Examination of witnesses (Questions 360
- 379)
THURSDAY 13 APRIL
MR LIONEL
JOYCE, PROFESSOR
FINLAY GRAHAM,
DR SURYA
BHATE, MR
SEAN BRANNIGAN
and MR STUART
ALLISON
360. So what sort of provision of beds do you
maintain in hospital?
(Mr Joyce) Relatively speaking we have got quite a
large number, 125 acute beds, then we have some rehabilitation
beds and secure beds and some patients who have come from the
criminal justice system go into those beds to be cared for. We
are not a small provision, but what we would like to see are many
more staffed hostel beds. There are two excellent social services
ones in Newcastle but we have to fight political battles to keep
them alive and they are very good quality. If we could have another
three or four of those, it would be terrific.
361. You see a lack of appropriate accommodation
to some extent?
(Mr Joyce) Yes.
Mr Gunnell: Thank you very much.
Mrs Gordon
362. If I could turn to minority groups. It
seemed clear from the evidence we received that black patients
tend to access services later when they are more acutely ill and
are more likely to receive treatment under compulsion. How do
you tackle the provision of culturally sensitive services especially
when there are relatively low numbers of people from minority
communities using the services? Obviously it varies across your
whole area.
(Mr Joyce) Surya is a bit of an expert on this.
(Dr Bhate) There are two problems. One is that minorities,
particularly from the third world, have chosen to settle in the
large urban areas so there is a larger population in the South
East of England compared to northern cities like Newcastle or
Middlesbrough with 8,000, 9,000, 10,000 people. There used to
be a model suggesting there should be specialist services for
minorities because black patients tend to like to see black doctors
and black nurses, and that model has been attempted. The difficulty
with that model is that while it aims to please some people some
of the time, in the long term we are talking about a model which
will not be to the advantage of the patient because some are second
or third generation. If you create minority services they become
ghettos. Good quality immigrant doctors with the appropriate coloured
skin will not take the job there. They wish to be part of a centralised,
multi-faceted service. So short-term gain would be long-term loss
for those communities. There need to be champions within the service
but they ought to emerge from mainstream services in mental health
because when people talk about minorities they are talking about
ethnicity and cultural differences and I think while one can concentrate
on the needs of Ugandan immigrants when they arrive from Uganda
but Leicester said do not come here and 80 per cent of them decided
to settle there. It is wrong to have a doctor who does not understand
the culture, religion and language of those patients but that
would be true for Irish and Scots and women and a number of other
minorities. I think what we need to recognise is that if there
is a sizable proportion of minorities, the Poles who came after
the Second World War or whatever it is, then we need a workforce
that reflects the needs of the community that we aim to serve
and there ought to be recruitment and training for those individuals.
Currently it is fair to say that it is failing except in certain
areas particularly for children and women, I think. Therefore,
if you are psychotic you do not need to speak the language, you
do not even need to be a psychiatrist, the porter knows who is
nuts. So I think we need to recognise that these people are not
receiving services that the majority of communities are provided
with in terms of psychotherapy and interventions in the community
and the rest. The problem is of provision. If you have a 10,000
or 15,000 population which includes Bengalis, Punjabis, Indians,
Sikhs with different religions, people presume I, as a person
of Indian extraction, understand all of them but the Pakistani,
once he learns that I came from India, might not be as friendly
towards me although both of us may have faced the same problem
in a sense. So I think we are failing them up to a point but I
think our solution ought to be awareness of the population and
their needs because needs change between first and second generation
children and second and third generation. My son's accent is so
Geordie that my friends in Bombay cannot understand him on the
telephone and his needs would be much different than my needs
or my parents' needs if they were living here.
363. Do you support any advocacy service for
people? You are talking about they should have a champion, an
advocate. What practical measures do you take if someone is presenting
themselves with a mental health problem on language? Do you provide
interpreters and how is that organised?
(Dr Bhate) In our trust and in conjunction with the
local authority, interpreter services have existed for over 10
years as far as I remember. It is 24 hours and we can call on
them and it includes Chinese as well as Bengali as well as somebody
who can speak Urdu. The problem of interpreters in psychiatry
is problematic. You can ask simple questions Does it hurt here?
When did you fall? Are you not able to walk? But it is different
using interpreters to do psychotherapy or family work particularly
with children or young people. There has been a historical tendency
to use children as interpreters. Children present themselves to
psychiatric services because of persistent marital disharmony,
violence and the rest. How is the doctor going to inquire about
fathers who come home drunk or whatever it is. If we have those
issues then we really need to almost positively discriminate in
advertising employment saying that you would need knowledge of
Urdu or Bengali because ethnic minority populations live in areas
we serve. That is certainly true of Pakistanis, Bengalis and Gujuratis
in Leicester. They do not speak much English. They do not have
to because the shop keepers and barbers speak the same language.
That happened with the Poles who arrived after the Second World
War. When I worked as a consultant in Leicester I met a mother
who had not spoken much English and it suddenly dawned on me that
because I was supposed to be ethnically sensitive psychiatrist,
I was still a totally inappropriate psychiatrist to meet a Polish
lady. You cannot get them for all of them. I think we have to
be innovative. I found a Polish priest who she trusted and we
worked with that family. T here needs to be some adjustment. But
children and families are not using child psychiatry services.
That is certainly true in terms of total under-utilisation. Maybe
they are more sensible than the indigenous population!
364. You agree with the statement that there
is a tendency not to access services earlier?
(Dr Bhate) That is correct.
365. What can you do about that?
(Dr Bhate) When I worked in Leicester between 1975
and 1982, 35 per cent of the city's population was Asian. I was
the only Asian psychiatrist there (to start with). I was a child
psychiatrist and I used to do a clinic for adult patients. One
lady was brought in for taking a bath at 5 o'clock and refusing
to allow a male nurse to be present when she was bathing. I thought
that was normal. I think perhaps the diagnosis of psychosis was
made by a psychotic psychiatrist because it was so obviously cultural
difficulties there. Now that has been addressed I think, consciously
or otherwise, because Leicester was a medical school and when
I was appointed they said, "Congratulations, you are the
first Asian consultant in this medical school", and I quipped
back and said, "Did you have something against good quality
applicants?" The Chairman of Appointments Committee remembered
that. To be congratulated because I was appointed as the first
Asian consultant to Leicester medical school to me showed a lack
of their awareness rather than my excellence. So there are those
issues there.
Chairman: You are very modest. Eileen, have
you finished?
Mrs Gordon
366. I was going on to women. Another minority
group within the mental health services although not within the
population is provision for women. We have had evidence that it
is pretty poor actually and when we visited Ashworth we saw they
are aiming to have all women campus, if you like, because at the
moment there is an intimidation factor. It is very much a male
orientated organisation. And also with acute wards they are often
in the minority and do feel isolated, threatened, frightened.
I picked up in your introduction that you are developing some
sort of separate service for women. Do you make separate provision
at the moment for acutely ill women within the community and in
secure services as well? Perhaps you could expand on that.
(Mr Joyce) I will ask my colleagues to expand about
secure services. In general in adult psychiatry we are not only
doing the separate provision that the Secretary of State asked
for but women-only services, women doctors, areas of wards where
only women are allowed, I am not allowed to go and visit them.
That has come out of patient need. A patient who has been sexually
abused and is now really depressed, how are we going to respond
to that? So that is coming up. It was not a top-down approach,
that was a bottom-up requirement that we respond to patients and
it is real and we are doing it.
(Professor Graham) With our service, which is for
young people up to 20, we have tried to keep a healthy balance.
It has tended to be 50/50 or 60/40. If it goes below that we feel
there should not be girls at all. They do tend to be the minority.
We did a survey with the young people in our own unit and a number
of other units and, not surprisingly, they came back saying they
did not want complete separation. Teenagers do want to have the
other gender present. But you have got to allow degrees of privacy
in terms of bathing, etcetera. Our ideal, which we are moving
to now, is to have an 18-bed unit specifically for girls so the
girls would not have boys with them while they were living in
a female environment but they will mix in education activities
and socially. We think that is probably the best option. All the
rooms have integral sanitation anyway. That is the optimum which
we think gives the best quality of life and meets the express
wishes of the young people. As I say, they do not want separation.
Some of our young patients in forensic could be in for four years.
To put them in a single sex environment between the ages of 14
and 18 I do not think is a good developmental model at all. You
have got to try and interpret some of these issues like the needs
of patients and also a view in adolescence of what is good, normal,
healthy development. Total separation is not. In forensic services
if we wanted to we could provide total separation. We could make
it an all-female environment if we wished. I do not think that
is the right way to go. I think there has got to be some sort
of balance and reflection of what is healthy development.
(Mr Brannigan) Within the adult service, particularly
in Newcastle, one of the problems was that we have a 12 and 13-bedded
ward. The ratio of males females within secure services tends
to be 9:1 so we no longer admit females to one of the wards and
we have made it a designated male only ward and females only go
to the second ward. As it is we only have three females on that
ward. Part of my role as case manager working with commissioners
is to attempt to identify females within the northern half of
the North Yorkshire region, females who require high, medium and
low secure services, and then as the commissioners together to
put forward a bid for a female service. So we would be working
in conjunction with the Hutton centre which is in the south of
the northern bit of the region in doing this piece of work and
identifying a female only service.
367. Within that 12-bedded ward where you have
got three women what kind of security arrangements are in place?
(Mr Brannigan) There is a designated female-only area.
None of the male patients are allowed there on their own. They
have their own bathing facilities so there is no reason for them
to come outside for bathing facilities or for the use of toilets.
The staffing ratio on the unit is probably 50/50 in terms of male
and females but again, similar to the adolescent service, females
do not want to be segregated entirely with females but they want
periods of time with privacy and that separation is of their choosing.
Chairman
368. Can I just ask a brief question on the
review of the Mental Health Act, putting my questions to Mr Brannigan
and Professor Graham, asking for your views on community treatment
orders. We have also taken evidence on the concept of treatability,
the personality disorder issue, you are aware of the debates around
that, and the possible broadening out of the concept of treatment
in relation to the Mental Health Act to allow less traditional
forms of what has previously been deemed treatment in terms of
compulsion. What are your views on the broad direction in which
we are going on and whether what is on offer at the moment is
right or wrong.
(Mr Brannigan) Difficult question. From a personal
perspective, I suppose it is a question of talking about additional
components of the Mental Health Act and you have to wonder whether
they are always necessary or whether we want to use existing legislation
in different ways.
369. Particularly in terms of community treatment
orders what are you looking at, guardianship?
(Mr Brannigan) That is very rare. I cannot think of
any cases where we have used it in Newcastle.
370. Are you basically implying that the existing
legislation could be better used and that would obviate the need
to move towards something like CPOs?
(Mr Brannigan) There is a recognition that present
legislation could be better used.
(Professor Graham) For young people there is mileage
in combining the social service and health budget for kids and
allocating resources to the identified needs of children rather
than arguing which budget it is going to come out of, which is
what we normally do. My starting point is that community treatment
is inevitable and our aim certainly in adolescent services is
to get kids back into the community and that involves some sort
of community treatment. When it comes to community treatment orders
the only thing I would say is there really should be an assessment
by the professionals of the person's suitability for treatment
prior to the order being passed. To get a patient put to you saying
you will treat them when you have not had a chance to meet them
and look at that would not be viable. Providing there has been
an assessment it is a worthwhile option to pursue for some children.
(Dr Bhate) The guardianship order has been infrequently
used because of two factors. One is that you need to have a local
authority to agree to receive the person under guardianship. There
has been slightly more willingness to accept those with learning
difficulties as opposed to children. I had one young man with
mild learning difficulties who committed a serious sexual assault,
however hospitalising him was not a possibility because as opposed
to 3,200 beds for adults (in Forensic Psychiatry), at that time
for the entire United Kingdom there were ten beds (we now have
16 beds) for children and young people which is quite puzzling
to me professionally and the judge ordered guardianship. The difficulty
with that order is that you can require a person to reside at
a specified place, you can require him or her to go and see a
psychiatrist or psychologist but you cannot require him to take
treatment which may include in the case of somebody with psychosis
medication or drugs. In this instance it did not arise but before
the Judge made the order it needed few phone calls and the judge
threatening to subpoena Professor Liam Donaldson and everybody
else on my advice to get them to agree to do this. So it has not
been frequently used. I think mainly because of local authorities'
lack of willingness or to a degree under-funding and absence of
community facilities where individuals with serious difficulties
could be safely managed who are under an order of some kind
371. So in a sense what you are saying, which
is what we are picking up from other people, is that a debate
around community treatment orders in particular in a sense is
perhaps peripheral to the real issue of getting the organisation
right and social services/health delivery is crucial on this and
ensuring we have got proper facilities in the community to treat
people, to help people?
(Mr Joyce) Yes.
(Dr Bhate) That certainly is crucial with children
and young people. As a professional I do not know who should manage
the single budgets because all my life I have been complaining
that whoever manages it is not doing the right job. I have been
prejudiced from that point of view because I always want more
money for my patients perhaps. But without those budgets we have
a situation of 240-plus secure beds in Local Authority and it
is not unusual to find anything between 30 and 50 per cent of
those children suffering from a definable and treatable mental
illness locked up under the Children Act with no beds for them
in Health Service and when we go on to the age group 17 to 20
and they are languishing in prison and there is a lack of Forensic
Psychiatric facilities for them. Whilst I was able to persuade
Mr Joyce and the board of the need to establish the service, there
are only three adolescent forensic services in the country. Whilst
it gives a sense of achievement to us, being an exotic animal
is not right. We treat common conditions hopefully with adequate
competency but the only people we can compare ourselves with is
Manchester.
372. We went to the other exotic animal earlier
this week so we know a little bit about what you are talking about.
(Dr Bhate) I find that strange. Within that, particularly
for adolescent girls, I feel it quite strongly, but for the fact
we are about to get 18 beds we have severely damaged, disturbed
young ladies who in 80 per cent of the cases have been sexually
abused, with all the disadvantages you could think of, being asked
to be locked up without therapeutic services and legislative controls
and requirement to explain what we are doing. Our unit is hoping
to provide those services but health authorities are saying, "We
never paid for this before." I say to them, "You did
not pay for penicillin, you certainly did not pay for heart transplants,
so why aren't you asking those questions of us?" It is difficult
to be the champion of unlikeable children who do nasty things
and who actually are not even grateful to me when I succeed in
helping them. I say to them but that is my job. This is one job
where you will never get thanks. The only patients who thank me
are the patients I have failed because they have become dependent
on me. The majority say, "I sorted it out because I did it
myself. You were a waste of time," and I turn round and say
to my colleagues, "Here I have been successful."
Chairman: It is a bit like being a Member of
Parliament! I am conscious you have turned us on to an area I
know Eileen wanted to explore. Peter, you come in because it is
important to explore those areas before we move on.
Dr Brand
373. You have got quite a lot of leverage for
resources because most of your patients are through the direction
of the court and alternative ways of looking after your patients
are also expensive. I am very interested in the concept of community
treatment orders. Are they going to be a way into getting resources
at all? I know there is now some evidence that people are encouraged
to take people to court because that is a good way of getting
some treatment whereas the treatment could have been delivered
without their intervention. We had some evidence from people in
London last week who said the only way you can get any acute psychiatric
services is to get sectioned. There is no access unless you are
sectioned.
(Professor Graham) I could not espouse that.
374. It is pretty frightening to have that sort
of statement made by user and carer groups. If we are going to
extend community treatment orders it may well become the norm
rather than the exception.
(Professor Graham) It is the duty of clinicians, even
if it is not necessarily resourced at the start, to advocate for
that patient and try and get appropriate resources. I think when
we have done that I could almost count on the one fingers of one
hand the numbers of times it has failed. To say you need a court
behind you to get that I have never found necessary. We have almost
always got resources from local authorities to treat patients.
Sometimes you do have an advocacy role and some clinicians balk
a bit at that and say, "That is not really my job,"
but it should come naturally. You have got to put a bit of effort
in. When you do health authorities to me have not been obstructive.
375. You have obviously got a very enlightened
management structure.
(Professor Graham) Absolutely.
(Dr Bhate) It has taken six or seven years to enlighten
them.
Chairman: Only six or seven years? Eileen?
Mrs Gordon
376. If I could go back to the adolescent issue.
I agree absolutely about the inappropriate way that children are
sometimes treated. We saw when we went to Manchester young people
who would move on to a Rampton or somewhere and may not ever get
out of that system. If they had gone into prison instead they
would serve a set sentence and then they would be free but for
some of these young people I just felt there was no hope of getting
out of that system. Do you have any protocols for this transfer
between the child and adolescent services to adult services? How
do you manage that transition where they have been in a special
adolescent unit? What happens? Do you have a fixed age, is it
18 or whatever? How do you manage that transition?
(Dr Bhate) Two things. We serve up to the age of 21.
We follow the Reid Committee recommendations although in practice
we go up to the age of 22. The issue is decided on the needs of
the patient as opposed to an arbitrary cut off because if you
look at the definition of adolescent for females it is 21 and
for males it is 25 and that definition was proposed by a male
because I meet 30 year old males who are less mature than 21 year
old females! Age itself is not a good indicator. The needs of
the patient is a good indicator. The difficulty with services
is that most services accept 18 as the age of transfer. We have
been open in terms of in-patient services for three years and
we have as yet not transferred a single patient to adult forensic
on the basis that although we may have been very successful with
some patients and clever with others, there are going to be some
patients who will require continuing care. I think the transfer
should be on the basis of patient needs and maturity. I guess
if we tried it too often we would not succeed because of the blockage
of beds in adult forensic because half those patients ought not
to be there and so on and so forth. So there is going to be difficulty
there. Our main aim has been to work with young people with acute
difficulties, settle them and attempt to rehabilitate them back
to the local authority specialised service and there we find considerable
difficulty because local authorities have increasingly reduced
their services and their finances appear to be under strain. Ten
years ago if you needed money for children very few directors
of social services refused. Now they refuse very regularly. That
is a problem but I think Finlay may have one or two observations
to make.
(Professor Graham) I think you have got to look determinedly
at the sort of follow on placements you want. We have managed
to move out some to local authority care where the local authority
have put on a specialist package for the youngster. Sometimes
that is rented housing in the community and 24-hour social worker
cover. The private sector have put on some pretty good follow-on
placements for us as well and sometimes we have used the non-secure
end of the adult mental health spectrum. A lot of it is about
patient advocacy and really pressing for it. Another one is seeing
assessment of risk as a more dynamic concept rather than this
person has done something at 14 and therefore there is a risk
for the rest of their life. I think there has got to be some creative
management of that and a preparedness to stand up to the media
hysteria there has been on this. We know some of them will do
it again. There is no way we will alter the laws of statistics
and we can say completely cure people of ever doing a risky thing
because we cannot and we have got to have the confidence to say
that. With young people I really think our purpose is to try and
move them on and the interface with adult services is a difficult
one but not impossible. We have moved on quite a large number
of patients now. It can be done. You have got to judge the age
appropriate to the particular patient. Some should be moving on
at 18 or 19. Others you might think at 22 or 23 are vulnerable
emotionally immature individuals. I think we need a target age
and the norm would be 18, 19, 20. Personally I do not have a strong
view on which one of these ages is a targets as long as it was
not an absolute one and you moved the patient and they are going
to have another few months in an adult service and really destabilise
them before they move on.
377. If they have to go to a special hospital
do you follow them through? Do you monitor what happens to them?
(Professor Graham) We have not sent anyone on to a
special hospital. We have tried to avoid it. If we did, we would
follow them on. We have taken transfers from special hospitals,
gone and seen them and brought them back. Certainly for young
people we would like to see a minimum period in special hospital
because as a rehabilitative environment for a 17-year-old, it
does not seem to me to be the optimum.
378. Do you feel some people are at the moment
staying longer in a high-security situation than they need? There
is this problem with step down that the facilities are not there.
(Professor Graham) I think there is and I think there
is a lack of recognition in the secure system that you could get
behaviours that are particular to the secure units. You get people
living in a very close community, very intense emotions and whether
you should be necessarily generalising out from the behaviour
there and predicting to the community, I do not know. You could
look at paradoxical approaches and say it will be necessary to
behave that way when you are walking away from a situation.
379. That environment could actually increase
the problems?
(Professor Graham) Yes, I think it could provide a
false picture if you exclusively looked at behaviours in the secure
unit and generalised out to the community from that. We have got
one patient in particular at the moment whose behaviour is pretty
problematic and aggressive in the unit but whose behaviour out
on leave is exemplary, he does not put a foot wrong. That leaves
you with a real dilemma as to what you do. There is no evidence
that he is a risk to the public; he is a risk to my staff. Maybe
we should keep them apart.
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