Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 600 - 619)




  600. It is obviously all his fault, as you can see. My perspective, looking at it from the outside, is that until recently the two government departments responsible for this area frankly barely spoke to each other on how we resolve some of these issues. Sir David, Dr Reed, you are both nodding. Is that a fair perception? I accept there is movement now, we have got some progress, possibly not as much as we want. Is that a fair perception of why we have the current situation?
  (Sir David Ramsbotham) Yes.

Mr Burns

  601. Sir David, Dr Reed, in the evidence you have sent in advance and also that you have reinforced today in answers to questions, you have fairly and squarely damned the service as being a disgrace and appalling and in that respect I certainly do not disagree with you in any way in that I fear that if the level of health care, both general health care and for mental patients, were at the level of that provided in our prisons nationally outside our prisons then Members of Parliament would be inundated day after day by aggrieved and angry constituents. It is a sad reflection on the society we live in and governments of all political parties, to be fair, that we are prepared to tolerate this and have been prepared to do so. What I have just said has been pointed out by many people over many years with boring and rather tragic repetition but nothing has been done. Why do you think that things do not improve and that we have tolerated this and it has dragged on and on?
  (Sir David Ramsbotham) I cannot comment on why it has dragged on and on because I only came into this scene in 1995 and I have to say that in my second week in office I inspected Holloway which immediately set me off down this trail because I was totally appalled by what I found. Frankly, what I think is one of the barriers to it has been the barrier between ministries in Whitehall and the Department of Health and the Home Office and others have been going down their individual routes. I remember this in the Ministry of Defence, we were not very good at liaising with other people or other people with us. That is a simplistic answer but I did find it absolutely fascinating that the moment we suggested that the way out of this particular morass was to go down the NHS route, because the NHS was the responsible organisation in the country, and then discovered that only prisons in this country were excluded from it, there were quite a lot of squeals about "oh, you cannot afford it" to which I said "have you actually looked at it?" because what in fact the Prison Service had been having to do was to duplicate what was already available if they had functioned as outreaches of the NHS. Therefore, what you had was a small service functioning on its own isolated from the mainstream of development, as indeed were its staff, which was one of the things that worried us. At one time we discovered that only 10 per cent of the senior medical officers in prisons were qualified to function as GPs in the NHS. That is something which should never have been tolerated frankly, nor should it now do we believe.


  602. How far back was that, Sir David?
  (Dr Reed) 1996-97.
  (Sir David Ramsbotham) Three years.

  603. Quite recently.
  (Sir David Ramsbotham) Very recently. I personally think that it is not all that productive to go on looking back because what has happened is that now there are recommendations in our paper for the patient or prisoner saying "for heaven's sake consider this", followed by the working party to which Dr John Reed referred, followed now by the task force, followed by the arrangements which you are going to see at Belmarsh which include the contracting out of primary and secondary mental health care from prisons into the regional authorities bringing in the clinical governance, and that has started a process. I think we ought to concentrate on the starting of the process and in particular encouraging the many good staff there who are trying to do a job against the odds. You can waste a lot of time worrying about the blame factor in this.

Mr Burns

  604. That is very interesting. You also said earlier in your response that you felt that government departments did not talk to each other. I certainly got the impression, particularly at the back end of 1996/97, that certainly the Department of Health did not want to talk to the Home Office. I believe the Home Office would have been more than happy to transfer the Prison Health Service to the NHS because it then would not come out of their budget and I certainly know for a fact that the Department of Health did not want to touch that hot potato with a barge pole because there were enough pressures on the NHS budget in the far more politically sensitive area of health care for the general public outside prison without wanting to take on the additional burden, a burden that, notwithstanding some of the savings you may make because of duplication, was far outweighed by the additional burden of not only financing the Prison Health Service but also the initial investment that would have to be put into it to bring it from a kind of Third World Health Service to a state of the art NHS on a par with the health care outside prisons in this country. Given that, and notwithstanding the good practice that you have highlighted which may be the beginning of a new dawn that develops throughout the country, but it may not, how confident are you that it will move forward and will radically improve and enhance health care?
  (Sir David Ramsbotham) I am an optimist and, as I said right at the beginning, one of the things that makes me optimistic about it is that inquiries such as this, and such as the work of the task force, are now bringing in all the people who should have been brought in.

  605. Right.
  (Sir David Ramsbotham) The obstacle, as you quite rightly point out, is money. It seems to me, and this is being idealistic, that the problem is that everyone thinks of the money first and then the solution second. For heaven's sake, let us think of the solution and then look and see how much of that can be afforded and, if so, from where. We go about it the wrong way round if we do not analyse where the problem is. For example, some prisons do not need more than a good nurse practitioner running a minor injuries unit, they do not need a massive health care centre and all that goes with it. When you actually look at what the needs are in each of the prisons then I believe you will come up with the cost which has to be looked at. The Prison Service demanded that every prison should have completed a needs assessment by July 1997. To date not a single prison has completed it, nor did the Prison Service demand it. The needs assessments are now currently being produced. Hopefully they will include mental health needs as well. Once that is there and once you have got a description of what the problem actually is then I believe you can tackle it, you can start putting the money to it. If you start putting the money to it before you analyse the problem, you are going to confuse any solution you come up with.

  606. In the light of that example, do you think that maybe your optimism might in the end prove to be misplaced because it is a sad fact of life that there are not many votes in prison and health care, particularly as the client base does not even have a vote?
  (Sir David Ramsbotham) If I am cynical, the moment litigation starts under the European Convention on Human Rights, because of the way people have been misplaced, the financial penalties on people will be such that I think it will wake them up to what has been done.
  (Dr Reed) Could I go back to one of the Chairman's original questions to me about how did I feel about progress that has been made since the Mentally Disordered Offenders Review at the beginning of the 1990s. I hope I came over as being fairly positive about the development. At that time, when we published the report, we costed what costs would be to implement it all over and we came up with the extraordinarily alarming figure of £100 million. I have to say that is something that civil servants kept to themselves. It is important not to be frightened by sums like that, it may cost more to develop good quality health care services in prisons, that is something that needs to be examined. But, there is no big bang solution to this. If it does cost money it is going to be money over a considerable period of time because the limiting factor for the mentally disorder offenders' work was training additional staff, more psychiatrists, more mental health nurses, and you cannot do that quickly. It takes a minimum of 10 years to train a doctor. If you work out costs and they come up to something rather startling, you have to think of that as £100 million over 10 years, £10 million a year, which is quite a different prospect. If one is to succeed in that it does depend then on people continuing to see this as an important area and Committees like your own continuing to keep it on the agenda, otherwise it will slip back. Can I just make one point. You say "Right, there are not too many votes in mental health care for offenders", well maybe as we learn more about this people will realise that these are important things, not just for prisoners but for them. I have recently made some inquiries about a recent series of post homicide inquiry reports, the inquiries that are run by the NHS when a mental disordered person has committed homicide. I asked someone who has been involved in a great number of these how many of these people who went on to kill had been in prison in the year beforehand? Without pausing the answer was "Well, the last five anyway". There are important public safety issues as well as important personal health issues.
  (Sir David Ramsbotham) If I could just endorse that. This comes up in prison after prison after prison. At the last prison we were inspecting last week, a young offenders' establishment, the staff told me they were extremely concerned last year about a boy who quite clearly had homicidal tendencies. They reported this to the local authorities, they reported it to the police, they warned everyone, nothing could happen and out he went. Sure enough three months' later he chopped someone's head off. They were at that moment very worried about a boy who was openly saying he was going to kill. They simply did not know who was going to listen to their cry saying "This is what is going to happen unless you listen to us". Again, it is desperately important that all involved establish this dialogue and listen to each other.

Mr Hesford

  607. Can I address the issue of transfer between those who might need some care in a different kind of Prison Service from the NHS. Can I ask, first of all, Mr Boyle. I am not sure so far, Mr Boyle, from what you have been able to say what it is you are able to say to the Committee. I would be grateful if you could say something about this. We have been given evidence that transfers are slow. How can you speed up the system? What is the Home Office thinking on speeding up the system of transfers?
  (Mr Boyle) Can I just be clear, are you talking about transfers of people from prison to hospital?

  608. Yes.
  (Mr Boyle) Rather than transfers within the hospital system?

  609. Yes.
  (Mr Boyle) I just ask because we have responsibility to give consent at both ends of the system.

  610. Yes.
  (Mr Boyle) As far as transfers out of prisons into hospital are concerned, our narrow responsibility is in effect to look after the mechanics—we have to give the formal authority rather than making the actual arrangements. In that respect we think that in my unit we are offering quite a good service. From a figure of under 200 prisoners transferred to hospitals per year in the late 1980s, the figure has increased, largely as a result of extra capacity in the health system I suspect, to a level of 750 transfers a year. One of our targets, which we virtually without exception achieve, is to process all the necessary paperwork to provide the authority for the transfer within 24 hours of being informed that a bed is available for the prisoner. At that level the system works. The issue is elsewhere in the system and I think it is related, first of all, because I think there is a theme that has emerged from the previous discussion, to identifying the fact that the prisoner actually is suffering from a mental disorder that is so serious as to warrant specialist treatment in hospital and then, secondly, identifying the right place in the hospital system for them to go to. Perhaps I should just add that is not just a question of bed availability in the very high security hospitals because last year out of the 742 people we transferred to hospital, actually less than ten per cent went to high security, the great majority went to either NHS or private sector medium security and quite a good proportion to low security as well. It is a question of capacity throughout the system. The final thing I would just say in relation to our role in the system is that we do encourage prison doctors both to use the existing arrangements that have been set up by which if they are having problems identifying an appropriate placement for a prisoner they go through the regional specialised commissioning units to see if they can resolve the problems and clear blockages at that level, but also to make sure that they let us know if they are having real problems in that respect because we do have a reserve power to direct the admission of a prisoner to hospital. Even if the hospital says "we are full, we have not got the room", if our assessment is that the situation is so serious that the prisoner has to be directed to that hospital, we have that power. It is one that we use very sparingly, we only used it four times last year, but it is there in cases of real need and we are willing to use it if we need to.

  611. Dr Reed, I am given to understand that in a recent BMJ article you spoke about prisoners who might just need 24 hour nursed care who would not necessarily be detained or diagnosed under a Mental Health Act diagnosis and those might be helped by temporary licence transfers. Can you say a bit more about that, particularly in the light of what Mr Boyle has said?
  (Dr Reed) The second paper you have looked at the care of people who are inpatients in health care centres. They divide them into broadly three groups. There are ones who I think you could call proper sick bay cases, people who are getting over the flu or have broken their wrist and they need to be protected from the rest of the world for a while. That is about a third. There are a third who have difficulty in coping with life in prison and who get upset, and that is a group that is not particularly relevant to your discussions here. There is this third group of people with serious mental illness who if, instead of looking at what you have to do pragmatically, you look at what their clinical needs are, these are people who need to be in the NHS psychiatric service. The great majority of them need to be in medium secure care. A small proportion, a single figure percentage, need to be in the high secure or in the general psychiatric service. The great number need to go into medium security. You can project from the study that we did—and we commissioned some work in the West Midlands Forensic Service looking at two whole NHS regions and the prisons in those—that there are probably at any one time 500 seriously mentally ill people in prison health care centres who really, if their clinical needs are to be met, ought to be in NHS secure care. There are, of course, others who are out on the wings who I spoke about earlier who we do not know about, but that is a clearly identified group. Now, at present, it is the almost universal experience that it is an extremely slow process to transfer mentally ill people from prison to the NHS. To a certain extent this is because of disputes about the proper level of security that they need, whether they should have high security or medium security. To a much lesser extent nowadays there are disputes about funding, who should pay. The big problem from the prison perspective is simply unavailability of beds for them to go to. Particularly this is true of the longest waits of people transferring to the special hospitals. Certainly I have been in prisons where people have waited well over a year before a bed becomes available in the special hospitals. Meanwhile, the prisons, with their limited and not very adequate resources, have to do the best they can. There is also a problem of medium security though the length of wait there is not so long and it varies very much from place to place. For instance, at Liverpool Prison there was no problem, the local forensic psychiatric service took people out and if they waited a week it was viewed as a failure. They managed it very rapidly. I think there is scope for study as to why they are so successful and others are not. There are serious blockages in the system. This is particularly difficult for people who are in prison on remand because at any moment they may go back to court and the court may make a non custodial disposal while you are trying to transfer them to secure psychiatric care and they are lost in the system.
  (Dr Snowden) I think it is fair to say that there are some secure units, like in Merseyside, which are able to transfer individuals from prison to hospital fairly rapidly and that may be something about the number of beds that unit has for the geographical area that it is responsible for. I think it is fair to say on the whole on any one day, let us take today, it is unlikely that there will be a single medium secure unit bed available in the NHS, it is unlikely that there will be a single high security bed available in the NHS. There is no spare capacity and that no spare capacity has been caused by the long stay patients with secure needs who have silted up the system and usually gravitated to the highest level of security, but there are some in medium secure services. I agree with Mr Boyle that there has been an increase, and I am sure there will continue to be an increase, in prison transfers from prison to the health care settings but it is increasingly difficult and many end up going into independent sector secure provision. The problem with that is that when they are deemed well enough to move to the NHS there is a discontinuity of care. Someone else takes them over, has to relearn their case and in terms of risk assessment of these, at times, very difficult individuals I think that is problematic for the community. I think apart from capacity there are process issues. For example, we have discussed already the identification of individuals with severe mental illness but the assessment process can be very time consuming. If I have a Manchester resident who ends up in a prison on the Isle of Wight it could take a day or a day and a half to go down with a multi-disciplinary team, do a proper assessment, come back, do the report, etc., because the Prison Service is unable in most cases to get its head around transferring the prisoner close to the health care service which is supposed to be providing the care. Fortunately, again there may be other areas of good practice but I am aware in Manchester the Governor there is able to organise a spare bed or two within the health care centre to allow prisoners to be transferred from further afield to Manchester so we can organise a fairly urgent assessment. There are a number of process issues about but I think the bottom line is capacity.

Dr Brand

  612. It is nice to have the opportunity to visit the Isle of Wight. It is very interesting. We have been told that the Prison Service is the method of managing waiting lists, basically, for NHS provision. Dr Reed, I think you gave a figure of 500 beds.
  (Dr Reed) Yes.

  613. Your assessment being noted.
  (Dr Reed) Yes.

  614. We have been told by the Department they are planning almost 500 new medium and low secure units but that presumably does not take into account the other end of the logjam which is the special hospital to make more space available there. Is the total figure of 500 an appropriate figure? Is that a Prison Service derived figure? Has it taken into account the need which we discussed earlier of the special hospitals to move on the 20 to 30 per cent of people that they have got who could be placed elsewhere?
  (Mrs Foley) The 500 that John has talked about are the 500 that are sitting in the Prison Service.
  (Dr Reed) Purely in prison.

  615. Can you give us the total figure? From your experience of the special hospitals, how many beds in medium and low secure units do you need to complete this jigsaw?
  (Mrs Foley) I think, as we heard right at the very beginning of this from the Chairman, there is a general acknowledgement that between 25 and 30 per cent of patients who are in high security at the moment do not need that.

  616. We are talking about another 400?
  (Mrs Foley) Yes.

  Dr Brand: That is very helpful. Has anyone done any costings of what it costs to keep someone in a prison, someone in a secure unit? It would be helpful if somebody could give us a note.

  Chairman: Perhaps you could write in. I am sure you have these figures.

Dr Brand

  617. I am sure it will be very helpful in our final report. The last question I would just like to ask Sir David or Dr Reed. Sir David is quite right in saying that we have to think about patterns that meet the problem rather than look at the funding, but do you believe that the current funding for, say, secondary care for prisoners, which is based on a capitation system, is adequate? Certainly my health authority is very much out of pocket in providing hospital care for prisoners in our three prisons because the capitation based system does not take into account the higher rate that group costs. That makes them very reluctant to start volunteering imaginative schemes of increasing the NHS involvement.
  (Sir David Ramsbotham) I bow to Dr Reed.
  (Dr Reed) That is more an answer for my colleague from the Department of Health. My understanding is they have been looking at funding in that light, as you say. The Isle of Wight is the crucial case.

  618. I always think so.
  (Dr Reed) Three big prisons. I understand they are looking at that. It is something you will have to ask them. Just on the money issue, okay I say there are 500 people currently in prison health care centres who ought to be in the NHS, the corollary of that is there are 500 beds in the Prison Service which could be closed.

  Dr Brand: Unfortunately, I think they will probably be filled up.

Mrs Gordon

  619. I just want to make a quick point. When we visited Broadmoor last week they said there were no women on a waiting list to come into Broadmoor but there were 20 men on this waiting list. As you have already said, there can be a lengthy wait. Presumably you would agree that these men on the waiting list, their outcome is poorer so they are not receiving the treatment they really need.
  (Sir David Ramsbotham) Yes, that is absolutely right.

  Chairman: I think we are going to move into areas away from directly the prison environment with Mr Gunnell. Can I make a brief point, perhaps on a lighter note. We are looking at concerns over medical provisions within the prison system. I received a letter yesterday from a GP in my constituency on behalf of a patient, who was a prison officer, expressing concern that the prison officer with a particular condition was getting a poorer service on the outside than the prisoners that he knew of within the prison in which he worked.

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