. So although some women in high secure care will still move to a step-down service, most are already known to medium care services.

'There are women currently in Rampton and in Broadmoor whose care planning we are already involved in,' says Mr Petrie. 'It is all about getting people back to their local area, but we have to work through the risk process and be clear about what we can manage here.'

Mr Halpin says that as the number of high secure beds for women decreases, he expects the criteria for admission to these settings to be raised. He is concerned that this may put extra pressure on medium secure places.

'We will be getting referrals for people who in the past would have been considered for high secure. That will increase pressure on low secure and community-based local services,' he says.

Where women from medium secure settings move to depends on their needs and circumstances. Those continuing with a prison sentence go back to the criminal justice system. Others may be ready for the community. However, many will only be able to return to the community in a supported setting.

'The preferred model is a high-support hostel-style setting in the community to encourage moves towards independence. Women tend to need supervision and support to be available 24 hours a day. But although there are a few hostels available there are not enough, and some of those are mixed sex so they are not appropriate,' adds Mr Petrie.

But he talks enthusiastically about what can be achieved for women needing a secure setting.

'Working with women is another speciality,' says Mr Petrie.

'They definitely engage better than males, who just want to do their time and get out. Women want to sort things out.'

Mr Halpin points out the effects that treatment and rehabilitation can have on offenders with mental health problems. 'Having treatment produces significantly lower rates of reoffending. We can deal with the major illness and then equip women with social skills and education - the core skills that they need to rebuild their lives and have a meaningful future.'