This report presents the results from the project ‘Challenges with the protection of society and secure mental health services from a municipal perspective’, commissioned by the Norwegian Association of Local and Regional Authorities. The main research question in the project is as follows:
How do local authorities assess the challenges associated with meeting the needs of people with a serious mental illness, possibly with concurrent substance abuse, and assessed as posing a safety risk?
The report discusses the local authorities’ challenges in providing proper services to persons who are discharged from mental health care/secure mental health services, and implementing a community treatment order (CTO) for the coercive treatment of people living in the community, where consideration to the protection of society is vital. The target group includes those who have had a CTO imposed on them by a criminal or civil court, and who are deemed to pose an increased risk of violence. The Norwegian Association of Local and Regional Authorities set out four research questions in the project announcement:
- How many people are there in the municipality with a serious mental illness and/or substance addiction who pose a challenge to the protection of society?
- What part of the health and care services would be appropriate for meeting the needs of this group?
- What does it cost the local authorities to provide services for those who pose a risk of violence?
- What capacity does the specialist health service have from the local authorities’ perspective for assessing the risk of violence?
The empirical basis was obtained from case studies in six municipalities, and a survey of a sample of local authorities. The survey was sent to 69 local authorities and 10 district authorities in Oslo. Responses were received from 34 local authorities and 8 district authorities, corresponding to a response rate of 53 per cent. In the report, the local authorities and district authorities are referred to collectively as ‘local authorities’.
In no man’s land
The report shows that the local authorities provide services to a complex group of service users with a serious mental illness, and often concurrent addiction problems, where there is an increased risk of violence and compromising the safety of themselves and/or others. Different service areas in the local authority are involved in the follow-up of the target group, and the service users in question often find themselves in a no man’s land between primary care services and the specialist health service. Under the Mental Health Act, the specialist health service is responsible for assessing and treating people with a serious mental illness. The Act also includes provisions on coercion. The local authority is responsible for the housing and service provision under the Health and Care Services Act, but municipal services are based on voluntary participation. The report shows that primary care services and specialist health services can often have different understandings and make differing assessments of patients’ needs, and that they have limited knowledge of each other’s context and framework. Operating in this no man’s land can be a challenge, as there can be disagreement about the patient’s situation and needs, what service will be suitable and effective, and who is responsible for providing the necessary services, treatment and follow-up. The limited in-patient capacity in mental health care puts pressure on staff to discharge patients and increases the threshold for admission.
Number in the target group
Twenty-nine of the 42 local authorities report having people who have had a CTO imposed on them by a criminal court, 10 do not have anyone in this category and 3 do not know. None of the smaller local authorities in the sample have users in this category. Thirty-six of the local authorities report having people with a serious mental illness and an increased risk of violence who were discharged with a CTO, 4 do not have anyone in this category and 1 does not know. Almost everyone in this group is reported to have concurrent addiction problems. Our survey shows that the challenge for the local authorities, in terms of meeting the needs of those with a mental illness, addiction problems and a high risk of violence and compromising the safety of themselves and/or others, applies to much more than the two defined categories focussed on in the project.
In total, the local authorities in the sample report that there are 134 people who have had a CTO imposed on them by a criminal court, and 368 who pose a high risk of violence who were discharged with a CTO. Our survey results do not enable us to give specific figures on how many in the target group are followed up by the local authorities. There is considerable variation between the local authorities.
The local authorities report that providing suitable housing and services for people with complex problems is particularly challenging. Many in the target group are considered to have concurrent addiction problems. There are also service users with concomitant low cognitive functioning, or other health-related and social problems. Several of the service users do not want help and refuse services and follow-up
The municipal housing and service provision
The potential for facilitating a suitable housing and service provision can be impacted by both the size of the municipality and how well developed the provision is. There are large variations in the housing and service provision between the local authorities. Standard rented municipal housing is what is primarily used for the target group in many of the local authorities, while others also use co-located housing and shared housing. The establishment of co-located housing and shared housing reflects the need for close follow-up. Many local authorities report having staff in attendance 24 hours a day in staff bases associated with co-located or shared housing. Many have an ambulatory follow-up team in mental health and addiction, which is available during normal working hours. More resources are called for to enable close follow-up and to provide services outside normal working hours. A small group of service users is considered to have a need for housing with round-the-clock staffing. Many are calling for better access to ambulatory care services from the specialist health service.
The various considerations that need to be made in relation to housing for the target group create a challenge. Location, consideration for neighbours and local communities, access to staff and adaptation of buildings to ensure security and prevent damage all need to be factored in.
Twenty-eight of the 42 local authorities pay for places in private housing, treatment or care services for the target group. Ten of the 29 local authorities with service users who have had a CTO imposed on them by a criminal court pay for external places. There are several reasons for this, such as the fact that the local authority cannot follow up the specialist health service’s reports of the need for housing with round-the-clock staffing, measures for limiting the patient’s lifestyle, testing for drugs and monitoring.
Violence risk assessment and management
The focus on violence risk assessment and management varies between local authorities. Some types of measures are widespread, but the extent to which systematic competence initiatives have been established for staff in the services varies. There is also highly variable access to violence risk assessments from the specialist health service when people in the target group are declared ready for discharge. More than half find that no information is collected about how well the service user is functioning in their housing and community environment when carrying out violence risk assessments.
Most local authorities say that they carry out some form of structured violence risk assessment, the most widespread of these being risk and vulnerability analyses.
Thirty-seven of the 42 local authorities report having staff with expertise in violence risk management and dealing with aggressive and threatening behaviour. Half of them have staff with further education or training in violence risk assessment and management.
The local authorities have very few physical aids or static measures to protect the safety of staff, service users and neighbours. The most common measure is staff alarms in shared housing or other types of municipal housing. About half of the local authorities have these.
In relation to the specific target group for the survey, 25 of the 42 local authorities indicate that they receive the necessary assistance from the police during episodes of aggressive behaviour and increased risk of violence.
Cooperation with the specialist health service
Treatment services, priorities and practices for cooperation with the local authorities vary between the different hospital trusts.
Most local authorities have access to some form of ambulatory care services, but the capacity and availability of these services varies. Three of the 42 local authorities report having access to a specialist treatment team for people with a serious mental illness who pose a risk to safety.
There is generally considerable variation in the local authorities’ experiences with cooperation on discharge. Slightly more than one-third of the local authorities in the sample consider the cooperation with the specialist health service to be good in terms of discharging service users in the target group.
Most local authorities have had disagreements with the specialist health service about its assessment of whether a patient in the target group is ready for discharge. The disagreement primarily relates to the assessment of the patient’s ability to function. This applies to the question of whether a patient’s treatment is completed and they are actually ready for discharge when a need is described for round-the-clock services, restricted access to intoxicants, control of exit doors and other measures which in practice involve the use of coercion.
Meeting practices for planning discharges vary. Thirteen of the 42 local authorities report that meetings are always held to plan the discharge of the target group and the same number report that this is done often.
Twenty-eight of the 42 local authorities indicate that they work together to devise a plan prior to the discharge of patients in the target group, while 10 do not. Plans that provide a good basis for cooperation are often comprehensive plans with detailed descriptions and clearly defined roles and responsibilities.
More than half of the municipal respondents state that it is difficult to get access to planned admissions if they consider someone in the target group to have deteriorated and to be in need of round-the-clock care. Only six local authorities feel that this is easy. Eighteen of them report that, in such situations, it is easy to obtain guidance from the specialist health service. However, 11 local authorities find this difficult.
The survey shows there is frustration in the local authorities over the lack of consideration given to the municipal context in the specialist health service’s assessment of patients’ capacity to consent. Few respondents find that the service users’ functioning in their housing and community environment is taken into account in assessments of their capacity to give consent in connection with any decision to impose a CTO. Seven of the 42 local authorities feel that the person responsible in the specialist health service does take this into account. Several find that consideration is given to the risk to the service user’s life and health in the local community and the safety of others.
Almost all the local authorities in the sample indicate that they have service users with a serious mental illness, some with concurrent addiction problems, and an assessed risk of violence who do not receive the treatment they need. Insufficient inpatient capacity and a lack of access to ambulatory care are cited as the main reasons for this.
Cost analysis
The report shows that local authorities have high costs in relation to resources for managing the heightened risk of violence and the protection of society. The need to increase staffing levels is the key cost driver. The other cost driver is the outsourcing of services when a local authority is unable to establish a suitable housing and service provision. A modelled but realistic example shows a net cost of over NOK 3 million per year for a local authority to pay for a place with round-the-clock staffing for one person in the target group. Where higher staffing levels are needed, costs can be much higher. There are also costs linked to the adaptation of buildings, various safety/security measures and skills enhancement. Finally, there are significant administration costs in connection with planning and contact with the specialist health service and other partners.
Calculations of costs for four hypothetical local authorities illustrate the significant cost differences. The size of the municipality and design of the municipal housing and service provision can affect cost levels. Close cooperation with the specialist health service and access to ambulatory care teams are factors that can contribute to cost-effective solutions. Developing competence and municipal services can boost the quality of the service provision and reduce the need to procure expensive services for individual users.
The socioeconomic costs will be significantly higher than came to light in the survey. Considerable extra resources will be needed in relation to, for example, emergency clinics, police, and the ambulance and fire services.
Recommendations
At the end of the report, a number of suggestions are given for how the local authorities can facilitate better follow-up of the target group and protection of society. The suggestions concern a framework within mental health for the follow-up of the target group and the cooperation between the local authorities and specialist health services. This applies to arrangements for funding municipal efforts in the area, and clarification of the legal latitude and the various stakeholders’ responsibilities. It also applies to the need to develop new housing and treatment services in order to better meet the complex needs of the target group.
