Secure mental health services provide accommodation, treatment and support for people with severe mental health problems who pose a risk to the public. Secure services work predominantly with people who have been imprisoned or admitted directly to hospital following a criminal offence.

The three levels of secure services (low, medium and high) have about 7,000-8,000 beds. The cost of a year in a medium secure hospital is an average of £165,000. High security is in the region of £300,000.

Transfers from prison to secure services should ensure offenders with severe mental health problems have access to the right treatment and care. Such transfers, however, are often subject to excessively long delays even for very acutely unwell prisoners. People get stuck in the system - they can't get in to secure care when they need it or get out when they don't.

The Bradley Report called for a mandatory 14-day maximum transfer time for prisoners to be admitted to hospital and for a review of security at low and medium secure units.

Secure care pathways

In 2011, we examined the extent to which pathways into and through secure mental health services can be improved and ensure a better flow between prison and secure services.

Secure mental health services vary widely across the country in terms of who they admit and what support they provide. Most patients spend longer than a year in secure hospitals, with a lack of community support for those who could be discharged a common cause of bed blocking.

Achieving more consistent commissioning and provision of secure mental health care depends on a number of factors:

  • changing how secure services are commissioned, i.e. a move from block purchasing (of mainly medium secure beds) to purchasing pathways and discrete packages of care that provide incentives to move patients to the lowest level of security they need and support community aftercare;
  • developing effective community support and liaison to support reintegration and mainstream mental health services’ capacity to promote the recovery of former secure service patients;
  • reviewing the balance of investment to ensure adequate step-down provision is developed;
  • standardising treatment programmes so that treatment can be carried across tiers;
  • developing a national secure service patient data-set that allows both individual progress monitoring and aggregated data to monitor performance and outcomes;
  • developing shared learning networks to improve communication across tiers and in standardising treatment and care packages.

A summary paper of this report available to download below.

Download Pathways to unlocking secure services summary PDF (1.5 MB)

What you can do - policy

NHS England should develop a framework of guidance and quality standards for secure services to support equity of outcome and equitable access to all tiers across the country.

NHS England and the Ministry of Justice should develop much clearer criteria for admission to the different tiers of secure care to help speed up the transfer of patients from prison to the NHS.

NHS England and the Ministry of Justice should review the roles of low secure and step-down care to inform commissioning decisions and systems. The efficient use of the higher tiers of secure care, and in particular medium secure, depends on having well developed and understood provision in the lowers tiers. 

NHS England and the Ministry of Justice should develop a national secure service patient data-set to allow both individuals’ progress through services to be monitored and aggregated data to be collected to assess providers’ performance and outcomes.

What you can do - commissioning

Commissioners should better balance their investment to enable step-down and community provision based on a local assessment of needs. This will necessarily involve the decommissioning of some existing block-purchased secure care beds in order to free resources for more needs-based provision.

Commissioners should purchase specific care packages with specified outcomes for care. Commissioning should include a system of incentives as part of a charging/payment framework that is geared to improve quality and efficiency, and overcomes barriers to both.

Commissioners should use guidance and quality standards to define, develop and standardise treatment and care packages across different settings, with a specific focus on more support for mainstream community mental health services.

Commissioners should routinely use feedback from service users to measure the performance and outcomes of secure care services. 

What you can do - in practice

Patients should receive a single assessment that has the expertise and capacity to decide on timely entry to any tier of security.

Prison and secure mental health services should develop improved relationships to help to facilitate faster transfers.

Mainstream mental health services should not exclude people discharged from secure services, including those with personality disorders.

Secure care services should promote the Recovery approach across the secure care pathway. In addition, training in the Recovery approach should be available to all secure care staff.