Forensic psychiatry is a branch of psychiatry deling with the assessment and treatment of offenders in prisons, secure hospitals and the community with mental health problems. It requires a sophisticated understanding of the links between mental health and the law.
Nature of the work
Forensic psychiatrists must balance the needs of each person assessed and/or treated with the risks of harm to others, including the person’s own family and associates, criminal justice or health service staff or the wider public. They most commonly provide treatment in a secure hospital environment, but may deliver services to prisons or deliver specialist community services. Generally, their patients are subject to legal restrictions.
Forensic psychiatrists need expertise in assessing and limiting further harm to the patient or others and also need highly developed multidisciplinary clinical and inter-agency skills. The work requires an ability to work effectively with other psychiatric specialties. They also contribute to the design of treatment facilities and programmes and provide expert advice to other health and social care professionals.
Knowledge of relevant legislation and criminal, civil and case law is central to the work which means working with criminal justice agencies and the courts. Almost all patients have had previous health service assessment and treatment - many have also had previous contact with the criminal justice system. Most are referred from the criminal justice system but other health service facilities are an important source of referral when a patient is perceived as posing a risk – often to staff or other patients - which cannot be safely managed in a less secure environment.
An important part of the work is assessment of risk of harm to others as well as to the patient themselves. This task is only complete when a resultant management strategy has also been documented, even when that strategy is an argued case for disowning any risk. Where risk management is assumed in whole or in part by the forensic mental health team, the forensic psychiatrist must ensure appropriate, regular review of the assessment and strategy.
Forensic psychiatrists also provide specialist advice to the courts, the probation service, the prison service and other psychiatric colleagues. They also prepare reports for mental health review tribunals, hospital managers’ hearings, other practitioners and criminal justice agencies. It has also seen development of forensic low security hospital beds for patients working towards discharge and recovery.
There has also been a reduction in the number of high security hospital beds which is likely to mean further expansion in low security hospital services and fuller development in community forensic services.
“It’s so rewarding to see people recover from the most fractured state of mental health”.
Dr Brad Hillier, Locum consultant forensic psychiatrist South-West London and St George’s Mental Health Trust
Forensic psychiatrists regularly provide expert witness evidence to courts at all levels. Psychiatrists in other specialties may also have sufficient training to do this, but, more commonly forensic psychiatrists are called to the higher courts – including crown courts or the Court of Appeal in more serious criminal cases such as homicide, other serious violence and sex offending. They may also be asked for expertise in the family court or on other civil matters, such as compensation after major trauma or disaster. Areas of expertise required include:
- defendant’s fitness to plead and fitness to stand trial
- capacity to form intent
- advice to the courts on the available psychiatric defences
- appropriateness and circumstances required for an individual’s admission to hospital for assessment
- appropriateness of a mental health disposal at the time of sentencing
- nature of a particular mental disorder and link to future risks
- prognosis and availability of “appropriate treatment”
- level of security required to treat a patient and manage risk
When advising colleagues in the care of patients deemed to be a risk to others, forensic psychiatrists will need to be competent to provide a detailed assessment including advice on:
- risk of harm to others, including use of structured risk assessment/professional judgement tools
- risk management
- expertise on pharmacological and psychological treatment approaches to violent behaviours associated with mental disorders
- psychodynamic formulation of the case, including psychotherapeutic strategy
- therapeutic use of security
Community forensic work provides opportunities to assess and to work with mentally disordered offenders in facilities run by HM Prison and Probation Service and/or third sector organisations. In addition, although all psychiatrists should have a basic understanding of the system of Multi-Agency Protection Panels, in practice forensic psychiatrists must be very experienced in such work. Ethical issues, such as information sharing, differ under such working arrangements from usual clinical practice. Skills needed include knowledge of when and what otherwise confidential information must be shared with others in these circumstances, clarity of understanding of role in the arrangements and appropriate confidence in requiring information from other agencies when necessary for good and safe care.
Forensic psychiatrists must participate in regular audit within and outside the specialty, thus helping to improve the quality of the service offered to patients.
They must understand clinical governance procedures, attend meetings and investigate complaints and serious incidents alongside colleagues in the multi-disciplinary team.
Teaching and training is also an important part of the work. This includes weekly supervision of specialist higher trainees in forensic psychiatry, but also more junior trainees in any specialty. With recruitment and retention in mind, it is important to engage with undergraduate medical trainees too. Given the multi-professional nature of the work, a contribution to the teaching and training of people from other relevant disciplines is also expected.
People with needs relevant to the whole psychiatric spectrum may offend or become dangerous to others. In some areas this is so common that joint training has been set up to allow those who complete the training to be able to claim expertise in both (or more) areas. There is a growing need for old-age forensic psychiatry, and most offender patients have problems with substance misuse, but the three recognised combinations to date are:
- adolescent forensic psychiatry
- forensic learning disability psychiatry
- forensic psychotherapy
Want to learn more?
Find out more about:
- the working life of a doctor in forensic psychiatry
- the entry requirements and training and development
- a first-hand account of life in forensic psychiatry
Pay and conditions
Expand / collapse
This section provides useful information about the pay for junior doctors (doctors in training), specialty doctors, consultants and general practitioners.
Find out more about current pay scales for doctors, more information can be found on the BMA website.
NHS employers provides useful advice and guidance on all NHS pay, contracts terms and conditions.
Medical staff working in private sector hospitals, the armed services or abroad will be paid on different scales.
Where the role can lead
Expand / collapse
Read about consultant and non-consultant roles in forensic psychiatry, flexible working and about wider opportunities.
Managerial opportunities for consultants include:
- clinical lead - lead NHS consultant for the team
- clinical director - lead NHS consultant for the department
- medical director - lead NHS consultant for the trust
Most NHS consultants will be involved with clinical and educational supervision of junior doctors.
Here are some examples of education and training opportunities:
- director of medical education - the NHS consultant appointed to the hospital board who is responsible for the postgraduate medical training in a hospital. They work with the postgraduate dean to make sure training meets GMC standards.
- training programme director - the NHS consultant overseeing the education of the local cohort of trainee doctors eg foundation training programme director. This role will be working within the HEE local office/deanery
- associate dean - the NHS consultant responsible for management of the entirety of a training programme. This role will be also be working within the HEE local office/deanery
SAS doctor roles
SAS doctors (Staff, Associate Specialists and Specialty Doctors) work as career grade specialty doctors who are not in training or in consultant posts. You will need at least four postgraduate years training (two of those being in a relevant specialty) before you can apply for SAS roles.
Further information on the SAS doctor role is on this site.
Other non-training grade roles
These roles include:
- trust grade
- clinical fellows
If you have trained on an academic psychiatry pathway or are interested in research there are opportunities in academic medicine.
For those with a particular interest in research, you may wish to consider an academic career in psychiatry. Whilst not essential, some doctors start their career with an academic foundation post. Entry is highly competitive. This enables them to develop skills in research and teaching alongside the basic competences in the foundation curriculum.
Entry into an academic career would usually start with an Academic Clinical Fellowship (ACF) at ST1-2 and may progress to a Clinical Lectureship (CL) at ST3 and beyond. Alternatively some trainees that begin with an ACF post then continue as an ST trainee on the clinical programme post-ST4.
After completion of the academic foundation trainees can then apply for academic core training posts (instead of normal core training). A PhD is often taken, either during core or specialty training.
Applications for entry into Academic Clinical Fellow posts are coordinated by the National Institute for Health Research Trainees Coordinating Centre (NIHRTCC).
There are also numerous opportunities for trainees to undertake research outside of the ACF/CL route, as part of planned time out of their training programme. Find out more about academic medicine.
The Clinical Research Network (CRN) actively encourages all doctors to take part in clinical research.
Psychiatrists often undertake research, which includes collaborating with colleagues in the UK and overseas, writing papers and presenting work at conferences. Research within this specialty, as is often the case, is subject to financial constraints. There is not always sufficient money to carry out all the necessary work.
There may also be opportunities to work in the private sector and overseas.
Job market and vacancies
Expand / collapse
This section provides useful information about the availability of jobs, how to find vacancies and sources of further information.
Job market information
Psychiatry is the fifth largest medical specialty in the UK. Consultant psychiatrists comprise 4.5% of the mental health workforce and 10.5% of the total NHS consultant workforce (Health and Social Care Information Centre, HSCIC 2014). Most areas of psychiatry have seen considerable growth in the consultant workforce in the last ten years, and forensic psychiatry is no exception. In 2003 there were 212 (full-time equivalent) forensic psychiatrists in post and by 2013 this had risen to 311, showing a 47% growth. (CfWI analysis based on HSCIC, 2014).
About 8% of consultant psychiatrists specialise in forensic psychiatry, although a much higher proportion have training in some aspects and join in forensic psychiatry faculty conferences.
In 2016, the competition ratio for CT1 core psychiatry training was 1.50, and for ST4 specialty forensic psychiatry training was 1.92 (NHS specialty training 2016).
In 2014 there was an in depth review of the whole psychiatric workforce by the Centre for Workforce Intelligence (CFWI).
On this section we have information for England only. For information regarding Scotland, Wales and Northern Ireland please click on the links below.
Where to look for vacancies
Specialist forensic psychiatry training is open to those who may want to train flexibly on a less than full-time basis (LTFT). You can request and apply for this after you have been offered the job. Restrictions apply.
Recruitment into specialist psychiatry training (excluding Northern Ireland) is coordinated by the North Western Deanery, Health Education North West.
Registration and applications for psychiatry core and higher specialist training is online via Oriel.
Northern Ireland has its own recruitment process for psychiatry. For further details please visit the Northern Ireland Medical and Dental Training Agency website.
Expand / collapse