Examination of Witnesses (Questions 80
- 99)
THURSDAY 23 MARCH 2000
DR SHEILA
ADAM, MS
DENISE PLATT,
MR JOHN
MAHONEY, DR
BOB JEZZARD,
MR JULIAN
OLIVER, MR
SAVAS HADJIPAVLOU
AND DR
GILLIAN FAIRFIELD
80. What is your definition of somebody who
should not be in a special hospital but is?
(Mr Mahoney) I think the key is danger to themselves
or others. The Institute of Psychiatry along with the Universities
of Manchester and Nottingham has undertaken a detailed study of
every single patient at the moment using standardised formats
and will be making recommendations about people's futures, whether
they be medium, low or high secure so we will have detailed analysis
patient by patient within 12 months. We will know exactly where
people should go. Numerous studies have shown that there are large
groups or, shall I say, significant groups in all three high secure
hospitals who should not be there.
81. But on whose definition should they not
be there?
(Mr Mahoney) It is the definition of risk. Definition
of various issues but risk would be the key and symptoms I suppose
would be the other, and risk to others is clearly a major feature.
(Dr Adam) One of the issues, if I can just add, is
that these are people who need long term secure care. At the moment
it is difficult to provide that except in a high secure hospital
and that is why it is perhaps a surprisingly large number of people.
At the moment this is not a reliable figure and that is why we
are doing a study with the Institute of Psychiatry. We think there
may be quite significant numbers in each of the three hospitals.
Audrey Wise
82. A few years ago the Royal College of Psychiatrists
produced a proposal for compulsory treatment orders in the community
and the Health Committee did an inquiry. In the event we came
out in opposition to their proposal. When we were drawing up our
report, which was really the first time we had compared notes
as Members about our own views, we discovered that all of us,
across party, without exception, every Member had started off
inclined to support the Royal College's proposals but in the light
of the evidence that we had heard and read we all individually
and without conferring, as it were, changed our minds. I was very
struck by this because you do not often get such a clear demonstration
of the role of the inquiry process, its effect on the members
doing the inquiry. Every one of us had moved from here to here.
The sorts of things which influenced us were the sorts of things
that Simon referred to in an earlier question: loss of trust and
all that, alienating both the professionals and the patients.
There was quite strong evidence that, for instance, community
psychiatric nurses thought that people to whom they should be
administering compulsory treatment and where those people objected,
they would go missing and the CPNs did not look forward to the
notion that they would become tracers of missing persons, especially
missing persons who had a very strong wish to remain missing.
That struck me, and I think it struck all of us, as being quite
a legitimate and telling argument. Certainly nobody produced a
convincing rebuttal. Could you produce a convincing rebuttal to
that fear?
(Mr Oliver) I do wonder whether there has been a shift,
in fact, in thinking on community treatment orders. Certainly
when the Expert Committee was established, their terms of reference
were not whether community treatment orders should be implemented
but how they should be implemented. Nevertheless, when they consulted
the field with their draft proposals, plainly the community treatment
order issue was raised in their report, it had to be because they
were recommendeding how community treatment orders might be structured
and how they might work. Certainly there was no unanimity that
community treatment orders were necessarily a bad thing. In fact
there was quite a degree of support from a wide range of organisations,
including organisations which represent users and carers in one
instance. I think probably there has been a bit of a misunderstanding,
also, about how community treatment orders might operate, a certain
sense of fear that people are going to be compulsorily treated
in their own homes. There is no sense in our proposals for community
treatment orders that this would occur. There has always been
an understanding in our proposals of how community treatment orders
would work in that patients who needed treatment and who were
refusing treatment but were on a community treatment order would
always be taken to a suitable medical venue for the administration
of any treatment that had to be given to them.
Dr Brand: Can I ask a brief question which will
take a very long answer but it will be quite useful to have in
a written form. When we talk about secure services, it would be
very helpful, I think, if we had a costing of what it costs when
somebody is in high security, medium and low security National
Health establishment and also for the Prison Service. Could we
have the real cost rather than there is a written answer today
on the Prison Service where thousands of people in the Prison
Service are being held two in a cell, that clearly distorts costings.
So if you could ask the Home Office what the real costs ought
to be as opposed to the current costs, the two figures would help.
In addition if you have got any work done on this, an estimation
of your perception as to the number of people that should be in
the different categories as opposed to the number of people that
are in the different categories. I think it would be very helpful
to the Committee to have some way of looking at whether we have
been cost effective with what we do currently. Certainly looking
around my local prison on the island there are a number of people
there who could do with low secure units and actually benefit
a great deal more.
Chairman
83. You will come back to us on that?
(Mr Mahoney) Yes.
Mr Burns
84. In B18 of your memorandum, page 37, you
talk about admissions to hospital, the isolation, the lack of
contact with family and friends, etc., etc. Presumably with these
three special hospitals this is even more accentuated because
of their geographical positioning so that compounds the problems
for patients, though it has the advantage also that they are secure
areas that protect the public?
(Mr Mahoney) There is a lot of work going on at the
moment about catchmenting and looking at the role of hospitals
in relation to catchment areas they serve. There may be quite
a lot of movement over time at least to get people closer to home.
85. Very briefly, are there still continuing
problems at Ashworth? You slightly answered this in one of your
earlier answers to another question. What progress has been made
since the Fallon Inquiry Report? Apart from the obvious answer,
why is there yet another new Chief Executive?
(Mr Mahoney) The recommendations contained in the
Fallon Report obviously have been implemented with the exception
that the management team have not relocated inside the high security
perimeter but that will be happening. Things that were asked of
them have been done and they have monitored regularly. In terms
of staffing, it is still steady state, if you like, but there
is some evidence of lots of interest recently and they have recruited
some good psychologists. There are some problems in the medical
workforce which they are continuing to address.
86. What sort of problems?
(Mr Mahoney) Recruitment to the personality disorder
unit, they have one out of four people in substantive posts but
there are people who are locally in those posts. As regards the
Chief Executive, he is the Director of the Centre for Medical
Health for the North West and the project champion for mental
health. I know it is difficult to imagine this but it is a move
that he wanted, it is a move upwards. There is a new Chief Executive
coming. It is very difficult to argue otherwise, I know, but it
is a major job he has got to develop mental health services in
the North West region.
87. Finally, what plans do you have to provide
long term care at an appropriate level of security for those patients
who no longer need to remain in a specialist hospital or the existing
medium secure unit but who do need long term supervision?
(Mr Mahoney) I think from the many things we have
discussed this morning, there will be a strategy being developed,
there will be a review of everybody in the high secure unit and
from that, for the first time, everybody will have a detailed
strategy of what should be needed at every level. As part of that
I am sure the Department will talk to the medium secure people
who have expertise in their region.
88. That review of every patient, I think you
said earlier, will be completed in about a year or up to a year
from now?
(Mr Mahoney) Yes.
89. Are you confident that when it is complete
and you have a much clearer picture of exactly what the position
is that there will be enough funding and places to then deal with
those patients as they should be dealt with and looked after rather
than having to take short term expedient measures because of a
lack of resources or places?
(Mr Mahoney) For the first time ever money will actually
follow patients. We have to be extremely careful on that, make
sure that the hospitals are stabilised, that will be a major responsibility
when we look at that, to make sure that whatever movements are
planned are planned in such a way that they do not destabilise
Ashworth, Broadmoor or Rampton. The perverse incentives have been
removed and if we can organise it in such a way that perhaps large
groups move, it should be possible to fund developments from existing
known resources.
90. With proper security arrangements?
(Mr Mahoney) Yes.
Chairman: I am conscious that we have not brought
Dr Fairfield in so far and I would like to put a specific question
to you so you do not feel neglected.
Dr Brand: Marginalised again.
Chairman
91. The memorandum you have given us summarises
a number of improvements in the prison mental health services.
I wonder if you could give us a bit more detail about the new
referral arrangements to high and medium secure services which
you refer to in the memorandum and, also, explain how you envisage
prisoners accessing community mental health services?
(Dr Fairfield) Local health authorities, local mental
health providers and prisons will be working together to assess
jointly the needs of that group of the population and, based on
that need, they will be developing a Health Improvement Plan for
prisons which fits into the wider health improvement programmes
locally and medical health providers will be setting up services
whereby the community mental health team will reach into prisons.
Also, prisons are exploring ways in which outreach on the wings
can take place so the prisoners in prison can have the equivalent
of community services in prisons that may be delivered by a different
skill mix in that prison. There are a few prisons at the moment
where community psychiatric nurses are reaching out to the wings
so that prisoners with medical problems do not necessarily have
to fit in to prison health care centres.
92. I have been encouraged to see the prison
involvement of the IMP and HAZ initiative in the Wakefield area.
What I am not clear on is what funding arrangements will underpin
these local partnerships? Has there been a change in the arrangements
in relation to funding?
(Mr Hadjipavlou) I think as part of the work on the
future organisation or prison health care we recognise that the
provision of services as they are at the moment is partly funded
from within the Prison Service and partly funded by the Department
of Health within the NHS. The conclusion of the group, accepted
by the Government, was that for the time being that pattern of
resource should remain the same underpinned with the sort of framework
and process that Dr Fairfield was describing to identify what
the needs are and the best means of delivering them to prisoners
while they are in prison.
Mrs Gordon
93. If I could pick up the issue of women in
special hospitals and medium secure services. There is evidence
that neither of these provide a genuinely safe environment for
women, many of whom have suffered abuse throughout their lives
and many of the men who are placed there have committed crimes
of violence. I do not know who is going to answer this. What is
your view of the adequacy of current provisions of high and medium
secure services for women? If you like, what would be the ideal
structure to put in place to help this problem?
(Mr Mahoney) The High Secure Commissioning Team, who
have developed a strategy report for women, is being wound up
in March, the new commissioning arrangements are taking off on
1 April. The report has been some two years in the making involving
a huge range of agencies and individuals including the organisation
WISH, Women in Secure Hospitals. That has produced a strategy
for services for women that has gone beyond the high secure strategy
for women, it has gone way back to what services should be provided
for women in every locality. What we need to do is check that
against the National Service Framework and take it through the
national oversight group whose responsibility it is for commissioning
high secure services. They had a first sight of it last week.
They were really impressed with the work that had been undertaken.
It is now down to them to commission the activity that is done
to develop that strategy. It will address many things that you
raised.
94. Can you give us any indication of this strategy?
What will it be changing?
(Mr Mahoney) I think the first thing it recognises
that very large numbers of women should not be in high secure
hospitals, they require a different environment. That is one of
the most fundamental things. Then there are a whole range of developments
around specific services for women, services which are gender
sensitive throughout mental health services.
95. I am just worried about this. I have had
a case where a man wandered into a women's ward, it is the safety
aspect as well which interests me. Is there anything coming up
about that?
(Mr Mahoney) Obviously the safest environment is probably
the high secure hospital but it is not the right environment.
Sound services and effective services are seen as the safest type
of service for women. It is a bit early yet, this report has been
two years in the making, it has only just been produced. The actual
specifics of how the service will develop from that have not been
worked out yet.
(Dr Adam) I think we recognise that the gender issue
does cut right through the mental health services. It can be just
as much a problem on the local inpatient unit, perhaps more so
as John was suggesting, I think. My sense is that as we begin
to think more clearly about mental health services, the issues
of all sorts of individuals and groups become much clearer, whether
it is women, whether it is black and minority ethnic groups. I
think part of the development of the National Service Framework
is going to be really teasing out how we can build better services
working with these groups. I think our services have been designed
for the stereotype, the white man, and there are issues for women
just as much as for black and minority ethnic groups. We are at
an early stage of that, it would be fair to say, but it is something
that we are concerned to make progress on.
Chairman: You have taken us very neatly on to
the last area which we want to touch on which is diagnosis. I
am conscious that perhaps we ought to have started on diagnosis
but we want to look just briefly at it before we finish.
Mr Austin
96. If I can go back to the question which John
Gunnell put earlier. There has been some concern expressed that
the wider definition of mental disorder was appearing to rely
less on capacity. Now the Law Society suggested that this could
lead to an increased and unwarranted use of compulsion. How would
you react to those concerns expressed by the Law Society?
(Mr Oliver) I think, first of all, I would start off
by saying that the proposals for the reform of the Mental Health
Act are about introducing a modern framework for mental legislation
that represents modern patterns of care and treatment. It is not
about increasing the numbers of people who are subject to compulsory
care and treatment. We have had discussions with the Law Society
and others about the definitions and the criteria that we use
or rather we have proposed in the Green Paper should be used to
determine whether or not a patient should be subject to compulsory
care and treatment. If it looks from the outcome of consultation
that the proposals that we have made will result in significant
increases in the numbers of people under compulsory care and treatment
then we will have to look at them again.
97. Can I raise another issue that continues
to concern me in terms of diagnosis and what triggers the appropriate
person to respond, particularly in the light of other concerns
following the Macpherson Report. It is 20-odd years now since
Aggrey Burke and others began to write about the way in which
black people were treated in the mental health service and diagnosed.
I can remember 13 or 14 years ago going to the West Lambeth Unit
which Professor Rowden was then responsible for which was a pioneer
in terms of coming to grips with racial awareness in psychiatric
services. I do not really see that very much has changed and the
way in which black people are treated in the health service and
the Prison Service, how they come into contact with the psychiatric
services, the way in which they may be more likely to seek physical
rather than non physical treatment, a whole range of issues, nothing
appears to have moved on in the last 15 to 20 years in terms of
services for black people in the area of mental health. I wonder
what the Department is doing about that?
(Mr Mahoney) There is enough evidence to show that
once people get into the system that black people find themselves
in much greater positions of security than others. One of the
key features of research now is the path needed to stop people
going into the system in the first place in the way that they
do in terms of pathways to care. More and more it shows that black
people are far more likely to be living alone and to be isolated
and, therefore, have nobody to negotiate access to care on their
behalf, and contact the GP and contact services. By the time they
come to the attention of psychiatric services it is nearly always,
if you like, when they are out of control and it is much more
coercive often involving the police. The key is to target people
who are likely to be isolated and this is where one of the framework
standards will help. In the implementation of these standards
we must make sure that that feature, particularly around black
and minority ethnic groups, is addressed.
(Dr Adam) I think underpinned by a clear commitment
to work closely with a range of people who use services and their
carers so we are getting direct feedback on what is working for
them and what is not, using things like the national survey to
help them understand that better, using bodies like the Social
Services Inspectoratend the Commission for Health Improvement
to inspect and audit on our behalf. I think, very importantly,
linking this back into the workforce discussion. Ultimately the
way that we will best meet the needs of people from minority groups
is when our staff roughly reflect the same distributions. We are
actively recruiting from minority groups so we have staff from
the same communities as the service users. That is going to take
some time to achieve. Meanwhile, I think we have to heighten awareness
of this issue and get people challenging their attitudes, thinking
in the way that John is talking about, what sorts of services
do we know are going to be more effective and how do we put those
into place. Again, we have got some examples of good practice
which people can learn from and we will be enabling them increasingly
to do that.
Chairman
98. Ms Platt, do you want to add something?
(Ms Platt) Very quickly. We have just completed a
series of inspections on compulsory mental health admissions and
have focused on what has happened to black and ethnic minority
people in that process. We did have black inspectors on the team.
We are just beginning to pull together information from that inspection
and if we can do that during the time of your inquiry we will
make that available.
Chairman: That will be very helpful.
Mr Austin
99. What has been said has been known for a
long time. There does appear to have been an implementation deficit
except in those areas that you have mentioned which are examples
of good practice. What you are describing to me is a mental health
service which I would describe as institutionally racist, would
you accept that definition?
(Mr Mahoney) If I can answer that. In some places
it has led to very different types of services being developed.
Talking to an earlier point, the service around intervention,
far more black people seem to develop serious mental illness—schizophrenia—so
there are new services around early intervention, different types
of services, assertive outreaches not aggressive outreaches, plenty
of support and what is called crisis resolution and home treatment
services. All the evidence shows that black people are far more
likely to use those services and, therefore, engagement is much
better and that is in the NSF. That is the big challenge for us,
I think, to roll out that NSF which will lead to much improved
services to black people.
(Dr Adam) I think we all have to look to see whether
we do have institutional racism. My sense is that people who work
in public services reflect the communities from which they come.
If these are racist then we should expect that we will have those
issues in our services. Obviously, thinking through the implications
of the Race Relations (Amendment) Bill, currently under discussion,
that will have significant implications for the health service
and for social services, although I think that they have been
probably more engaged with this agenda than the health services
have. I think we are all going to be challenged to look very critically
at what we each do individually as well as what we do in our areas
of work and ensure that we are hearing what we need to hear and
responding appropriately to that.
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