Secure services for patients should be needs based and locally available

Dye et al's ¹ timely editorial on ‘locked rehabilitation’ highlights the need for a closer working relationship between local and specialist commissioners in order to achieve appropriate, least-restrictive local care provision. It also raises the question whether the emergence of locked rehabilitation units is caused by a reduction in open hospital or community-based rehabilitation facilities, combined with a difficulty in accessing low secure units.

In our experience, the pathway into locked rehabilitation is usually via acute in-patient facilities where treatment focus is on stabilisation of mental state and early discharge. In the absence of appropriate open or community-based rehabilitation facilities available locally within the National Health Service (NHS), patients requiring longer periods of rehabilitation are referred for locked rehabilitation in the private sector, usually out of area. A significant minority of these patients have a history of violence, including serious physical assault and fire-setting, but have neither been charged nor convicted.

Regardless of current or future risks, ‘gatekeeping assessment’ to low secure care on behalf of NHS England relies on the non-clinical requirement that the person has either serious offence charges pending or has been convicted of an offence. This becomes a barrier to accessing appropriate local secure care because in some areas police are reluctant to charge patients with long-term psychotic problems, as it may be clear that eventually they will receive a psychiatric disposal. Clearly defined criteria for gatekeeping assessment are not readily available for referrers, although the Joint Commissioning Panel for Mental Health refers to a guidance to improve assessment consistency. ² If the criteria set out by the Department of Health are taken as a reference, ³ a substantial majority of patients undergoing locked rehabilitation would satisfy them.

There is a need for clarity and transparency to ensure accessible, equitable and local care to this vulnerable group of patients. Local and specialist commissioners need to redefine secure rehabilitation care pathways with input from both general adult and forensic mental health professionals to make low secure care more needs based than based on legal charge. To improve patient care, a review of allocation of financial resources across the low secure/locked rehabilitation healthcare system involving both general adult and forensic mental health professionals is urgently required.