Memorandum by Dr Peter Snowden, Acting
Medical Director, Mental Health Services of Salford NHS Trust
PROVISION OF NHS MENTAL HEALTH SERVICES (MH
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 Unitfor 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. THE PROVISION
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
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. SERVICES FOR
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. PRISON HEALTHCARE
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.