, et al. A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation. Health Serv Deliv Res 2017;5(11). Health Services and Delivery ResearchISSN 2050-4349 (Print) ISSN 2050-4357 (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www.publicationethics.org/).Editorial contact: nihredit@southampton.ac.ukThe full HS&DR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www.journalslibrary.nihr.ac.uk Criteria for inclusion in the Health Services and Delivery Research journalReports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. HS&DR programmeThe Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012.The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services.For more information about the HS&DR programme please visit the website: http://www.nets.nihr.ac.uk/programmes/hsdr This reportThe research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 11/1024/06. The contractual start date was in March 2013. The final report began editorial review in March 2016 and was accepted for publication in September 2016. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors' report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the ...

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood.Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England.Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings.Results: 22% of patients in high security and 18% in medium security met the definition for “long-stay,” with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample.Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.

Introduction: Assessment of the effectiveness of individual placement and support in forensic mental health settings is a relatively new field of research despite evidence demonstrating its effectiveness in generic mental health settings. Method: IPS was implemented into a community forensic mental health setting within a large National Health Service trust in the United Kingdom over 6 months. Using the Consolidated Framework for Implementation Research this paper describes the lessons learned from implementing individual placement and support into such settings. Results: Our findings suggest that implementation of individual placement and support in forensic mental health settings is complex and requires robust planning and collaboration with internal and external agencies. Barriers to implementation included staff attitudes, difficulty engaging employers and lack of employment related performance indicators, and facilitators included the support of service managers and outside groups. Adaptations to the IPS model were made to address challenges encountered, including difficulty starting rapid job searches, concerns about stigma, lack of confidence, uncertainty around employment opportunities, offence restrictions and lack of interest from potential employers. Conclusion: This paper adds to the limited literature in the field. Findings are relevant to practitioners and service providers who wish to implement individual placement and support services for people with mental disorder and offending histories.

IntroductionPeople with involvement in forensic psychiatric services face many obstacles to employment, arising from their offending, as well as their mental health problems. This study aims to assess the feasibility of conducting a randomised controlled trial (RCT) to evaluate the effectiveness of individual placement and support (IPS), in improving employment rates and associated psychosocial outcomes in forensic psychiatric populations. IPS has been found consistently to achieve employment rates above 50% in psychiatric patients without a history of involvement in criminal justice services.Methods/designThis is a single-centre feasibility cluster RCT. Clusters will be defined according to clinical services in the community forensic services of Nottinghamshire Healthcare NHS Foundation Trust (NHCT). IPS will be implemented into 2 of the randomly assigned intervention clusters in the community forensic services of NHCT. A feasibility cluster RCT will estimate the parameters required to design a full RCT. The primary outcome is the proportion of people in open employment at 12-month follow-up. Secondary outcome measures will include employment, educational activities, psychosocial and economic outcomes, as well as reoffending rates. Outcome measures will be recorded at baseline, 6 months and 12 months. In accordance with the UK Medical Research Council guidelines on the evaluation of complex interventions, a process evaluation will be carried out; qualitative interviews with patients and staff will explore general views of IPS as well as barriers and facilitators to implementation. Fidelity reviews will assess the extent to which the services follow the principles of IPS prior, during and at the end of the trial.Ethics and disseminationEthical approval was obtained from the East Midlands Research Ethics Committee-Nottingham 1 (REC reference number 15/EM/0253). Final and interim reports will be prepared for project funders, the study sponsor and clinical research network. Findings will be disseminated through peer-reviewed journals, conferences and event presentations.Trial registration numberNCT02442193; Pre-results.

Introduction We aimed to identify the barriers and facilitators to the implementation of a high fidelity individual placement and support service in a community forensic mental health setting. Method In-depth interviews were conducted with clinical staff ( n = 11), patients ( n = 3), and employers ( n = 5) to examine barriers and facilitators to implementation of a high fidelity individual placement and support service. Data was analysed using thematic analysis, and themes were mapped onto individual placement and support fidelity criteria. Results Barriers cited included competing interests between employment support and psychological therapies, perceptions of patients’ readiness for work, and concerns about the impact of returning to work on welfare benefits. Facilitators of implementation included clear communication of the benefits of individual placement and support, inter-disciplinary collaboration, and positive attitudes towards the support offered by the individual placement and support programme among stakeholders. Offences, rather than mental health history, were seen as a key issue from employers’ perspectives. Employers regarded disclosure of offending or mental health history as important to developing trust and to gauging their own capacity to offer support. Conclusions Implementation of individual placement and support in a community mental health forensic setting is complex and requires robust planning. Future studies should address the barriers identified, and adaptations to the individual placement and support model are needed to address difficulties encountered in forensic settings.