Select Committee on Health Minutes of Evidence

Memorandum by Dr Peter Snowden, Acting Medical Director, Mental Health Services of Salford NHS Trust



1.1  Mental Health Services of Salford NHS Trust is a specialist Trust, providing general mental health services for adults and older people in the city of Salford. The Trust also provides a wide range of specialised and forensic mental health services, for the people of Greater Manchester, the North West of England, and for some services beyond these limits. I am currently Acting Medical Director with a remit for the specialised and forensic mental health services, which in this Trust includes: the medium secure unit (Edenfield Centre) and the forensic community services, the adolescent medium secure unit (Gardener Unit) and community assessment and treatment service, the high dependency service (Bowness Unit—for patients with longterm mental health needs who require a "slow stream" rehabilitation model and who do not require medium security) and there are also mentally disordered offenders on the John Denmark Unit, which provides a service for patients who are profoundly deaf.

  1.2  Mental Health Services of Salford NHS Trust is in the early stages of a consultation process which is likely to lead to the development of a new Trust organisation in 2001, which will include high security mental health services, which are currently based at Ashworth Hospital.

  1.3  I am currently Chair of the Forensic Faculty of the Royal College of Psychiatrics and am a member of the Home Secretary's Advisory Board on Restricted Patients.


  2.1  In 1975 there were not many more than half a dozen forensic psychiatrists in Great Britain. These specialists had split posts and worked between a prison base, and a local hospital. They did not have secure hospital facilities and only some had access to in-patient beds. The notorious case of Graham Young, which led to the joint Home Office/Department of Health and Social Security report of the Committee on Mentally Abnormal Offenders (the Butler Report 1975), led to the expansion in forensic mental health services with the development of medium secure units in most of the health regions in England, and in Wales. There are currently around 130 consultants in forensic psychiatry and 76 specialty registrars training in this field.

  2.2  Section 41 of the Health Act 1999 enables the Secretary of State for Health to establish for the first time, NHS Trusts responsible for providing high secure services. There are now two consultation documents setting out the plans to bring Rampton Hospital and Broadmoor Hospital into mainstream NHS services. The Ashworth Hospital and Mental Health Services of Salford consultation document is now out for consultation locally in draft form. To date, high security hospitals have developed outside of mainstream NHS services and arguably this isolation has been to the detriment of both staff and patients.

  2.3  Forensic mental health services in the health regions developed from the medium secure unit base. These services provided not only in-patient medium secure beds, but a community forensic service, which follow up in the community individuals (many of whom were discharged from medium secure care) who continue to present concerns with regard to risk to others. These services in order to function efficiently, have developed close working relationships with the local prisons, the courts, and the probation service.

  2.4  It is fair to describe the services as they have developed for mentally disordered offenders as being a patchwork, with the variable connections with other health service facilities and services, and with the criminal justice system. The patients managed by forensic mental health services are difficult and have complex needs, and many do not always easily "fit" into one service. There are often interface tensions between high security services and medium security services, between medium secure services and local mental health services, and at times between the NHS and the prisons.

  2.5  In 1991, the Review of Health and Social Services for Mentally Disordered Offenders and Others Requiring Similar Services, Chaired by Dr John Reed, published a series of reports. It recommended that the number of medium secure places should be increased from the recommendation of 1,000 beds contained in the Butler Report to 1,500 medium secure places. It was clear by this stage that there were not enough medium secure unit beds and that this was causing blockages in the system, preventing patients from moving to the most appropriate health care environment. The Reed Committee also recommended that there should be a range of secure provision available in every district health authority. For medium secure units to function appropriately, there needs to be a range of other, more locally based services, such as intensive care beds, an adequately resourced in-patient unit and community facilities, including, for example, 24 hour nurse staffed hostels. This is not always available.

  2.6  In 1999, the Report of Committee of Inquiry in the Personality Disorder Unit at Ashworth Special Hospital (the Fallon Report), presented its Reports to the Secretary of State. In Part 7, Volume 1, under the heading "Time for Change", there is the first clear statement by an authoritative body that forensic services could be provided in a different way. Although this report was primarily focused on offenders with a severe personality disorder the recommendations in this part of the report also cover the needs of offenders with mental illness. The Fallon Report suggested a new model for the provision of mental health services with a number of key principles, which I would support. There should be a regional focus for all forensic care. High, medium and low security must be managed as a network of local services. There should also be flexibility with clear pathways between different levels of security within the NHS and independent forensic services, and between the NHS and the criminal justice system.

  2.7  It is clear that this is now the direction of travel for forensic mental health services, and that under the new arrangements in the NHS and that regional commissioning will encourage the development of networks that will better meet the needs of this complex group of patients. However, it is clearly easier to develop this kind of new arrangement in health service regions such as my own, where there is currently a high security hospital. I believe that it is important to seriously consider (as others have argued) reducing the size of the current high security hospitals, but this can only be done if the number of high security services, will be better able to network with the forensic services provided at lower levels of security.

  2.8  I am sure that the Committee has concerns about patients being inappropriately placed in secure or acute mental health services. This is primarily because we have not yet developed the kind of regional networking of forensic mental health services that I would support, and which I have described above. In some health regions, I believe we are not too far away from this vision. The difficulties that exist between the secure hospital system and acute mental health services is in my view more complex to understand. In part this is due to inadequate resources (bed numbers), the drive towards community care in some parts of the country has been at the expense of the in-patient mental health unit. In many parts of the country, the range of local mental health facilities suggested above are unavailable. Many psychiatrists believe that they are now practising against the background of a "blame culture" and which makes them reluctant to take on the management of offenders within local mental health services. The probation service often finds itself in the middle of a "turf war" between secure and local mental health services. There are many areas of the country where good practice exists and I would argue that the mental health services and the probation service could be encouraged to work together better if locally based agreed protocols could be developed, that would help manage these tensions and would, I believe, encourage the movement of patients to the most appropriate care setting.


  3.1  Historically, many of these individuals, if they are successful in finding their way into the secure healthcare system, end up in a high security hospital. Many of those who are currently detained under conditions of maximum security, do not need this level of secure care and could be managed under medium security, but are not appropriate for a medium secure unit. This is because medium secure units provide a service for patients who are likely to re-enter the community. In short, they provide a rehabilitation service for mentally disordered offenders. However, all medium secure units have a variable number of patients who have been unsuccessful in reintegrating into the community. Many of these patients also have longterm medium secure needs. I do not believe that it is appropriate to meet these patients' needs by redesigning secure beds as "a longterm medium secure bed". This is what is being done in some medium secure units.

  3.2  The independent sector has moved into this service niche. A large number of medium secure beds have now been opened in the independent sector. Some of these beds meet the shortfall in "standard" medium secure unit provision, but many now provide a service for patients who have longterm secure needs. Independent sector forensic services offer only in-patient beds, these services do not provide community services for those who are thought to be appropriate to re-enter the community.

  3.3  I do not believe that there is yet a clear vision as to how and where patients with longterm medium secure needs should be managed. Probably, the Regional Commissioners of Forensic Mental Health Services, will in time make local decisions to meet their assessment of need.


  4.1  I do not intend to make any detailed comments on the Government's Consultation Document. It is unclear what service and legislative decisions the Government will make. I note that the Health Committee will be hearing oral evidence from the Head of the Mental Health Unit at the Home Office.


  5.1  In 1999. The NHS Executive and HM Prison Service published the document The Future Organisation of Prison Healthcare. I support the formal partnership between these two services and I know that both nationally in the Policy Unit and Task Force, and locally, there are changes underway, which will, I am sure, improve the healthcare for mental disordered offenders.

  5.2  There has already been an increase in the transfer of prisoners under the 1983 Mental Health Act to hospitals. For example in 1984, the total number of sentenced and unsentenced prisoner transfers was 129 and in 1994, this had increased to 784 cases. This in fact represented a twelve fold increase in unsentenced prisoner transfers, and a threefold increase for sentenced prisoners. This increase was made up almost entirely of individuals with mental illness. These figures, which are available in the 1997 report of the Health Advisory Committee for the Prison Service, also notes the steady increase in court activity for hospital disposals under the 1983 Mental Health Act from 276 cases in 1984 to 450 in 1994. The majority of this increase relates to male offenders, the figures for females are little changed from 43 in 1984, to 49 in 1994.

  5.3  I believe that the Committee will be concerned about the delays in transferring mental disordered offenders who require in-patient treatment to secure hospitals. Although there has been an increase in such transfers, the limiting factor is the number of secure in-patient beds. Patients in secure hospital care, do not move quickly and even when they are thought to be ready to move on in terms of their clinical needs and risk to others, there can be delays because many are subject to oversight from the Home Office Mental Health Unit. There are also difficulties in finding appropriate placements in the community. All of this prevents the rapid movement of patients from the prison system to the healthcare system.

  5.4  Also the prison service can sometimes be less than helpful in making it easy for health services to assess individuals. Manchester Prison is perhaps one of the few who are flexible enough (and this is to the credit of Dr Walker the Director of Healthcare) to agree to prisoners being transferred from a distant prison to the healthcare centre at Manchester Prison for my service to undertake an assessment. It is clearly difficult to assess and come to a decision on an individual who is being held at the opposite end of the country, from the service being asked to provide a bed. There are also limits placed on when assessments can take place to fit in with the prison regime.


  6.1  I am sure that there are other matters that the Health Committee will be interested in . I have not discussed services for female offenders with mental health needs in any detail or services for other mentally disordered offenders with special needs. Womens services in Mental Health Services of Salford NHS Trust and Ashworth Hospital have developed closer links with the appointment of a senior consultant psychiatrist to work across both services. My own unit, the Edenfield Centre, is possibly one of the first medium secure units in the country that has opened a womens ward.

  6.2  I would like to support the concluding remarks contained in the Memorandum of Evidence submitted to the Health Committee by Mr Robert Lee, Acting Chief Executive, Mental Health Services of Salford NHS Trust, and Mr Peter Clarke, Acting Chief Executive, Ashworth Hospital Authority. There is much by way of good practice in the North West, and in particular within my own trust. However, "if the Government's policy objectives for developing mental health services and for integrating high secure services more closely into the mainstream of the NHS are to be successfully achieved" then the Government will continue to need to fund and increase the funding allocated specifically to this development work.

  6.3  I hope that this document is a useful contribution to the work of the Health Committee.

May 2000

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