title: Women's secure hospital care pathways in practice: a qualitative analysis of clinicians views in England and Wales.
abstract: BACKGROUND
  In England and Wales women form a small but significant group within the wider, largely male, secure hospital population. Secure hospitals are designed to assess and treat individuals with both mental health problems and significant criminal behaviour. The theoretical approach to the care of secure hospital women is increasingly informed by a grasp of gender-specific issues. However, there is a lack of evidence on the adequacy of current structures and processes of care delivery.
  
  
  METHODS
  This qualitative study explores the nature and quality of care pathways for women in low and medium secure hospital beds by eliciting participants' views of factors enhancing or impeding care. Beds are publicly funded and provided either by the National Health Service (NHS) or the Independent Sector (IS). Participants from both sectors were local experts (40 Consultant Psychiatrists, 7 Service Managers) who were well placed to describe their immediate health environment.
  
  
  RESULTS
  Evidence from the study indicates that participants were focused on the physical relocation of women to less secure conditions, even though many women do not readily achieve this.Participants were alert to potential conflicts between ideal care and affordable care. Ideal care was compromised by the absence of suitable local services (beds or community placements), curtailed episodes of care and changes of care team. It was promoted by an awareness of the specific needs of women, continuity of care and support for teams unfamiliar with women's needs.
  
  
  CONCLUSIONS
  Future service design must address these challenges in care delivery, incorporating a better understanding of and response to the ways the system can echo women's experiences of trauma and their negative attachment histories. Specifically, critical transitions in care must not be allowed to further reinforce the discontinuity, failure and rejection experienced by individual women earlier in their lives.
authors.affiliation: Department of Population, Health Sciences and Education, St George's, University of London, Cranmer Terrace, London SW170RE, UK. nadia.somers@nhs.net.
authors.forename: Nadia
authors.initials: N
authors.lastname: Somers
authors.forename: Annie
authors.initials: A
authors.lastname: Bartlett
mesh_terms: D000328:Adult; D003365:Costs and Cost Analysis; D057237:Criminals; D004739:England; D005260:Female; D006301:Health Services Needs and Demand; D006302:Health Services Research; D006778:Hospitals, Psychiatric / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D001523:Mental Disorders / Q000191:economics / Q000534:rehabilitation*; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D036301:Qualitative Research; D013222:State Medicine; D014852:Wales; D016387:Women's Health