Annie Bartlett

What same sex civil partnerships may mean for health

A growing number of countries have introduced a form of marriage or civil partnership registration for same sex couples. Marriage confers health benefits on heterosexual men and women and similar benefits could arise from same sex civil unions. The authors argue that legal and social recognition of same sex relationships may reduce discrimination, increase the stability of same sex relationships, and lead to better physical and mental health for gay and lesbian people.

Interventions with women offenders: a systematic review and meta-analysis of mental health gain

Currently, a conjunction of policy, legislative change in health and social care and the criminal justice system, combined with funding for innovative services make it opportune to assess the evidence base for interventions with women offenders. Women offenders have a distinctive criminological, health and social profile and a gender specific approach to their difficulties is advocated. This systematic review and meta-analysis focus on mental health gain in adult women offenders in forensic health settings, criminal justice institutions and in the community, following therapeutic interventions. Interventions were assessed in terms of specific outcome measures of depression, trauma symptomatology and global mental health status. Comprehensive search strategies yielded 3018 articles, from which we obtained 199 full text articles. Seventeen articles were included in the final review, of which six were excluded from the meta-analysis as there was no comparator group. There is a modest, but increasing, body of evidence for the utility of some interventions, notably those addressing the consequences of earlier trauma, including interventions which also address comorbid substance misuse. This does not amount, to date, to a robust evidence base. Limitations of these studies are discussed and include small sample sizes, their restriction mainly to prison populations and that they were substantially undertaken in the US. Variations in outcome measures follow-up and the difficulties inherent in measuring change in this complex population are also detailed. However, the review delineates definite avenues for further work. To achieve this, those responsible for policy, practice and purchase of services should both be mindful of existing evidence and promote additional, high quality research into interventions which are designed around a coherent, theoretical approach.

Decision making in medium security: Can he have leave?

This qualitative study investigates how the decision is taken to grant leave to patients in a forensic psychiatric in-patient medium secure unit. This study aims to understand better the process of decision making at multidisciplinary ward rounds. The study is based in a single medium secure unit. Data were collected by a researcher from ward rounds over a period of 15 months using non-participant observation. These data were subjected to content analysis. Two main thematic dialectics emerged: risk and humanity and power and responsibility. Leave decisions were made in 96 instances and risk, per se, was seldom explicitly discussed. This study raises key questions about the balance between explicit information and implicit clinical knowledge that underpins routine clinical decisions. This study is important because it has implications for the reliance on written records in the review of clinical practice, specifically in relation to serious acts of violence committed by psychiatric patients.

Pathways of care of women in secure hospitals: which women go where and why.

BACKGROUND Care pathways for women needing expensive, secure hospital care are poorly understood. AIMS To characterise women in low and medium security hospitals in England and Wales and to compare populations by security and service provider type. METHOD Census data from all specialist commissioning areas. Sociodemographic, clinical, medico-legal, criminological and placement needs data were requested on all women in low and medium secure hospital beds. Parametric tests were used for continuous data and chi-square or Fishers exact tests for categorical data. Thematic analysis was used for free text data. RESULTS The independent sector is the main service provider. A third of all women (n = 1149) were placed outside their home region despite spare local National Health Service (NHS) capacity. The independent sector provides for women with relatively rare disorders, including intellectual disability. The NHS admits most serious offenders. One in 20 are detained because of self-harm alone. CONCLUSIONS Patient-specific factors (notably the diagnosis of personality disorder) and organisational inadequacy (commissioner and service provider) contribute to placements that compromise rehabilitation. Responses should include local solutions for women whose main risk is self-harm and a national approach to women with highly specialist needs.

Women prisoners: an analysis of the process of hospital transfers

Department of Health guidelines (Bradley, 2009) suggest that transfers of prisoners with mental health problems to hospital using the Mental Health Act should take 14 days from first assessment to transfer. This study examines the extent to which transfers of women prisoners from a large womens prison in England is meeting this target. It considers in detail 100 recommendations for hospitalisation and analyses the process to establish rate of transfer and where applicable reasons for slow transfer. Of the 86 women who completed transfer, the process took 37 days (median) with only 13% of cases being moved within the 14-day recommended period. This study also found that legal routes intended for urgent hospitalisation were no quicker than other methods. The study recommends review of Section 48, the urgent treatment order.

Language, foreign nationality and ethnicity in an English prison: implications for the quality of health and social research

Background More than one in 10 of all prisoners in England and Wales are Foreign Nationals. This article discusses whether the research applications to one London prison are aimed at understanding a prisoner population characterised by significant multinational and multilingual complexity. Methods We studied all accessible documents relating to research undertaken at a womens prison between 2005 and 2009 to assess the involvement of Foreign National prisoners and women with limited English. The source of information was prison research applications and protocols. We also looked at available final research reports and journal articles. Results Two key findings emerged from this study. First, studies at this prison frequently excluded Foreign National prisoners and women with limited English. Second, Foreign National prisoners were often clustered as a homogeneous category in the research reports reviewed. This is despite their diverse cultural backgrounds, their variable immigration status and their differing competence in English, all of which affect their lives. Conclusions The failure to include and/or identify social subgroups of the population can undermine the value of research, including, in the case of the study prison, funded health research. This can compromise associated needs assessments and service delivery, particularly important in already disadvantaged populations; this may encourage and/or perpetuate a range of health inequalities. There is a pressing need to examine cultural exclusion in other health and criminal justice settings, to assess the ways in which—and the extent to which—such exclusion may compromise the merit of proposed and completed health and social research.

Women's secure hospital services: national bed numbers and distribution

A mapping exercise as part of a pathway study of women in secure psychiatric services in the England and Wales was conducted. It aimed to (i) establish the extent and range of secure service provision for women nationally and (ii) establish the present and future care needs and pathways of care of women mentally disordered offenders (MDO) currently in low, medium and enhanced medium secure care. The study identified 589 medium secure beds, 46 enhanced medium secure beds (WEMSS) and 990 low secure beds for women nationally. Of the 589 medium secure beds, the majority (309, 52%) are in the NHS and under half (280, 48%) are in the independent sector (IS). The distribution of low secure beds is in the opposite direction, the majority (745, 75%) being in the IS and 254 (25%) in the NHS. Medium secure provision for women has grown over the past decade, but comparative data for low secure provision are not available. Most women are now in single sex facilities although a small number of mixed sex units remain. The findings have implications for the future commissioning of secure services for women.

Women’s secure hospital care pathways in practice: a qualitative analysis of clinicians views in England and Wales

BackgroundIn England and Wales women form a small but significant group within the wider, largely male, secure hospital population. Secure hospitals are designed to assess and treat individuals with both mental health problems and significant criminal behaviour. The theoretical approach to the care of secure hospital women is increasingly informed by a grasp of gender-specific issues. However, there is a lack of evidence on the adequacy of current structures and processes of care delivery.MethodsThis qualitative study explores the nature and quality of care pathways for women in low and medium secure hospital beds by eliciting participants’ views of factors enhancing or impeding care. Beds are publicly funded and provided either by the National Health Service (NHS) or the Independent Sector (IS). Participants from both sectors were local experts (40 Consultant Psychiatrists, 7 Service Managers) who were well placed to describe their immediate health environment.ResultsEvidence from the study indicates that participants were focused on the physical relocation of women to less secure conditions, even though many women do not readily achieve this.Participants were alert to potential conflicts between ideal care and affordable care. Ideal care was compromised by the absence of suitable local services (beds or community placements), curtailed episodes of care and changes of care team. It was promoted by an awareness of the specific needs of women, continuity of care and support for teams unfamiliar with women’s needs.ConclusionFuture service design must address these challenges in care delivery, incorporating a better understanding of and response to the ways the system can echo women’s experiences of trauma and their negative attachment histories. Specifically, critical transitions in care must not be allowed to further reinforce the discontinuity, failure and rejection experienced by individual women earlier in their lives.

Characteristics of women in a prison mental health assessment unit in England and Wales (2008–2010)

BACKGROUND The high prevalence of mental disorders among women in prison is recognised worldwide. In England and Wales, successive governments and independent reports have argued that the equivalent of community care in prisons is acceptable but that some mental health assessment units (MHAUs), staffed by professional clinicians, should remain. These have not been researched. AIMS This paper aimed to explore patterns of use of a MHAU in a womens prison in England and to test the hypothesis that it was being used only, as intended--to hold women pending transfer to a health service hospital or in a bona fide crisis. METHODS Anonymised data on all women transferred to one MHAU between 1 January 2008 and 31 August 2010 were obtained from the prison files and subjected to descriptive analysis. RESULTS Less than a third of these women were transferred to an outside hospital; this group stayed longest in the unit. An overlapping group of 52% of the women was under a special assessment, care in custody and teamwork protocol because of suicide or serious self-harm risk. Thus, 188 (68%) admissions fulfilled national protocol criteria for MHAU admissions. Two in five women admitted were released or returned to ordinary prison locations. Nevertheless, over 80% of the women were known to external mental health services, and 64 (30%) were so unwell on arrival in prison that they were transferred directly to the MHAU. Over a third of admissions were of women admitted more than once during the 32 months of study, and this was significantly more likely after release from prison directly to the community. CONCLUSIONS Our hypothesis was not sustained, and it seems unlikely that this prison MHAU is unique in being used outside its strict remit. A shift from studying the epidemiology of mental disorder in prisons to the epidemiology of mental health needs could benefit this vulnerable group and the wider community alike.

Intellectual disability screening in women prisoners: preliminary evaluation

Purpose – The purpose of this paper is to evaluate a new Intellectual Disability (ID) screening service within a women’s prison in England. Design/methodology/approach – Analysis of prisoner records was carried out to establish characteristics of women entering the prison, rates of screening completion and time intervals for all stages of the assessment pathway. Findings – In total 198 women were received into prison and underwent 202 ID screens. Nine out of ten women completed a screen, almost all on arrival or very soon afterwards. There were 23 referrals for secondary assessment but only four were completed. Most of the women identified for additional screening left the prison before this could be achieved. Originality/value – This evaluation is the first to show that preliminary screening for ID is feasible in prison. This screening alone is useful for prisons to make the kind of reasonable adjustment required of public bodies by the Equality Act. However, its value is constrained unless resources are...