Select Committee on Health Fourth Report



Capacity in the secure system

176. The evidence that we received on the state of the general mental health services painted a picture of services currently under stress, with patients living in the community not necessarily receiving the support they need to cope (see above, paragraph 83). As a result, it was difficult for us to judge whether the undisputed pressure on acute in-patient beds reflected an actual need for these beds to be increased, or whether the current provision would be adequate once comprehensive community services, in particular supported housing provision and crisis services, were in place. However, pressure on acute beds is not affected solely by the adequacy of community provision, but also by pressures in the secure system of mental health services: the low security "locked" wards, the medium secure units and the high security Special Hospitals.

177. One of the triggers to this inquiry that we mentioned earlier was the visit we undertook in 1999 to an independent secure unit in Yorkshire, many of whose patients were from London. The need to send patients both into the independent sector and 200 miles from their homes indicated to us a clear problem with the capacity of the secure system, an assumption confirmed by many of our witnesses.[415] However, the problem is not limited to a straightforward lack of NHS secure beds in the right part of the country. The Department of Health published a document in 1995 which suggested that, of the 1520 patients then in the Special Hospitals, 540 needed only medium levels of security, while 150 needed long term low security, and 80 did not need secure care at all.[416] The reason these patients could not move on was because appropriate facilities were not available for them further down the system. These rough figures were certainly supported by our witnesses in this inquiry: MIND, for example, argued that data from the Mental Health Act Commission showed that between a third and a half of patients in the Special Hospitals did not need that level of security,[417] while Sheila Foley, the chief executive of Rampton agreed when giving oral evidence that around 400 patients did not require Special Hospital care.[418] We were thus presented with a picture where patients in need of secure services could not access them, while patients already in that secure system were "silting up the system"[419] because there were no suitable facilities for them to move on to when they were ready for less secure care.

178. This position is exacerbated by the fact that there is currently very little provision for long-stay medium secure care. The medium secure units aim to rehabilitate mentally disordered offenders, and non-offenders deemed to need secure care, within a time-scale of around 18-24 months. They are therefore not designed to act as "step-down" facilities between the Special Hospitals and general mental health services, a point made to us by the Sainsbury Centre for Mental Health.[420] Thus patients in Special Hospitals who no longer need the high level of security provided by measures such as the perimeter fence, but who still need long-term care with some measure of security, have nowhere to go. We were told on our visit to Bracton Clinic (part of Oxleas NHS Trust) that a number of their medium secure beds have been designated "long-term", in order to meet this need.[421] Despite measures such as these, it is clear that many such patients either remain longer than they need in the Special Hospitals or are provided for in the independent sector. The Independent Healthcare Association estimated that at present around 55% of all medium and low secure beds used by NHS patients are provided by the independent sector.[422] Dr. John Reed, the Chief Medical Officer of HM Inspectorate of Prisons[423] and Dr. Peter Snowden of Mental Health Services of Salford NHS Trust[424] also both highlighted that there is no clear view on how long-term medium secure care should be provided:

    "It is not just a question of resistance. It is also a question of knowing what the right models are."[425]

179. The Department told us that nearly 500 secure beds had been, or were being, established through Modernisation Fund moneys: 221 in 1999/2000 and 250 in 2000/2001.[426] In a supplementary memorandum, they told us that they were "confident that the number of secure beds currently planned will be adequate to meet need on the basis of current predictions".[427] We were therefore rather surprised when two weeks later, after the publication of the "Tilt Report"[428] on the security of the Special Hospitals, the Secretary of State announced funding for a further 200 medium secure beds.[429] We have also been unable to obtain a precise figure for the number of medium secure beds currently in the system. In its supplementary memorandum, the Department told us that they believed that there are currently "some 2208 medium and low secure places in the NHS" in England, but that they were in the middle of an exercise to confirm these numbers.[430] It is unclear how this figure of 2208 breaks down between low and medium secure beds, and also whether it includes the 250 beds promised in 2000/2001. We would like to have received mutually compatible and robust assurances from the Department of Health and the Home Office that their forward plans for the increase of low and medium secure places would enable all categories of patient to be offered appropriate accommodation and treatment. We do not feel that we received such an assurance from the figures that were presented to us.

180. We were also told by the Department that, although the Government remains committed to the NHS as the main provider of healthcare, the intention was to work in partnership with the independent sector and to build such a partnership into local planning arrangements. The Department also believes that there will always remain a "niche" market for very specialised services, such as those provided by Thornford Park in Berkshire who look after frail elderly patients who nonetheless still require conditions of security.[431] The Department's emphasis on partnership seems to be very much in sympathy with the argument put to us by the Independent Healthcare Association who told us that "the sector wishes to have a greater input into policy development and planning".[432] We, however, remain uncomfortable with this approach. We were impressed with the evidence of Dr. Peter Snowden of Mental Health Services of Salford NHS Trust who told us that one of the problems with the use of the independent sector was the lack of continuity of care when patients were well enough to be transferred to less secure facilities.[433] In our visits to NHS mental health services, our attention was also drawn to the great cost to health authorities of the use of the private sector, with the knock-on difficulties this has caused in the development of NHS facilities better integrated with the rest of the mental health system.[434] Moreover, since the independent sector will tend to provide only secure care, rather than the full range of mental health services, there seems to be a clear perverse incentive built into the system: it is hard to see how providers will have any incentive to push for patients to be moved on when they are ready. We welcome the Government's policy of increasing the capacity of the NHS to provide secure care on a local basis. We recognise that there has, historically, been a mixed economy of care in the secure services, and we accept that there is likely to remain a role for the independent sector in providing highly specialised "niche" services. However, we would like to see the NHS develop sufficient capacity in secure provision, properly integrated with general mental health services, so that routine reliance on out-of-area placements with the independent sector is no longer necessary.

181. The difficulties in the secure system are not limited to the number of medium secure beds, or the availability of long-term medium secure facilities as "step-down" facilities for the Special Hospitals. Dr. Snowden told us:

    "It is very easy to focus on where there is the current perceived gap which would be long term medium security. We need to look at all levels from specialised 24-hour nursed community placements right the way up to intensive care units, medium secure units."[435]

This view was borne out by other witnesses. On our visit to Broadmoor, the Women's Service Director told us that she believed that 60% of the women patients currently placed there could be cared for on assertive outreach in the community,[436] while Sheila Foley of Rampton Special Hospital described "local low secure facilities" as "the real gap".[437] Antek Leik, the chief executive of Local Health Partnerships NHS Trust took up the theme of low secure facilities when he told us that "it is [a problem] where we have the patient who does not require medium secure but is actually not suitable for a basic acute bed".[438] A psychiatrist from the same trust, Dr. Christopher Mayer developed the point further in making a distinction between the need for more short-term "intensive care" provision for patients too disturbed to remain on an acute ward, and the shortage of longer-term low security services.[439] Dr. Reed made the same point on long-term low secure care as he did on long-term medium secure care: that there are problems in deciding what services should look like in "practical on-the-ground terms".[440]

182. Another factor highlighted to us on our visit to Broadmoor was that of "restricted patients". Patients who come into the secure system via the criminal justice route (either through a court order after conviction or through transfer from prison later) can be transferred with restrictions under section 41 of the 1983 Act: essentially this prevents their discharge, transfer to another hospital or the granting of leave of absence, unless the Secretary of State gives his approval. Clinicians in the field were clearly frustrated by the limitations this places on their action and felt that it led to patients being detained at unnecessary levels of security.[441] Mike Boyle, Head of the Mental Health Unit in the Home Office, on the other hand, told us that the Secretary of State's function was "purely that of safeguarding the public interest in the risk dimension" and that "we are able to exercise an objective and discretionary judgement without the danger of becoming too close to the individuals and losing track of some factors that may still be quite prominent in the individual case which the care team may lose sight of".[442] He also emphasised that "it is not our function, in a sense, to apply a secondary punitive element to it by refusing to consent to the transfer or discharge where that is otherwise justified on the basis of the patient's mental health and the risk to the public".[443]

183. The fact that many patients in the higher levels of the secure system are judged not to need that level of secure care is clearly very worrying, not only from a service provision point of view but also, very significantly, from a human rights point of view. A number of witnesses drew our attention to the possible implications of the Human Rights Act 1998, when it comes into force in October this year.[444] The European Convention on Human Rights on which the Act is based permits the deprivation of liberty on the grounds of mental disorder, but it seems possible that the courts could take a very dim view of individuals being detained in very high levels of security when those responsible for their care have agreed that those levels of security are not necessary. We also found it extraordinary that, given the Government is aware of the number of patients who are inappropriately placed in the Special Hospitals, it has endorsed the recommendations in the recent "Tilt Report" to spend £30 million upgrading the perimeter fences of all three hospitals. Given the evidence in the report itself that there have been no breaches of the perimeter in the past six years, we feel that this money could be much better spent on tackling the many other problems in the secure services highlighted in this Report. We also feel that it would have been valuable for the Tilt Review Team to have included a great deal more clinical input: of the four members listed (excluding the Secretary) three came from the Prison Service, and the fourth was a manager in a mental health trust.[445]

184. The final point made to us on the question of capacity in the secure mental health system was that of the current unmet psychiatric needs of prisoners. Ashworth Special Hospital emphasised to us that "any planning for future high security services must take into account the potential for transfer of significant numbers of patients from the prisons".[446] It was certainly made very clear to us on our visits to Ashworth, Broadmoor and Belmarsh Prison that prisoners have to wait an unacceptably long time after being assessed as needing transfer to the mental health system for a suitable bed to be made available.[447] While Ashworth made this point very much in terms of capacity in the Special Hospitals, we were struck by evidence from Mike Boyle of the Home Office who told us that of 742 transfers from prison to hospital last year, less than ten per cent went to high security with the "great majority [going] to either NHS or private sector medium security and quite a good proportion to low security as well".[448] The Department of Health told us that 140 mentally disordered offenders are currently waiting in prison, after having been assessed as needing Special Hospital care, although they emphasised that not all of these would necessarily be deemed suitable by the Special Hospitals themselves.[449] Dr. Reed of HM Inspectorate of prisons estimated that at any one time there are about 500 seriously mentally ill prisoners in prison healthcare centres, who would benefit from transfer to hospital.[450] We will return to the question of mental health services in prisons at greater length below (see paragraphs 204-216).

Action to improve transitions between the secure and general mental health services

185. Although we were shocked by the evidence we received on the misplacement of patients within the system, and the subsequent unmet need of those unable to access suitable services, it was also clear to us that a great deal is currently being done to address these issues. Since April 2000, funding for high security services has been devolved to Health Authorities.[451] This means that these services will no longer be a centrally funded "free good" to Health Authorities, a system under which there was clearly no incentive for Health Authorities to take an active role in bringing "their" patients back from the higher levels of the secure system to the local mental health services. Both high and medium secure services are now being commissioned by "regional specialised commissioning groups", funded by Health Authorities on a levy system, and the Department of Health told us that, under this new system, "for the first time ever, money will actually follow the patients".[452] We gained the impression that it may be difficult for money to "follow the patient" in a completely direct way: it was made clear to us on our visit to Broadmoor, for example, that the contracts between the commissioning groups and the Special Hospitals will not be on a straight-forward "cost-per-case" basis, because, if they were, the loss of 10 patients would lose Broadmoor £1 million in annual income. This would simply not be viable given Special Hospitals' high fixed costs for their estate and security. It therefore seems likely that the extent to which money genuinely will "follow" the patient will depend on the levy arrangements between Health Authorities and the regional commissioning group: for example whether Health Authorities' contributions to the levy are proportionately reduced as they move patients from high security to medium or low security.

186. Despite this proviso, it was clear to us that the new commissioning arrangements would certainly address one of the major flaws of the previous system: that the funding system for medium and high secure services was so distinct from Health Authorities' general allocations that Authorities had no incentive actively to manage the care of patients from their area placed in these facilities and ensure they moved to less secure services as soon as possible. While the Sainsbury Centre for Mental Health suggested to us that "progress has been slow" on the regional commissioning groups,[453] most witnesses were very positive over the new commissioning arrangements and felt that they represented a good way forward.[454] The importance of keeping both health and local authorities involved so that patients in secure care would not be seen as no longer "their problem" was emphasised: David Joannides of the Association of Directors of Social Services, for example, commented that the problem in the past "is that we have not had a system of care management ... I think you have had evidence from the Department of Health that they are interested in looking at a care management approach of assessing individual patients. What we actually need is an injection of some short-term funding to act as a catalyst".[455]

187. The Department provided us with details of the assessment exercise currently taking place in the Special Hospitals: the Institute of Psychiatry has been commissioned to assess the needs of all Special Hospital patients by April 2001 so that properly informed decisions as to their future needs can be made.[456] The Department of Health circular setting out the new commissioning arrangements stated that data was available on the Health Authority of origin of patients in the Special Hospitals, and that funding would be devolved on the basis of patient numbers as at 31 March 1999.[457] It was clear from our visits to trusts such as South West London and St. Georges NHS Trust and Oxleas NHS Trust that managers are very aware of the number of "their" patients in Special Hospitals.

188. We feel that the changes in funding mechanisms for medium and high secure services can only be beneficial in improving the links between these services and the general mental health services. We also welcome the needs assessment which is currently taking place in the Special Hospitals. But we were struck both by the apparent lack of firm figures distinguishing the number of medium secure beds from the number of low secure beds, and by the evidence we received on the uncertainties surrounding the best models for long-term medium and low secure care. In these circumstances it is hard to see how anyone can be sure that the appropriate capacity has now been provided, or that it is being provided through the most appropriate models.

189. We recommend that the Department publish firm figures on the number of secure beds which will be available once all the additional beds which have been announced have been created, separately identifying short-term medium secure, long-term medium secure, short term low secure and long-term low secure beds. We also recommend that the Department should commission further research on the best ways of providing medium and low security services for those likely to need this support on a long-term basis, including specialised long-term community support for patients discharged from secure services.

190. We are deeply concerned as to the human rights implications of patients staying far longer than they should in the higher levels of security. It seems quite possible that claims under the Human Rights Act 1998 could place a considerable burden on already over-stretched services. We recommend that the action already being taken to assess individual patients' needs should be completed as speedily as possible, and that if short-term funding is necessary to provide appropriate placements, it should be made available.

191. Yet another forthcoming change in the management of secure services is the Government's decision that the three Special Hospitals should cease to be separately managed as Special Hospital Authorities and should be encouraged to merge with NHS trusts providing mental health services. Statutory authority for this development was provided through section 41 of the Health Act 1999 and all three Special Hospitals are currently in discussions with trusts providing a range of general and secure services: Ashworth with Mental Health Services of Salford NHS Trust; Broadmoor with Ealing, Hammersmith and Fulham Mental Health NHS Trust and Rampton with a reconfiguration of trusts in Nottinghamshire.[458] This development reflects the consensus that the three Special Hospitals have been allowed to develop too independently of the rest of the NHS, leading to isolation, a culture that is sometimes more akin to that of a prison than a hospital, and recruitment difficulties. Julie Hollyman, the chief executive of Broadmoor, for example described the Special Hospitals to us as being "always a reorganisation behind the rest of the NHS" with a very old-fashioned culture.

192. A very different solution to the isolation of the three Special Hospitals was put forward in the Fallon Report on the activities in the personality disorder unit at Ashworth Special Hospital.[459] The conclusions of the Fallon committee were clear and straightforward: high security services should be provided not in three isolated Special Hospitals but through regional networks of forensic services, embracing all levels of security from high security to community services.[460] In oral evidence to us, the Secretary of State justified his predecessor's decision not to accept this recommendation, emphasising that it had not just been rejected because it was seen as politically too difficult:

    "The reason why we have not gone for that [the Fallon] option is not actually the so-called political problem issue, it is the fact that actually these organisations have built up a level of expertise dealing with in some cases very difficult, very disordered and sometimes very dangerous people indeed."[461]

Earlier, Department officials had told us that it would be "even more difficult and significantly more expensive" to have more than three high security services.[462] Ashworth itself argued that much of the discussion about high security hospitals was based on old information, and that the only way of planning proper services in future would be to base decisions on clinician-led assessment of individual patients.[463]

193. Other witnesses took a very different perspective. In written evidence to us, Dr. Peter Snowden of Mental Health Services of Salford NHS Trust supported the Fallon recommendations.[464] In oral evidence, he expanded the argument, pointing out how in his area of the North West it was possible to develop a mental health strategy that would include provision for all levels of security within the NHS Region, because Ashworth happened to be within that region. Yet, he argued, "it is very difficult for a region such as Birmingham [West Midlands Region], which has a medium secure and other local facilities but no high security unit, to have the sort of relationship with services in high security and to encourage the same sort of movement between patients at different levels of security".[465] While Sheila Foley of Rampton made no comment on the idea of regional units per se, her description of how commissioning arrangements are progressing in her region of Trent[466] led us to draw much the same conclusion as Peter Snowden had done; that inevitably it must be easier to plan services across all levels of security and back into general services if all parts of this system are actually in the same region. Dr. Shooter of the Royal College of Psychiatrists went further, arguing that blockages in the system would be inevitable "unless every region has the range of facilities available, as the Fallon committee says".[467]

194. In our visits to a range of secure services, we tried to explore possible alternatives to the closure of the three Special Hospitals. Broadmoor described to us how they had arranged accommodation within the hospital on a geographical basis, so that better links could be developed between wards and the areas where patients came from. The Bracton Clinic (part of Oxleas NHS Trust) described the link arrangements they have to keep in touch with patients in the Special Hospitals and the independent sector, including the appointment of a dedicated nurse who is responsible for assessing patients and ensuring that they are "brought back" as soon as possible. We were particularly impressed with the system Bracton described to us, whereby ideally they are consulted whenever there is a question of any individual in their catchment area going to Broadmoor (although the medical director admitted that occasionally the system failed and they weren't informed): whenever possible the patient is placed with the Bracton Clinic, and if Broadmoor is deemed to be the most appropriate disposal, the Oxleas trust offers a commitment to accept them back as soon as possible.[468]

195. Our visits to Ashworth and Broadmoor, although short, made us sceptical as to the "special expertise" alleged as one of the benefits of the Special Hospitals. Although we had no doubt at all as to the commitment of senior management to change, we felt that the difference between management aspiration and the actual atmosphere on the wards was considerable. It was clear that while some staff members were making enormous efforts to improve services for patients (we were particularly impressed, for example, by the Women's Service in Broadmoor) others still appeared to regard their role as more custodial than therapeutic, with patients being treated less than sympathetically. One possible measure of the extent to which patient concerns are taken seriously is the way complaints are handled, and we were concerned to note from Ashworth's annual report that although 22 requests for independent review had been made in 1998/99, none had been granted.[469] This unease was increased by recent press coverage suggesting that a review commissioned by Ashworth of its complaints system was highly critical, and that a number of patients were contemplating claims relating to mistreatment in October when the Human Rights Act 1998 comes into force.[470] On the staffing front, we found it difficult to equate the claims of particular expertise with the difficulties experienced, in Ashworth at least, in recruiting psychiatrists and the subsequent reliance on locums.

196. We appreciate that our visits to Ashworth and Broadmoor were too short to be the sole basis for recommendations as to their future. We are also aware of the dangers of assuming the same problems arise in each of the three Hospitals, an issue we return to below in the section on women's secure services (see paragraph 200). But we feel that the arguments outlining the benefits of a genuinely regional focus to secure care are overwhelming. The new regional arrangements for commissioning care and the intention of merging the Special Hospitals administratively with other mental health trusts appear to us to represent a poor second best in the attempt to provide that regional focus. We have come to the conclusion that the reform and improvement of the Special Hospitals is probably not workable, despite the millions of pounds committed to them by successive governments, because of their isolation, their difficulties in recruiting and retaining highly professional staff, and the culture which has developed within these institutions. We repeat the recommendation of the Fallon committee, that the three Special Hospitals should be replaced by eight smaller, regional based units, fully integrated with existing medium secure, low secure and general mental health service provision. A decision to retain the existing system would, we believe, be prompted more by political expedience than by any genuine attempt to achieve the most appropriate and most secure provision. We believe that the distinction between high secure and medium secure provision needs to be retained. Clearly, public safety and staff safety in high secure services must be given at least equal weight with therapeutic considerations, and our proposal to replace the existing three Special Hospitals with regionally based units should be understood as a long-term project. We would endorse the approach taken in the Italian reforms of 1978 of introducing a moratorium on admissions to old facilities while capacity is built up in the new facilities.[471] Existing patients would only be transferred to the new services when these had consolidated their working practices and skills. We would also emphasise our belief that smaller, purpose-built units would in fact offer far better security for the public, for patients and for the staff than the existing unwieldy old estates where security is inevitably difficult to manage. Indeed, if we were not satisfied that public safety would actually be increased, we would not be in favour of the proposals outlined above.

Women's secure services

197. We commented at the very beginning of this Report that we were particularly interested in seeing how mental health services responded to the issues of race and gender. We received very little evidence on the position of women in the context of general mental health services, perhaps because our focus had been on community-based alternatives to hospital care, and it is in in-patient services that women's issues are particularly acute. The evidence we received on the position of women in the secure services, however, caused us a great deal of concern.

198. The first point made to us by a range of witnesses[472] was that many women in the Special Hospitals simply do not need that level of security. The Secretary of State told us that there were "around 110 women who are in these hospitals who all the evidence suggests need not be there".[473] The organisation Women in Secure Hospitals (WISH) argued that, even on conservative estimates, 78% of women in high secure care only need medium security and 69% of women in medium secure care only need low security.[474] As we have already noted, the Director of Women's Services at Broadmoor went further, telling us on our visit there that 60% of the women in her care could be looked after in the community on assertive outreach.[475]

199. Two explanations were offered to us as to why women are inappropriately placed in the Special Hospitals. Firstly, WISH argued that women are "spiralled" up the system because they are deemed too difficult to manage: they therefore end up in Special Hospitals even though they are not necessarily believed to be a danger to the public at large.[476] Secondly, there is a general consensus that medium secure units, as currently constituted, are simply inappropriate for women who may be the only female, or one of two, on a ward of a dozen or more male patients.[477] Peter Snowden, for example, characterised the situation of a female in-patient on a medium secure ward as being "downright dangerous".[478] While single sex medium secure units are gradually being developed for women,[479] at present many end up being transferred to Special Hospitals simply because there are no segregated facilities at lower levels of security. Given the evidence we also received on the history of abuse of many of these women patients,[480] we found it both extraordinary and alarming that the only options for such women appeared to be mixed wards at medium security, or transfer to Special Hospitals, some of whose male patients will have a history of being sexual abusers.

200. The second point made to us on the position of women in the secure services as a whole is that these services tend to be "gender-blind". Liz Mayne of WISH, for example described the system as having a "blanket approach", with women being "severely marginalised".[481] One example of this has already been highlighted above: the fact that there is little segregated provision for women at medium secure level, despite the high incidence of past physical and sexual abuse suffered by these patients. Even though facilities in the Special Hospitals are physically segregated, we were told by Sheila Foley of Rampton that some recreational and social events would be mixed[482] and Liz Mayne of WISH highlighted concerns that exploitative relationships could develop while women were still very vulnerable.[483] Another example which was drawn to our attention by both the staff at Broadmoor[484] and by Sheila Foley of Rampton when she gave oral evidence to us,[485] was the blanket nature of the security Directions issued by the Secretary of State following the report of the Fallon Inquiry. The Fallon committee had strongly criticised the fact that a child had been permitted to visit the wards of the personality disorder unit at Ashworth and was effectively being "groomed" for paedophile purposes. As a result, Directions were issued which strictly controlled child visiting.[486] Although the Fallon committee recommendations had related specifically to personality disordered men in Ashworth, the Directions apply equally to all patients in all three Special Hospitals, including women patients. One effect of the Directions, for example, had been to put a stop to the practice of allowing unplanned visits, and we were told at Broadmoor that in some cases it could take as long as a month to arrange a planned visit.[487] We were also told at Broadmoor that they had made strong representations to the Department about the effect these Directions had had on their women patients, in particular the therapeutic implications of making it more difficult for women to see their own children, or the children of close family members, but had received a very negative response.

201. The reasons for restricting child visitors to male personality disorder units are self-evident. We are, however, very concerned that recommendations made with one patient group in mind have been applied across the board to all patients, including women patients. We strongly recommend that the Government issue separate security Directions for women, reflecting their different needs. In particular, we would recommend that once an assessment has been made that it is safe for a woman to receive child visits, it should be possible for these to be made on an ad-hoc unplanned basis.

202. WISH made clear to us that they believed the only way forward was to develop a quite separate secure service for women.[488] In oral evidence, Liz Mayne of WISH developed this point further, telling us:

    "Without a national women's strategy and a clear government directive and a commitment by this government, there will be no movement. It comes down to funding. In the short term there does need to be made available transitional funding so that you can have a major shift out of current high secure units for women and develop appropriate services, some secure units, but some in the community." [489]

Sheila Foley told us that there had been movement on the development of a national strategy, but that it had now appeared to have come to a stop:

    "Liz and I have sat on a national group that has done a considerable amount of work, but it has reached the end now and we were both dismayed at a national conference quite recently where we were told that there is not going to be a national strategy."[490]

203. Ministers appeared to be open to these arguments: the Secretary of State told us that "our priority for discharge and movement out of the hospitals will be for women patients",[491] while John Hutton MP, the Minister of State responsible for mental health services told us that the National Oversight Group responsible for secure services was looking at the issue of the strategy "right now".[492] We agree that the way forward for women's secure services must be a completely separate service. We urge the Department to bring forward and publish a national strategy to achieve this as a matter of urgency.

Prison health services

204. The current position in the prison healthcare system seemed to us to link in with our concerns in this inquiry in two ways. Firstly it was drawn to our attention on a number of occasions that there is an enormous unmet need among prisoners for secure mental health services. When Broadmoor described to us how they managed their waiting lists, they highlighted the demand for their services from prisons,[493] and Department of Health officials emphasised to us in oral evidence that many of the places freed up in Special Hospitals when patients were more appropriately placed elsewhere would be filled from the prisons.[494] Secondly, Sir David Ramsbotham, the Chief Inspector of Prisons, and his Chief Medical Inspector, Dr. John Reed, submitted very powerful evidence to us on the low standards of psychiatric care within prisons, arguing that there are de facto two parallel systems for caring for mentally disordered offenders: one in prison and one in hospital. We felt that it would be impossible to look at the overall capacity of the general and secure mental health services, without looking in more detail at the current situation in prisons.

205. The evidence we received on the standards of prison healthcare shocked us. Dr. Reed told us that "care for mentally disordered people in prison is frankly a disgrace. There is no other word to describe it. It is appalling".[495] Sir David reiterated his medical inspector's description, telling us that the staff in prison healthcare centres "are neither trained nor resourced to look after them appropriately and the result is, as I say, damage or deterioration, or both".[496] Sheila Foley of Rampton Special Hospital made similar comments on the staffing problems in prisons:

    "There is a shortage of staff and it is not ... a particularly good place to go and work. The career options within a prison setting are fairly limited."[497]

The organisation INQUEST described standards of care in prisons as "appalling" and argued that "in our view imprisoning people with mental health problems is inhuman, dangerous and can exacerbate their condition". As an example of how inappropriate an environment prison can be to individuals in mental distress, they cited the tendency to see self-harming behaviour as a discipline problem, rather than a symptom of a health need.[498]

206. Sir David Ramsbotham's written evidence drew our attention to a survey carried out by Dr. Reed of 13 healthcare centres, in which he concluded that standards were well below those in the NHS, despite the fact that the policy of maintaining equivalent standards has been in place for almost a decade.[499] Examples given included low levels of staffing, staff with inadequate qualifications, very limited therapeutic activity and considerable use of seclusion. Dr. Reed argued that this was particularly disturbing given that the prisoners experiencing these low standards of care were not limited to those who were awaiting transfer to hospital under the Mental Health Act 1983, but also included many mentally ill prisoners who did not meet the criteria for transfer, even though they might need 24 hour nursing care. Thus, under current policies, this latter group of patients would not be transferred to hospital, even if the beds were available. Two possible ways forward were outlined: either raising psychiatric care standards considerably which would involve major upgrading of healthcare centres; or developing a new strategy of transferring all prisoners requiring specialist mental health care and full time nursing care to the NHS. Under this alternative, prisoners who did not meet the requirements for transfer under the 1983 Act could be transferred on temporary licence, in the same way as patients with physical health needs. Dr. Reed concluded that "this approach is more likely to provide an adequate service to patients, ensure uniform standards and avoid wasteful duplication". He estimated that this policy could lead to around 500 prisoners being transferred to the NHS, with the consequent closure of one third of the beds in the prison health care system.[500]

207. As a result of his medical inspector's research, Sir David had asked West Midlands forensic psychiatric service to review all inpatients in prison healthcare centres in the West Midlands and Trent regions to see if this sample corresponded to Dr. Reed's findings. This study showed that 32% of such patients needed transfer to a psychiatric facility and a further 20% needed accommodation in a unit in the prison providing psychological and emotional support.[501] Sir David's conclusion was that:

    "Continuing the present arrangements of having two inpatient services for mentally disordered prisoners, one in the NHS and one in prison, seems to me unsustainable. In my view, mentally ill prisoners requiring 24 hour nursing care should be in the NHS not in prison."[502]

208. We were also concerned to learn that there is no statutory provision for the compulsory treatment of mentally disordered offenders in prison. Mr. Boateng told us that there is a common law power to intervene in a crisis, but commented that "one of the reasons why there is a reluctance even to use the common law power is because there is a recognition that conditions in prison are less than ideal for the administration of treatment against the will of the individual concerned".[503] The fact that treatment in prison is given under common-law provisions and is not covered by the Mental Health Act 1983 also means that prisoners treated without consent do not have access to the safeguards found in the 1983 Act, such as the Mental Health Act Commission.

209. We have already described the new arrangements agreed by the Home Office and the Department of Health which aim to improve the standards in prison healthcare centres: namely the creation of a formal partnership between the NHS and the Prison Service, with a Policy Unit set up in the NHS Executive and a Task Force working with individual Health Authorities and prisons to improve services (see above paragraph 21) Sir David Ramsbotham told us that he "strongly welcomed" these changes[504] and commented that "at last there is genuine dialogue between the NHS and the Prison Service".[505] We were certainly very impressed with the arrangements that we witnessed when we visited Belmarsh Prison where the psychiatrists providing services to prisoners are from the Bracton Clinic (part of Oxleas NHS Trust) and primary care services are provided under contract by a local GP practice.[506] This system both provides good links between the prison and the wide range of mental health services provided by Oxleas, and addresses the problem that medical officers working in prisons tend to be very isolated with little career structure or professional support. It also enabled other specialist professionals, such as an occupational therapist and community psychiatrist nurse to provide "in-reach" services within the prison.

210. We hope that the new partnership between the NHS and the Prison Service will encourage developments on the lines of the system we saw at Belmarsh Prison and Oxleas NHS Trust. But we would agree with Sir David Ramsbotham that it is inappropriate to attempt to provide two parallel systems of specialist mental health services, one in prisons and the other in the NHS, especially as those remaining in the prison service do not enjoy the safeguards included within the Mental Health Act 1983. We recommend that all prisoners assessed as needing specialist mental health services should be eligible for transfer to the NHS, if necessary under temporary licence. We also therefore recommend that Dr. Reed's estimate of the number of prisoners involved (approximately 500 at any one time) should be taken into account when planning the number, and type, of secure mental health beds required in the NHS.

211. Dr. Reed's estimate of 500 prisoners in need of transfer at any one time was based on

prisoners already placed in healthcare centres. Sir David, however, drew our attention to a recent survey by the Office of National Statistics which demonstrated that there was a "vast amount of psychiatric morbidity that existed within the prisons of this country".[507] The figures quoted in the ONS report are certainly striking: of those given a clinical interview, 63% of male remand prisoners, 49% of male sentenced prisoners and 31% of female prisoners were assessed as having anti-social personality disorder, while the figures for functional psychosis were 10% male remand, 7% male sentenced and 14% for female prisoners.[508] Dr. Reed expanded this point, telling us;

    "They are not detected by the system, so they do not get treated. You get seriously mentally ill people, people with schizophrenia, who are out on prison wings on general medication, in an unfortunate place, quietly mad, behind their cell door, not getting any treatment."[509]

Dr. Peter Snowden of Mental Health Services of Salford NHS Trust quoted a figure of only one in four individuals with mental disorder being identified by the health screening tool used by prisons on their initial health assessment.[510] He suggested that this was because the tool used is "next to useless", but told us that work was being done in Newcastle at present to develop "a more sensitive screening instrument that asks the questions that we would want to ask".[511] A number of other witnesses raised with us the importance of adequate mental health assessment: both Professor Richardson, who chaired the Expert Committee on the review of the Mental Health Act 1983 and the Law Society argued that prisoners should have a right to a mental health assessment.[512] It is clearly crucial that prisoners should be able to have such an assessment not only when they first enter prison, but also when appropriate during their sentence. Sir David told us that the Prison Service had set a deadline of July 1997 for every prison to complete a health needs assessment but "to date not a single prison has completed it, nor has the Prison Service demanded it".[513] Paul Boateng MP, Minister of State at the Home Office, told us the following week that these health needs assessments were now being "prioritised".[514]

212. We recommend that the Expert Committee's recommendation that all prisoners should have a right to a mental health assessment should be accepted. We also urge the Home Office to ensure that the health needs assessments promised for 1997 are completed as a matter of urgency, so that the data can be used to inform planning for capacity in the NHS.

213. Much of the evidence we received on the inappropriate placement of mentally disordered offenders in prison focused on the problems in finding a bed once a prisoner had been assessed as requiring a transfer to hospital.[515] However, a number of other factors were raised with us. The National Schizophrenia Fellowship highlighted the problems caused where areas do not have court diversion schemes in their brief case study of a young schizophrenic man who committed suicide after being remanded to Wandsworth prison, despite being a known suicide risk.[516] Sir David Ramsbotham also raised concerns about the lack of court diversion schemes in some areas,[517] while Peter Snowden cited research showing that such schemes only pick up one in five individuals with serious mental illness.[518] We recommend that it should be made a requirement that courts liaise with local mental health providers to ensure that all courts are covered by court diversion schemes. We also recommend that the Home Office should commission research on best practice in court diversion schemes, to improve their efficacy in identifying vulnerable offenders.

214. The practicalities of transfers were raised with us by a number of witnesses. The Home Office told us that their target "which we virtually without exception achieve" is to process all the necessary paperwork within 24 hours of being told a bed is available.[519] Dr. Peter Snowden, however, highlighted the problems involved in first making the assessment that a patient needs a transfer: if the prisoner is housed in a prison a long way from the hospital to which he is likely to be transferred, it is a considerable commitment of clinician time for a multi-disciplinary team to travel to the prison to make the assessment, particularly as there are limits placed on when the assessments can take place, in order to fit in with the prison regime.[520] Dr. Snowden commented on the good practice found in Manchester Prison, whose director of healthcare allows prisoners to be transferred from other prisons to his healthcare centre, so that local clinicians can make the assessment without needing to travel.[521] The Law Society also endorsed a suggestion made by the Expert Committee on the review of the Mental Health Act 1983, that prison governors should be given the authority to permit the transfer of prisoners to hospital on the recommendation of three professionals, thus removing the role of the Home Office altogether.[522]

215. The importance of close working relationships between the NHS and the criminal justice system was emphasised by a number of witnesses. Dr. Snowden's comments on Manchester Prison, cited above, seemed to us a good example of how many time-wasting difficulties can be resolved through sensible co-operation. Sir David Ramsbotham also pointed out that prisoners with mental health care needs do not appear out of nowhere: "they have gone from treatment in the National Health Service and they are going back to it".[523] Indeed, prison could be seen as good opportunity to engage people with mental health problems who have formerly slipped through the net. Sefton Health Authority Regional Secure Commissioning Team told us that, while they were seeing "positive attempts to develop closer and more integrated inter-agency working", this would be enhanced if the flexibility to pool budgets were extended to other statutory bodies:

    "Currently the Prison Service funds all primary care within prisons. Secondary care is funded by the NHS and provided within their own structures. We believe that for the achievement of a comprehensive service providing public safety and individual rehabilitation, we will require mental health services across the NHS, Local Authority and Prison sectors to meet the spectrum of individual and societal needs. A project that was jointly funded - for example a joint NHS/prison mental health needs assessment and treatment unit - would strengthen the partnership interface between the two services, provide a stronger dynamic to the exchange of skills between the services and maintain a stronger focus on cost."[524]

The Department told us in a supplementary memorandum that they were undertaking an "evaluation process" of the impact of the new flexibilities for health and local authorities to pool budgets and that "the evaluation will indicate the extent to which other services might usefully be included in any future powers".[525]

216. The final point to be raised with us on the prison health system was that of funding. South London and the Maudsley NHS Trust argued that although the Department of Health's lead role in prison health care was welcome, current failings in the resource allocation system made it hard for trusts with large local prison populations to offer an adequate liaison service.[526] We are aware that the Department is currently reviewing the formula used for allocating resources to Health Authorities[527] and urge them to pay particular attention to the distortions caused in the local health economy by the existence of one or more large prisons. We also recommend that the Department give serious consideration to the possibility of extending the authority to pool budgets to the NHS and the prison service.

415   eg Ev., p145; Q559. Back

416   Department of Health, High security psychiatric services: changes in funding and organisation, June 1995, p8. Back

417   Ev., p57. Back

418   Q616. Back

419   Q611. Back

420   Ev., p306. Back

421   Ev., p368. Back

422   Ev., p263. Back

423   Q565. Back

424   Ev., p178. Back

425   Q565. Back

426   Ev. p10; Ev., p204. Back

427   Ev., p204. Back

428   Department of Health, Report of the review of security at the high security hospitals, May 2000. Back

429   Q643. Back

430   Ev., p204. Back

431   Ev., p204. Back

432   Ev., p271. Back

433   Q611. Back

434   eg Ev., p367. Back

435   Q559. Back

436   Q556. Back

437   Q559. Back

438   Q419. Back

439   Q425. Back

440   Q565. Back

441   Q620. Back

442   Q620. Back

443   Q622. Back

444   eg Q573; Q606; Ev., p57. Back

445   Department of Health, Report of the review of security at the high security hospitals, 2000, appendix 2. Back

446   Ev., p349. Back

447   eg Ev., p349; Q619. Back

448   Q610. Back

449   Ev., p205. Back

450   Q611. Back

451   Department of Health circular HSC 1999/141. Back

452   Q89. Back

453   Ev., p306. Back

454   eg Q556; Q559. Back

455   Q527. Back

456   Ev., p205. Back

457   HSC 1999/141. Back

458   Ev., p260; Q76. It has since been reported that the proposed Ashworth/Mental Health Services of Salford NHS Trust merger has been postponed indefinitely: "Ashworth plan stalls", Community Care, 29 June - 5 July 2000, p4. Back

459   The Report of the Committee of Inquiry into the Personality Disorder Unit, Ashworth Special Hospital, Cm 4194, January 1999. Back

460   Ibid, recommendation 47. Back

461   Q730. Back

462   Q74. Back

463   Ev., p350. Back

464   Ev., p177. Back

465   Q559. Back

466   Q579. Back

467   Q529. Back

468   Ev., p368. Back

469   Ashworth Hospital Authority, Review and Annual Report, 1998-1999. The equivalent figures for Broadmoor and Rampton, taken from their 1998-1999 Annual Reports, were ten requests for independent review in each hospital; again none had been granted, although two were outstanding in Rampton at the time their Annual Report was published. Back

470   "Hospital to face civil cases in court", The Times, 12 June 2000, p4. Back

471   Fioritti and Melega, "Reform said or done? The case of Emiglia-Romagna within the Italian psychiatric context", American Journal of Psychiatry (154:1), January 1997, pp94-98. Back

472   eg Ev., p182; Q577. Back

473   Q730. Back

474   Ev., p182. Back

475   Q556. Back

476   Ev., p182. Back

477   eg Ev., p306; Q579. Back

478   Q579. Back

479   Q579. Back

480   Ev., p181. Back

481   Q573. Back

482   Q582. Back

483   Q585. Back

484   Q571. Back

485   QQ569-572. Back

486   The Visits by Children to Ashworth, Broadmoor and Rampton Hospitals Directions, issued under Department of Health circular HSC 1999/160. Back

487   Q572. Back

488   Ev., p182. Back

489   Q576. Back

490   Q575. Back

491   Q643. Back

492   Q730. Back

493   Q619. Back

494   Q77. Back

495   Q565. Back

496   Q588. Back

497   Q592. Back

498   Ev., pp312-313. Back

499   "Inpatient care of mentally ill people in prison: results of a year's programme of semistructured inspections", BMJ, 15 April 2000, pp1031-1034. Back

500   Ibid; Q611. Back

501   Ev., p180. Back

502   Ev., p179. Back

503   Q694. Back

504   Ev., p179. Back

505   Q561. Back

506   The arrangements are described in more detail in a recent inspection of Belmarsh Prison: Home Office, Report on an unannounced follow-up inspection of HM Prison Belmarsh 6-7 December 1999 by HM Inspectorate of PrisonsBack

507   Q561. Back

508   ONS, Psychiatric morbidity among prisoners in England and Wales, 1998, p32 and p49. Back

509   Q591. Back

510   Q593. Back

511   Q593. Back

512   Q334; Ev., p316. Back

513   Q605. Back

514   Q730. Back

515   eg Ev., p178. Back

516   Ev., p333. Back

517   Q561. Back

518   Q593. Back

519   Q610. Back

520   Ev., p178. Back

521   Q611. Back

522   Ev., p316. Back

523   Q589. Back

524   Ev., p259. Back

525   Ev., p202. Back

526   Ev., p323. Back

527   Q35. Back

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