Section two Focus on detention issues The Bamford Review identified gaps in provision in Northern Ireland, where even with the opening of the Shannon Clinic (a medium secure facility), problems arise with allowing people transferred outside Northern Ireland to return and in allowing people to move on when appropriate from the Shannon Clinic. There are no secure mental health units for children and young people aged under 18 outside England and, as a result, where children from Scotland, Wales or Northern Ireland need secure mental health care, this is contracted on an individual basis and they are sent to England. There are well-known issues about the complexity of the process for these cross-border transfers, with mental health tribunals in Scotland having been reluctant to grant compulsory measures when a child is going to transfer directly from a secure residential facility in Scotland to a secure hospital in England, without first being admitted to a hospital in Scotland. A review in Scotland of referrals made and admissions to medium secure children’s services in England over a 10-year period concluded that there is a need for secure mental health provision for children in Scotland, and work is now underway to develop a unit as a national service.85 Security levels NPM members have noted that while there is now general consensus about definitions of security levels, which focus on physical, procedural and relational security elements, there are still variations in the restrictions experienced by patients at different levels of security.86 Some patients in Scotland reported to MWCS that they experienced more restrictive conditions in low secure wards than in medium secure wards. These issues become evident as patients move around the system. In addition, there needs to be greater clarity about how decisions are taken on what security level is appropriate to ensure individuals are detained in the least restrictive environment possible, under conditions of no greater security than is justified by the degree of risk they present to themselves or others. Some reports suggest decisions about allocation to a specific security level can be arbitrary,87 and concerns have been raised about whether at the time of admission patients are always admitted to a service that provides an appropriate level of security to meet their needs. 85. Scottish Government, 2017, Mental Health Strategy 2017–27, page 25 and Action 20. 86. Joint Commissioning Panel for Mental Health, 2013, Guidance for commissioners of forensic mental health services, p7, https://www.jcpmh.info/wp-content/uploads/jcpmh-forensic-guide.pdf [accessed 13/11/17]. 87. David Melzer Dr, Brian DM Tom, Traolach Brugha, Tom Fryers, Rebecca Gatward, Adrian Grounds, Tony Johnson & Howard Meltzer, 2014, Access to medium secure psychiatric care in England and Wales. 1: A national survey of admission assessments. Centre for Mental Health and National Mental Health Development Unit, 2011, Pathways to unlocking secure mental health care. 33