National Preventive Mechanism Eighth Annual Report 2016–17 NPM members have identified a lack of clarity about the function of medium and low secure mental health services. MWCS recently concluded that there are generally two distinct groups of patients held in low secure services – people with forensic histories who have transferred down from higher security levels, and people who have been transferred into low secure services because general psychiatric wards were experiencing difficulties managing stressed, distressed or agitated behaviour. The latter has been found to be the case more generally, with patients migrating into medium or low secure services because they have proven difficult to support in mainstream mental health care when they are acutely unwell rather than because treatment in a secure setting is indicated by the risk they pose.88 There are concerns that for people with a learning disability (who constitute a significant percentage of those in low and medium secure units in the UK) the lack of movement from secure care to community settings means that they are admitted to higher levels of security than required. It has also led to Scottish patients with a learning disability being transferred to units in England because of a lack of provision at a particular security level, which leads in turn to difficulties arranging transfers back. Similarly, patients with a personality disorder may remain in secure care, or at a particular security level, because of the lack of stepdown services. The introduction of excessive security appeals in Scotland (initially only in relation to the high secure State Hospital) is considered to have been an important driver in the development of medium secure services and, where an appeal is successful, allows patients to access pathways through detention settings. In Scotland, from November 2015 to March 2017, after the right to appeal was extended to medium secure hospitals in the Mental Health (Scotland) Act 2015, the Mental Health Tribunal Service received 56 applications relating to patients being detained in excessive security. Of these, 23 were successful. In addition, seven of the 56 people were transferred to a lower security setting before a tribunal hearing. A consistent concern is that pathways through secure care are often blocked and once patients are in secure mental health care, they become stuck in the system. The implications of this are that many people are held in conditions of excessive security. The need to address this issue has been recognised, requiring better definition, standardisation and integration of services as part of a whole pathway approach within and beyond secure care.89 In England, CQC has heard of concerns from clinicians and patients over delays in obtaining Ministry of Justice (MoJ) permission for leave or transfer, given current staffing difficulties in the MoJ’s casework section. It is of particular concern that such delays could cause patients to remain in hospital, or at particular levels of hospital security, for longer periods than is clinically necessary. 88. Centre for Mental Health and National Mental Health Development Unit, 2011, Pathways to unlocking secure mental healthcare. 89. Mental Health Taskforce, 2016, The five year forward view for mental health. 34