Examination of Witnesses (Questions 100
- 105)
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
100. Can I finally say I think it would be helpful
to the Committee if there are areas where you believe real progress
has been made and where there are examples of good practice, if
you could suggest those to us?
(Dr Adam) Yes.
Chairman
101. This may be the final question, depending
on whether anybody else has anything else to ask you. Can I ask
you a couple of points about the issue of the concept of treatability,
particularly in relation to personality disorders. I wonder what
the Department of Health point of view was when the Home Secretary
appeared to be suggesting that psychiatrists should be treating
people with personality disorders whom they deemed to be untreatable.
I found it very interesting the debate that went on at that point,
when he appeared to be suggesting the psychiatrists were wrong
in not using the Mental Health Act and the psychiatrists were
saying the Mental Health Act decrees that where a person is untreatable
they should not be sectioned by a psychiatrist. What was your
view on that?
(Dr Adam) Julian may want to add to this but I think
the Department of Health responded working with the Home Office
to say we need to seek views on services for people with personality
disorders. We recognise that we are not able to deliver all the
services which are required currently. It is an area that is extremely
difficult, as you will all know, so one of the things that we
have been doing is putting more money into research really to
try and get better at assessing need and be clearer about what
is effective in meeting those needs. We have consulted up to Christmas
and we are now holding those responses while we complete consultation
on the Green Paper. Then we will be drawing that together into
some proposals. We took the whole discussion very seriously.
(Mr Oliver) I do not have anything to add to that
except that if you are detaining people then there ought to be
services available under health legislation and there ought to
be services available to them which are going to help to treat
them.
102. Help to treat them or treat them? This
is a very important distinction.
(Mr Oliver) There ought to be services available for
them which in some sense are going to be therapeutic.
103. Can I just pursue briefly the Home Office/Department
of Health consultation document which uses the term "dangerously
severely personality disordered". As you will be aware, there
has been some degree of debate around the appropriateness of that
term, particularly in the context of what is happening in Scotland
where they have a different definition. Bearing in mind what is
quite clearly a lack of consensus about the diagnosis and treatability
of personality disorders, the difficulties in actually establishing
the concept of dangerousness in a vacuum, can you explain how
you envisage this working in practice? In a sense I am looking
at you, Mr Oliver, because I think this is your baby but if it
is not pass it on to one of your colleagues.
(Mr Oliver) As Dr Adam said, we need to take account
of both of the consultation exercises before we actually work
out how it can work in practice and we can make formal proposals.
In terms of the proposals for the review of the Mental Health
Act, we have deliberately followed the expert committee and set
a definition, set a criterion for compulsory treatment which does
not exclude people with personality disorders. We have accepted
that there should be scope within mental health legislation for
treating people who have personality disorders for very good reasons,
because there are going to be people with personality disorders
who are borderline personality disordered and who have concomitant
mental health problems as well. We need to work up the proposals
under the Mental Health Act significantly. As they work at the
moment, or rather as they would work under the proposals, nobody
would be subject to long-term care and treatment compulsorily
without the new independent tribunal, which the Green Paper recommends,
approving and agreeing the care and treatment plan. Implicit in
that care and treatment plan is that there should be services
available to provide care and treatment for any individual.
104. Have you given me something of a clue on
how we might move forward on this issue by your earlier answer
which I picked you up on? I picked you up on your use of the term
"treatment" because when we talked about the Home Secretary
and his discussions with the Royal College of Psychiatrists, their
arguments about treatability and the debate that went on around
that, you appeared to be stretching the term treatability, or
treatment rather than treatability, to mean something more than
the Royal College of Psychiatrists would deem it should mean.
Have I misunderstood what you said? The way you have used the
term implies a much wider approach than what I might narrowly
determine as being treatment in the traditional sense of the word.
I am not arguing with you, you may be absolutely right, but have
I understood you correctly?
(Mr Oliver) We have not defined "treatment"
in the proposals for the new Mental Health Act. Subject to the
results of the consultation we think that treatment ought to be
determined on a case by case basis and ought to be the subject
of a decision by the independent tribunal. We do not necessarily
think that treatment ought absolutely to be limited to conventional
psychiatric interventions, it ought to cover a whole range of
interventions, social interventions and psychological interventions
as well.
Chairman: You have clarified that point, I am
grateful. Do any of my colleagues have any further questions?
Audrey Wise: It reverts to the issue of young
people. In an earlier inquiry the Committee visited an establishment
in Northamptonshire which was a local county council establishment,
high security, for young people who were in dire trouble, some
of them quite serious offenders. We visited this and it was relatively
new at the time we went. I found myself extremely impressed and
I do not know that I expected to be impressed. I was surprised
by some of the things that impressed me, one of which was I had
not realised it would be possible to have an establishment which
was clearly high security and effective security, so that I had
no worries about the surrounding streets, and yet comfortable
and not oppressive in its atmosphere for the people living there.
That struck me very, very strongly. Of course it was quite expensive
to run, not from the security angle, the security angle was mainly
derived from extremely sensible planning, it was in the physical
nature of the building, they had made a building which lent itself
to being secure. I cannot think of any examples to illustrate
that but that was the case. Once they had got the building then
it was not a matter of needing staff at every doorway to keep
it secure or anything like that. I think it was expensive because
of the staffing ratios in such places. If they are to be effective
in modifying attitudes and the behaviour of the kids in there
there have got to be plenty of staff and good staff, and there
was and they were. Also, of course, when such establishments are
costed the whole cost is attributed, including the share of the
county council's administrative costs whereas, as Dr Brand was
saying earlier, when an equivalent place in a prison is costed
they would not include in the same way costs relating to the proportion
of the Prison Service. If there was a cursory examination of relative
costs the Northamptonshire County Council establishment would
come out badly but, on the other hand, if you were looking for
effectiveness and likely curative effects I think it would come
out very well. It had a problem in that as soon as the kids got
to 16 the Prison Service was apt to say "right, she is 16
now, we will have her back in prison". There was a girl there
who had been involved in a murder along with her mother and her
mother's boyfriend. Her mother was in prison at the time. Not
long after our visit I got a letter saying that the girl was going
to be taken into the prison where her mother was. This sent chills
through me but I could not see anything that I could usefully
do at the time. Are you aware of this establishment? Do you have
any views about local authority run secure places for young people?
If you have not got any views, or any knowledge, do you think
you should develop some?
Chairman
105. I suspect Ms Platt is completely on the
ball here.
(Ms Platt) You are talking about local authority secure
accommodation in which there has been a recent building expansion
to enhance the number of placements available by 170, so there
is a lot of new building and new design of exactly the sort that
you describe and some of the very old units have been decommissioned
as part of that process. Because we are talking about young people,
and we are talking about detaining young people, there are very
strict legal conditions which apply and local authorities have
to seek orders of the court to place children in such circumstances.
In future young offenders placed in local authority secure accommodation
will be placed by the National Youth Justice Board who are taking
on the role of commissioning all secure placements, whether they
are in prisons, young offender institutes, secure training centres
or local authority secure accommodation. In the first instance
they are asking local authority accommodation and secure training
centres to comply with the regime which is based on the Children
Act standards. I think the National Youth Justice Board knows
that it will take rather longer for other such establishments
to reach some of those standards. There will be places left which
local authorities will commission for those children who might
be there because of reasons to do with their own behaviour rather
than offending. I think you will probably find that the costs
of democracy are no longer loaded into these establishments as
they have had to tender to the National Youth Justice Board for
the contracts which the Youth Justice Board are leasing or letting
or whatever the technical term is. So they more properly reflect
the actual costs of running the establishment. You are right that
they are high cost because of the level of staffing that is required.
Chairman: Do any of our witnesses want to add
anything? Are there any points we have not covered or that you
want to clarify? If not, can I thank you on behalf of the Committee
for a very helpful session. I am sorry it has been so long but
it has been extremely helpful from our point of view. You have
indicated that you will follow up with a number of written points.
We are most grateful for your help. Thank you very much.
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