WEDNESDAY 24 MAY 2000
_________
Members present:
Mr David Hinchliffe, in the Chair
Mr David Amess
Mr John Austin
Dr Peter Brand
Mr Simon Burns
Mrs Eileen Gordon
Mr John Gunnell
Mr Stephen Hesford
Dr Howard Stoate
_________
MEMORANDUM SUBMITTED BY THE DEPARTMENT OF HEALTH
EXAMINATION OF WITNESSES
THE RT HON ALAN MILBURN, a Member of the House, (Secretary of State for
Health), MR JOHN HUTTON, a Member of the House, (Minister of State),
Department of Health; and THE RT HON PAUL BOATENG, a Member of the
House, (Minister of State), Home Office, examined.
Chairman
638. Can I welcome you to this session of the Committee. Can I
particularly welcome our witnesses and express our thanks to you for being
here today and also to your officials for the helpful evidence we have
received during this inquiry. Can I ask you briefly to introduce yourselves?
(Mr Milburn) Alan Milburn, Secretary of State for Health.
(Mr Hutton) John Hutton, Minister of State for Health.
(Mr Boateng) Paul Boateng, Minister of State at the Home Office.
639. Can I particularly welcome you, Mr Boateng, back by popular
demand I would say.
(Mr Milburn) It is just like old times, is it not?
640. Can I begin by saying that obviously this is the last formal
session of this inquiry. It has been an interesting inquiry and we have
picked up a series of what I would say are key messages, many of which are
positive. Firstly, that the National Service Framework has been very well
received and has informed the debate around the quality of the mental health
services in a very positive way. The other area I must mention, and this is
a personal perspective, is that we have been to special hospitals, regional
secure units, prison units, community mental health services, we have had a
range of different visits, and I think it is fair to say that we have all been
extremely impressed by some very dedicated people who are doing a first class
job in a difficult environment. I think that needs placing on the record and
I speak for all my colleagues who have been with me on these visits. If we
develop a dialogue on a negative front, I think it is worth making those
provisos first of all. What I want to say from a personal perspective is that
one of the concerns that has been expressed to us by many of the professionals
is while they are attempting to do their best, and certainly the National
Service Framework is informing debate at local level about quality, what they
appear to be lacking is a clear steer on the organisational framework within
which mental health will be placed over the next few years. There is a lot
of uncertainty about the direction of travel. I met my local community mental
health trust and met staff who in a year's time are not quite sure who will
be employing them. They are uncertain about their future employer and users
and carers are uncertain about where the services will be placed. So we have
got a picture of a developing pattern - some people describe it as a patchwork
quilt - of different service provision evolving in different areas. I am not
being negative about that because we have seen some excellent work being done
with different models being applied. What came over loud and clear from many
of the people we have spoken to is the lack of a clear message as to the
direction of travel from Government. That is the point I want to put to you.
What do you see as being the direction of travel for the mental health
strategy at a local level in the next few years?
(Mr Milburn) First of all, can I reiterate what you said, Mr
Hinchliffe, about the work that goes on in mental health services because
every word you have said is absolutely true. By and large we have first rate
people doing a very, very good job indeed, sometimes in very difficult
circumstances. Certainly what we have tried to do, and have been trying to
do over the last few years, is to bring some order to what I think most people
would regard - leaving aside the party politics - as what was a pretty chaotic
system. Certainly when I became Secretary of State I was pretty clear that
mental health services were important. They are important because so many
people rely on them. It is worth recalling that for all of the concentration
that inevitably there will be in the media and elsewhere about those with a
severe mental illness, the vast majority of people who have mental health
problems are no threat to anybody, no threat to themselves and no threat to
others. Indeed, it is also worth remembering that one in six members of the
public at any one time will have a mental health problem of some sort. The
range of services that we have to provide, therefore, are complex because the
number of problems and the range of problems we have to deal with are complex
too ranging from mild depression to very acute psychosis and in some cases
very, very severe illness indeed. What we have sought to do is to bring some
order out of chaos. I think the National Service Framework is very, very
important and it is a landmark as far as mental health services are concerned
because for the first time it sets out the sorts of national standards that
should apply not just in some places but everywhere. That has been widely
welcomed in the mental health field, in the NHS, in social care and more
generally. It provides the framework, if you like, for a long-term programme
of change and development. I want to reiterate that message too, because to
get these things right is going to take time. I think actually we have got
a good story to tell but there is a long way to go. I will come back to
services in a moment or two, perhaps in answer to further questions. As far
as structures are concerned, and I understand the point that is being made,
and in particular, as you know, and as Members of the Committee will have
picked up, there is a big debate going on out there about crudely whether we
are going to see a move towards more specialist mental health work housed in
Primary Care Trusts as they come on line, or whether we are going to see
mental health services being the preserve of Specialist Mental Health NHS
Trusts. My view about this is the key thing is to make sure that whatever the
mechanism is that it works. The truth is that there will probably be
different requirements for different areas.
641. Who is going to take those decisions because some people are
pointing to you as abrogating your responsibility, Secretary of State, by
leaving it all down to local determination?
(Mr Milburn) It is a funny old job this because I get accused of being
a control freak if I attempt to stipulate the way that services should be
organised - that is sometimes levelled against me by people who should know
better - and then one gets accused of abrogating responsibility if you do not
stipulate. We are at a very early stage of development here, we do not have
Primary Care Trusts up and running across the country yet. We have got a few
in the pipeline and there will be more to come, I have got no doubt whatsoever
about that, because I think GPs and others will see that makes sense. As we
have laid down in the National Service Framework, if we are going to see a
move towards more specialist mental health services being housed in Primary
Care Trusts then there are a number of key criteria which we will judge
against the bids that are made by Primary Care Trusts to take over control of
mental health services. Crucial to those is the preservation of capacity and
capability in any organisation that is responsible for mental health services.
Specialist Mental Health Trusts obviously have that, they have built that up
amongst the clinicians and the managers, and if we are going to see a move
towards the merger, if you like, of Specialist Mental Health NHS Trusts into
the Primary Care Trusts then I have got to be assured, and there will be clear
criteria laid down, that if that move does take place then it preserves the
capacity and capability that we will need in order to deliver first class
modern mental health services.
642. So if that criteria is met you are perfectly happy to see a
system evolving at a local level that would be markedly different from area
to area within the criteria? So we could have some Primary Care Trusts, we
could have a continuation of local Specialist Mental Health Trusts, we could
have, as is being discussed in my area, a county-wide Mental Health Trust
broadening out the area, The problem with that, as I see it, and what has
struck me very strongly in this inquiry, is the relationship between what is
happening in the local communities in relation to the quality and range of
provision and what is happening right down the other end of the system, say
in specialised units. We have clear evidence from visiting Ashworth where we
were told 25 per cent of patients at Ashworth could be contained, could be
supported, in managed units in the community and we were in Broadmoor and were
told that 60 per cent of the women in the women's unit could be supported in
the community under assertive outreach. What worries me about the models that
you are putting forward is how can you develop that kind of coherent response
to those problems right down the line when you have got such a patchwork quilt
of local community provision that will evolve from what you are suggesting?
(Mr Milburn) I think the question, with respect, sometimes presupposes
there is a perfect model and a perfect answer and there is not. The range of
problems that we have to deal with in mental health services is complex and
varied and inevitably wherever you draw the organisational and structural line
there will always be the need to ensure co-ordination as well as integration
between services. I think that is a fact of life in the health and social
care field. However, what we do have to do, as you quite rightly have said,
is ensure that the services that are provided are appropriate and right. What
is all too clear in the mental health field, as it is clear across the
National Health Service generally, is that all too often we have got the wrong
patient in the wrong place at the wrong time. Our programme of change and
reform is about getting the right patient in the right place at the right
time. That means you need the right number of beds in the right places as
well. You are quite right to raise the point about the high security
hospitals. It is perfectly evident, as we already know from the work that we
have undertaken and the evidence that you will heard, that there are people
in those institutions who can probably be outside of them, a lot of them are
women, and we have not hitherto had the resources, we have not had the
infrastructure if you like, to move people out from an inappropriate setting
into a more appropriate setting, but we are addressing that.
643. Some would argue that the Tilt money could have been spent in
a different direction. We will come on to that later, some of my colleagues
want to raise that.
(Mr Milburn) There is a variety of Tilt money, quite a lot of money,
going into improving security, which I think is absolutely the right thing to
do, but I will come back to that in a moment. Remember œ25 million of it is
being used to speed more appropriate care and treatment for people who are
currently in the three hospitals who could be elsewhere. We will be able to
provide with that money around 200 secure places. What I can tell the
Committee today is that our priority for discharge and movement out of the
hospitals will be for women patients who have been identified as probably not
requiring the sort of intensity and security of treatment that the three
hospitals provide. However, what we have been doing more generally across the
piece is providing the right beds in the right places. So over these two or
three years we will be dramatically increasing the number of secure beds, for
example. There will be 500 more secure beds by around 2001/02. As a result
of the Tilt money there will be a further 200 secure beds on top of that. We
will be providing around 320 24 hour staffed accommodation places for people
who might be in high secure prisons, might be in high secure hospitals, might
be in acute hospital beds at the moment who need not necessarily be there.
All of that has been informed by the National Beds Inquiry that, as you will
remember, we published in February and its conclusions were pretty stark. As
you will remember it said that a lot of our acute sector provision in mental
health hospital care was under severe pressure, particularly in the inner
cities. That is true and any psychiatrist, any clinician, working there will
bear that out. Largely that is a consequence of the fact that we do not have
an appropriate move on accommodation and it is that that we are putting in
place. Those gaps in provision have bedeviled the provision of mental health
services, particularly for those with a severe mental illness. We are putting
that right and you will see the fruits of that in the secure beds, the secure
places, the outreach teams that you have described, all coming on line. Our
priority when we got into office was to ensure that we got the right number
of beds in place. Indeed, one of the first things that Paul did when he was
covering John's job was to place a moratorium on any further closures of
hospitals to ensure that we could be assured, and patients and local
communities could be assured, that we had the right number of beds. We are
building up the number of beds. There is a good story to tell. Of course it
takes time to get there but increasingly what people will see is that we are
able to get the right patient in the right place.
644. Before I bring Peter Brand in, as the National Service
Framework is implemented do you envisage a shift in the balance of expenditure
between community provision right across the board, local authority health
provision, as opposed to acute? Is that balance going to shift and, if so, in
what way do you envisage it shifting?
(Mr Milburn) I think it is difficult to second guess ten years down the
line and, remember, the NSF is a ten year programme, we make no bones about
that.
645. Would you want it to shift?
(Mr Milburn) I think the important thing is that we get the balance of
service provision right. Clearly from the evidence that you have, and all the
data that we have, we know the balance is not right and it has got to be put
right.
646. Are you implying that the balance is too much in terms of the
acute beds sector?
(Mr Milburn) No, I do not think that. I mean that we do not have the
right people in the right place. For example, we have got people who are
occupying beds in hospitals now who could well be accommodated and provided
for and more appropriately treated in a less intensive environment.
Similarly, in the high secure hospitals we have got probably quite a large
number of people who could be accommodated and treated in a more medium secure
or low secure setting. It is that provision that we are putting in place.
Our first priority was to deal with these issues of public safety to make sure
that both the patient's safety, the staff's safety and the public's safety is
properly taken into account, hence the investment in secure provision. Our
priority now that we have done that, as you were indicating earlier, is to
move on and provide the range of community services that we think have got a
proven track record, and I suspect the Committee thinks have got a proven
track record, outreach teams, crisis teams, that will enable the pressure that
is currently on acute sector provision to be lessened.
Dr Brand
647. Can I explore that a bit further, Secretary of State, because
I think there is a terminological confusion sometimes between the primary care
and community. Primary care delivery is presumably based on general practice
and ECG, as it is at the moment, whereas there is a lot of community treatment
being developed, treatment and support, which is really secondary in nature,
the assertive outreach work and that sort of thing. Does that alter the
answer you gave to the Chairman's question on whether this secondary treatment
in the community should be provided by the PCT or would they be buying it in
almost as a sub-contractor? Do you not see there might be a conflict within
the PCT as being both the provider and contractor for those secondary
services?
(Mr Milburn) In truth, I am less bothered about the structural
arrangements than about the service provision. I think the structural
arrangements might take a variety of forms in different areas. For example,
it is perfectly clear to all of us that the needs of rural communities and the
needs of inner cities as far as mental health services are concerned are
probably markedly different for a whole variety of reasons. In the inner
cities it will probably be the case for many years to come that Specialist
Mental Health Trusts will continue to be the provider of mental health
services. However, I do not rule out the PCTs, where they meet the criteria
and where they can jump over the hurdles we have set for them, taking over
some specialist mental health services. I say that because we have evidence
already from the time before we were in office, when the previous Government
was in office, of some of the successes that have resulted from the
integration of primary care mental health services with more specialist mental
health services. I am thinking of the Berkshire Health Purchasing Project,
for example, which is a success story.
648. Would that extend to PCTs taking over the inpatient
facilities as well, other than the regional specialists?
(Mr Milburn) I think in some cases that might be feasible. That is
already happening in some places. For example, when the Committee went to
Birmingham you would have been aware that what you saw there was a primary
care team working hand in glove with the secondary care team to provide
outreach and crisis services in the community and that works. There will be
a variety of structures by which that is delivered. In the end, and I know
there is some big debate about this and I know there will be some uncertainty
about it, from my point of view what I am more interested in is the end
product, the end result rather than getting hung up on defining right now when
PCTs have only just begun their life. I am less hung up about the end
structural arrangements that we will see. We have got an opportunity now as
the PCTs develop and as we set the right criteria for them to test out there
what works.
649. You think that the PCTs, through the health improvement
process, will be able to integrate more successfully perhaps than some of the
mental health trusts have been able to with local authority provision?
(Mr Milburn) I think that is potentially the case, yes. All of the
inquiries and surveys that have been undertaken over recent years demonstrate
that one of the key failings, particularly when something goes seriously
wrong, is the failure of co-ordination. It is not just a failure of co-
ordination between primary and secondary care within the NHS, it is also a
failure of co-ordination between the National Health Service and the other
statutory agencies which are responsible for providing care and treatment to
people who are very, very vulnerable indeed. PCTs provide us with an
opportunity and a vehicle to overcome some of those barriers and obstacles to
a better co-ordination of services.
650. Can I ask the Minister for the Home Department whether the
Probation Service is going to take part in this process? There is a
tremendous spectrum. Would they be happy to work with a PCT as opposed to the
traditional links at the moment which are very much the super-specialist links
with secondary care?
(Mr Boateng) Dr Brand, I very much hope so. One of the reasons why we
are reorganising the Probation Service and giving it now local ----
651. Can I say how much I would welcome you changing your mind on
the naming of this.
(Mr Boateng) Yet another ringing endorsement from this Committee. That
is always welcome. One of the reasons why we are reorganising the Probation
Service, but not renaming it, is so that the national structure has a sound
local base and on the local boards I would want to see health interests
represented alongside the voluntary sector because everything we know from the
good work that has already been done at the very heavy end around public
protection and risk assessment shows that the Probation Service, the Prison
Service and the Police are working quite effectively with forensic
psychiatrists and other health interests in that area. So there is plenty of
scope for good joint working between health and probation.
652. That might prevent some of the confusion presently created by
your Department sponsoring with seed money essential services without making
arrangements for Mr Milburn's Department to pick them up, for instance in
support of people with drug problems?
(Mr Boateng) I think we now have a very effectively co-ordinated drugs
strategy.
653. There is seed funding for a year or two years and then it
dies because there is no other body, other than a public body, that can pick
it up.
(Mr Boateng) Much of that initial funding was so that we could get a
secure evidence base for subsequently mainstreaming the work, for instance
around drug treatment and testing orders. That has now been done and, in
fact, there are some very good examples of Health money, Home Office money,
voluntary sector money, Police money, being used effectively on the ground to
provide drug and alcohol, substance abuse programmes. I was at one this
morning as it happens, ADACTION in Brent, which is helping us there deliver
the drug referral interventions in a very effective way.
654. So we can be sure that where there is an effective service
that between you you will sort out the continued funding?
(Mr Boateng) Yes, and we have got the structures in place now to enable
that to happen.
Chairman
655. Before I bring Mr Burns in can I just ask a question on the
back of Peter's earlier question which probably he did not feel appropriate
to mention being a GP himself. One of the worries I have about the placement
of mental health within PCTs is the competence of some GPs in this are. As
someone who worked, as you know, many years ago very closely with GPs, their
capacity to address mental health issues was very variable. I do not want to
denigrate some excellent GPs who do their work really very well. How do you
envisage ensuring that wherever there is a move towards a PCT taking on
competencies for the mental health provision that they are in a position to
give the quality of provision, the expertise, that is required? How would
that be evaluated from your point of view?
(Mr Milburn) I think there are two answers to that. First of all,
remember that although this is being posited as a primary care takeover, if
it happens, Primary Care Trusts taking on a greater role as far as the
provision of specialist mental health services is concerned, it is not. It
is about the fusion of two sensible organisations, primary care and community
services. Therefore, that fusion will bring with it, if you like, a transfer
of expertise from within the Community NHS Trust setting into the primary care
field. That can only be beneficial for the organisation of PCTs and for those
working in them and, most importantly, for those patients who are receiving
the care. So, if you like, we will import both clinical and managerial
expertise into the Primary Care Trust from the specialist mental health world.
The second thing to remember about all of these discussions is that for the
overwhelming majority of people who have a mental health problem they get
their care treatment right now from GPs.
656. Or do not as the case may be.
(Mr Milburn) By and large they do and by and large they get good
service because it is an appropriate service. Remember, one in four GP
consultations right now are taken up with mental health problems. There are
around nine million GP consultations a year that are about mental health
problems. It is about locating the right level of expertise in the right
place to get the right patient the right treatment and care. Of course, there
will be a requirement for a small minority of patients to have more specialist
mental health services made available to them and, of course, people's care
sometimes is episodic just as their condition is episodic. People with
schizophrenia, for example, can be perfectly stable and well and living life
in the community independently going to a position where actually they need
more specialist help and support, sometimes in a hospital setting. It seems
to me self-evident and obvious that what we have got to try to do as far as
possible is to get the service provision properly balanced to match those
changing requirements and those different requirements between individuals
and, where it is feasible to do so, to reflect that in the structures. The
key thing is the service provision.
Chairman: The case for the defence from Dr Stoate.
Dr Stoate
657. Just for the record, Secretary of State, in fact there are
200 million GP consultations a year of which 50 million are people with mental
health problems. The order of magnitude is staggering. I want to agree with
you that 90 per cent of mental health consultations are carried out by GPs
very satisfactorily. When I meet GPs what they really want is more services
in the community that they have much more input into, as do their primary care
teams, their nurses and so on. What I am looking for from you in a way is how
are you going to make sure that those really do integrate into the primary
care set-up so that GPs and other primary care workers actually have got more
input into mental health services?
(Mr Milburn) Partially the PCTs might provide an answer to that but in
terms of service provision what we have done thus far with the establishment
of the outreach teams, and there are going to be around 50 outreach teams by
2001/02, providing care and treatment for sometimes pretty difficult to engage
people in the community, many will be homeless, many will be drug and alcohol
abusers and they need a specialist level of pretty intensive support in the
community, we are going to put that provision in place to accompany the secure
beds, the intensive care beds and the supported accommodation. There are
about 20,000 people in that difficult to engage group. The next important
group for us are the 650,000 people who are subject to the care programme
approach. Partially what you are seeing already in places like Birmingham and
Islington, and I launched a crisis team in Newcastle very recently indeed, is
taking that approach, crisis work in the community, out from the hospital
setting into the community precisely to reach those sorts of people who
otherwise would sometimes end up in the GP's surgery and perhaps sometimes not
be able to call on the requisite level of expertise there. So all the time
what we have got to do is get the right balance of services in the right
place. I think we are getting there but it does take time to get it right.
Mr Burns
658. Secretary of State, one of the issues that has arisen time and
time again during the course of this inquiry has been that of the question of
the workforce allocations, of national shortages, of problems with morale and
so on. Would you agree with those criticisms that we have been told about?
(Mr Milburn) Certainly we have got some shortages, that is
absolutely true. We have got some shortages as far as nurses are concerned,
we have got some shortages as far as psychiatrists and other specialist staff
are concerned. It is pretty variable. There is a localised and, indeed,
regionalised picture. It is worth bearing in mind, although people always say
to me on nursing shortages "heaven's it is always worse in mental health",
actually the vacancy figure in mental health is lower than the overall vacancy
figure. Our vacancy figure for nurses generally is around 2.6 per cent; for
those working in the mental health field it is around 2.1 per cent. We have
recruited an extra 2,000 nurses over the last two or three years to work in
the mental health field. We have got 350 more consultants working in the
mental health field. We are putting more money in to undertake more training
for specialist registrars, the future generation of consultants in elderly
care, child care and general adult too. That means that over the course of
the next few years we should have around 230 more specialists in mental
health. There are some issues there. I think what is true is that on morale
all too often the clinicians, and I think particularly the psychiatrists,
right now feel as if they have to fight the system rather than the system
working for them. I think that is a general problem in the NHS but it is
particularly true of mental health. If you are a psychiatrist on call and you
have to spend hours finding an acute bed for somebody then that is a pretty
frustrating experience, of course it is. It is that that we have got to put
right. The big decline in acute beds that we saw in my view is unsustainable.
The answer to that in terms of service provision generally is to get the right
provision in and that is where in the secure beds we are going to have a very
big build up. In historic terms these are very, very large increases in
provision that we will be seeing over the course of the next two or three
years. The number of secure beds over the course of the next couple of years
will increase by around 18 or 20 per cent overall. This is a big build up.
We will get the intensive care beds in as well. That will begin to make a
difference to people. It is undeniable that right now the people who are out
there working in the field doing a damn good job feel as if they are under
pressure.
659. When your officials came before us they told us that as part
of the NSF you had set up a Workforce Action Team and that it was going to
produce its interim report last March. Has it actually produced this interim
report? Can you tell us what the conclusions were in that report and what
your thoughts are so far?
(Mr Hutton) The group under Sue Hunt has actually now reported to the
Department, and did so in April. We are currently looking at their
recommendations. The final report is not due until April 2001, so it was very
much a first stab at some of the quite complex issues that they went into.
They are very keen for us to do some more detailed work in a number of areas,
particularly in relation to issues to do with skill mix, issues to do with
whether we cannot make greater use of other staff in the NHS and possibly
looking particularly at the greater use of psychology graduates who have a
significant contribution to make and by and large do not make it. The issues
are being looked at very seriously. Also, we are trying to look at it in the
context too of the work of the National Plan. Yes, there are some specific
issues the Secretary of State has referred to that are clearly apparent in
relation to mental health services but whatever recommendations the team
produce have to be consistent with our wider workforce investigation that is
taking place in the context of the National Plan.
660. Can I move on to the question of the current system of
mandatory homicide inquiries because many people would argue, probably
correctly, that this system which is in place contributes to a public belief
that the tragedies have increased under care in the community when, in fact,
the statistics suggest that the opposite is the reality. Do you think that
the time has come to stop this system?
(Mr Hutton) Certainly we are looking very seriously at all of those
issues at the moment. As you will probably be aware, Mr Burns, the Chief
Medical Officer has set up a group to look at adverse incidents across the
NHS. Lewis Appleby, who chairs the confidential inquiries into homicides and
suicides, has also made some recommendations in his Safer Services Report
which we are looking at too. The National Institute of Clinical Excellence
is looking at the funding and the arrangements in general terms that relate
to those confidential inquiry systems that we operate. I think the most
important thing here is that we have a system that works effectively in future
that is able to disseminate effective messages across the service about what
is good, what is bad or where we need to improve. In the main I think the
homicide inquiries have served a useful purpose in that respect. Lewis
Appleby's work has been particularly important in giving us, if you like, an
overview of the range of issues that those inquiries have reported on in the
past. I think we are pretty well placed now to make some forward progress on
that. I do not think there are any great arguments or secrets about where we
think we need to improve. Lewis Appleby's work in particular, which I am sure
the Committee has had an opportunity look at, has drawn attention to a number
of these issues where in the past it has been service failures that have
contributed to these terrible, terrible tragedies. Of course, it is our prime
responsibility to make sure that the service does not let down the patients
or the public. We are beginning to get a very strong steer about the future
of this and, hopefully shortly, we will be able to make some announcement
about how we want to see the system improved and informed in the future.
(Mr Milburn) It might be worth saying that hitherto we have had about
64 inquiries and there is a very, very common pattern, as the Committee will
be aware, of lack of co-ordination, lack of communication, sometimes a lack
of compliance with treatment which raises some very, very difficult issues
indeed, but they are issues that we have got to get to grips with. It is
very, very important when these things happen that we learn from them. The
most important thing is that we learn from them. We have had some of these
very, very clear systemic failures. I know it is the staff who get blamed and
sometimes it involves people who have done things wrong but there are actually
deep structural systems failures and it is that that we have got to put right
and learn from what goes wrong. We have got a lot of evidence under our belts
now. The evidence, as John was saying, has helped inform the programme of
change that we have got going on now which, indeed, the Committee has just
been questioning us about: co-ordination; how you can get the appropriate
range of services in the right place; how you can improve co-ordination and
communication between the different services. Those are very key things. We
are looking very, very carefully indeed at how we can make progress in the
future as far as this system of inquiries is concerned. Indeed, Lewis
Appleby's report on the confidential inquiry specifically asked the Government
to review whether or not we should continue with the system of individual
inquiries that has taken place hitherto. We have not made a final decision
about that. Clearly there is a lot of work going on, not just to learn from
mental health incidents when they have gone wrong but, as John quite rightly
said, the Chief Medical Officer is doing a major piece of work for us on
learning from adverse incidents more generally within the NHS.
661. Do you know when you are likely to reach a definitive
decision?
(Mr Hutton) Hopefully in the very near future. I hope we will be able
to make the position a bit clearer.
662. Just as a matter of interest, if you were to decide that the
existing system, maybe with some fine tuning or what are considered to be
improvements, the basic principles of the existing system after an incident
are going to be continued by you, how do you think, if you think it could
happen at all, that you can strip away from it the blame culture that has
grown up because of the series of inquiries in effect that the current system
puts in place after an incident?
(Mr Milburn) I think we all have a responsibility in that regard. We
do a variety of mental health promotion work, as you know, we lend support to
a variety of clinicians and so on and so forth. I think this is a job not
just for Government, it is a job for all of us. We have got to keep repeating
the message whether as employers, the Government, voluntary organisations,
Members of Parliament, local authorities or whatever, that a lot of people
have a mental health problem, a huge number of people do, and in the vast
majority of cases that is a problem for them but it is not going to be a
problem for everybody else. We have got to keep working on that continually.
We also have a responsibility when something goes wrong, and sometimes things
do, that we find out what went wrong and we learn the lessons from it. We
cannot abrogate our responsibility in that regard either.
663. Is that not the problem, that a tremendous amount of
excellent work is done by Ministers, members of Parliament, the professionals,
social services, health and everyone else you have mentioned to basically de-
stigmatise the whole area of mental health, but however much good work is
done, however much money your Department or the Government might spend on
pushing that agenda forward, and rightly so, every time one of these inquiries
is set up and reports you undermine far more the good work?
(Mr Milburn) With respect, what undermines the good work is the systems
failure, it is not the inquiry, it is when something goes wrong. We can argue
until we are blue in the face about the number of homicides and the number of
suicides but the truth is regardless of whether the figures are moving up or
down that is incidental because there are many too many suicides and there are
too many homicides and too often there have been real systems failures and we
have got to learn from them. My view, and I feel very, very strongly about
this, is that the patient's safety and public's safety comes first.
664. Absolutely.
(Mr Milburn) We have got to learn the lessons from what went wrong.
There is a debate about inquiries ---
665. You do not necessarily have to learn the lessons through that
system.
(Mr Milburn) Equally there would be concern from members of the public,
and indeed sometimes from the families affected, if people felt there was a
cover-up. That would be a terrible thing and we must not have that either.
We have got to try to get the balance right. Your phrase was about "blame
culture" and that is right, we have not got to have a blame culture but, boy,
have we got to learn the lessons. You and I could probably write a pro forma
for reports into these incidents right now. Every time it is the same set of
factors. The question that has to be asked is if we know that it is poor co-
ordination, if we know that it is poor communication, if we know that it is
lack of compliance with treatment, then is it not time that we did something
about all of those things? The answer to that is yes, and that is precisely
what we are doing.
666. Can I ask you another question which I was not planning to
but in the light of what you have just said I think I will. Another thing
that we have been told on numerous occasions is that the findings of many of
these inquiries are by and large repetitive, and you have basically confirmed
that, but then people have gone on to say that the lessons never seem to have
been learned even though the findings are repetitive. Would you reject that?
(Mr Milburn) Yes, I would now because regardless of what has happened
in the past what concerns me is what is happening now and what is going to
happen in the future. For me, mental health services are a priority along
with cancer and coronary heart disease, they are the services where we have
got to see most development, most improvement, most modernisation now and in
the future. For the first time we have a set of standards that are laid down,
standards that have got to be applied everywhere. We are plugging the gaps
in service delivery and, sure, that takes time but we are getting the beds and
the staff in place. We are backing that with significant resources, big
investments going into these areas, and we want to underpin it too with major
legislative change that allows us to learn the lessons in legal terms from
what has gone wrong in the past.
Chairman
667. I know John Austin wants to come back on the staffing issue
but before we move on to this can I briefly reinforce the point that Simon has
made. This has come over as a very major issue among many of the staff we
have met. Can I put to you the message that we have got from a number of
people that in the work we are doing with seriously mentally ill people
inevitably risks have to be taken, and presumably you accept that risks have
to be taken. If we do not take risks then everybody who has a serious mental
illness may end up locked away for life, which did happen in the past and no-
one would defend that system. One of the themes that we have picked up in our
evidence is that there does not appear to be any kind of guidance on risk
emanating from your Department. Is that an area that you have looked at or
do you think it is appropriate to leave that entirely in the hands of
professionals at the local level? Having done both mental health and child
protection work, and I was in child protection work at the time of Maria
Caldwell, as somebody who has been a social worker I know there is a very,
very difficult tightrope you are on. When in somebody's eyes you take the
wrong decision the worse thing is when you get it wrong the Government kicks
seven bells out of you. Having been the subject of an SSI Inquiry I speak
with some feeling on this issue. What guidance do you offer on risk taking
in such circumstances?
(Mr Milburn) As you say, Chairman, we have not got to allow
professionals, whether in the social care world or in the health care world,
out there on their own to flounder, if that is what is happening. They have
got to be supported, they have got to be given the appropriate help. I think
that is the right thing to do and ----
668. If they get it wrong what do you do? This is the worry that
we have picked up, and we were talking yesterday to somebody who is a fairly
experienced psychiatrist who was talking about colleagues who were excellent
professionals with super careers but one thing went wrong and it finished
them. Is that right?
(Mr Milburn) We have got a whole set of proposals and we have got a
whole strategy in place to deal with precisely that. That applies not just
to mental health but to clinical practice more generally. The view hitherto
has been that by and large you allow clinicians to get on with it and if
something goes wrong then somebody somewhere comes down on them like a ton of
bricks but that is not appropriate it seems to me. That is why, for example,
the Chief Medical Officer in his proposals, Support Doctors, Protecting
Patients, advocated that we should move to a system of annual appraisal. The
General Medical Council have now proposed a system of revalidation so that we
do not assume that once a clinician qualifies that is it, they can do the job
for life, if you like they have got to prove that year on year they have kept
up to date as far as clinical practice is concerned. We have imposed a duty
of quality on NHS organisations. There are clinical governance arrangements
now in place in the NHS being developed right now to assure quality systems
in all parts of the service, whether that is in primary care, mental health
or, indeed, in the acute sector. For the first time we have an independent
inspectorate, a Commission for Health Improvement. If anybody had said three
or four years ago "we are going to have annual appraisal and an independent
inspectorate and we are going to require revalidation for doctors" people
would have said "you are not going to achieve that because there will be so
many obstacles and so much obstruction". But it has happened and it has
happened precisely because, in my view, out there in the service and in the
clinical community there is a desire to get things right, to learn the lessons
and to apply good practice. You have seen what happens in mental health and
elsewhere, but also to assure the public that what happens in the NHS and the
people who work within it are accountable for the work that they undertake and
that is a big change.
669. You have talked a great deal about the quality measures and
we all accept that those are having an impact because we have seen that
directly but what I asked you about specifically was risk and where risk is
taken, and it is appropriate risk is taken, and it goes wrong, does the
Government not have a duty to think through the fact that we have to take
risks and if we do not take risks then we will have a very strange mental
health system?
(Mr Milburn) One of the things I always say to doctors and to others,
to members of the public, is "look, medicine is an imperfect science, it just
is and sometimes things go wrong".
Dr Brand
670. Hear! Hear!
(Mr Milburn) It is a difficult area. This is a difficult area above
all else, particularly dealing with people who have severe mental health
problems. We recognise that. The issue is how do we set the national
standards to help people so that their clinical practice is informed by the
best clinical evidence about what works and what does not. How do we ensure
that we have systems in place of clinical governance, annual appraisal and an
independent inspectorate that deal with these problems before they arise? I
think we have got a good set of quality measures in place, not just for mental
health but more generally for the NHS, that should, over time, allow us to nip
the problems in the bud. The CMO is working right now on what I think will
be a very, very important set of proposals and documents about how we do learn
from adverse incidents in the NHS. There are a lot of adverse incidents, the
key thing is how we learn lessons from them.
Mr Austin
671. Just to go back on the figures of 2.1 and 2.6 per cent
vacancies, which seem to me to be lower than I would have expected, I do not
expect an immediate response necessarily but ----
(Mr Milburn) It is nice to bring some good news.
672. Maybe you could provide us with some details of how those
vacancy rates are calculated. Do they make assumptions about shortfall, are
they budgeted staffing, are they targeted staffing, are they by local
authority?
(Mr Milburn) We can certainly provide the data for you but they are
based on the annual survey that we undertake.
673. Are they applied standardly authority by authority?
(Mr Milburn) Yes.
674. And available authority by authority?
(Mr Milburn) I do not know the answer to that but we can probably find
out. We will let you have whatever data we have got.
Mr Burns
675. Are they of actual figures or funded because we have just
discovered ---?
(Mr Milburn) Those are two very good questions to which I am sure there
is an answer but I have not got it.
Mr Burns: Will you find out because it is crucial. It has only just
emerged about police officer vacancies.
Mrs Gordon
676. Secretary of State, earlier you said that mental illness can
be episodic and quite often that is the case. One of the things that became
clear to us talking to users and carers was that the things that concern them
most when they are going through an episode of mental illness are issues like
money, jobs and housing, the fact that they are often in and out of work and
this is obviously very disruptive to their everyday lives. The problems that
they highlighted included dealing with agencies, dealing with housing benefit,
employment issues, in fact the whole gamut of government agencies. What plans
do you have to ensure that the benefits system and employment services remove
barriers to full social integration of mentally ill people? I agree with
joined-up government but is it working in this area and, if not, what can we
do about it because it is a real problem?
(Mr Hutton) You are absolutely right, this is a hugely important area
for us to be connected with. We have to start from a very simple starting
point which is the NHS has a major contribution to make in providing better
services but we cannot guarantee good mental health on our own. Good mental
health is going to be conditional upon a range of other services and support
mechanisms including housing support, jobs, benefits and so on and we have
accepted that. We are trying to do some work in that area. Let me give you
an indication of how we are trying to tackle that and we are trying to do it
in a joined-up way right across government departments. One of the exciting
areas where we are beginning to connect with these concerns is in the health
action zones. There are 26 of them across the country in some of the most
deprived parts of England with some very high needs in terms of mental health
services. We are looking at putting together schemes to make those
connections between care workers in the NHS and other key agencies. There is
a very good scheme in Lambeth, Lewisham and Southwark looking at doing exactly
that with young people with mental health problems and the early signs of that
are looking very encouraging. The health improvement programme approach is
going to help us in this area because what we are doing there is linking up
all local authority functions with the NHS so we are looking at social
services, the contribution they can make, but housing and benefits advisory
services too. There is an opportunity through IMPS for local authorities to
work with health authorities to put those services together. We have issued
some new guidance in relation to the care programme approach which stresses
the need for exactly that kind of on-going support for those sorts of services
so NHS staff know what to do in those circumstances. The New Deal for
Disabled People is breaking some ground in this area and there are some early
signs too that progress there looks quite encouraging. We are doing a lot of
work around the needs of mental health patients. And the Department of Health
and the Department of the Environment, Transport and Regions very soon will
be issuing some joint guidance about housing support and other services for
people with mental health problems. It is a problem. We have got a lot to
do, to be perfectly honest, to get that approach right. We are approaching
it from a number of different angles working across government to try and get
the answer but the question in short terms is absolutely right; it is a very,
very serious area where the system has not worked effectively in the past and
people slip through the net and their condition has deteriorated and we get
this revolving door syndrome. We cannot support them effectively out in the
community and they come back in, sometimes as a detained patient, under the
Mental Health Act. That is a totally unacceptable state of affairs. We have
got to be much better in all these areas. In some of those areas we have
indicated we are trying to cross the lines, get rid of some of the
organisational boundaries that impede effective support for people with mental
health problems. We firstly recognise that as an issue and we are trying to
put mechanisms in place to deal with that. In doing that we are, as you said,
breaking some new ground in trying to see mental health services in that more
holistic sense. It is not just what the NHS can bring to the table or what
social services can bring, it is a whole service response going right across
the range of local authorities as well.
677. At the moment when people are at their most vulnerable they
are hitting their heads against a brick wall going from one agency to another
with no co-ordination or understanding really. One of the suggestions from our
witnesses is the need for a new kind of worker, a generic mental health
professional who would do this job, prioritise aspects like benefits and
housing as well as social and health care. Has it been looked at in the
health action zones as a possibility or would you be willing to do some
research on whether that is viable?
(Mr Hutton) This is a primary area where the workforce action team
will begin to develop some more specific proposals for us. They have only
started to get their work on line. An interim report has come out and one of
the issues in relation to Mr Burns' questions was the idea of a skills mix in
teams of workers. Do we have the right people there with the right range of
skills and expertise to open some of these doors up? In a time of crisis in
a person's life sometimes it does take someone to open those doors. Yes,
absolutely, we have got to look at that and we have got some quite challenging
issues to address as we try and equip the mental health workforce for some of
those new challenges in the new century. We have got a lot to do and the idea
of generic qualified workers and people who can cross those professional
demarcations is a very interesting one and we are looking at that, I can
assure you.
(Mr Milburn) The idea of the generic health social care worker,
whatever the proposal is, let us have a look at it, but there is more general
issue too and that is if we are going to do what we want to do and ensure that
support for people with mental health problems is not confined and ghetto-ised
to the National Health Service and social services we have to have the
appropriate training in the housing system and the benefits system and
elsewhere. That is going to take some time but that is what we need to do
because otherwise we will not be able to deal with the range of problems those
agencies have to confront as well as the problems that the NHS and social
carers have to confront day in day out. So there are some very big training
recognition issues we have to get to grips with across government, not just
in the Department of Health but elsewhere as well.
(Mr Hutton) I would also say the issues were fully flagged up in the
National Service Framework too, identifying those areas where we need to
improve the range of services currently on offer to people with mental health
problems.
Dr Brand
678. Can I probe you a little bit on housing benefit verification
where people with mental health problems are placed with supported landlords
either by a social worker or a CPN and that landlord does not get paid until
that verification gets made by somebody in the housing revenue department and
that could take weeks and we are losing social landlords because they are not
getting paid. This is a real problem. I have written to you and to the DETR.
I am told that joint working is possible on the ground but if you ask the
individuals on the ground they say, "No, they have got to see the person in
their home before any money is paid." That is notoriously difficult if you
have got somebody on the street most the time or who does not answer their
door. It is these frustrating things that are not only difficult for the
patient but totally time-consuming and frustrating for the people actually
working. That is not lack of goodwill at local level, that is government
regulation getting in the way.
(Mr Hutton) This is something that the joint Department of Health/DETR
guidance is going to address. What we want local authorities to be able to
do in conjunction with health authorities and social services is to provide
an effective range of housing support services for people with mental health
problems. That is what we are trying to do in the guidance and I will want
to keep the Committee fully informed on how that is moving on but, yes, there
are problems and I think we recognise that and we are trying to address those
in some of the work I have outlined particularly looking the guidance we
intend to issue to local authorities.
Dr Brand: I look forward to seeing it.
Mr Austin
679. I want to follow up on Eileen Gordon's point and raise a note
of caution about generic workers because whilst I think there is some
immediate attraction in the concept as she put it, I think there is also a
very real danger of devaluing the very real skills that particular
professionals bring to a job. A health trust not a million miles away from
this building who sought to get rid of all art therapy workers and replace
them with generic mental health workers was a denial of the real skill the art
therapy workers had. On the question of the welfare rights issue, I think it
is very difficult for people to keep up to date and on track with a very
complex area. I know that government is trying to simplify matters but in the
very complex area of welfare rights, would you not agree that what is required
is a resource available to whoever it is, social worker, OT or other
therapist, to have access to a very skilled and up-to-date welfare rights
service which can provide the advice and information?
(Mr Milburn) Probably, yes, we do need to make sure that information
is accessible to people and understandable to people. That must be the case.
On the first point about the generic workers, in some senses it is rather like
the argument about PCTs versus specialist mental health trusts. We are
terribly hung up about the structures, but actually what counts is making sure
the patient, whoever he or she is, is getting the right access to the right
level of skills. There are two or three things we have got to do there, one
is expand the capacity of the workforce in mental health and elsewhere to make
sure there are more doctors, more GPs, there are more specialist registrars,
there are more CPNs and social workers able to do the job. Secondly, we have
got to make sure, with this business about the majority of people with mental
health problems getting very good care from general practice, that there are
no barriers to patients getting access to the right level of skills that is
necessary for their condition and for their treatment. It will be very
important, in my view, that the NHS takes a very hard look at the skills that
are available within the workforce to make sure that we are maximising the
potential of nurses and physiotherapists and others and we do not assume that
every clinical task is a medical task. That will be an important thing we
need to do. A third thing we will need to do is self-evidently we will need
to take a good look at proposals for merging the functions between different
members of staff where that is the right thing to do because in the end what
counts is not the staff label on the uniform, what counts is the services and
skills that are being provided for the individual patient. If there are
proposals around let's have a look at them by all means, but the key thing in
all of these things is to make sure the patient is getting the right level of
skill commensurate with the problem.
(Mr Hutton) We are not deskilling the workforce. That is a hugely
important point for the Committee to understand. If we are going to go down
the road of looking at more generically qualified workers, there is no
suggestion, and no one should read into it any intention on our part, to
somehow produce a workforce with lesser skills or lesser qualifications. We
are talking about re-skilling workers and there is a very important difference
between those two things.
Mrs Gordon
680. I think what people really want is for services to revolve
around the patients rather than the patient revolving round all these
different agencies. Your door thing, that is the real need.
(Mr Hutton) Absolutely.
(Mr Milburn) That is the frustrating thing for the patient. As Dr
Brand quite rightly says, it is the most frustrating thing. Members of staff
at every level, primary care, secondary care or community health services,
have this sense that somehow or other the system is not able to cope with
getting the right patient in the right place. You would see that over the
road if you went and visited St Thomas' today. The staff of the A&E
department would say to you, "It would all be fine if only they sorted out on
the acute bed side", and the people in the acute bed side would say, "It would
all be fine if we had some rehabilitation services out in the community", and
so it goes on and that is particularly sharp in mental health where the
problems are very complex and changing rapidly for the individual patient.
That brings me back to my first point to the Committee. It is about plugging
the gaps in service provision and making sure you have got the right range of
services across the piece.
Mr Gunnell
681. Is the œ700 million which is promised for the three years to
2002 going to be sufficient for you to take the implementation of the
framework as far as possible?
(Mr Milburn) It will certainly pay for what we said it will pay for,
which is the increase in the beds, the 40 outreach teams that will be in the
community dealing with this difficult to engage group. It will pay for more
drugs and treatments coming on-line. It will do all that and it is pretty
carefully costed to do so, but again I remind the Committee that the œ700
million is just the tip of the iceberg because, remember, if it is true, as
it is true, that the majority of people with mental health problems are being
seen in primary care, there is a lot more money going into primary care as
well, and a lot more money going into hospital services as well. We reckon
right now that probably as far as hospital and community health services are
concerned, that mental health services account for about 12 per cent of the
overall budget. It is quite a lot of money overall that is providing care and
treatment for a range of conditions and treatments in the community, in
primary care and in the acute sector as well.
682. I should say that in the visits that we have done around and
the people we have talked to we can say that it is very important that that
commitment has been made and that is a commitment that people are very anxious
to see remain to the mental health services because I think it is the first
time that a commitment of that size has been given to mental health services
in this country and people do regard it as very important indeed. However,
as we get into the detail of looking at services, are you sure that you will
not need to expand it a little because if we look at capital spending which
is necessary to fill in, for example, some of the gaps that we have seen in
the medium secure provision and the things that we need in order to make sure
people are placed in the sort of setting they should be treated in, you will
have found that it is likely to cost a good deal more. You have planned
really for it to be fully implemented over the next ten years. Have you got
a figure yet as to the sort of sum that will be needed over that period of
time?
(Mr Milburn) I am always slightly nervous, it is my Treasury
inheritance, about second-guessing ten years' time but what is clear is as
with the NSF that if we want to do what we need to do as far as modernising
and improving mental health services are concerned, that is going to require
sustained levels of investment. That is true. We know what the position is
because we have committed the money for the first Comprehensive Spending
Review period. As the Committee are aware, the NHS is now in a position where
it knows the level of funding not just for this financial year but for the
three subsequent financial years too and there is a lot of money going into
the NHS, double the growth rate we have seen in the past. We have got to make
sure that mental health services get their fair slice of those extra
resources. As John has alluded to, the national plan the government will be
publishing in July will set out the ways in which we are going to spend the
money for the next four years but also, most importantly, set out the ways we
are going to use that money to modernise and improve services for patients.
As I said at the time I became Secretary of State, there are three big service
development priorities: cancer, coronary heart disease and mental health. It
would be surprising therefore if mental health did not get a reasonable level
of investment.
683. I may say that people on the ground regard that commitment to
mental health as being very important indeed and we have seen, as we have gone
around, that very frequently you have got a mixture of old and new facilities.
At Broadmoor, for example, we could see the example of both bits of the
building that are in use and there was a feeling that perhaps the
modernisation had not yet got quite far enough because there was a good deal
more which they wished to do in building terms in order to improve the
facility for the benefit of all the patients. I do not think they were
thinking of a large amount being spent on the perimeter fence.
(Mr Milburn) No, perhaps not!
Mr Austin
684. Our witnesses have got their back to the gallery and I was
going to say how welcome it was to have the Opposition front bench here but
they seem to have gone again.
(Mr Milburn) Are you talking about Paul!
Chairman: They were in the audience. Mr Austin is totally out of
order, as usual!
Mr Austin
685. Can I turn to another issue because in your Memorandum to the
Committee you have concluded by saying: "This represents an ambitious agenda
of developing modern mental health services which are culturally appropriate".
Yet nowhere in the Memorandum is there set out any action specifically geared
to making those services more culturally appropriate. I would like to ask
what steps you are taking, but I would like to take the discussion a bit
further and ask whether the concept of just thinking in terms of culturally
appropriate services is somewhat of a dated concept. It was the 1960s and
1970s when Rack and others were talking about cultural awareness in
psychiatric services and I thought we had moved on a bit since then and,
indeed, witnesses that we have had before us have gone on the record as
describing the mental health services as "institutionally racist". I think
it is not just a question of cultural appropriateness of services but tackling
the racism which is inherent in the services. I think all of the evidence
shows that black and other ethnic minorities are less likely to have easy
access to mental health services, are more likely to receive physical than
non-physical treatments, are more likely to access the psychiatric services
through the criminal justice system and I think that feeds through the
criminal justice system as well, that black people are more likely receive
custodial sentences across the board and I would have thought post-MacPherson
there would have been a more serious comment about not just "culturally
appropriate services" but tackling the institutional racism.
(Mr Milburn) It is certainly true there are very real barriers to
people from the black and ethnic minority communities getting the appropriate
services that they need. That is best evidenced not only by the work of the
Schizophrenia Fellowship but our own work in the Department that black people
are much more likely to be detained under the Mental Health Act than white
people are. We know that; the issue is what are we going to do about it? It
is not true to say that do not take it seriously.
686. I did not suggest you did not take it seriously, I said it
was not in your Memorandum.
(Mr Milburn) It does say that we should be "sensitive to the needs of
people from a variety of backgrounds". That is absolutely right. I think
what is becoming evident already is that a new range of services that are
being provided, outreach teams and crisis services that you have seen in
Birmingham and elsewhere, are not just beneficial across the piece but are
probably of particular benefit to people from black and ethnic minority
communities because the evidence seems to suggest that people from those
communities access the services too late in the process and as a consequence
we have a very high level of detention so the issue is how you can ensure you
get the appropriate early intervention that is necessary and certainly as the
signs from Birmingham and elsewhere seem to suggest, these services are able
to provide a more appropriate level of treatment and care for people earlier
in the care process than perhaps otherwise would have been the case. That is
important. Nobody should be under any doubts about the Government's
commitment to tackling racism wherever it appears in the NHS. As you know
yourself Mr Austin, my predecessor Frank Dobson made absolutely clear his
determination, and I share it, that we are going do deal with these issues.
That is why, for example, we are now saying that all NHS trust boards will
have to undertake training on management of diversity issues. We want to see
a new programme of managerial and clinical leaders from the black and ethnic
minority community. We want to see local NHS organisations in their workforce
better reflecting the nature of communities that they serve. It is a very
difficult target indeed for NHS trust boards to up the number of people that
come from these communities. There are a variety of things that need to
happen in order to tackle what are sometimes pretty entrenched problems within
the service. I think both at a service provision level and institutional
change level, nobody should be under any doubt about our commitment to do
precisely that.
Chairman: Can I bring Mr Boateng in and ask a question probably more in
the context of being a London MP rather than your ministerial duties. I was
very struck in the inquiry we did into regulation of the private sector by a
visit to a private hospital near York, secure provision, which appeared to us
to be full of black men from London. I think we were all struck by the
failure of the system in these circumstances. I wondered in particular as a
London MP what your thoughts were on why we have got that problem and then
also you will probably want to respond to some of the wider points John made.
Mr Austin
687. You have pinched my second question!
(Mr Boateng) You have put your finger on a very real issue for us not
only in London but across the country and there is no doubt that one of the
priorities for the NHS Prison Service Policy Unit in relation to prison health
care is to look at this issue of ethnicity, mental health and the criminal
justice system because there is some interesting data as well as anecdotal
experience coming out. What is clear is that ethnic minority people are over
represented in the prison system, proportionately twice that of the white
community. So there is an issue there, undoubtedly. Post-MacPherson we
recognise the issue of institutional racism within the criminal justice
system, but when you then come to look at mental illness and mental disorder
in prison a number of things strike you. First of all is the paucity of
decent information and one of the problems that the Secretary of State, and
his predecessor, and myself in my previous incarnation, found when we looked
at what was coming out of the trusts was the paucity of information and the
poor data. That is one of the things that the Secretaries of State have
addressed in health over the years. We are now going to do the same and are
going to be doing the same together in relation to the prison system and the
NHS. What we know at the moment is that it may well be that black offenders
are more likely to be diverted into secure provision and there is a certain
amount of evidence that indicates that and that would explain why when you
actually do a survey - and there has been some work done of the prison system
itself, there was an ONS study carried out in this area - it found that there
was a lower prevalence of one of the most serious forms of mental illness,
functional psychosis, amongst black prisoners than amongst white and one of
the reasons for that might well be they are more easily pushed out into the
secure system. So we are addressing this issue both in the context of our
work with health but also in the context within the Prison Service of our
corresponding programme that deals specifically with issues of ethnicity and
discrimination within the Prison Service.
688. Can I come on to the preventative side. I have been very
impressed by some community-based organisations working in the mental health
field particularly amongst particular, specific ethnic minority groups. I
just wonder what evaluation there has been made of the work of some of those
groups and what plans there may be for more adequately securing the funding
of those which are proven to be successful and working because it does seem
to me that the funding of some of those organisations, which I think do an
extremely valuable job, is somewhat hit and miss and depends on transitional
funding.
(Mr Milburn) That is right. Certainly within the statutory sector we
do not have the fount of all wisdom as far as good service delivery is
concerned and there are very, very good voluntary providers, of course there
are, doing some very, very good work in this area. They are subject to a
fairly rigorous evaluation procedure not least because their funding in part
is dependent on their performance, and so it should be. If you want to send
me details of the particular organisations you are referring to, we are quite
happy to have a look at it, what they have been doing and what we have been
doing to them by the sound of things as well.
Mr Hesford: Can I turn to the question of the reform of the Mental
Health Act. This is an issue which provides enormous opportunity for us all
to get future care for the mentally ill right and it is an opportunity which
only arises once in a generation for politicians in the cycle of how often
reform is made of any particular Act. In terms of the Richardson Group which
was set up in advance of the Green Paper, they suggested ten principles which
might find their way to underpinning the Act, but I do not believe any of them
found their way into the Act as such. Could you give us your thoughts as to
why they did not and what is the thinking behind that?
Chairman
689. You mean the Green Paper?
(Mr Hutton) Let me be clear about one or two things. It is very much
our desire in the Department of Health that the new legislation should be
underpinned by a set of clear general principles. In terms of law-making in
this place we rarely do that in the legislation. The Children Act was an
exception and there are one or two other exceptions but in the main we do not
do that. We felt very strongly in the context of this legislation which is
about a very sensitive area, the protection of public safety but civil
liberties too, that it would be helpful on this occasion, given we have this
unique opportunity to get it right, to put those clear principles down on the
record. I think there is some misunderstanding about the exact nature of what
we have done, what we have not done, what we have rejected, what we have not.
We have certainly not rejected, for example, the principle of
non-discrimination. There has been very clear evidence of misunderstanding
about that. We do not want patients to be discriminated against, of course
we do not, simply because they have mental health problems. That would be a
monstrous situation and we have no intention of discriminating against people
simply because they have mental health problems. We could not anyway because
it would be illegal under disability discrimination. But that does raise a
general concern. If these principles are going to be meaningful and
effective and are going to be a proper aid to interpretation of the new
legislation, then clearly they cannot duplicate other provisions elsewhere.
That is the first point. Particularly in the area of discrimination we would
be duplicating the provision in other statutes. They have got to address the
fundamentals here which is that this legislation is about compulsory
treatment. It is a hugely sensitive area, I accept that, but what we cannot
have, and I made this argument very clearly in the Green Paper, is a set of
principles that might make it harder for the courts to interpret a framework
of law which is about compulsory treatment, in other words making a direct
infringement on the principles that usually govern the basis on which people
accept treatment, which is consent. We have got to be very clear about that.
It is not because we do not like the idea of principles that we have come out
with the four we have suggested in the Green Paper, far from it - it was very
much our idea that there should be a clear set of principles in the
legislation - but we have got to make sure that those principles are going to
be effective and are going to assist the courts, not make their job more
difficult, in interpreting the legislation and we do for the first time set
out a very clear framework. One of the most important principles we emphasise
here is wherever possible the treatment should be consensual and that is the
case in fact for the vast majority of people with mental health problems. We
are by definition talking about legislation that is unusual. The mental
health legislation has always been about this. It is about compulsory
treatment and that is the context within which we have to develop a set of
principles. We have worked very hard to develop a set of principles that we
hope will be effective and take forward the new spirit we want to underpin
this legislation. There is no sense here of the government either being
reluctant about the concept of having declaratory principles of legislation,
far from it, or that the set principles was not consulted on. They are by
way of consultation. People may have other ideas and we will listen to those
but there is no suggestion that these principles in any way detract from the
purpose and principles we are trying to take forward. I think this is the
first time any government has tried to set out a proper framework of general
principles which would underpin what is by common consent a hugely difficult
area of law-making.
Mr Hesford
690. Thank you for that. I think that does take the argument some
way forward and, if I may say so helpfully, but quite a lot of the evidence
we have received and indeed some from surprising sources, some from the
psychiatric profession, psychiatrists, has suggested that if the legislation
was framed in a certain way, the new spirit that you helpfully spoke of would
actually be assisted and to enshrine the idea of non-discrimination and
respect for patient autonomy psychiatrists have told us that would help them
culturally perform their job better from a professional point of view. That
is without looking at the issue from the patients' point of view.
(Mr Hutton) It is a consultation exercise and we are quite prepared
to look at the detailed consultations that have come in. I think over 1,000
responses have currently been received in relation to the Green Paper so we
have got a lot of work to do to trawl them. If people have serious
suggestions about how those principles could be improved, of course we will
look at them, but I think there is a particular difficulty and we did spell
this out in the Green Paper in relation to both those principles you have just
mentioned in terms of non-discrimination and autonomy. Non-discrimination is
already dealt with in legislation elsewhere. There is a very real question
of why would we want to replicate that legislation in another piece of law?
We do not usually do that in this place. The second issue of autonomy, again,
is very controversial and difficult because to emphasise the autonomy might
well be seen by the courts to conflict with the basis and purpose of this
legislation which is to set up a framework of compulsion. How do the
principles of autonomy and compulsion sit side by side? We found that very
difficult to reconcile but we are open to this. If people have other sets of
proposals, of course we will look at those as part of the response to the
Green Paper.
691. If I may say so, one aspect of what you have said might leave
questions open and it might be useful to reflect on that at this point. You
have mentioned a number of times the concept of the courts being involved.
It is not entirely necessary to get the system working that a court would be
involved in terms of how a patient should be treated.
(Mr Hutton) That is obviously true and it is very much our desire, and
we have made it clear in the Green Paper, that patients with mental health
problems should be treated on the basis of consent where that is possible.
We have made that very clear but I think by definition in the context of these
proposals we are talking about a situation where there may not be consent and
therefore the role of the new mental health tribunals is inevitable as part
of the process of making determinations as to whether a patient should lose
what we all cherish which is our right to say no to certain types treatment.
It is a very, very sensitive area, we accept that. We are going to proceed
with this carefully and sensitively and listen to what people have to say.
We would be kidding ourselves, to be quite honest, if we thought it was
possible in all cases to avoid this sort of issue coming before the courts.
Every developed country in the world has a framework of mental health
legislation which is about this issue of compulsion. Let's be absolutely
clear about that. There is absolutely no possibility of us getting to a
situation where we do not have those powers to compulsorily treat a patient
because if we were not to do that it would not only be inhumane because we
would be denying a patient access to appropriate care but it would be
dangerous not only for the patient themselves to go untreated, but dangerous
for the community, their families, the carers, and staff who work in the NHS
and social services too. We have got to strike the right balance here. We
are trying to do that. People have said it is all about public safety, that
is not true. We are trying to draw a balance between all of those competing
pressures. It is not the easiest thing to do but we have to make no apologies
for the need to preserve the safety of the system, both for the patient and
public, and we are not going to apologise for that. It is very important we
do that, but we strike a fairer balance in terms of the rights of individual
patients. That is why I think I do not buy the argument, to be honest, that
there is a trade off between improving the safety of services and somehow
fundamentally compromising the civil liberties of individual people. I do not
accept that. In fact, if you look at the proposals, as I am sure you have in
detail, what we have been trying to do is strengthen the safeguard for
patients too with this new mental health tribunal which for the first time
will take off from the clinicians the responsibility for decisions about
whether somebody should be compulsorily detained. In future that will be the
sole preserve of the mental health tribunal. That is a very important
safeguard for the first time we are building into the framework of compulsory
treatment.
Mr Austin
692. On the point you made your argument was it would be wholly
wrong in the patient's interest to not have some mechanism for compulsory
treatment when it was clearly in the patient's interest and yet someone who
is detained at Her Majesty's pleasure in a prison who more appropriately ought
to be in an NHS facility is denied that because am I not right in thinking
that a person who is in a prison, even in the health wing of a prison, cannot
be compulsorily treated even if the doctors think that they require it?
(Mr Hutton) No, that is not true. Paul may well be the person to deal
with this but my understanding is that the provisions of the existing
legislation do permit that to happen under the terms of a restriction order
or transfer to hospital order.
(Mr Boateng) At a time of crisis there is a common law power to
intervene.
693. A common law power?
(Mr Boateng) Yes and to treat compulsorily, otherwise there is not, but
of course it is our concern and one of the outcomes of the reform package that
we are developing in the NHS and the Prison Service and one of the benefits
of the new investment the Department of Health is making in beds, that we are
going to be getting people through the system much quicker in terms of getting
them out of prison into appropriate NHS facilities. We are not satisfied with
the rate at which we are doing that now and we are looking at and we are
beginning to make real inroads into improving that situation.
694. I think we would have no difference on that. I should say it
has been put to us that you can have a situation where a prisoner is having
a florid psychotic episode, waiting for transfer to a secure unit or elsewhere
where clearly intervention would be in the patient's interest, and is it not
undertaken. You are saying that the power exists in common law?
(Mr Boateng) It is not an entirely satisfactory situation but 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.
695. I think we will come on to that later.
(Mr Boateng) And that is one of the reasons why it has been found not
to be something that is very often seen as a preferred course of action. Much
better rather to get the person into a clinical setting where treatment can
be administered, if necessary in those cases compulsorily.
(Mr Hutton) Section 47 of the Mental Health Act does enable the
prisoner to be transferred from the prison to a mental health provision.
696. If a bed is available.
(Mr Milburn) That is not a legal problem, with respect, that is a
capacity problem.
697. By the time the bed is available the person's health has
deteriorated because they have not had treatment.
(Mr Milburn) We accept that point and that is why we are working hard,
and why indeed the Home Office and Department of Health are represented here
today jointly. We recognise that prison health care is obviously not what it
should be and it needs real improvement, in particular to avoid the revolving
door syndrome in the criminal justice system as much as to avoid it in the
mental health system. Where appropriate, we will of course try to treat
prisoners within the prison environment and we need to see more community
health services provided in prisons, but equally where it is appropriate we
have got to have a position, just as we have for non-prisoners, where people
can get access to services particularly where they have a severe problem. The
issue there is, frankly, more one about lack of co-ordination and capacity
hitherto than of legal impediment. We have got the legal power to do that;
the issue is whether or not the services are available.
(Mr Hutton) Can I clarify one point because it is important the
Committee appreciates this. You are right that in practice it is unlikely
those powers under the Mental Health Act would be used unless there had been
notification that a bed was available but in exceptional circumstances the
Home Secretary can direct one of the high security hospitals to receive
patients in exceptional circumstances.
Mr Hesford
698. It has been mentioned to us a number of times by different
witnesses across the board that they would like to see the issue of capacity
dealt with on the face of any new Act or, another way of approaching the same
issue, a definition of incapacity. What are your views and thoughts on the
issue of capacity?
(Mr Hutton) Again these are very important issues and what we tried
to set out in the Green Paper was not a government position because we have
not resolved this argument either way, but simply to offer an alternative to
the model proposed by Genevra Richardson which did not involve a capacity test
and we asked people to say which of the two options is probably the better one
for us to follow. I do not want to go into the detail of the responses we
have received yet because it is probably not appropriate to do that today, but
I would draw the attention of the Committee to some very interesting things
that did come through from that consultation. There is a very strong split
of opinion on this, as you would expect. There is a group of organisations
who say there should be a capacity test. There is, equally, a very strong
body of opinion which says either there should not be a capacity test or the
proposals of the Richardson Committee were unworkable. We have got to look
at all of these arguments very carefully ourselves. There is some very, very
substantial opinion stacking up against a capacity test.
699. The unworkability question is a key question. Can you say
more about that?
(Mr Hutton) The problem at the moment is that there is no agreed
protocol or system for defining capacity. That is a point made by two of the
Royal Colleges who responded to the consultation. The Royal College of
Psychiatry said it would be a really difficult issue and the Royal Society of
General Practitioners were opposed on that basis to the capacity model at all.
They felt it would not work and would make the whole system much more complex
than it otherwise needs to be. I am not yet in a position to say what the
Government's response is going to be, but there is a very important issue here
underlining the future operation of this legislation, whether we have a
capacity test or whether we make a gateway into compulsion a proper system of
risk assessment. This has come up in the context of earlier questions put to
the Secretary of State. That is one of the most important issues we will have
to come to a decision on soon in relation to the future model of mental health
legislation but we have not come to a decision about that yet. We understand
the strength of feeling on both sides of the argument here. What we must have
is a workable piece of legislation that can command general support
particularly amongst those who have to operate it and apply it, and we will
proceed on that basis.
700. What about the question of enshrining in any new Act a
general right to appropriate treatment?
(Mr Hutton) I do not know whether the Secretary of State will want to
say something about that but I think we are addressing the issues of equality
that underpin that question in a number of areas already, partly through the
National Service Framework, partly through the clinical governance
arrangements we are going to be overseeing across the NHS, and partly too
there is an important role for the mental health tribunal which we should not
lose sight of. It is part of our proposals that when somebody is being
compulsorily detained and treated there is a requirement that those care
services are being provided. I think it would be difficult in the context of
the general sweep of NHS legislation to have a particular right to a range of
services for mental health patients but to no other group of patients, so that
is something we will have to think about very carefully. I can reassure the
Committee, I hope, that the quality of care being provided to people who might
be compulsorily detained is of prime concern to us. We want the patient to
benefit from this treatment. Clearly there is no point in going through this
exercise unless they do. The requirement to ensure top-quality, first-class
treatment of care underpins all the initiatives we have put in place to try
to modernise and improve mental health services.
(Mr Milburn) I think it is worth adding on this point, as John quite
rightly said, what the Green Paper proposed is that the first principle is
wherever possible care and treatment should be based on the voluntary
consensual principle and I think most of us would regard that as absolutely
right. Given the range of people that require mental health services that
must be right and indeed there will be a requirement on those providing
non-voluntary and non-consensual treatment who must be able to show that they
properly examined the voluntary and consensual option before moving to
compulsion. If you like, that principle is enshrined in the Green Paper
proposal. Obviously, as he has also said, there is a range of responses, well
over 1,000 to this and a big split in views and we will have to take some
difficult decisions about this. I think it is just worth reminding the
Committee beneath the level of the legal niceties and nuances about this what
the realities are for staff working in the field and psychiatrists in
particular as far as compulsion is concerned. Psychiatrists who speak to us
say they face day in day out the conundrum between the civil liberties of the
patient and the safety of the patient. Just park to one side for a moment the
safety of the public, the safety of carers and the safety of their families,,
the safety of the patient, and under the current Mental Health Act provisions
psychiatrists face the preposterous position where they treat in a hospital
setting, sometimes compulsorily, patients who are then put back into the
community knowing fine well that those patients will probably come back in as
part of a revolving door syndrome and the psychiatrist and clinicians are
powerless to do anything about it because they do not have the ability to
compulsorily provide treatment in the community. In other words, the
legislation as it is stacked at the moment is based on, frankly, a complacency
culture where only when an adverse incident happens, either to the patient or
to their career or sometimes to a member of the public, does the clinician
have the legal power to act. That has got to be wrong and sometimes when this
argument is being stacked up about the civil liberties of the patient it fails
to take account of the fact that the patient also has a right to have their
safety enshrined and protected by a mental health system that is designed to
do just that. None of this is easy and there are profound civil liberty
issues we have got to look at very, very carefully indeed but sometimes I
think the question is posed in a way that does not accord with the reality on
the ground and the poor old clinician is placed in that hopeless position
right now, an extremely frustrating position, and it is again one of those
instances where people working in the service feel they have to fight the
system and in this case have to fight the law and, frankly, that culture of
complacency which is embedded in the legislation, in my view, is long overdue
for change.
701. Can I ask a last question on the new Mental Health Act. I
think I am right in saying that 100 per cent of the evidence on this points
one way in terms of confidence building and how patients can view with some
sanguinity any new Mental Health Act. Given the difficulties that you have
very helpfully and adequately outlined, we have been given to understand what
would be an immense help would be a statutory right to advocacy enshrined in
any new Act.
(Mr Hutton) I think the issue about advocacy is partly addressed by
the proposals that we have made in the Green Paper for the new role for the
mental health tribunals. I think we have also made it clear in the Green
Paper that we are looking very seriously at the future role of the Mental
Health Act Commission and the contributions it can make in this important
area. We have not come to any decisions about that but we are, I can assure
you, looking very seriously at how we can ensure a proper and effective system
of advocacy for patients who find themselves facing the prospect of compulsory
treatment.
Mr Gunnell
702. How do you respond to the concerns that we have heard that
compulsory treatment in the community will have a damaging effect on the trust
relationship which exists between a patient and the mental health professional
that he is working with?
(Mr Hutton) I try and address these concerns in two ways: Firstly,
compulsion is not new. Compulsion has been an aspect of the mental health
legislation in this country for decades. I think partly lying behind that
question might be a slight misunderstanding of exactly where treatment in the
community is going to take place. It is not going to take place in people's
homes so we are not going to ask community-based mental health teams to be
administering quite difficult mental health treatments in people's living
rooms or bedrooms. That is not happening. I think the role of staff in the
community will be essential even under the new proposals, and will be very
similar to their existing role under existing legislation which is to make
sure the patient is safely conveyed to hospital where the treatment can take
place. I do not think there is anything in the community treatment order
proposal itself that is going to add significantly to concerns about the
relationship between the user and the profession. Secondly, Mr Gunnell, I
think the other important point here to bear in mind is that certainly under
the current legislation it is the staff themselves who make the decision to
compulsorily treat. That is a responsibility in future that will rest
entirely with the mental health tribunal. I think that will improve the
relationship and trust and confidence between patient and staff.
703. Yes because a patient can start off with a mental health
professional who can in a sense talk them towards a treatment and hopefully
convince them that is it is necessary.
(Mr Hutton) Yes.
704. Could I ask another question "in passing", as the previous
questioner said. I have taken a particular interest in electro-convulsive
therapy and I have been pleased to note that as we have gone round to various
places, both prison and special hospitals, it hardly has had a mention at all.
Knowing that you collect statistics in these matters and the extent to which
it is used, would it be fair to say that it seems to be much less in use now
than it was before and that the real need for that as a particular form of
compulsory treatment has greatly diminished?
(Mr Hutton) In fact, figures show there has been an increasing use of
powers to compel treatment under the Mental Health Act and that trend has been
with us for some time.
Chairman
705. He is asking about the use of ECT.
(Mr Hutton) I did not hear that, I am sorry. We did cover that in the
Green Paper, the suggestions that Professor Richardson put forward for
extending additional patient safeguards around the use of ECT and we are
looking very seriously at the points made in relation to that consultation.
We have always been quite clear, and the evidence is fairly strong, that in
some cases it can be a life-saving treatment. I am not sure anyone knows why,
but it can be a life-saving treatment. That is particularly true in the case
of quite serious psychotic illness. We want to be very careful about whether
we might inadvertently deny people access to what could be potentially
life-saving treatment. There is a very strong cross-section of views on that
right across the spectrum about whether we need additional safeguards or not
and we will certainly be looking very carefully at that when we come to
consultation.
Mr Gunnell: You will know I have views on the compulsory use of
electro-compulsive therapy and I hope its use on that basis will be at a very
minimal level.
Chairman
706. Before I bring in Dr Stoate, going back to John's original
question about community treatment orders, what steps have you taken to
evaluate the new supervised discharge orders and the use of guardianship in
the context of thinking about community treatment orders because a lot of
people feel that you are proposing something that could be covered by existing
provision?
(Mr Hutton) I think we are pretty sure, Chairman, that it is not
covered by existing legislation. In particular, the provisions of the 1948
National Assistance Act do not extend to medical treatment and the minor
changes made in the 1995 Act which did modify the Mental Health Act did not
provide for community compulsory treatment either. We would certainly not be
proposing a change of this kind if we did not feel there was a need to do it,
in other words existing legislation provided us with the sort of provisions
we needed. I can tell the Committee one thing which I think they might be
interested to know. There has been some concern, and perhaps underlying your
question this may be the point you were making, on the issue about whether in
fact if we go down this road we will improve the safety of the services we are
providing for both the patients themselves and for others as well. The first
evidence is now beginning to emerge that in fact community treatment orders
will provide a better level of safe services for people and it was published
in last month's edition of the British Journal of Psychiatry. It was a
randomised control trial in the US and of course a randomised control trial
is the gold standard in terms of research studies and it did point to quite
a significant impact of the contribution that CTOs can make to safety of the
public and patients and staff at large and we will certainly look at that
evidence very, very carefully indeed as we proceed.
707. I would just make one point, that this Committee at a time
when I was not a member did do an inquiry into community treatment orders and
I think the Committee as a whole started with a majority in favour and came
out completely against it. You may want to have a look at the conclusions of
that inquiry which were interesting.
(Mr Milburn) Just before Dr Stoate comes in, could I say that we will
look at that and I think it is also important to get a sense of perspective
about this. The community treatment order is intended to deal with the issue
of non-compliance. Not all non-compliance means high risk either for the
patient or for members of the public but some does and obviously in applying
the CTOs we have got to do so on a case-by-case basis and we have got to do
so on a sensitive basis, but it is worth reminding the Committee about what
non-compliance has meant in practice. Certainly from the evidence we have had
from the National Confidentiality Inquiry report which John referred to
earlier, Safer Services, which was published last year, it said in a two year
sample of over 2,000 suicides by psychiatric patients 26 per cent were non-
compliant with drug treatment in the month before death, and in an 18 month
sample of 54 homicides by psychiatric patients 30 per cent were non-compliant.
Now there is a choice for us. We either try to continue with the existing law
which most would say is inadequate but forces clinicians into the hopeless
position I described earlier where they are incapable by law of providing the
treatment and care which they know patients need, or despite all of the
caveats we try and change the law and modernise it to make sure it is more
appropriate to the way services are provided nowadays in the community rather
than in hospitals. Despite all the difficulties with CTOs, it seems to me,
based on the evidence we have there is a very, very powerful case indeed for
changing the law and ensuring on an appropriate basis and of course on a
sensitive basis that people are able to receive the treatment they need in the
community rather than just assume that the current mental health legislation
will cover all eventualities. It does not, it has failed, and this toll of
suicides and homicides I am afraid has been the consequence.
Chairman: We could spend a lot of time in this area and I am not
expressing an opinion either way but just saying that we have had strong
evidence from some of the professionals involved in administering and dealing
with this order that they feel it may not work in quite the way the Government
envisages, but we will look at this in our report.
Dr Stoate
708. Mr Hutton, you talked earlier about the difficulty with
capacity and I understand the problems you have as a Government in responding
to that, but an awful lot of witnesses have said to us that the very wide
definition of mental disorder proposed in the new legislation actually is
helpful because it does clarify a lot of areas and does avoid arbitrary
exclusions. What they have also said to us is that it does have to be
accompanied by some sort of reference, either treatability and/or capacity,
or it becomes impossibly wide. How would you respond to that comment?
(Mr Hutton) I think the approach we have tried to make in framing this
proposal, certainly in the consultation document, is to listen to advice from
the expert committee firstly - and they were very clear they wanted and
recommended that definition of mental disorder and I think there is a general
consensus that is quite a sensible way to start the ball rolling - but then
we need to make sure, particularly when we talk about compulsion, that the
crucial issue, leaving aside the argument about capacity at the moment, is
that we have a proper system of risk assessment. One thing is very clear, at
least I hope it is, that what we are not trying to do is increase arbitrarily
the number of people who are subject to compulsion; of course we are not
interested in that. This is a scarce resource, if you like, and we have to
make absolutely sure that it is only used in cases where clearly the patient
will benefit from that treatment, and that is in fact one of the general
principles we suggested might inform the new administration, that there has
to be clear evidence that the patient would benefit from that treatment
programme. There is also evidence, and it is very strongly referred to in the
Richardson Report, that there is dissatisfaction with the treatability
concept, and that is why Professor Richardson and her team recommended we do
not proceed in the future legislation with the treatability test because it
was not working in a way which was helpful, and in many cases it was literally
denying people the opportunity to receive care and support. We have tried to
put in this framework of proposals in a way in which we can simplify the
gateway into compulsion, make sure it is based on a robust system so it is
only used in cases where it needs to be used and where patients can benefit
from it, but do not at the same time replicate some of the mistakes we know
are apparent in the existing legislation. I have to say that the issue of
treatability is very clearly documented in the Richardson Report as an issue
where they were clearly of the view we should not proceed with that in the new
Bill.
709. I happen to agree with you on that point. Obviously up to
now treatability has been the hinge as to whether somebody can fall under the
auspices of the Act. I want to move the debate on now to dangerous severe
personality disorder and start off by saying that several people have said it
is a very confusing term because actually it is not found in a standard
classification. Would it be better to use the term "dangerous anti-social
personality disorder" because that would somehow clarify things? Would you
agree it is confusing at the moment? Perhaps I should ask Mr Boateng.
(Mr Boateng) Dr Stoate, the Secretary of State for Health made his
little joke earlier on in the Committee's proceedings in relation to the Home
Office being the opposition sat alongside him, and of course he meant it as
a joke ---
Chairman
710. Did he!
(Mr Milburn) For clarification and for the record!
(Mr Boateng) --- but we are working very closely together in the area
of prison health. But of course underpinning that there is a serious and
quite proper and I believe creative tension between our two roles, because we
in the Home Office can "never" park to one side the safety of the public even
for the sake of argument. That is a tank which is firmly parked on our lawn -
we do not have a lawn in the Home Office, we have a reinforced concrete
carpark - it is quite properly there and it is our responsibility. I think
it is only fair to share with the Committee at the outset that the
Government's proposals on dangerous people with severe personality disorder
are first and foremost a criminal justice measure and they should not be
confused with the issue of mental health and these very important reforms.
I say that with some passion as a former mental health minister because I know
that mental health and the field of mental health and people suffering and
living with mental health problems are all too often stigmatised in the public
eye by this essential confusion. There are, as you will know, Dr Stoate,
about 2,400 people who have and exhibit what we have chosen to call the
indications of being dangerous people with severe personality disorder, 1,400
of them are in prison, 400 in secure NHS hospitals, and we have between 300
and 600 out in the community. We have quite deliberately chosen this term in
order to avoid the confusion that would otherwise arise if we were to adopt
a clinical or medical approach to this issue. It is a specific decision we
have made which is why we have used this term. We can have a debate and we
can have a discussion about the semantics of it but I think we are pretty well
able to identify that small group of people about whom we are talking.
Dr Stoate
711. Can I say how pleased I am with that answer because that is
exactly what I wanted to hear, that is that you see this as a criminal justice
issue and not a mental health issue, because I believe the two are separate.
I meet psychiatrists on a regular basis and they are extremely worried about
their role in trying to determine whether somebody is likely to be a dangerous
individual and in fact they would much rather it was left to the criminal
justice system which they believe is better able to protect society if society
believes it needs to be protected in that way. So I am very pleased with the
answer you have given us.
(Mr Boateng) But let me say in response to your statement that whilst
it is a criminal justice issue we do not say that there is no role for
psychiatry. All the evidence is - and I would commend to the Committee a
visit, if you have not in fact made one, to the Van Hoven (?) Clinic, for
instance, in the Netherlands - that interventions can be made of a
multidisciplinary nature, which involves psychotherapists, psychologists, the
Probation Service, psychiatrists, but it needs to be seen in this
multidisciplinary way. These proposals are brought forward to avoid the fault
line opening up around treatability which has led to so many tragic cases
where people have even sought access to the system and been denied it because
they were "untreatable".
Chairman
712. Did I misunderstand the Home Secretary's comments nearly a
year ago when he appeared to be highly critical of the Royal College of
Psychiatrists' position on treatment orders and treatability? He appeared to
be suggesting that they were in a sense opting out of their responsibilities
by arguing that the DSPD - well, we were not into that categorisation at that
stage - that the personality disorder was effectively untreatable. If I
misunderstood him, I owe him an apology - at the time I asked a fairly
critical question about this and I think at the time you were in the
Department of Health - but he appeared to be saying at that stage something
very different from what you said just now.
(Mr Boateng) No. What he was drawing the public's attention to in a
robust, trenchant way - entirely justified and entirely appropriate - was the
very real problem which existed and which still exists to a certain extent,
there being what amounts almost to a lottery as to whether or not you are able
to access this area at all in terms of any sort of interventions in a
therapeutic context because there is a division within psychiatry, a very real
division, between those who believe it is possible to make a series of
interventions in relation to dangerous people who exhibit severe personality
disorder which can make a difference and which will bring about some
improvement and reduction of risk, and that school in psychiatry which says
basically there is nothing you can do, and indeed by trying to do anything you
may make the situation worse. What he was drawing attention to was the need
for psychiatry to wake up to the importance of working in a way which
facilitated research and the development of services in this area because that
was something which some psychiatrists did not do - not all by any means,
because there are a number of distinguished forensic psychiatrists, and the
sub-committee of the Royal College contains a number of them, who are working
in this field. But he was drawing attention, rightly, to a gap in provision.
713. So those of us who assumed he was ticking off psychiatrists
for refusing to sign treatment orders on people they deemed untreatable read
the wrong message?
(Mr Boateng) No, what he was doing ---
714. Because that message was read in the same way I read it by a
lot of other people.
(Mr Boateng) What he was doing, and again I say rightly, was to draw
attention to the consequences of some psychiatrists simply washing their hands
of this problem and saying, "We want nowt to do with it", and the dangers
which would flow from that. That is why, if I may say so, in conclusion in
response to this part of your question, the work we are doing together, albeit
with that quite proper creative tension between the Department of Health and
the Home Office on this issue, in close collaboration with the Royal College
amongst others in actually getting the research in place, getting the pilots
off in Whitemoor and now in the secure NHS sector, is so very important,
because we are making real progress.
(Mr Milburn) It is just worth adding that Paul is absolutely right
about this and indeed the Royal College of Psychiatrists themselves, as you
will be aware, have now called for, quite rightly, randomised control trials
into this high risk group. Not only is the jury out but there is mixed
opinion within the psychiatric profession and that is just true and there is
a big argument and a big, big division, as it happens, not between the
Department of Health and the Home Office but within the psychiatric
profession. That is all very well and good and these debates need to happen
in the clinical community, we need to undertake with the medical profession
the sort of clinical trials which have been advocated, but in the mean time
there is a very small but a very high risk group of people with severe
personality disorder who are dangerous in the community and we have to do
something about it.
715. Let me put to you what has come over to us from talking to
other people. You have both referred to the inevitable tensions between the
Home Office and the Department of Health and these are legendary over the
years and we have picked them up on numerous issues, not least the juvenile
justice versus care question which is a classic area of tension. The picture
we have got, and certainly I have got, from a number of people is that in
areas of health care, areas which really are within the area of responsibility
of yourself, Secretary of State, the Home Office has taken over and is in the
driving seat with a law and order message behind what is being put forward.
That is the picture I have got and my colleagues can disagree or agree, that
in a sense you have been hijacked by the Home Office in this area of policy.
It may be right or it may be wrong but that is the picture I have got from a
number of people. How would you respond to that?
(Mr Milburn) I would say it was wrong. I do not know what the
perception is but, if that is the perception, it is the wrong perception.
This is a problem for the Government as a whole, it is not just a problem for
the Home Office but a problem for the Department, for the Prison Service, for
mental health services, and somehow or other we have to find a solution to
that problem. The truth is we can only do that together. Paul has alluded
to the fact that we have pilot work going on in HMP Whitemoor at the moment,
we have work going on in the National Health Service too to try and crack this
problem, and in the end it will only be cracked on the basis, one, of cross-
governmental co-operation, which there is, and, two, on the basis, as he says,
of multidisciplinary team work because the range of interventions which will
be required here will be deeply complex.
(Mr Boateng) I would just say this, Mr Hinchliffe, I am, uniquely I
think in this field, in the position of having had a responsibility at one
stage in my life in government for Department of Health officials working on
this area and then subsequently moving over and having responsibility for the
group of Home Office officials who have been working with those Department of
Health officials prior to my move. I can only say that they have worked
consistently to the same agenda, drawing together their various strands of
professional skill and departmental experience. I would not want you to think
this was something which was only applied in relation to dangerous people with
severe personality disorder, because day in and day out the mental health unit
of the Home Office is having to work with the Department of Health and front-
line clinicians in the special hospitals dealing with issues in relation to
risk assessment and people who present a danger, whether mentally ill or
people with severe personality disorder, on their release from prison or from
secure hospitals into the community. This is work experience which goes on
day in and day out and one pays tribute to them and to the Probation Service
for the work that they have done in this area, and the extent to which the
public are, as we speak, being protected by that collaborative work.
Dr Stoate
716. Clearly this is a very complex area and I am sure we could
debate this for a very long time and the working of psychiatrists is a very
complex area and you will never get psychiatrists to agree ----
(Mr Milburn) You can say that!
717. --- but there are two issues, risk and treatability. Clearly
there are some people who are high risk and there are some people who are
untreatable. I think most of us would probably agree that, even if we cannot
necessarily agree on which people are untreatable, there are going to be some
groups of patients who are untreatable for whatever reason. The problem I get
and the problem I get from psychiatrists is that previously it has been too
easy to dump it back on psychiatrists and say, "Well, you must have some
intervention you can come up with and there must be something you have not
tried" and therefore try and get them back under the auspices of the Mental
Health Act, and that was a laudable aim up to now, but there will still be
people who fall outside that and about whom the psychiatrists will say, "There
is nothing we can do". What I want to focus on is what we do about them. How
are the proposals you are putting forward as a Government to deal with people
in this group going to work? How is it going to function? Will we simply
fall foul of the human rights legislation by detaining somebody who is not
treated for being mentally ill nor have they necessarily committed a crime?
(Mr Boateng) Firstly, if I can deal with the ECHR point, because it is
a very important one, we must not be confused here about what the impact of
the ECHR is. The ECHR does not refer to mental illness, it refers to mental
disorder. The ECHR enables the detention of people who are suffering from a
mental disorder in circumstances where that detention is justified on the
grounds of public safety. Indeed it is that, together with appropriate
safeguards around review and appeal, that will be built into either of the
options that we have proposed. Now Option B has been endorsed by the Home
Affairs Select Committee, we have not yet come to a view on it, but whether
we have Option A or Option B, one, we are satisfied it is ECHR-compliant - and
there is good precedent from elsewhere in Europe and I refer again to the work
in the Netherlands to indicate that - but, two, we are going to build into the
system a whole raft of review and appeal mechanisms which ensures that people
have an opportunity to demonstrate and question and challenge the assessment
of risk that the multidisciplinary team make. Let me just say one thing which
I think is important, I do not actually accept that there is a group of people
for whom no intervention can ever have any beneficial effect whatsoever. It
may be that there is a very, very small group of people who can never safely
and in an unsupervised way be released into the community but the evidence
from everybody - the experience from the Van Hoven Clinic and the Peter Barnes
Centre in the Netherlands, the work which is being done in the Mendota Mental
Health Institute in Wisconsin, which I have seen for myself, in the Moose Lake
Sexual Psychopathic Offender Treatment Centre - indicates that these people
can be held in secure environments which, whilst they are not clinical
environments and are not prison environments, are environments where you can
ensure there is a range of interventions and activities which ameliorate their
condition and at least keeps them in a state which is far better than that
which a number of them are presently ensconced in within existing prison and
NHS services.
718. Let us take the example of a life-long paedophile who has
served his sentence - and we can all think of good examples of this - and
therefore is, as far as society is concerned, free of his service, he has done
his however many years and he is out. He does not come under the definition
of treatment for a mental disorder and therefore the Mental Health Act is no
good. He then says, "I am not going to have any more treatment, thank you,
but there is a pretty good chance I will reoffend, what are you going to do
about?" What are you going to do about it?
(Mr Boateng) Already this Government has taken steps in relation to
paedophiles to give the courts the capacity through the greater use of
discretionary life sentences to pass such a sentence and for those people to
be held indefinitely in a prison context. That can happen at the moment.
Where the courts have been unwilling to pass a life sentence and currently at
the moment that paedophile comes to the end of their sentence, it is
undoubtedly a cause of great concern to the public and a concern which the
Secretary of State has indicated we have to respond to; they are released into
a situation in which they are undoubtedly a real and ever present risk to
children, and there is absolutely nothing that we can do about it. I do have
to tell you that these provisions are designed to enable us to do something
about it and it will mean holding them in a form of preventative detention,
and I do not want to deny that for one moment; preventative detention with
safeguards compatible with the ECHR and to hold them in a decent, safe and
secure condition which enables us to protect children. If I can give you just
this one example from a recent constituency case of one of our colleagues,
just such a person was released, we had no power to hold them, there was the
usual - all too usual - argy-bargy about where they should live and where they
should be housed, with one local authority completely washing their hands of
them, they were ultimately, thanks to close police/probation work, picked up
in a McDonald's in Ealing having attached themselves to a party of young
children.
719. Pretty frightening.
(Mr Boateng) That is the reality. That is going on now, there is
nothing we can do about it and we are determined, whether we go for Option A
or Option B, to do something about it.
720. Finally, I would like your comments on Peter Fallon's
recommendation for reviewable sentences. Do you think that is a reasonable
option? Somebody could have their risk assessed on an on-going basis and, if
necessary, their sentence reviewed and extended and extended, if they were
felt to be at significant risk before they were released, rather than under
the current situation where they are often released knowing they are a danger.
(Mr Boateng) What one would say to that is, of course, that is not
inconsistent in any event in terms of what potentially might happen with the
discretionary life sentence. It is not inconsistent with that. We do not
believe that that proposal deals with the whole situation because it does not
enable us to develop the sort of services we are very anxious to develop -
Health and Prison Service together - around the needs of people with severe
personality disorder. One of the great advantages, whether it is an Option
A or an Option B, is a whole range of service enhancement gains. So although
my first concern has to be the safety of the public, one of the reasons why
Health and the Home Office have worked so well in this area is because we do
see here too the needs of the offender, the needs of the person who suffers
from the severe personality disorder, being better met as a result of this
joint work, the development of a risk assessment tool, the piloting which is
going on in our two services. Peter Fallon's proposal, while one understands
why he makes it, does not enable that to happen, nor does it deal with that
group of people whom I have described, some 300 to 600, who are currently out
in the community whom we need to deal with if we are to protect the public.
Dr Brand
721. I am getting increasingly confused because you are describing
two quite separate circumstances. One is someone who has offended, been
through prison, refused therapeutic intervention quite often, and at the
moment you have not got the powers and you want to acquire powers and I think
that is perfectly right under the criminal justice system. But we are really
talking about another group where I was surprised that you said this was a
criminal justice issue which is to pre-empt danger to the public, after risk
assessment, and compulsorily detain someone under the criminal justice system.
That, I think, is quite a different issue. Your comments on the European
Convention of Human Rights were interesting because that does also make
reference to therapeutic intervention and this is why clearly in the
Netherlands they have gone very strongly for that. I must say I seldom agree
with anything the Home Secretary says but his opinion of psychiatrists I do
rather agree with. The actual question is, do you not think you have to base
your criminal justice legislative framework on a therapeutic intervention
possibility, because otherwise you do not have a hope in hell's chance of it
actually sticking? It is not really a criminal justice issue, it is a
therapeutic and therefore health issue.
(Mr Boateng) I am not sure this is a particularly helpful approach to
the problem which I accept exists, and this is a very complex area, with that
very, very small group of people who are out there in the community at the
moment, who do not and would not necessarily access this system, whether we
go for Option A or Option B, through the current criminal justice process or
through the current or indeed even an amended, to remove the condition of
treatability, Mental Health Act. There is a small group of people, very
small, who are out there in the community. We would not intend that that
group should be detained in anything other than an environment that, whilst
it was not a hospital, was not a prison either. So there would be a context
in which they would be held and subject to a range of interventions, some of
them of a therapeutic rather than an overtly clinical nature.
722. But surely the justification for holding them would be that
there is an intervention that is likely to be therapeutic?
(Mr Boateng) No. The justification for holding them, and this is why
I make the remark I do about the necessity in some instances for a form of
preventative detention, is that they present a real and present danger to the
public and cannot be released until such time, if ever, that risk has been
minimised.
Dr Brand: Mr Chairman, I think this may be a very good issue for pre-
legislative scrutiny because I can see great difficulties in this. No doubt
you have had lots of advice but it would be very helpful, if we can use that
process for something as uncontroversial as the Food Standards Agency, to have
a one-off Select Committee look at this because it does raise incredibly
important civil liberty issues. Whereas I have every confidence in a British
Government applying this sort of reasoning reasonably ---
Chairman: We could have Mr Boateng back again!
Dr Brand
723. --- even where Mr Boateng is so powerful in the Home Office,
it does open up all sorts of worries. This is how Russia ran their mental
hospitals.
(Mr Boateng) I think that is slightly over-egging the pudding, Dr
Brand, if I may say so; uncharacteristically so. It is almost inconceivable
that this would apply to somebody who had never had any previous contact with
the criminal justice system. I do think that point ought to be made. It is
almost inconceivable that this would apply to someone who had not had previous
contact with the criminal justice system, but the evidence, such as it is, is
that it might be possible for somebody who had not to be caught under the
provisions that we propose under the new regime, either in relation to Option
A or Option B. But if that were the case, then the justification would be
subject to the most rigorous scrutiny through the review and the appeals
procedure, would in any event be subject to that scrutiny, but would in any
event be subject too to a process whose justification would be public
protection. This is an issue around public protection rather than an issue
in relation to treatability or mental health. I would end my answer on the
basis, because it is very important to understand the rationale behind the
provision, that the mental disorder link with public protection and risk to
the public is justifiable under the ECHR.
Chairman: I am conscious that we were hoping to try and finish by half
past six and there is a whole range of areas we would still like to touch on.
Mr Amess
724. Before doing that, Chairman, and I do not want the three
members to comment on it, can I just say that we had an excellent visit to
Belmarsh, which was opened in 1991, yesterday, and Bracton, opened in 1984.
Although we will not expand on it, they certainly were concerned about the
whole issue you have just been discussing, and I think there was some sort of
video link after it had taken place whereby it was suggested that heads be
knocked together because they were not singing the same song, but I want you
to reflect on the views from those two excellent establishments. Gentlemen,
you are only too well aware there seems to be a shortage of services for
helping young and adolescent people, and in particular there is a problem when
people move on from the adolescent stage to the adult services; a big gap
there. Those problems are compounded by the cut-off age of 16, 18 or 21.
Officials have given us evidence telling us that they did not necessarily
think, when it was suggested we had a cut-off point of 18, that was good.
They suggested that the present system was suitable because of the flexibility
that it enjoyed although we seemed to have contradictory evidence about that.
I just wondered what your views would be on the youth service which would deal
with late adolescents and people in their early 20s when conditions of
schizophrenia and others seem to develop. I think the overall view of the
Committee was that youngsters seem to be slipping - and this is not an
original statement - through the system and this is particularly impacting in
the realms of offending.
(Mr Hutton) I think there is a problem here and we acknowledge that
but I would say there is a number of difficulties we need to make some further
progress on before we can be confident that the options you are proposing and
others are proposing will sort this out. Firstly, there is no absolute
consensus about what the cut-off or the transitional age should be between
youth services or children services and adult services. The other problem is,
should we be using rigid chronological ages as being the threshold for
transition from young person services into adult services because, of course,
as we all know from our own experience, somebody who is 16 may actually have
very different emotional needs from someone who is 18 and in fact the person
who is 18 may actually present as a person with much younger problems. So
there is a problem about that, we are looking at a range of proposals which
have been put forward by groups like Young Minds and others to see what
further progress we can make there. I would just draw the Committee's
attention, very briefly, to the National Service Framework which made a number
of recommendations to get local agreements in place to cover some of these
concerns. I think we will make more progress in this area thanks to the
significant investment which is going into child and adolescent mental health
services, œ90 million over the next three years, a big investment, and it will
allow us to turn round some of the historic problems we inherited. I have to
say that one of the problems we inherited when we came into government was
that the actual number of beds, just one aspect of the service, had almost
halved in number in the preceding two years. We have to turn that round.
There are other issues we need to address too, but I think the new money and
the new focus in the National Service Framework and the desire generally on
our part to address these issues means we will make some real progress.
(Mr Boateng) I would endorse what John Hutton has said because it does
have, as Mr Amess indicated, implications for young, young offenders, and it
will be very important, and we are working hard to ensure this happens, that
the youth offending teams are able effectively to draw on the experience and
expertise of the local health service in terms of their work and their
intervention in the youth justice system. But also, and the Secretary of
State was referring to this earlier, as we get the community mental health
teams working more in prisons - and they are going to be coming in, working
not only in the health centres but, particularly importantly, on the wings -
it will be important that we target that group of people who do not
necessarily fit in between the old definition of 18 to 21 but who may be 23,
24, 25 but who are held within the prison system who do have very real mental
health needs which are currently not always picked up, either by the Prison
Service or by the NHS.
(Mr Hutton) One issue we are very keen to address is the inappropriate
placement of young people on adult acute psychiatric wards. That is a very
serious issue and some of the extra money which is going into these service
areas will hopefully minimise that, but it is something which is of very real
concern and I think we are making good progress in providing extra capacity
in that part of the service, and that is a very positive development.
725. With only three minutes left, Chairman, I will not be
provoked about shortage of beds, just simply to reflect that we visited two
excellent establishments founded in 1991 and 1984, and I am sure you get the
point I am making there. You are not ruling out the youth service?
(Mr Hutton) No, but I think it may not be quite as simple as that.
726. But it is not being ruled out?
(Mr Hutton) The important thing is to get the transition right from
young person's services to adult services and I think there may be a variety
of different ---
(Mr Milburn) That is why the NSF, for example, stipulates to the local
health services on this cusp between adolescent services and adult services,
but there have to be protocols for managing the transition between the two
and, in particular, this crucial issue about young people being
inappropriately placed on adult wards. The message which the NSF sends out
is that should be minimised. Of course it should, it is just inappropriate.
But over time we can solve that problem as we grow the capacity.
Mr Gunnell: There is some good work in North Birmingham where they
have an integrated approach, where young people move smoothly into getting
help when they need it, at the point when they start to need it.
Mr Amess
727. A final point about Young Minds, they said that even to use
the term "adolescent psychiatric services" was a misnomer, because they
thought that specialist services were so rare in that group. Would you agree
that this amounts to a form of treatment by post code and how do you intend
to deal with the enormous variation in service - in one and a half minutes?
(Mr Hutton) I will try and keep a very straight face as I try and deal
with that question because I have to say that was the legacy we inherited.
We are addressing exactly that problem. It was, I am afraid to say, Mr Amess,
your party's contribution to the National Health Service and we are going to
be the ones to sort that out.
Chairman: Can we just squeeze in a couple of quick questions on the
special hospitals and secure services? I know Eileen wants to speak briefly
on women and I think Peter wants to say something. What I wanted to press you
on was the concern I have had over a long period of time that we have had
report after report, the Reed Report in particular, we had Dr John Reed here
at the Committee last week, we had the Fallon Inquiry which made specific
recommendations with regard to effectively breaking up the Specials and moving
towards a regionalised provision. Is it right that I draw the conclusion that
that will never happen under any Government because of the political
difficulties of developing regional secure units within localised areas? That
is my question but what I would like to do is to bring my colleagues in and
perhaps you can answer all the questions at the same time.
Mrs Gordon: I could go on for hours about women's services and I am
glad, Secretary of State, you mentioned that earlier as being one of the
priorities. One of the things which is most depressing and shocking is the
number of women in special hospitals inappropriately who really should not be
there, and some in pre-discharge wards certainly in Broadmoor for years. It
is just awful. Part of the problem is that there is a kind of gender
blindness, that they are just lumped in with the men's services without any
special consideration for their special needs. One of the terrible things is
that one of the new security directives is limiting child access. This was
obviously done for a good reason after Ashworth and the inquiry there and
obviously that needed to be done but it applied to a specific group of men and
yet it is being applied to women as well so they are now having limited access
to children and relatives. It just seems a gross misjustice that they are
being covered with this blanket security when they did not cause the problem
in the first place and indeed most of them should not be there to begin with.
I wondered if you would look at that, the access to their children and the
whole direction of looking at women's needs. The other thing is that I
understand there was a move to produce a strategy on women's secure services,
a national strategy, and I would like to know what has happened to that and
when it is going to come into being.
Dr Brand
728. Very briefly because it relates to that, we have already
discussed inappropriate placements, the Secretary of State said there would
be an extra 200 beds on top of the 500, as I understand, and that of course
is extremely welcome, but I am disappointed that in the memorandum from the
Department we have got costings for the cost of a secure bed but it is not
possible for us to have a figure for a medium secure or low secure facility.
If you are planning them, you are costing them, and presumably there are some
figures available. There are no figures for the average cost of treating a
psychiatrically-ill person in a prison. It would be quite helpful if a little
more work was done on that, because I know a lot of resources are spent
sectioning prisoners with suicide risk, so we can also strengthen the economic
argument as well as the clinical argument. The evidence we have had from Dr
Reed confirms that there are 500 people probably in the Prison Service who
ought to move on and that there are at least 400 people - this is from the
people running the special hospitals - in the special hospitals, so the
shortfall is more likely to be 900 than 700. But one cannot ask for
everything all the time, even I would not do that.
(Mr Milburn) That is very generous of you, if I may say so!
729. Until we have the extra penny.
(Mr Milburn) That will solve all the problems, as you keep telling us.
On this issue of the number of people who are wrongly placed in the system,
that was our starting point this afternoon, and it is certainly true. Just
a word of caution, yes, there are problems with those who are, if you like,
in the discharge system within the three high security hospitals, that is
true, but there is, as you know, a huge process which has to be gone through
to ensure that they can be discharged, and there are rather fewer who have
gone through that process and are waiting for placement - around 60, I think,
who have got Home Office approval overall. So we do recognise that there is
a problem, of course there is, and there is a lot of people who are
inappropriately placed there. There are some people who are inappropriately
placed in prisons ---
730. But they cannot be discharged because there is not a suitable
place to discharge them to, and that is probably why the Home Office have
limited the ---
(Mr Milburn) That is precisely why there is a focus on the intensive
care medium secure and low secure beds as well. As far as costings are
concerned, we can have another look at that certainly. There are costings,
as you know, leaving aside specialist medical treatment. Keeping somebody in
prison for a year costs between œ20 and œ25,000, to keep somebody in one of
these hospitals costs well over œ100,000, but in the end what should inform
judgments is not so much the cost, it should be the appropriateness of the
treatment and the care and indeed the security which is necessary for some
people. The starting point was Mr Hinchliffe's question about the potential
closure down the line of some of these hospitals. The reason we have not gone
for that 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. The worst thing possible, in my view, would be to
lose that expertise and that experience. What we do have to do, however, is
to overcome if you like the isolation of the three hospitals. It is perfectly
clear, and indeed it has been a continual line of inquiry both in the hearing
this afternoon and in your previous evidence, that because of the hospitals'
isolation and because of the perverse incentives of the funding arrangements -
remember, right now, it is a free choice for health authorities to stick
somebody in one of these hospitals - that is precisely the reason why we have
devolved decision-making down to a more localised level so that the clinical
decision is matched by some financial responsibilities as well on the part of
service commissioners. I think the model we now have with, if you like, a
National Oversight Group ensuring co-ordination, backed up by more regional
specialised commissioning arrangements involving not just high security but
medium security, is the right way to go on that. That will help us overcome
this problem, particularly for around 110 women who are in these hospitals at
the moment who all the evidence suggests need not be there but probably do
need a degree of security and secure environment but probably not the level
they are receiving at the moment.
(Mr Hutton) Can I just respond to Mrs Gordon's question about strategy
for women in a high secure state? The National Oversight Group are actually
looking at that right now and we have asked them to go away and bring that
work forward as quickly as possible. As the Secretary of State has said,
there is no question at all that those women inappropriately placed in the
high security estate will be amongst the principal beneficiaries of the
additional resources we are making available to improve the operation of the
system. In relation to your queries about the child directions, I think we
have to be clear about the child directions. They are aimed at the generality
of child visiting but there are specific issues around particular categories
of offenders who have a record and a history of either abusing other children
or their family members as well. I think you have to be absolutely clear that
we need to exert very careful control over inappropriate child visiting to the
high security estate. Judge Fallon was very clear about that in his report.
At Ashworth, I accept, it was in relation in the main to male offenders in the
personality disorder unit, but I think his point about offenders and the
reason why a person might be in a high secure unit applies equally to men and
women, particularly those women who have been convicted of serious violent
offences against children and other members of their family too. The child
directions I believe certainly chime with Judge Fallon's recommendations and
I think they are an attempt to try and address what he described as a totally
inappropriate pattern of child visiting into the high secure hospitals, but
we have tried to do it in a way which is fair to all patient groups and
prisoners. The basic principle and purpose of this exercise was to safeguard
the children themselves. Rather like in relation to public safety, I think
it is absolutely right that that should be our principal concern.
(Mr Boateng) There are issues for women generally which go beyond the
special forensic service and I think Mrs Gordon is absolutely right to draw
attention to the need for, in some instances, a gender-specific approach. If
I can give you an example, 40 per cent of women prisoners have received some
form of help or treatment for mental or emotional problems in the 12 months
before entering prison. That figure for men is 20 per cent. Two in five
women in prison have at some time attempted suicide. What that is telling us,
amongst other pieces of information we have, is that there are high levels of
mental ill health amongst women in the general prison population which we need
to address, and one of the ways in which we are doing that is to prioritise
the health needs assessments which we are now developing with the NHS in the
Prison Service. For instance, Holloway has been given a very high priority,
it has now completed its health needs assessment. There are issues there to
be addressed and we are seeking to address them but one of the ways in which
we are doing that is by putting the women's estate under one single area
manager now, so there will be a particular focus on women in the Prison
Service. What we need to do is to make that a safer and more decent
experience for them, and one in which these underlying problems in relation
to mental illness as well as substance and alcohol abuse, which are also there
and often related to it, are addressed. So Mrs Gordon's point is well-taken
in terms of the general prison population.
Chairman: I will resist the temptation to ask my colleagues if there
are any further questions and end by saying that there are a number of areas
we would have liked to touch on in more detail and some we have not touched
on at all, but on behalf of the Committee I express our gratitude to you for
coming today in what has been a very helpful session.
