the forensic network 1 a study of major change: legislation, education & practice
TRANSCRIPT
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1The Forensic Networkwww.forensicnetwork.scot.nhs.uk
A Study of Major Change: Legislation, Education & Practice
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2The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Lindsay Thomson, MD, Medical Director, The State Hospital/Forensic Network/ Edinburgh University (Chair)
Andreana Adamson, BSc (Econ) MBA, Chief Executive, The State Hospital/Forensic Network
Ed Finlayson, CQSW, DipSW, Head of Social Work, South Lanarkshire Council/The State Hospital
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3The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Legislation Practice
Education
A study of major change
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4The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Legislation
Mental Health (Care and Treatment) (Scotland)
Act 2003“The best mental health legislation
in the world?” Holyrood Magazine (7/5/07)
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5The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Background
• 20 years out of date?
• Significant changes in mental health policy and
service delivery
• Human Rights
• Millan Committee
• MH Act Reference Group – Working Together
Legislation
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6The Forensic Networkwww.forensicnetwork.scot.nhs.uk
MHA 2003
• Royal Assent 25 April 2003
• Preparing for Implementation Programme
• Act Implemented 5th October 2005
• 23 parts with over 300 sections
• Code of Practice, 3 Volumes
Legislation
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7The Forensic Networkwww.forensicnetwork.scot.nhs.uk
The Act
Mental Health
(Care and Treatment)
(Scotland)Act 2003
Legislation
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8The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Principles
• Take Account of Patients Wishes
• Maximise Participation• Provide Maximum Benefit• Non Discriminatory
Practice• Take Account of Views of
Named Person
• Carers Needs• Appropriate Services• Minimum Restriction• Child’s Welfare is
Paramount• Duty to Maintain Parental
Relationships• Social Inclusion
Legislation
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9The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Protection / RightsAdvocacy
• Duty to Inform Patient of Advocacy Services
• Duty to Take Steps to Arrange Advocacy Services
Legislation
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10The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Protection / RightsNamed Person
Nominated by a patient in accordance with the
provisions of the Act to act in their best interests.
The named person is entitled to receive certain
information about the patient and to act on behalf
of the patient in certain circumstances and at
certain times
Legislation
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11The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Protection / RightsAdvance Statement
A written, witnessed document made when the
patient is well, setting out how he or she would
prefer to be treated (or not treated) if they were
to become ill in the future
Legislation
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12The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Protection / RightsMental Welfare Commission• Monitor operation of act and promote best
practice• Patient visits; investigations; interviews and
medical examinations; inspect records• Publish information and guidance; give advice or
bring matters to the attention of others including services and government.
Legislation
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13The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Protection / RightsMental Health Tribunal Scotland
• New independent body to make decisions in relation to applications, reviews and appeals
• Legal Members, Medical Members and General Members
• Right of appeal against compulsory measures• Right of appeal against excessive security
Legislation
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14The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Definition of Mental Disorder• Mental Illness
• Learning Disability
• Personality Disorder
Exclude if only by reason of:Sexual orientation; sexual deviancy; transexualism; transvestism; dependence on or use of alcohol or drugs; behaviour that causes harassment, alarm or distress; acting as no prudent person would do
Legislation
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15The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Definition of Treatment
• Nursing
• Care
• Psychological Interventions
• Habilitation
• Rehabilitation
Legislation
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16The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Grounds for Compulsion
• Mental Disorder
• Treatment is Available
• Significant Risk to Health, Welfare or Safety
• (Significantly Impaired Decision Making)*
• Compulsion is Necessary
* Only applies in Civil Procedures
Legislation
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17The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Menu of Compulsory Powers
• Detention in Hospital
• Compulsory Treatment
• Attendance at Services
• Access for Service Providers
• Place of Residence
• Notification or Approval of Change of Address
Legislation
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18The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Requirements for Compulsory Powers
• Psychiatric Reports
• Mental Health Officer Reports
• Designated Responsible Medical Officer and
Mental Health Officer for all cases.
Legislation
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19The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Mental Health Officer
• Registered Social Worker
• Training in Mental Disorder and Mental
Health Law
• Appointed by the Local Government
Legislation
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20The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Care Plan
• Objectives of Treatment
• Details of Community Care Services
• Details of any other Treatment or Services
Legislation
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21The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Issues
• Number of Interim Orders and Tribunals
• Provision of Information to Named Person
• Managing Views of Victims
Legislation
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22The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Outcomes
• Fewer Emergency Orders
• Fewer episodes of compulsion
• Increasing use of community measures
• Successful appeals against security
Legislation
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23The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Use of Mental Health LegislationMH(S)A 1984 MH(C&T)(S)A 2003
1/4/05-4/10/05 5/10/05-1/4/06
Emergency 2410 920(62%)
Short term 1511 1666(10%)
Long term 773 528
Hospital 469
Community 59
Legislation
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24The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Mental Health Tribunal - good for patients?
“Patients feel they are being listened to by the panel members – that has to be a
good thing”
Carolyn Little, Chair
National Schizophrenia Fellowship
Legislation
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25The Forensic Networkwww.forensicnetwork.scot.nhs.uk
A Study of Major Change: Legislation, Education & Practice
Questions?
Legislation
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26The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Practice
MEL 1999 (5) Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland provides the basis for Forensic Mental Health Services in Scotland.
Policy
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Practice
Mentally disordered offenders should be cared for: • with regard to quality of care and proper attention to
the needs of individuals• as far as possible in the community rather than in
institutional settings• under conditions of no greater security than is justified
by the degree of danger they present to themselves or to others
• in such a way as to maximise rehabilitation and their chances of sustaining an independent life
• as near as possible to their own homes or families if they have them
Guiding Principles of MEL 1999 (5)
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28The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Scottish Ministers call for new approach to FMHS
“.. to bring a pan-Scotland dimension to the planning process for services .. to support the development of local services .. and to secure protocols to ease the management of patients
through the system”
Mary Mulligan, MSPDeputy Health Minister, 2002
Practice
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29The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Context
• Population: 5 million
• Forensic inpatient population 500
• Under developed services in 15 health authorities
• Forensic Services within NHS – 1 small independent provider (24 beds)
Practice
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30The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Media
Practice
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31The Forensic Networkwww.forensicnetwork.scot.nhs.uk
“Review the process for determining the right care for mentally disordered offenders”
“Consider wider issues surrounding patient pathways .. Including information systems,
education and training and strategic planning”
Scottish Executive Health Department, March 2003
Objectives
Practice
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32The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Forensic beds
High 240 Low
Currently
Planned
Low
Practice
500 BedsApproximate figures
Med 50
Low
High 140
Med 150
Low
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33The Forensic Networkwww.forensicnetwork.scot.nhs.uk
“A key measure of success will be a smaller State Hospital … services can and should
be provided in other secure and community settings”
Malcolm Chisholm, MSP
Health Minister, 2003
Practice
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34The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Network Board
• Multi Agency – Health, Scottish Executive, Social Work, Police,
Prison, Local Government Housing, Carer agencies
• Regional Representation– North, South and East, West, Northern Ireland– Each circa 1.5m population
Practice
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35The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Principles
Practice
• Pan Scotland approach
• Strategic Planning
• Performance Management Frameworks
• Information Systems
• Education and Training
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36The Forensic Networkwww.forensicnetwork.scot.nhs.uk
National High secure
Regional Structure
Practice
Local Low Secure
Local Low Secure
Local Low Secure
Local Low Secure
Local Low Secure
Local Low Secure
Local Low Secure
Medium Secure
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37The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Local Services – Low Secure
Regional – Medium Secure
National High secure
Community Services
Regional Structure
Practice
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38The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Appeals against excessive security• 66 applications
• 34 heard
• 24 upheld
• 8 declined
• 17 cancelled/withdrawn
Practice
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39The Forensic Networkwww.forensicnetwork.scot.nhs.uk
“The Forensic Network is an excellent example of how we can bring together
national, regional and local perspective on the planning and delivery of services”
Hugh Henry, MSP
Justice Minister, 2005
Practice
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40The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Strategic Planning
• Definitions of Levels of Security– Obvious starting position– Matrix of security– Tool for audit of existing and planned services– Recommended development of Secure Care
Standards
Practice
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41The Forensic Networkwww.forensicnetwork.scot.nhs.uk
• Secure Care Standards– Eleven standards– Three generic standards across all security
levels (1 assessment & care planning; 2 delivery of generic and specialist treatments, interventions and support for recovery; 3 teams, skills, staffing)
– Remaining eight specific to security level (maintenance of detention; suspension of detention; management of violence; excluded items; communication and technology; movement of personnel and contingencies)
Practice
Strategic Planning
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42The Forensic Networkwww.forensicnetwork.scot.nhs.uk
• Services for Women
– Small patient-specific group
– No need for high secure beds
– Favour community based specialist services
– Small number of medium secure beds
Practice
Strategic Planning
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43The Forensic Networkwww.forensicnetwork.scot.nhs.uk
• Services for Learning Disabilities– Small population
– Robust community based services
– Regional multi-agency risk management groups
– 12 high secure beds
– Separate services for LD, small regional units
Practice
Strategic Planning
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44The Forensic Networkwww.forensicnetwork.scot.nhs.uk
• Personality Disorders– Significant population in NHS and Prisons
– “PD should not be a diagnosis of exclusion from forensic mental health services in Scotland”
– No change to current clinical in-patient practice
– Pilot work with criminal justice and prisons
Practice
Strategic Planning
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45The Forensic Networkwww.forensicnetwork.scot.nhs.uk
• 2006 Policy and Guidance– Including conflict resolution and patient flows
• Care Programme Approach• Risk Management • Clinical Governance• School of Forensic Mental Health
Launch October 2007
Practice
Policy
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46The Forensic Networkwww.forensicnetwork.scot.nhs.uk
A Study of Major Change: Legislation, Education & Practice
Practice
Questions?
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47The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
School of Forensic Mental Health:
Teaching, Training & Research
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48The Forensic Networkwww.forensicnetwork.scot.nhs.uk
The Three Graces
Education SoFMHSchool of Forensic Mental Health
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49The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Venus de Milo
Education SoFMHSchool of Forensic Mental Health
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50The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Knowledge and Understanding of the MH(C&T)(S)A 2003 within Trainee Psychiatrists
• Response Rate 93% (n=48)• Mean Total Score 22/61 (range 6-51)
- FY2 19- SHO 29- SpR 38- Principles: mean 2/10 (40% - 0)- Detention Criteria 2/5
Education SoFMHSchool of Forensic Mental Health
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51The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Survey of Services for People with “Forensic” Personality Disorder
• 7 implicitly exclude people with a
primary PD Dx from admission
• 7 assess people with a primary
diagnosis of PD
• 8 use multidisciplinary and 10
comprehensive methods of
assessment
• 4 use structured clinical tools for
the assessment of PD
• 6 services did not accept people with a primary diagnosis of PD for specific intervention, treatment or management, 4 services did not accept people with a secondary dx
• No reliable figures
• Training requirements were identified in particular for developing case formulations and employing evidence based
Education SoFMHSchool of Forensic Mental Health
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52The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Rationale“The Network provides the opportunity for
participating stakeholders to consider …. education and training . . . and the
commissioning of research to establish an evidence base for service development”
Scottish Executive Health DepartmentMarch 2003
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53The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Network Working Group• Multi-agency expert group• Objectives
– Review provision of forensic education and identify gaps
– Review recent research – Develop proposals and models for school of forensic
education and research (if required)
– Consider advantages and disadvantages– Consider resource and funding issues
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54The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Identifying needs• Two scoping exercises (including independent)
• Both highlight clear gaps• Complex nature of needs (risk, law, complex system & clients)
• No postgraduate provision• No forum for multidisciplinary training although clinicians
work on multidisciplinary basis• Limited forensic mental health training in non health
agencies• Research efforts are small and uncoordinated
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55The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Meeting the needsDevelop a Forensic School• Coordinating body (consortium)• Provider and Commissioner • Build on existing resources• Programme development• Training trainers• Teaching materials
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56The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Option Appraisal
• I Do nothing
• II Refer to a Coordinating Body
• III Establish a Virtual School
• IV Establish a Physical School
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57The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Business Case• Appraisal of options
• Advantages/disadvantages
• Costs
• Risk assessment
• Establish and weight benefits criteria
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58The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Option AppraisalScore
• I Do nothing 2.54• II Refer to a Coordinating Body 7.52• III Establish a Virtual School 16.03• IV Establish a Physical School 14.38
Affordability
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59The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Principles
• Practical Utility
• Inclusive
• Feasible
• Financially viable
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60The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Delivery (1)• All of Scotland• Links with educational institutions• Board – stakeholders• Administrative base• Use of existing materials• Development of new materials• NHS & educational interface
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61The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Delivery (2)• Multidisciplinary courses in forensic studies • Modular basis with clear assessment of
competences• Access to modules, diploma or MSc• Part-time• Distance learning• Multi-agency• Specific training
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62The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Sample Modules
• Law and Mentally Disordered Offenders
• Mental Disorder and Crime
• Risk Assessment and Management Treatment
of Mentally Disordered Offenders
• Services for Mentally Disordered Offenders
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63The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Support for the school
• Government Policy
• NHS Education Scotland
• Scottish Executive Health Department
• Forensic Network Associates
• Higher Education Institutions
• Further Education Institutions
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64The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
New to Forensic
• Commissioned by NHS Education Scotland
• Designed for clinical and non clinical staff
• 6 month self directed learning programme
• Students supported by mentors
• Twelve chapters with case scenarios
• Delivery by network of trainers within services
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65The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Chapter 1 - Aims and Teaching Methods
Chapter 2 -Understanding Mental Disorder
Chapter 3 -Definitions, Principles and Policy
for Mentally Disordered Offenders
Chapter 4 -Civil Mental Health Legislation
Chapter 5 -Forensic Mental Health Services
Chapter 6 -Attitudes to Mentally Disordered
Offenders and ways of dealing
with personal emotions and
boundaries
Chapter 7 -Forensic Mental Health Services and the
Criminal Justice System: Understanding the
relationship
Chapter 8 -Psychiatric Defences and Legislation for
Mentally Disordered Offenders
Chapter 9 -Assessment, Treatment and Management
of Mentally Disordered
Offenders
Chapter 10 -Multidisciplinary Working, Communication
and Managing Difference
Chapter 11 -Safety of Staff, Patients and Public
including Risk Assessment and
Management
Chapter 12 -Taking Account of the Views of Users and
Carers
Education SoFMHSchool of Forensic Mental Health
Content (1)
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66The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Content (2)
•Differential objectives
•A problem based learning approach
•Participants supported by experienced mentors
•Use of a reflective diary
•Case studies designed to challenge thinking
•Links to other learning materials throughout the programme
Education SoFMHSchool of Forensic Mental Health
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67The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Mentor Mentor
Trainer
Trainer
Mentor Mentor
Trainer
Trainer
Mentor Mentor
Trainer
Trainer
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68The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
Current Work
• Police Probation Training
• Strategic Change Grant
• Network of Trainers
• Risk Management Agenda
• Psychological Therapies Training
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69The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education SoFMHSchool of Forensic Mental Health
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70The Forensic Networkwww.forensicnetwork.scot.nhs.uk
Education
SoFMHSchool of Forensic Mental Health
Come and see for yourself ……
IAFMHS 2009 Conference, Edinburgh
PracticeLegislation
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71The Forensic Networkwww.forensicnetwork.scot.nhs.uk
A Study of Major Change: Legislation, Education & Practice
[email protected]@[email protected]+ 44 1555 842018