The final outcome framework contained six overarching domains containing 42 individual outcome areas. The domains were ordered according to a suggestion from the PPAG and agreed by the research team. This order moves from more personal, internal and subjective concepts, to those that are more objective and externally determined. It is not however intended to represent a hierarchy of importance.

It should be noted that the items within the PROM & ClinRo do not directly align, as whislt the PROM contains all items from the 6 domain, the ClinRo provides additional questions that assess observational behavior.

All domains and constituent outcome areas are framed in the first person to emphasise the importance of the individual patient’s perspective:

• ‘About me’, concerns questions of self-concept and encompassed ideas of meaning and belonging, as well as feelings of control and wellbeing;
• ‘My quality of life’ considers the interaction of a person with the outside world and the degree of satisfaction this affords that individual. Outcome areas in this domain span from simple items, such as whether a person’s basic needs are met, to more complex concepts, such as whether they feel respected and accepted by others;
• ‘My health’ then considers the individual’s physical and mental health, such as whether they are able to maintain a healthy weight or their mental and emotional health is good;
• ‘My safety and risk’ concerns both behavioural and internalised aspects of risk, such as avoiding behaviours and situations that reduce safety and recognising and coping with difficult feelings;
• ‘My life skills’ incorporates both current and future capabilities, from being able to look after every day needs, to being able to make realistic plans;
• ‘My progress’ attempts to quantify the person’s position within the care pathway, both considering where that individual is at that point in time, to thinking about where they need to move towards.

The 20-item PROM and 23 item Clin-RO provides between them include items covering the six domains of About me, My quality of life, My health, My safety and risk, My life skills and My progress. The ClinRO does not include any items from the About me or My quality of life domains, due to their subjective nature, which can only be meaningfully assessed from the patient’s own perspective.

Responses are provided on a 5 item Likert-scale and whilst we do not recommend weighting individual domains, a numerical score can be produced if required. It is up to users how they wish to interpret responses in ways that are most useful to them; further guidance is under development.

More details of the scoring system and administration procedures for FORUM are provided in the FORUM scoring guide/user manual which can be accessed as part of the licensing procedure.

The approach used to develop the FORUM was an iterative process involving multiple, linked components. The development process had three main parts: firstly concept elicitation, secondly concept prioritisation and thirdly drafting and refinement of the new instrument.

All parts of the work were overseen by the research team, supported by a dedicated Patient and Public Advisory Group (PPAG), which included patients who had previously used forensic mental health services and carers of such patients.

The selection of items for inclusion in the initial draft was guided by discussions in the research team, based on the results of the concept elicitation and prioritisation work. The introduction and instructions were designed to be as short and functional as possible. The timeframe for ratings was guided by the expected pace of change in forensic services. The length of stay is long in such services and comprehensive reviews usually take place every six months through the Care Programme Approach (Hare-Duke et al., 2018; Tomlin et al.,2021).

The PROM was then reviewed by the PPAG and revised before undergoing two rounds of cognitive debriefing interviews (CDI) with patients. Patients in Oxford Health NHS Foundation Trust who had participated in the concept elicitation and prioritisation exercise were invited to participate. The CDIs included a ‘thinking aloud exercise’ and a series of verbal probes. The CDIs were informed by a topic guide developed in collaboration with the PPAG. The PROM was revised after each round of CDIs. The CROM was also reviewed by the PPAG and clinicians from a range of professional backgrounds. The final drafts were agreed by the research team and PPAG.

The study was approved by the London – Surrey Research Ethics Committee (Reference
18/LO/0929). All participants provided informed consent to participate.

The development of the FORUM was funded by the National Institute for Health Research (NIHR) through a Doctoral Research Fellowship (DRF-2017-10-019) awarded to Dr Howard Ryland. The views expressed on this website are those of the authors and not necessarily those of the NIHR, NHS, or the UK Department of Health and Social Care.