Select Committee on Health Fourth Report


SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS

(a)We agree with the Law Society that the appropriateness of any definition of mental disorder will depend on the purpose for which it is being used. We also agree that any criteria used for determining access to services should be far wider than those used to define the circumstances when compulsion may be permitted (paragraph 25).
  
(b)While we appreciate that stretched services need to set boundaries in order to be able to care for the patients on their case-load, we believe that, from the patient perspective, inflexible labelling is both unhelpful and often stigmatising. Given the fluctuating nature of mental illness, concepts such as "severe and enduring", while useful for targeting resources, must not be used inflexibly to restrict access. We recommend that when individuals are discharged from specialist services, such as those provided by community mental health teams, they should receive clear information on how they can easily re-access these services if their situation deteriorates (paragraph 28).
  
(c)Given the high incidence of co-morbidity of mental disorder and substance misuse, and the link between substance misuse, mental disorder and violence, we believe it is crucial that greater priority be given to this group of patients. We welcome the fact that the Department has been funding service development in this area, and intends to disseminate any lessons learned. We would also endorse the "practical steps" suggested by the Centre for Mental Health Services Development at King's College London, namely that the Department should:
  
•  require joint working and coordination between mental health and substance misuse agencies, to address the complex social and clinical needs of this client group;
•  require mental health services to take the lead for those people on enhanced CPA [Care Programme Approach] with a dual diagnosis;
•  include working with people with a dual diagnosis as a requirement within the remit of assertive outreach services (paragraph 33).
  
(d)The Centre also argued that the Department should extend the duty of partnership imposed on the NHS and local authorities by section 27 of the Health Act 1999 to include substance misuse and housing services. Section 27 requires NHS bodies and local authorities to "co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales". We would understand this to include local authority responsibilities for housing and substance misuse provision, as both have a clear input into the "health and welfare" of local residents. We recommend that the Department should issue guidance, clarifying this position (paragraph 33).
  
(e)We would also draw to the Department's attention the difficulties being experienced by some patients with a dual diagnosis of learning disability and mental disorder. While this group of patients may not be as visible as those with the dual diagnosis of substance misuse and mental disorder, it is clear that services are far from adequate. We recommend that the Department should issue guidance highlighting the needs of this group of individuals and encouraging mental health and learning disability services to work much more closely and co-operatively together (paragraph 34).
  
(f)There have been undeniable failures in service since the policy of care in the community was first launched. But we feel that it is both misleading and unhelpful to state that the policy of care in the community has failed, as the Government has done on a number of occasions. We urge the Government to make clear in the language it uses (as indeed it has already done in the policies it has embraced), that care in the community is a positive policy and one which it supports (paragraph 39).
  
(g)Work is clearly of real importance to the many people with mental health problems who want to regain power over their own lives. Help with training, education and finding work is crucial, as is the provision of information to employers to encourage them to support and retain people with mental health problems in employment. We believe that the employment service provided by South West London and St. George's NHS Trust provides an invaluable route back to "ordinary life" for people who have experienced mental health problems. We were pleased to hear that several other NHS trusts are developing similar schemes, and recommend that all trusts providing mental health services should consider how they can provide similar services to their users (paragraph 42).
  
(h)It is clear to us that a far more "joined-up" response is necessary from statutory agencies if users of mental health services are to be properly supported in the community. We do not believe it is acceptable or realistic to expect vulnerable individuals to deal with complex systems without support, especially where it is clear that these systems are ill-equipped to deal with fluctuating illness. We would encourage the Department to give particular attention to the idea of a dedicated worker, who would be responsible for liaising between the various statutory agencies and ensuring that users of mental health services, living in the community, have access to the benefits and other services to which they are entitled. We recommend that the Disabled Person's Tax Credit should be extended to those working fewer than 16 hours per week and that the period for which benefit claims may be suspended, rather than closed, when individuals leave benefit to go into work, should be extended to a year. We also endorse the recommendations of our colleagues on the Social Security Committee, that the doctors undertaking assessments for disability benefits should receive better training on mental health issues with specialists available for dealing with more complex cases (paragraph 47).
  
(i)We welcome the fact that the Department of Health has spoken of "pulling all the necessary levers" to ensure that mental health services remain a priority. We remain unsure, however, who is in a position to "pull the levers" when action is required across Government Departments. We were encouraged to hear that the Department of Health and the Department of the Environment, Transport and the Regions have been working together on joint guidance, although the content of that guidance has not yet been made public. We also hope the newly appointed mental health "national director" will be in a position to highlight areas of work that require a cross-departmental approach. Nevertheless, we remain concerned that more formal arrangements, such as the existence of a dedicated mental health Cabinet sub-committee, are not in place to ensure the necessary co-operation between Departments (paragraph 48).
  
(j)We were impressed with the way NHS and social services staff have clearly responded to the challenge of working together to provide a more coherent service for the service-user. Nevertheless, we remain unconvinced that it is sensible to retain two separate organisations, each with their own hierarchical structures, when the aim is to deliver a seamless service for the public. We believe that the evidence we heard gives additional weight to the recommendation we made in an earlier inquiry, that health and social services departments should be merged into single entities (paragraph 51).
  
(k)We welcome and endorse the Secretary of State's clear statements on the need to make the NHS workforce more representative of the communities it serves. We were also impressed with some of the examples of good practice which were described to us. Nevertheless, we remain concerned that many patients from ethnic minority backgrounds clearly experience a far from adequate service, for a variety of reasons. Our concerns are heightened by the fact that these problems have been recognised for some years, but that change remains slow in coming. We note that discussions about institutional racism are current in many public services and believe that mental health services should not be excluded from these debates. Many of our recommendations below on issues such as user involvement and advocacy may be particularly relevant to ethnic minority patients. In addition, however, we would make the following specific recommendations. Firstly, the Department of Health's requirement that all NHS trust boards should undertake training on management of diversity should be expanded, so that all front-line NHS staff receive training on race awareness. Secondly, all educational bodies providing pre-qualification training to health professionals should be required to include training on cultural and racial issues as part of their core curriculum. Thirdly, all NHS trusts should designate a board member to take the lead on issues of race and culture within their trust and to ensure that active policies are in place to champion the needs of the ethnic minority groups in their area. Fourthly, the Department should ensure that trusts have access to a comprehensive network of interpreting services, if necessary providing grants to the voluntary sector to enable the necessary services to be developed. Fifthly, given that there is clear evidence that ethnic minority groups currently access services late, we recommend that priority is given to developing early intervention services, such as easy access to counselling. We believe that it is as important for trusts which do not include large minority ethnic populations in their catchment area to act on these recommendations as it is for those which do: the mobility of NHS staff means that staff trained in one part of the country may end up working in very different environments a few years later; and the vulnerability of minority populations to inappropriate services is arguably greater when they represent a tiny proportion of the local population (paragraph 58).
  
(l)We believe that it is crucial that users and carers are involved in all aspects of service delivery. User-involvement in setting the outcomes which services aim to achieve should be central in service planning. It is clear that such involvement can only be more than lip-service if the professionals involved are prepared to regard users and carers as equal partners, to involve them early on in the process when decisions are actually being made, and, sometimes, to hear uncomfortable views without feeling personally or professionally threatened. We appreciate that this will involve, for some, a new approach, and strongly recommend that both the pre- and post-qualification training of all health and social care professionals should include structured input from users as part of a national programme (paragraph 62).
  
(m)We agree that, the more mental health services are able to "get the basics right", the easier it will be to challenge the fears surrounding mental ill health. We would encourage the inclusion of discussions of mental illness in the school curriculum. But we also call upon the Government to take a more proactive approach in challenging the perceived link between mental disorder and dangerousness. We recommend that the Government should fund a high profile public education campaign on similar lines to that supported recently by the Australian government which included extensive television, cinema and outdoor advertising to educate the public about the realities of mental illness. We also believe that the Government's own current emphasis on risk conveys a highly misleading message to the public. We return to the subject of risk later in this Report (paragraph 66).
  
(n)We were impressed with the arrangements described by the Department of Health for the implementation of the National Service Framework at local level and in particular with the requirement to produce detailed gap analyses so that there is clear information on where services need to be improved. We urge the Department to ensure that this information is made publicly available, at both local and national level. We would also emphasise the need for regular monitoring of progress within the Framework. If a need for more specific guidance on prioritisation emerges from that monitoring, then such guidance should be provided at national level (paragraph 69).
  
(o)While the Modernisation Fund money is clearly welcome, we believe that it is the overall level of funding going to mental health services via Health Authority allocations that will be more significant in ensuring that the National Service Framework becomes a reality and not merely an aspiration. We urge the Secretary of State to ensure that mental health services do indeed get their "fair slice of the cake". We also recommend that the Department should monitor the very disparate levels of spending on mental health services between Health Authorities, and where necessary draw Authorities' attention to spending which falls well below the national average (paragraph 71).
  
(p)It was clear from the evidence we received both that there are considerable shortages in key mental health professions, and that the National Service Framework is unlikely to become a reality unless these shortages are addressed. We realise that the NSF Workforce Action Team is actively considering these issues, and urge it to take on board the evidence submitted to this inquiry. We would particularly draw attention to the evidence we received on the limited numbers of training places for occupational therapists and clinical psychologists, the importance of providing early placement in mental health services for nurses in training, and the desirability of developing "core-skills" training across professions. We would also urge active consideration of the development of appropriate training and recognition for workers to be the "eyes and ears" of professionals, as described by David Joannides and others (paragraph 78).
  
(q)The question of the mandatory homicide inquiries is a very sensitive one. Like the Secretary of State we are anxious that there should never be any question of a "cover-up" if a member of the public has been killed by an individual in touch with mental health services. At the same time, it is clear to us that the effect of these inquiries on the professions, especially psychiatrists, is deeply counter-productive, with the ensuing danger that inquiries set up with the aim of improving services may have the opposite effect by driving away competent staff. We would recommend that there should continue to be public inquiries into such events, but that they should be carried out on a systematic, national basis, for example by a specialised division within the Commission for Health Improvement, with the outcomes published in an annual report on the lines of that produced by the Health Service Commissioner. This would allow a body of expertise to be built up, and for lessons learned from inquiries to be more effectively disseminated (paragraph 79).
  
(r)We find it very disturbing that there is clearly such a shortage of psychologically-based treatments in the NHS, given the general consensus as to their value for many patients. The evidence we received did not enable us to judge whether the rarity of such treatments is primarily due to the shortage of professionals able to deliver them, lack of awareness among those responsible for purchasing mental health services as to their benefits, or cost. We therefore urge the Department of Health to undertake further research in this area and, if appropriate, to feed the results of that research into the work of the Workforce Action Team (paragraph 81).
  
(s)We are aware that the National Institute for Clinical Excellence (NICE) is currently considering guidelines on the management of schizophrenia, which are likely to include recommendations as to whether or not the more expensive atypical drugs should be the first-line treatment. We will not attempt to anticipate the work of NICE, but we would urge those carrying out the evaluation of atypical drugs to give serious consideration to the outcomes of treatment from the user's perspective, including the benefits of making compliance with drug treatment less onerous (paragraph 82).
  
(t)We believe that particular attention should be given to the development of a range of accommodation with suitable support arrangements, including long-term supervised hostel accommodation which is adequate to support people with high-level needs, such as those discharged from medium secure units and those with histories of drug and alcohol abuse. There is an additional need for appropriate provision of ordinary high quality housing in the community that can be made available to people with mental health problems who may need support and specialist services from time to time, but who enjoy full rights as tenants. This will require close partnership working by health and social care with housing authorities and local housing providers. We are aware that the Government is currently working on the details of a new single funding stream for housing support services, to replace the current arrangements through Housing Benefit from April 2003, and urge that the needs of people with mental health problems be taken fully into account in the development of the new system (paragraph 84).
  
(u)We accept that, although organisational change can be immensely disruptive, in particular circumstances it may be appropriate for Primary Care Trusts to take on the provision of specialist mental health services, for example in areas of the country where there is already successful provision of specialist mental health services in primary care settings. However, we strongly believe that this should only take place if the PCT has been able to demonstrate clearly that the new system will provide significantly better services to local users. We would suggest that the Department give consideration to those PCTs that are able to progress early on this front becoming pilot sites, sharing their learning and expertise with others. We also urge the Department to consult with users when setting out the criteria which PCTs will have to meet before being permitted to provide mental health services (paragraph 92).
  
(v)The Disability Partnership is currently looking at ways of improving the liaison between general practice and secondary care, and their proposals include:
  
•  educating and orienting primary care staff on mental health issues
•  developing some services, such as counselling, anxiety management and understanding psychosis, at general practice level
•  creating and refining care pathways into secondary care
•  obtaining user-input into training primary care staff, user representation on PCG boards and user involvement in service evaluation.
  
We endorse these proposals which we believe would do much to improve the relationship between general practice and specialist mental health services (paragraph 94).
  
(w)We were very impressed with the work of the home treatment and assertive outreach teams that we saw in our visits to Northern Birmingham and South West London. We were also struck, however, by the research presented by the Centre for Mental Health Services Development on the variations in outcome achieved by assertive outreach teams, and by the similar evidence on home treatment provided by the Sainsbury Centre for Mental Health. Given the rapid development of these services at present, as part of the National Service Framework, we recommend that the Department should review current research on assertive outreach and commission further research on home treatment and other forms of crisis intervention, so that services can be developed on the basis of the best available evidence. The evidence base should incorporate the views of users and carers about the effectiveness and acceptability of services, including specific views of people from black and minority ethnic communities (paragraph 97).
  
(x)We were very disturbed by the evidence we received on the quality of in-patient care. We feel that the environmental standards on in-patient wards are important for two reasons: because an improved environment will increase the therapeutic value of units; and because natural justice and the principle of reciprocity demand that those who are detained on such wards without their consent should be provided with accommodation which affords reasonable privacy and dignity. We believe that a capital modernisation fund, aimed specifically at improving environmental standards on in-patient wards, could make a significant difference to the quality of life of patients staying on these wards. The views of service users should be incorporated into any local plans for ward improvements (paragraph 99).
  
(y)It is clear from the evidence we received that the environment of the traditional hospital is not the best environment for helping individuals in crisis: people suffering acute phases of mental illness may need a "safe haven" away from their own homes, and sometimes secure surroundings, but this need not be in an institutional building. Indeed, the use of such buildings appears to be based on necessity rather than on any belief that they are the best or only way of providing care to individuals in distress. We recognise the need to balance domesticity, good quality care and security which is emphasised in the Royal College of Psychiatrists' report Not just bricks and mortar. However, we do believe that further research on how these aims can best be achieved would be very valuable. We therefore urge the Department to fund pilot schemes following the "core and cluster" model described by Professor Rowden and Dr. Moodley, so that their effectiveness can be rigorously evaluated. If such pilot schemes are successful, we recommend that the Department commit itself to providing the capital expenditure necessary to expand them swiftly (paragraph 101).
  
(z)The work of the voluntary sector in mental health services is clearly of immense value. Yet individual organisations are perpetually on the brink of collapse because of the uncertain nature of the funding system. We recommend two improvements in the current system. Firstly, the Government should provide central funding for initiatives offering administrative and practical support (such as pay-roll services) to small voluntary organisations on a local basis. Secondly, Health Authorities should apply the same principles to their voluntary sector service agreements as they are required to do in their NHS agreements: that is, that they should set up three year rolling agreements, subject to adequate review and appraisal arrangements. If this recommendation were implemented, voluntary organisations would always have the certainty of three years funding, allowing them to plan more strategically and to recruit able and committed staff (paragraph 104).
  
(aa)It is clear that the shape of the future legislation will be fundamentally affected by the Government's, and ultimately Parliament's, view on the purpose of mental health legislation. We believe that it would be difficult to equate the emphasis placed in the National Service Framework on non-discrimination and combating stigma with legislation which focused solely on compulsion. The need for legislation specifically aimed at people suffering from mental disorder certainly derives at least partially from a recognition that in certain circumstances compulsion may be acceptable in a way that has always been regarded as unacceptable for those suffering from physical disorders. But it also derives from an awareness that the possibility of such compulsion brings with it reciprocal obligations: the obligation to provide services for those in mental distress so that compulsion should only ever be a last resort, and the obligation to protect the civil rights of those who have been labelled with what is still seen as a stigmatising condition (paragraph 107).
  
(bb)We believe that respect for the principle of autonomy need not, and should not, mean that an individual can never be restrained from endangering others. However, it does imply that the refusal of treatment by a competent individual should be taken very seriously, and over-ridden only with good reason, such as the existence of a serious risk to others. We believe that the principle of respect for autonomy, and the principle of non-discrimination from which it flows, should appear on the face of the new Act. We would recommend that, if the Department remains concerned that the wording of the principles could cause legal confusion in an Act concerned at least partly with compulsion, it should seek independent legal advice on possible re-wordings. Any such re-wording should encapsulate the aim that respect for an individual's autonomy should be the starting point in any consideration of treatment, and that decisions to over-rule autonomy must therefore be based on transparent and sufficient criteria (paragraph 117).
  
(cc)Many witnesses argued that an objective test for capacity should form part of the criteria used for determining whether a patient can be subject to compulsion. In principle we believe that this would be desirable as long as it was workable in practice. We appreciate, however, that there are genuine concerns as to how - or indeed whether - such a test could be developed. We recommend that the Department should investigate further the ways in which such a test might be implemented successfully (paragraph 122).
  
(dd)We recommend that the Department of Health should take legal advice as to whether the capacity "test" set out in the White Paper Making decisions would be interpreted by the courts in such a way that a person making decisions which conflict with their own "real" values (as judged by the patient him or herself when well) would be deemed incapable. If necessary, we recommend that an additional criterion be added to that test, to ensure that this is clear. We also recommend that the new mental health legislation should include provision for advance directives and crisis cards to be used when determining what the patient's "real" views are (paragraph 124).
  
(ee)Homicides are clearly an appalling tragedy for those directly affected, and proper consideration of risk to others must be a key element in the criteria which determine whether compulsory treatment is necessary. But we believe that the focus of mental health legislation should be on the therapeutic benefit to the patient. We are concerned that the high profile given to tragic, but nonetheless relatively rare, events may hinder the development of services focused on the needs of the patients, and might even be counter-productive in driving patients away from the system (paragraph 128).
  
(ff)We are also concerned that the "blame culture" to which we alluded earlier (see paragraph 73) risks driving away much needed staff from mental health services. It seems to us that individual professionals are being asked to make very difficult judgements as to potential risk, with little guidance and in the knowledge that the wrong decision might have disastrous consequences. We ask the Department, in association with the appropriate professional bodies, to bring together and update any existing guidelines on the assessment of risk. We also believe that professionals would welcome an acknowledgement in those guidelines that risk can never be eliminated altogether, and that occasionally decisions will be made in good faith, on the best evidence available, that in hindsight are proved to be wrong (paragraph 129).
  
(gg)We do not feel that we received sufficient evidence on [the issue of harm to self] to make a judgement as to whether or not competent patients should be compelled to accept treatment for their own safety, rather than for that of others. We do, however, agree with Professor Richardson that this is a serious moral issue, and one which demands consideration. We are concerned that it was not raised at all in the Green Paper, and ask the Department to ensure that it is discussed publicly, before the future legislation is framed (paragraph 131).
  
(hh)We recognise the danger that a "treatability" criterion, such as that found for psychopathic disorder and mental impairment in the 1983 Act, may be used as an excuse for not seeking to help individuals when resources are stretched, or where clinical opinions are divided. But we believe that if an individual is to be compulsorily treated under mental health legislation, one of the criteria for compulsion must be that they are likely to benefit from that treatment. We note that while the Government endorses this principle, respondents to the Green Paper do not believe that the proposals contained within it will achieve this aim. We therefore recommend that the requirement that a patient is likely to benefit from the treatment being proposed should be made much more explicit in the criteria for compulsion. Taking up Mr. Hutton's point that there must be "clear evidence" that a person will benefit from the treatment programme, we would make a distinction between patients accepting treatment voluntarily and those being treated against their will. We appreciate that how an individual patient is going to respond to treatment can never be predicted with complete certainty, but we would argue that the levels of certainty required if treatment is to be provided compulsorily must be much greater than in cases where treatment is being provided as part of a consensual contract between doctor and patient (paragraph 138).
  
(ii)We suggest that it would be more helpful for the term "health benefit" to be used in any future legislation [when referring to benefits of treatment], in order to emphasise the potential breadth of therapeutic interventions which might be appropriate (paragraph 139).
  
(jj)There are clearly some very serious concerns about the prospect of compulsory treatment in the community. At the same time, we were impressed by some of the arguments put to us, that the principle of community treatment orders accords with the spirit of treating patients closer to home, and that mental health professionals have always had to juggle the possibility of compulsion with the necessity of building a trusting relationship. We believe that if the Government is to introduce some form of community treatment order, it is imperative that the safeguards set out in the Expert Committee's report, particularly those relating to reciprocity, and the right of the user to request an assessment, should be included. We also reiterate our earlier recommendations that the criteria used for determining who is subject to compulsion should in principle include a recognition of capacity and should require clear evidence of health benefit for the patient (paragraph 146).
  
(kk)The question of the burden on tribunals is clearly directly related to the criteria used for entry into compulsion and hence how many people will be potentially liable to being made subject to community treatment orders. We draw the Department's attention again to our recommendations on the use of much tighter entry criteria: as Mind pointed out to us "if the criteria are too wide, the tribunal is no protection at all" (paragraph 148).
  
(ll)We were very struck by the positive response from witnesses on the proposal that there should be a statutory right to advocacy. It was clear from the evidence given to us by users that they see advocacy as something quite separate from an institutional safeguard such as a tribunal, and something which would help to make them more "equal" within the system. We recommend that there should be a statutory right to advocacy, in the sense of access to adequately funded schemes providing advocates for individuals. We also recommend that such schemes should be funded, and be accountable, through a national structure, to enable them to keep the appropriate distance from local statutory authorities (paragraph 151).
  
(mm)We very much welcome Mr. Boateng's explanation that these proposals [on "dangerous severe personality disorder"] are "first and foremost a criminal justice matter". However, we are still concerned at the use of what could be described as a "quasi-medical" definition, which runs the risk of being highly stigmatising for the many people suffering from personality disorder who are not judged by anyone to be dangerous. We are also very unclear how the estimate of around 2,400 individuals has been derived given the very unspecific nature of the definition being used. We recommend that a definition similar to that being used in Scotland, for example "serious violent and/or sexual offenders who may present a continuing danger to the public" should be used in the English proposals, to make clear that they are concerned with offending behaviour and not mental disorder (paragraph 156).
  
(nn)We feel that the whole debate around the care of those designated "DSPD" has been fundamentally muddied by the various different meanings attached to the concept of "treatability". We welcome the recognition that services for people with personality disorder have in the past been very patchy, and we urge the Department to take positive action to develop more consistent services, based on the best research evidence available. We were told that the Royal College of Psychiatrists has called for randomised controlled trials into the treatment of anti-social personality disorder and we strongly endorse that proposal (paragraph 159).
  
(oo)We would also like the Home Office, as a matter of urgency, to clarify whether it sees the "interventions" that it is developing for "DSPD" individuals as being different in kind from the "interventions" that are currently available, albeit patchily, in the NHS. If these interventions can be defined as "treatment" in the very broad sense discussed earlier, and are aimed at individuals with a recognisable mental disorder, then we would argue that they should be provided by the NHS on the basis of mental health legislation. If, on the other hand, they can be distinguished clearly from any "treatment" that the NHS might provide, then we would argue that they should be made available in prisons, to convicted offenders, as part of the criminal justice system (paragraph 160).
  
(pp)As we have indicated above, we would certainly welcome "service enhancement gains" for people suffering from anti-social personality disorder who are currently being excluded from services. However, we do not understand why these service improvements cannot be provided without the sort of legislative change put forward in the Home Office/Department of Health document. We believe that the proposal for reviewable sentences put forward by Peter Fallon QC deserves further consideration (paragraph 162).
  
(qq)It will be clear from our conclusions above that we are unable to support either Option A or Option B in the Home Office/Department of Health discussion document. We repeat our recommendations that research should be initiated on the treatment of anti-social personality disorder, that adequate facilities should be made available within the NHS for those suffering from a recognised disorder who are able to benefit from treatment, and that further thought should be given to the proposal of reviewable sentences to provide for those who are deemed a danger to the public but who are genuinely not amenable to treatment in the NHS (paragraph 165).
  
(rr)We find it quite extraordinary that in certain parts of the country 16 and 17 year olds who are not in education can be excluded from both child and adult services, at a time when they may be most vulnerable. We recommend that the Department should consult on the most appropriate age, on average, for transfer to adult services and set that age as a national target age for transfer. Local services would then be clear what the normal age for transfer was, but would be able to vary this as appropriate for individual patients. We also recommend that, whatever the age chosen, there should be no possible gap between adolescent and adult services (paragraph 171).
  
(ss)We believe that the current poor relationships between child and adolescent mental health services are highly unsatisfactory. We are aware that the National Service Framework, although aimed primarily at adults, does touch on interface issues between adolescent and adult services. We recommend that the Department should require local NSF Implementation Groups specifically to consider how working relationships between these two services could be improved, and should ensure that the monitoring of the NSF pays particular attention to this issue (paragraph 173).
  
(tt)We agree that one of the most important factors for young people in the services provided for them will be a factor of choice. We also appreciate that a service aimed at young people, whether 14-19, 16-25, or any ages in between, will have its own boundary issues to resolve. We do, however, feel that [a "youth service"] is an idea worth pursuing. We recommend that the Government should commission research on how such services are working in this country and elsewhere, with a firm commitment to developing them if good models emerge (paragraph 175).
  
(uu)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 (paragraph 180).
  
(vv)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 (paragraph 188).
  
(ww)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 (paragraph 189).
  
(xx)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 (paragraph 190).
  
(yy)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. 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 (paragraph 196).
  
(zz)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 (paragraph 201).
  
(aaa)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 (paragraph 203).
  
(bbb)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 (paragraph 210).
  
(ccc)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 (paragraph 212).
  
(ddd)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 (paragraph 213).
  
(eee)We are aware that the Department is currently reviewing the formula used for allocating resources to Health Authorities 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 (paragraph 216).


     
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