RESOURCES
34. Some £89 million is already spent each year
on the 1,800 people in prison or special hospital who are deemed
both to have a severe personality disorder and to be dangerous.
This is based on the estimated non-capital cost for dangerous
severe personality disorder individuals of £38,000 in prison
and £90,000 a year in a secure hospital.[31]
The cost of the prison place is calculated on the basis of close
supervision in a category A/dispersal prison. A male place in
a local prison costs £24,600.[32]
The approximate annual cost for a severe personality disorder
patient in a clinic in the Netherlands is £75,000.[33]
35. The three high secure hospitals in England are
Ashworth, Broadmoor and Rampton; there are also regional medium
secure units and low secure units attached to other hospitals.
Some of the evidence we have received indicates that a shortage
of resources—rather than deficiencies in the law—is
the major issue. In particular there are shortages of both staff
and beds in psychiatric hospitals. We were told:
"the biggest problem is unavailability
of services and insufficient help for individuals with a diagnosis
of personality disorder whether in the community, prison or hospital".[34]
"the wide definition of treatment [under
the existing law] allows for the detention of most DSPD individuals,
and a failure to detain has often been a failure of the relevant
services, linked to lack of resources, rather than a shortcoming
in the law".[35]
"there is a problem across mental health
in terms of staffing; but there is a particular problem in terms
of the special hospitals and the prison health care system, and
for differing reasons".[36]
36. The consultation paper clearly envisages the
need for extra spending on the different priorities in this area,
whichever option is chosen. We have not received detailed evidence
on the additional expenditure required. Plans are already in hand
for increasing the number of beds in medium and low secure units
and for recruiting more psychiatric staff in prisons.[37]
The main areas on which expenditure will be required are:
- research
to develop assessment tools
- capital and running costs for assessment and
review facilities
- facilities to accommodate those detained.
37. The main difference between the two options,
A and B, is that the latter would involve people being detained
in services managed separately from mainstream prison and health
service provision. Option A represents the current arrangement
of people being detained either in prison or in hospital. A new
service under Option B might require 25 to 50 units throughout
the country, each accommodating 50 to 100 people. The Fallon inquiry
into Ashworth Hospital advised against concentrating large numbers
of people in a small number of institutions.[38]
The Minister told us that a new service would not necessarily
require new building and, on the other hand, continuing with the
existing prison/hospital system may actually require new building.[39]
Separate and suitable accommodation will also be needed for the
very small number of women likely to be affected. The facilities
needed were described thus:
"if we are looking at people
being in these institutions for considerable periods of time,
possibly for the rest of their lives, when they are not serving
any sort of tariff period of a sentence, then I think you have
got to look at much smaller units with the whole range of facilities
that enable life to be bearable inasmuch as it can be bearable
if you have lost your liberty ... things like leisure facilities,
work, education facilities, contact with the outside world through
befriending schemes or those sorts of schemes. Obviously there
would have to be proper provision for physical health care ...
you have got to put in high-quality facilities for a range of
activities".[40]
38. We believe, however, it is essential that reform
should be driven by a clear vision of the kind of institution
that is called for. If society is to deprive people of their freedom
on grounds of public safety, the place where they live must provide
the closest possible equivalent to normal living conditions. Clearly
security must be the paramount consideration, but it is important
to create something as close as possible to a normal world compatible
with the need for security. As described in paragraph 31 we saw
in the Netherlands the type of accommodation and regime which
may be suitable. Such facilities will have to provide for legally-different
categories of people who are dangerous and who have a serious
personality disorder:
- those who have not committed an offence, but
whose continued presence in the community poses an unacceptable
risk to public safety
- those who have not committed an offence, but
are already detained under the Mental Health Act 1983
- those who have committed an offence but have
been sent to a secure hospital
- those who have committed a serious offence and
are currently in prison.
39. This raises a real question about the treatment
of those who have not committed any offence, who are likely to
be only a small proportion of those detained in such facilities.
It could be argued that they should not be accommodated with those
who have been convicted of an offence. On the other hand, if the
medical treatment, regime and facilities being provided are identical,
there may be little good reason to keep them separated. The arrangements
for those detained in secure hospitals under the Mental Health
Act 1983 do not distinguish between those who have been convicted
of offences and those who have not. This is a matter which requires
further examination by the Home Office, which will need to take
into account both medical advice and the interests of those detained
and their families.
40. The Government's proposal set out in option B
is for a dedicated service, separate both from prisons and psychiatric
hospitals, for individuals who have severe personality disorder
and are dangerous. Among the reasons for taking this option are:
|
the current division between prisons and
hospitals is arbitrary and unsatisfactory to both |
| people with this diagnosis have different
needs from other prisoners and from psychiatric patients in terms
of the balances between care and punishment, custody and containment
and control and empowerment |
| more targeted treatment could be provided
- helping to foster a culture of rehabilitation, working towards
eventual release and lower rates of re-offending |
| closely monitored rehabilitation may enable
some of those with personality disorder to work towards the effective
management of their condition, enabling them to lead a close to
normal life |
| the mentally-ill should be cared for in
a different environment from those with personality disorder as
personality disordered people are adept at manipulating mentally
ill patients. |
Pros
41. On the other hand, there may be disadvantages
in moving in this direction:
| it will not be easy to categorise dangerous individuals
for this new provision, because some will also have mental illness
and other prisoners will have some form of personality disorder
although not necessarily severe or dangerous |
| a third service will create more bureaucratic barriers
and more gaps between provision |
| since resources are limited, extra money might be
more likely to deliver positive results if channelled through
existing structures. |
Cons
42. The annual cost of a patient in a clinic under
option B might be comparable to the Netherlands figure of about
£75,000 a year—twice the current annual cost of £38,000
for keeping a prisoner under close supervision in a high security
prison. This is still significantly less than the £90,000
a year for a place in a secure hospital. If a scheme similar to
TBS was adopted in the UK, it is possible to envisage additional
spending on people currently in prison who were transferred to
a special clinic but some reduction for those transferred from
a secure hospital. There would also be savings from returning
an individual to the community after a shorter total period in
detention. There would also be savings accruing from the lower
propensity to offend again. There is also scope, as the Minister
of State has recently suggested, for allowing patients to earn
money and to make a contribution to offset part of the cost of
their upkeep.
43. On the face of it, option B—which envisages
the establishment of a third way, separate from the existing prison
and hospital facilities—would appear the more expensive.
As we discuss in paragraph 64 below, the provision of suitable
facilities will be an important element in satisfying the human
rights requirements associated with potentially indefinite detention.
Against such additional costs, there will also be some less quantifiable
benefits in improving public safety. Any analysis of the options
needs also to consider both the benefits of such dangerous people
not being at large in the community and the long-term savings
which could arise through reduced rates of re-offending on release.
44. We conclude that substantial initial expenditure
will be needed for the future management of dangerous people with
severe personality disorder, irrespective of what other changes
are made in the law affecting them or the way the facilities are
organised. This is a cost which, in the interests of public
safety, we believe to be justified.
45. The experience of the Netherlands, in our opinion,
supports the proposals in option B for managing dangerous people
in the UK.
46. We recommend that the Home Office should publish
the cost benefit analysis underlying its consideration of the
options proposed, including the implications of adopting a TBS-type
arrangement in the UK.
47. The transition to a new system will have to be
gradual with both the Home Office and the Department of Health
being involved in this task. The staff needs of new facilities
are bound to deplete the existing mental health facilities. But
such a change may be welcomed by the medical staff involved. The
Royal College of Nursing told us " we could imagine a situation
where a lot of nurses would wish to come forward to [work in a
new separate service], provided that the resources are provided".[41]
31 Home
Office consultation paper p9 para 7. Back
32 HM
Prison Service Report and Accounts 1998-99. Back
33 The
assessment process is twice as expensive on a comparable basis. Back
34 Appendix
4, summary para 2. Back
35 Appendix
3, para 3.4. Back
36 Q132
(Mr Boateng). Back
37 House
of Lords Official Report 20 January 2000 WA col 158. Back
38 Appendix
4, page 27 para 36. Back
39 Q134. Back
40 Q104-5
(Mind). Back
41 Q172
(Mr Green). Back
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