Examination of witnesses (Questions 165
- 179)
TUESDAY 30 NOVEMBER 1999
DR MIKE
SHOOTER, DR
NIGEL EASTMAN,
MR BARRY
TOPPING-MORRIS,
MR CHRIS
GREEN and DR
SIOBHAN SHARKEY
Chairman
165. Good morning, ladies and gentlemen. Thank
you for your evidence and thank you for coming to help us this
morning.
Mr Singh
166. We have had evidence from MIND who were
very concerned and said that "... the biggest problem is
the unavailability of services and insufficient help for individuals
with a diagnosis of personality disorder whether in the community,
prison or hospital". Obviously the proposals the Government
are making are somewhat reliant upon additional resources and
facilities being available. Could you give us some impression—I
am not sure to whom to address the question directly—of
the scale of staff shortages and how it varies by institutions
and by speciality?
(Dr Shooter) If I may go first. I think that is a
very, very important practical issue. We will no doubt argue about
legal issues and ethical issues but the Royal College of Psychiatrists
is just as concerned about the staffing issues. If I may set this
in context. If we are talking about the availability of forensic
psychiatrists, for example, in the mid to late 1970s when the
secure unit programme began there were just seven or eight consultant
forensic psychiatrists in the UK. The latest manpower survey we
have shows there are something like 134 consultant forensic psychiatrists
and around 76 specialist registrars who are going to be the consultants
in the not too distant future. Those figures, however, and that
increase masks enormous problems. First of all, we have something
like a 15 per cent consultant post vacancy and climbing. In other
words, it is becoming more difficult to recruit good quality consultant
forensic psychiatrists and we are losing some en route. We have
particular difficulty in recruiting to exactly the sort of service
that we are talking about today, and the sort of population that
we are talking about today, for all sorts of reasons which no
doubt we will discuss. In the lead up to preparing our response
to this whole document, we did a very intensive questionnaire
survey of forensic psychiatrists throughout the UK and also other
psychiatrists who were involved in this sort of work. It was very
clear that amongst the 20 or 30 per cent who would say that they
were very interested in working in any new facility under these
proposals, the vast majority of those would come from the old
system, in other words they are already working with this sort
of client load in the old system. We did not get any response
from people working outside this system. So, in other words, we
are going to run up against an enormous recruitment and staffing
problem because in the process of building any new facilities
what I fear will happen is that we will drain off the best expertise
from the old system which per force has to continue.
Chairman
167. Forgive me, what is the training period,
please, for forensic psychiatrists?
(Dr Shooter) Four or five years. We will drain off
the best expertise from the old system and a system that is already
in a parlous state in many ways, particularly in personality disorder
units, for example, as we have seen at Ashworth, is going to be
even more compromised. Ashworth itself has only solved its consultant
problem by dragging back in a retired, albeit eminent, forensic
psychiatrist for a locum period. So to say, as the proposals do
say, that they feel they could staff the existing system and staff
a newly developing system within resources as they exist at the
moment I fear is naive to say the least.
(Dr Eastman) I wonder if I might add something to
that, with the Chair's indulgence. I think it is important also
to emphasise the nature of training and the nature of experience.
A lot of store has been put by the comparison with Holland. The
tradition of training and practice in forensic psychiatry in Holland
is substantially different from this country in that it has a
much stronger psycho-therapeutic bias to it. I speak from knowledge
and experience of many colleagues there, from meetings there and
so on. I think it is important to emphasise that the lack of resources
and push behind this, if you like, hybrid disorder problem of
personality disorder in this country has resulted in the sort
of scientific ambivalence that you are observing and not any sort
of emotional ambivalence amongst psychiatrists, it is a scientific
uncertainty. I think that has been reflected in the relative paucity
in training in psychotherapy of forensic psychiatrists. I make
the point because these are not disorders which by and large are
responsive to medication. One has to think not just in terms of
how many forensic psychiatrists are there but how many forensic
psychiatrists and nurses and occupational therapists and other
professions are there who actually have specific psycho-therapeutic
skills, and by that I do not mean budding Freuds of the next generation
but that they have fairly straight forward behavioural, cognitive
and other types of skills. There is a subtlety to it behind the
raw numbers.
Mr Singh
168. Are there currently shortages in those
other areas you mentioned?
(Dr Eastman) Yes, there are and, in fact, if I say
to you that just now there is agreement and movement towards creating
some specialist registrar posts, particularly in forensic psychotherapy,
that is only just starting and so we are nibbling at starting
this where the Dutch have been doing it for generations.
169. Let us say that the Government proposals
went through but the therapeutic side, that type of intervention,
did not take off the ground at the moment but you did just what
forensic psychiatrists are doing at the moment, what increase
in workload would you anticipate and what increase in the numbers
of various staff levels would you anticipate if you were doing
no more than you are doing at the moment?
(Dr Shooter) If we were doing no more than we are
doing at the moment, and simultaneously we staff with forensic
psychiatrists and all the other professions a new system, and
the old system while the new system is coming into operation,
then it will be difficult to quantify that workload, but my guess
is it will become impossible in many cases. I think it would become
impossible most obviously in the old system and what worries me,
for example, about some of the proposals from a practical point
of view in Option A, is the idea that already over-stressed and
over-stretched acute psychiatric wards, and we have many independent
assessments of the parlous state they are in at the moment pouring
out over the course of this year, are going to be stretched to
breaking point. It is already very difficult to get general psychiatrists
to work on wards which now have become little more than custodial
wards with almost no treatment possible because most of the staff's
time is taken in looking after potentially unruly, violent, unwilling
patients. If, for example, under Option A, the treatability clause
was removed, and we had added to that a whole raft of people who
were unwilling to be there, potentially violent, a risk to themselves,
to other patients and to staff and staff morale sank because their
job was reduced to being a custodial job rather than an efficacious
treatment job, then I think we would have an almost impossible
job to recruit people to work under those conditions. That would
go for psychiatry and my guess is it would certainly go for all
the other professions involved as well.
(Dr Sharkey) Yes. Certainly we would be very concerned
because there is a national shortage of mental health nurses and
we know that, for example, recruiting agency and bank nurses does
very little for the quality and continuous care of people with
mental health services in special hospitals. We would be very
concerned on two points. First of all, how are you going to attract
people into any new service under either option and what is the
impact of the drain from existing services on the staffing of
existing services for people in special hospitals and in acute
mental health settings?
170. Let me get this clear. If I understand
you correctly, if the new system was in place today the extra
people who were going to be detained, the only service that could
be provided to them is pure custody, just custody? You would not
be able to provide them with any therapeutic services or services
of mental health nurses?
(Dr Shooter) I think what we are saying is something
slightly different. If a new system was introduced and was in
operation today under Option B for example, there would be quite
a substantial proportion of forensic psychiatrists, and my guess
is it would be true for other professions as well, who would find
that an attractive sort of system to work within or more attractive
than the system they are working in at the moment. What I think
we would see is a wholesale shift from the old system to the new
and not much extra recruitment from outside. That might staff
new facilities, though even then I am not so sure there would
be enough, but what it would do is to drain off any remaining
expertise from the old system where people still have to work
with this clientele in the long transitional period that these
proposals are talking about. We are talking here about the transitional
period potentially of a decade or two decades.
(Dr Sharkey) There are people in special hospitals
today that would not necessarily end up in the new service and
would need to continue to be cared for.
(Dr Eastman) I think there is another difficulty which
is that the question is understandably posed from the point of
view of the numbers that are in the paper. I do not think that
the College is convinced that the numbers will be restricted to
those numbers. There are some definitional problems which the
Chairman referred to. If you combine definitional fuzziness, if
I can put it that way, with concern about public safety as a social
and public issue and how that impacts on professionals, it is
bound to be the case that there will be defensive practice, and
we may come on in a minute to how one identifies the group and
the danger, but there is bound to be defensive practice. My own
view, and I am a practising and academic forensic psychiatrist,
my own view is that the numbers would expand very substantially
and that that would include expansion of the numbers of those
not currently facing a conviction.
Chairman
171. And nobody would want to risk a headline
in The Sun.
(Dr Eastman) Absolutely and I think it is unrealistic
not to expect that that is what will happen. There is a lot of
evidence that with mental illness, psychiatrists are behaving
much more carefully, but perhaps in a way that just is too careful,
if one is allowed to put it in those terms, that it is actually
over-defensive and, as I say, we will come on to those issues
perhaps later, but the resource question of course has to be seen
in terms of the numbers of people we are talking about.
Mr Singh
172. What would you suggest needs to be done
to overcome staff shortages now and those predicted in the future
in the medium term?
(Dr Shooter) In terms of our own profession in psychiatry
and in terms of forensic psychiatry in particular, first of all,
we want to see a change in some rather bizarre governmental policies.
We have had a year-long battle, for example, by a formula which
I find great difficulty in understanding, but other people do,
to prevent the Government reducing the numbers of specialist registrars
in training in forensic psychiatry; and it really has been a very
difficult year-long battle. We have won that battle, but these
are the bread and butter of a service we are talking about who
are going to come on stream as consultants in five or six years'
time and if we do not build up those numbers in training, then
we are not going to have remotely the numbers that we are going
to need to staff any new system or a properly beefed-up old one.
There are things that we can do within the Royal College as well.
We are reviewing the psychiatric training in forensic psychiatry,
in general psychiatry and in all the other aspects of psychiatry
involving this sort of work. We might, for example, make sure
that our trainees get a proper, more lengthy exposure to the current
special hospital system. We are clearly concentrating an increased
focus on knowledge and research into personality disorders in
general at the severe end of the spectrum. We are encouraging
very greatly what my colleague, Dr Eastman, talked about earlier
on which is the very new profession of forensic psychotherapy.
Forensic psychiatry as a whole is in its infancy, and forensic
psychotherapy is almost still in the fallopian tube. We have just
a handful of people in training, and a small handful at that,
at the moment and they are only going to be qualified in five
or six years' time, and clearly that is going to be very, very
important. We make a very strong plea in any change for a very
slow and careful transition period because staffing two systems
at once is going to be almost at breaking point.
(Mr Green) In the nursing profession, there is a great
deal of interest in working constructively with patients with
personality disorders. There is a great deal of interest among
community psychiatric nurses in developing systems like assertive
outreach. Now, this is very much on the basis of trying to engage
a patient with very serious needs who is a suffering person in
a process that can relieve their suffering and in the process
it does of course provide some protection to the public. Now,
certainly insofar as resources can be devoted to nurses trying
to do this work, working also in the prisons, working also in
custodial settings indeed, but not confined to them, and certainly
not confined to treatment without consent, then we could imagine
a situation where a lot of nurses would wish to come forward to
do this, provided that the resources are provided.
Chairman
173. Let me just confirm this with you: that
I have the impression of this branch of the Health Service that
it has been starved of resources for X number of years. Is that
right?
(Dr Shooter) Thank you very much for putting it in
that way.
174. There is a question mark at the end of
it. I will come clean in my own constituency and across the City
of Birmingham that it is generally acknowledged that this branch
of medicine across the whole mental health arena has been the
Cinderella of the Health Service. Now, steps have been taken,
I think, just this very year to try and put that right, but is
that accurate?
(Dr Shooter) Absolutely accurate and we are still
waiting for the invitation to the ball.
(Dr Eastman) I think the other thing to say is that
one of the reasons it has been more starved is, as I said in a
point to Mr Singh just now, that it is, if you like, perceived
as a hybrid disorder, both morally and medically, that it is not
a mental illness, that there is uncertainty as to whether to see
such people as mad or bad, and there is uncertainty as to whether
one should see this as a disorder or delinquency and, therefore,
uncertainty as to whether one should treat it or punish it. I
think that that runs through the literature for decades, almost
centuries, and I think that that is an important factor, so to
speak, in driving much of what has happened in the past. That
is not to say that we should go on with that ambivalence, but
it is to take note of it and to accept that it is not going to
just go away.
175. Can we move on to this vexed question of
diagnosis which again is one of the issues at the heart of these
proposals. I would really like you both to comment on this, if
you would. Can you give examples of the difficulties of trying
to diagnose for not just personality disorder, but severe personality
disorder? You heard the exchange with the Minister on this. I
assume the word "severe" is in there because the Government
attaches a meaning to it, otherwise, it would not be in here,
so what is the difference between that and can the anti-social
and psychotic personality disorder be distinguished from severe
personality disorder?
(Mr Green) Anti-social and psychotic personality disorder,
that is actually a misuse of terms. The term "personality
disorder" is a description of personality traits. It is the
presence of certain personality traits to an abnormal degree.
176. Forgive me, but you precisely would have
heard the Minister use definitions which picked up on the anti-social
and the psychotic.
(Mr Green) We have the ICD-10 definitions which are
quoted in the document, page 13, which is a list of personality
traits, such as non-concern for the feelings of others, gross
and persistent attitudes of irresponsibility—the Minister
read them out. Now, these are all descriptions of personality
traits and they are obviously present to an abnormal degree, otherwise,
one would not call it a disorder. Now, that is conceptually distinguished,
and there is a great deal of difficulty with these concepts, but
it is conceptually distinguished from a disorder of the mind where
for some reason you cannot think properly, and I think that is
a reason why it has always been treated very differently from
something that is described as a mental illness. Now, psychosis
is necessarily, and I would refer this back to the psychiatrists,
but psychosis necessarily describes a process that you would describe
as a mental illness and not in itself as a personality disorder.
A personality disorder does not in itself imply the presence of
any illness.
(Dr Shooter) May I say something broadly before handing
over to my colleague, Dr Eastman. I think it is very important
here to think in terms of levels and I think one of the problems
with the proposals document is that it slips backwards and forwards
between different levels at random. First of all, if we think
in terms of pure personality disorder, there are many people who
say that this is the bread and butter of many psychiatric services
already, but there will be some disagreement on definitions of
different sub-types of personality disorder and indeed there is
much overlap, but also some differences, between two great international
systems of classification, the International Classification of
Diseases and the Diagnostic and Statistics Manual, DSM-IV; but
I think most psychiatrists would begin to get some sort of agreement
about basic sub-units of personality disorder. If we are then
talking about severe personality disorder, we are then talking
about something that is not actually a current psychiatric diagnosis
and we are entering into the realms of subjectivity rather than
objectivity on the current tools as they stand at the moment.
If we then leap from there to dangerousness, then the whole business
becomes fraught with subjectivity and different views and of course
you are bound to get differences of opinion on the current state
of science not just in this country, but internationally too and
not just in psychiatry, but in every profession that deals with
these people. If we are going to be talking about knocking heads
together, as you were earlier on, then we are going to be knocking
heads together throughout the world because the current state
of science says that at that sort of level and with the current
set of diagnostic tools that we have, we really are in a very
difficult situation.
(Dr Eastman) I have not got a lot to add to that,
but perhaps I may just state the obvious just to make sure it
is on the record. In very simple terms, an illness is something
that arises in somebody who is, if you like, essentially classified
as normal before they get ill, so the illness amounts to a change
away from their normal functioning. Now, that may become a chronic
change, or it may be you can see the early prodromal signs of
it, for example, in schizophrenia, in late adolescence or whatever,
but it is essentially somebody who gets an illness which distinguishes
them from their previous normality and also which clearly qualitatively
distinguishes them from other normal people. A personality disorder
is very different from that because it is essentially a developmental
disorder, it is the person and it is not, so to speak,
treatable in the same way as an illness, and the way in which
you decide whether somebody has a personality disorder is essentially
in terms of setting them against a backcloth of a normal population.
You are looking at a normal distribution, a Poisson distribution
curve and you are trying to decide essentially whether somebody
is so far up the end that you are going to call it personality
disorder. To give another analogy, we all have personalities that
are made up rather like patchwork quilts of traits and the question
is whether this person has got so much red, so to speak, that
you are going to call them a red personality disorder, if you
get my analogy. I think that difficulty arises in diagnostic terms,
just in terms of personality disorder, I accept what Dr Shooter
just said, but there is greater difficulty in getting agreement
about who has and has not got PD because there is a subjective
judgment about how bad it is, which is different from deciding
whether somebody has got delusions and hallucinations if they
have got schizophrenia. So if you look at all the studies of inter-rate
of reliability, that is different doctors deciding on the same
case, if you like, there is a much higher rate of agreement, much
higher rate, in relation to psychotic illness, schizophrenia and
other illnesses, than there is in relation to personality disorder.
As Dr Shooter said, if you then take that on and say, "Well,
now are not just saying PD, but we are going to say SPD",
then you add in, as he said, another layer of subjectivity, which
is why it becomes so fuzzy and difficult. If you then add dangerousness,
which is not even a medical construct, but may bear some relation
to personality disorder, but may not, then it becomes even more
difficult because you are going partially outside the psychiatric
construct field.
177. It is a social judgment.
(Dr Eastman) I think you can have somebody, for example,
who has a not very severe personality disorder who would not be
SPD, but who would be very dangerous for social reasons, ordinary
delinquency reasons. You could have somebody who had a very, very
severe personality disorder indeed, such as an obsessive personality
disorder, somebody who cannot get out of bed because they cannot
decide how to weigh up the pros and cons of getting out of bed,
but who is not dangerous to anybody, because they stay in bed
all the time.
Mr Winnick
178. I would like to deal with the numbers,
if I may. You may have heard, because I believe you were listening
to the Minister and his civil servant, the numbers involved who
are estimated to be suffering from severe personality disorder
and you would have heard that somewhere in the region of between
2,000 and 3,000 was what we were told. Would you agree broadly
with that and what would be the split insofar as one can make
such a division between those who are in some institution and
those who are in the community at large?
(Dr Shooter) If I may make some attempt to address
what is an extremely difficult question, I did hear the Minister
saying that we cannot know and I think he was very accurate in
that statement. I think one can look at this in two different
ways. First of all, one can ask whether the pool of people that
we are talking about within the community is accurately measured
in terms of the sort of numbers we are talking about currently
in detention, the sort of discharge rates that the proposals talk
about at the moment and the sort of intake rates and so on. The
College Research Unit who have looked at this tell us that no,
it therefore has to be a vast underestimate of the number of people
in the community, and in fact there are some people within the
Research Unit who would say that it is a ten times underestimate
of the sort of people we might be talking about in the community.
The other way of looking at it is to ask in terms of risk assessment
what sort of level of accuracy do we have to aim at when we are
talking about these people in the community and there, if we extrapolate
from the figures that are in the Government's own document, we
are talking about possibly aiming for one or two people in 100,000
population and that then begins to make people extremely anxious
about the current state of risk assessment tools. Could we possibly,
with those sort of fuzzy definitions of numbers and with a poor
toolkit as far as risk assessment is concerned at the moment,
hit those people with such accuracy that we would not get enormous
numbers of false positives and if we are dealing with measures
as severe as these, then that becomes a huge ethical issue, I
think.
(Dr Eastman) May I just add that there is a technical
term for this called, the "base-rate phenomenon". I
am not a sophisticated statistician, but the base-rate phenomenon
says that if you have something that happens on a base rate with
very, very low frequency, it will be overestimated massively in
terms of, as Dr Shooter says, false positives.
(Mr Topping-Morris) If I might say so, I think my
colleagues drawn from forensic psychiatry have rightly been preoccupied
with the ethical dilemma faced by the profession in trying to
meet the needs of this difficult client group and the practical
difficulties in arriving at an accurate assessment of their needs
or the diagnosis of their actual condition. I think the nurses,
borne out of my very recent experience of speaking to the large
group of forensic nurse managers who are currently tasked with
the responsibility of caring for this client group and forensic
nurses who are currently working in the personality disorder unit
at Ashworth Hospital, they report to me first-hand that the matter
that gives them greatest concern within the proposals within the
consultation document is the process by which we will arrive at
the ultimate decisions and the position that nurses will find
themselves in in attempting to arrive at that ultimate decision.
I think at the moment the forecast is that at its shortest, the
assessment period would last for some six to seven weeks and during
that process, given the accepted complex needs of the client group
and, therefore, the need to apply very complex multi-professional
assessments of risk and health need, nurses are going to be close
to the client group throughout that process and either implicated
very considerably in terms of reaching or contributing to a decision
or, in the absence of that, caring for these people meanwhile
within what I think the Government hopes will be a therapeutic
milieu. I am doubtful that we will be able to create a therapeutic
milieu in order to facilitate the best possible assessment in
environments which our former colleagues from the Home Office
described as possibly being piloted within the prison services.
Chairman
179. Are you saying there are problems here
that exist presently under the arrangements for detaining people
for assessment under the Mental Health Act?
(Mr Topping-Morris) I think the scale of those problems
will be critically linked to the environment within which the
job is being done and I am not—
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