An article by Dave Hearn, Associate Head of Commissioning & Contracting, Health Education Kent, Surrey & Sussex
When electronic monitoring was first trialled in the 1960’s by the Gable brothers at Harvard the overarching aim was to promote positive behaviours in participants using ideas from behavioural psychological theories.
In the ensuing decades electronic monitoring has found widespread use globally as a measure of control and punishment. This article presents some learning from a project using electronic monitoring therapeutically in secure mental health services.
Medium Secure Units (MSUs) provide care for those people with mental health problems who “pose a serious danger to the public” (Centre for Mental Health 2011). Patients may come directly from court, from other hospitals or on transfer from prison, all will be detained under the Mental Health Act 1983 (MHA) and many will be detained under restriction orders. Many patients will come into contact with Probation services and MAPPA on discharge from hospital.
Leave out of the ward is very important to all detained patients within MSUs. The focus of clinical teams is on the recovery of patients and progression of leave is fundamentally linked to this process of recovery.
MHA detention is justified in terms of risk and need rather than an offence-related court imposed tariff – there is no EDR and the length of stay in hospital can vary depending on the individual patient’s progress.
Leave is therefore a reward, an incentive, a treatment and a measure of progress all rolled into one with patients always working towards the next milestone – getting leave for the first time, working towards leave outside of the hospital grounds or without escort and, eventually, overnight leave to a future residential placement.
Alongside patient recovery a core role in MSUs is public protection. Breaches of leave do occur and these are defined as follows: Abscond – A patient unlawfully gains liberty during escorted leave of absence outside of the perimeter of the originating unit/hospital by getting away from the supervision of staff; Failure to Return – A patient fails to return from authorised unescorted leave (DH, 2009).
Bowers et al (1999) found that patients decided to breach leave conditions due to ‘socio-environmental factors’ such as anger (following unwelcome news), feeling trapped and confined, the quality of the food, boredom, fear of other patients, worrying about relatives or property and the need or desire to carry out an activity or responsibility. Breaches are rarely planned ahead: the majority are impulse-driven, spur of the moment events. The proximal cause of absconding then is most usually the decision to abscond taken in the moment and influenced by these socio–environmental factors.
Occassionally patients unlawfully at large commit offences. Public expectations remain high and tolerance for mistakes and incidents is, quite rightly, low. Following a homicide committed by an absconded patient (France, 2009) GPS tracking was trialled for the first time within forensic mental health services (Hearn, 2013; Tully et al, 2014) for patients taking leave.
The device used was small and lightweight and worn on the ankle. The strap is fitted to the individual wearer and incorporates thick cabling (to make the device non-removable) and optic fibres (to provide anti-tamper alarms). The device is able to give a location of the wearer to within a few metres using GPS signals, much the same as a SatNav or Mobile Phone, and can be set with geographical parameters that are completely individualised for the wearer. These parameters are known as Geo-fences, enabling the creation of Exclusion and Inclusion zones. For instance:
When deciding to use GPS tracking with a patient firstly a risk assessment is carried out. The decision to grant leave is made by the clinical team and if GPS tracking is being considered the patient will be given an information leaflet and the opportunity to discuss this with family, friends or an advocate.
Patients assessed as high or medium risk must wear a device when leaving the unit (this cohort of patients would not normally be considered for authorised leave under Section 17 MHA – their leave will normally be for court appearances, hospital appointments or on compassionate grounds).
Patients assessed as low risk are asked for their consent to participate with the scheme. If a patient does not wish to use the device they have leave as normal, however patients who consent to use GPS tracking will usually be able to access more leave more quickly due to the added assurance the device gives.
The results of the pilot were stark. Firstly, as the table below shows, the number of incidents overall reduced by 75% in the first 2 years and absconds reduced to zero. Reduction on incidents is only one half of the story – any unit can achieve a reduction of incidents simply by reducing the amount of leave or tightening up procedures. This will hinder patient’s progress and likely have an impact on increasing length of stay.
Conversely, we have found a significant (and unexpected) increase in the amount of leave being facilitated across our services following the introduction of GPS tracking. In addition the ratio of escorted to unescorted leave has reversed significantly, meaning that since the scheme’s introduction more patients are achieving the more trusted status of being able to use leave unaccompanied.
As unescorted leave is less resource intensive this means that patients are able to access longer periods of leave with greater geographical freedoms (monitored through setting of Geo-fences). In short GPS tracking has enabled patients to have more leave, with less restrictions and greater liberty, more safely and with less incidents.
Discussions with patients have revealed a generally pragmatic attitude towards GPS tracking – whilst there are drawbacks from wearing the device it helps them achieve more leave more quickly and so is therefore on balance acceptable.
Some have stated that it has been helpful at times when they have been at risk of breaching leave, helping them to make safer decisions fitting with crime theories like Rational Choice Theory or Routine Activity Theory.
Using GPS tracking for forensic mental health patients on leave was a bold and innovative initiative. First impressions of many have been negative – we have had many conversations with clinicians and service user representatives who are concerned about the implications for liberty and privacy and we recognise those potential pitfalls.
However with careful management of this, at the end of the first year of the pilot we have found that:
- The proximal cause of absconding is most usually the decision to abscond taken in the moment and influenced by these socio–environmental factors
- Use of GPS tracking helps patients not to make impulsive decisions early on in their recovery when they are most vulnerable – decisions that have long reaching implications on length of stay, liberty, etc.
- The system has helped to manage risk and at the same time has significantly increased patient access to leave which is important for recovery.
There are parallels with how this project utilized GPS tracking with some of the Integrated Offender Management projects such as in Hertfordshire.
It shows the therapeutic potential of GPS tracking through supporting individuals to make better, safer decisions in the community.
Exclusion Zones: For a wearer with leave but who may not be allowed to enter a named area a Geo-fence can be drawn around this area and an alert will be raised should the wearer cross the boundary into this area (this is an Exclusion zone). These exclusionary Geo-fences can be small or large ranging from alerting access to a specific building to a campus or area (such as a hospital, school or a radius around a specific address) up to a large area such as a London Borough.
Inclusion zones: These are very similar but raise an alert when the wearer attempts to exit a specified area. Useful examples might be: patients with only hospital grounds leave, patients admitted for treatment to a general hospital or those only allowed leave in the local area (e.g. a four mile radius).
Bowers, L; Jarrett, M; Clark, N; Kiyimba, F and McFarlane, L. (1999) 1. Absconding: why patients leave. Journal of Psychiatric and Mental Health Nursing 6, pp: 199-205
Centre for Mental Health (2011) Pathways to unlocking secure mental health care Centre for Mental Health, London
Department of Health (2009) Absent Without Leave. Definitions of escape and abscond DH, London
France A. (2009) Escaped lag killed OAP for drug cash. The Sun http://www.thesun.co.uk/sol/homepage/news/2482862/Escaped-lag- Terrence-OKeefe-killed-OAP.htm
Hearn, D (2013) Tracking patients on leave from a secure setting Mental Health Practice 16(6): 17-21
Tully, J, Hearn, D & Fahy, T (2014) Can electronic monitoring (GPS ‘tracking’) enhance risk management in psychiatry? British Journal of Psychiatry 205: 83-85