Dr. Harinder Bains, MBBS, FRCPsych, LL.M.
Clinical Director and Consultant Psychiatrist, Elysium Healthcare, UK
The secure autism spectrum disorder (ASD) specialist inpatient service has been developed in partnership with South of England – National Health Service (NHS) with the aim of meeting regional needs of patients in line with the national Transforming Care programme (Department of Health, 2012). The service has been rather unique in that it was developed with NHS under a programme of bed closures, in order to meet a regional need to repatriate
patients closer to their ‘home’ areas and successfully discharge patients into their local communities. Most of these patients have been seen as ‘difficult to discharge’ patients. The aim of the service has been to achieve this through collaborative care pathway management with
community care stakeholders.
The 14 bedded service aims to provide a high-quality specialist service focussing on engagement in individualised outcome-focussed treatment and rehabilitation programme in a suitable environment. The physical environment is ‘autism friendly’ (National Autistic
Society) within a therapeutic milieu conducive to addressing specific autistic needs, risk management and enable patients to work towards living safely, with appropriate support, in the community.
All patients have a multi-disciplinary therapeutic treatment plan which is outcome-based. The care plans address any comorbid mental and physical health conditions, which along with other psychosocial considerations, form the framework for care plan outcomes. Patients have access to a range of individual and group rehabilitation activities that include educational, leisure, vocational, sporting and community skills development.
The patients admitted to the service have been relatively young (below the age of 35 years) and this is consistent with previously described target age group for such services (Alelly, 2018).
The service has had an overrepresentation of individuals who have committed sexually-based offences and an adapted programme for those who committed such offences has been developed. Treatment plans include communication, functional and sensory assessments.
Multidisciplinary input includes psychiatry, specialist nursing, psychology, occupational therapy, speech and language therapy, art and drama therapy. Patients have individualised risk management plans that are based on philosophy of positive risk-taking (Department of Health,
2014) and proactive approach to reducing use of restrictive interventions.
Carer and family involvement is an essential component of the collaborative model and this is done through formal clinical processes (such as Care Programme Approach meetings and Clinical Treatment Reviews) and promoting a culture of communication in the team, with
families and carers, and managed through the team’s social worker.
A monthly ward audit reviews the use of restrictive approaches to managing patients. The use of physical restraint, segregation, and seclusion is monitored by an organisational restrictive intervention reduction programme. This service in particular has the challenge of working with enhanced external framework such as sexual harm prevention court orders due to larger than
usual number of such orders in this service.
All patients are detained under the Mental Health Act with some having restriction orders (Mental Health Act, 2007) including a larger than usual number of patients under ‘hybrid’ orders (s.45A of Mental Health Act). This reduces likelihood of indefinite restriction and introduces a predictable timeframe, which is helpful for patients with ASD.
The primary outcome measure for the service has been successful and suitably supported discharge into community. Outcomes in relation to progress includes qualitative and quantitative measures that are monitored by the multidisciplinary team and external stakeholders through involvement of commissioning case managers through formal processes (NHSE, Clinical Treatment reviews) and informal liaison with the clinical team. This
has resulted in development of transparent collaborative clinical practice which in addition to providing external scrutiny and assurance, has also helped expedite involvement of community services for discharge at relatively early stages.
A particular challenge with the patient group is that there tends to be lack of clarity in community as to which community mental health provision can most appropriately meet needs of people with ASD. This has led to delays in discharges due to lack of clear guidance as
to whether general adult psychiatric or learning disability community provisions are the commissioned service for adults with ASD without intellectual disability. It is therefore not surprising that regions with specialist forensic teams (Devapriam & Alexander, 2012) have
been able to facilitate and support discharges more quickly than regions where such a provision does not exist. Where such community services exist (NHS, 2017) they have been able to support community discharges by providing specialist expert consultation to community services. Eight of the 10 community discharges from the service have been to regions with such specialist community support.
Acknowledgement: Prof. Quazi Haque, Executive Medical Director Elysium Healthcare, UK for his contribution and review of this article.
To provide feedback on this article, please contact Dr.Bains directly (harinder.bains@elysiumhealthcare.co.uk) or the editor, Dr. Coupland (sarah_coupland@sfu.ca).
References
Allely, C. S (2018). A systematic PRISMA review of individuals with autism spectrum disorder in secure psychiatric care: prevalence, treatment, risk assessment and other clinical considerations. Journal of Criminal Psychology 8(1), 58-79. http;//DOI:10.1108/JCP-06-2017-0028.
Care Quality Commission, Guidance for providers Success factor 8 https://www.cqc.org.uk/guidance-providers/all-services/success-factor-8-courage> accessed 7th January 2023
Department of Health (2012). Transforming care: A national response to Winterbourne View Hospital Department of Health Review: Final Report. London, UK.
Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions. London, UK.
Department of Health et al (2015) Transforming Care for People with Learning Disabilities – Next Steps. London, UK.
Devapriam, J. & Alexander, R. J. (2012). Tiered model of learning disability forensic service provision. Journal of Learning Disabilities and Offending Behaviour 3 (4), 175-185.
Melvin, C. L., Barnoux, M., Alexander, R., Roy, A., Devapriam, J., Blair, R., Langdon, P. E. (2022).
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(https://www.legislation.gov.uk/ukpga/2007/12/contents)
National Health Service England (NHSE), Care and Treatment Reviews
(https://www.england.nhs.uk/learning-disabilities/care/ctr)
National Health Service England, (2015). Building the right support-A national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviours that challenge, including those with a mental health condition.
(https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-planoct15.pdf)
NHS England, (2017). Community Forensic Support for people with a learning disability and or autism -a national perspective. http://www.iow.gov.uk/azservices/documents/2910-workforceCompetencyv6.pef
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