Examination of Witnesses (Questions 600-621)
DR PHILIP
MCCLEMENTS,
PROFESSOR ROY
MCCLELLAND
AND DR
IAN BOWNES
16 OCTOBER 2007
Q600 Mr Murphy: Thank you very much,
Chairman. As usual, because of Alasdair's previous life he has
covered most of the points I intended to make! However, gentlemen,
if I can deal with two points in relation to people suffering
from personality disorder. In your view do you think the Mental
Health (Northern Ireland) Order 1986 should be amended to make
it similar to the Mental Health Act 1983 where people with severe
personality disorders can be detained?
Dr McClements: If I can lead on
that, the answer is yes.
Q601 Chairman: Having led on it,
would you like to amplify a little!
Dr McClements: Having said that,
I have a lot of friends in the medical profession specialising
in psychiatry who strongly disagree with me, so I will hand over
to two of those colleagues.
Q602 Chairman: You both strongly
disagree with him?
Professor McClelland: Can I come
in from the policy direction. The review of mental health and
learning disability in Northern Ireland has taken an entirely
fresh root and branch look at the state of mental health, learning
disability services and legislation in Northern Ireland, and I
do not think you can separate the consideration of the legislative
reform from the service reform. Not least of all, services for
people with personality disorder in Northern Ireland are really
characterised by a black hole within a Cinderella service. There
has not been a development of specialisms within Northern Ireland's
mental health services generally in recent years and people with
personality disorder are one of the groups whose needs are poorly
met within the health and social care system per se. Inevitably,
as a consequence you do find the criminal justice system tending
to absorb some fallout from that. Secondly, we have our particular
take on legislation. It is not dissimilar to the 1983 Act but
it is crucially different with respect to the expressed exclusion
of people with personality disorder. The Bamford proposals for
reform of legislation is that a much greater emphasis on capacity
should be the defining criteria and that people who require substitute
decision-making, either because of risk to themselves and/or to
others and proportionate to that risk should have arrangements
to protect them and others. It is indifferent to the medical diagnosis
and it is indifferent to whether or not it is mental health or
physical health so that we have a system being proposed for consideration
by Government which would be much more inclusive. The question
which would have to be asked is to what extent someone with a
personality disorder may or may not meet the criteria? From the
point of view of the Review, that is an equal playing field on
which to judge whether or not someone should have their freedom
taken away under a mental health provision as opposed to criminal
justice.
Q603 Mr Murphy: If these people genuinely
posed a threat to themselves or to the general public, in your
view should they be detained?
Professor McClelland: The concept
being promulgated within the proposals for reform of our legislation
is that if someone is capacitous and understands the nature and
consequences of their actions, then one does not have a right
to trump those actions. If that is an issue for public risk, then
we have criminal justice law to protect the public and that must
be allowed to express itself. On the other hand, if someone is
incapacitous with respect to particular decision-making, then
they ought to have protection and the public ought to have protection
in relation to their impaired decision-making.
Mr Murphy: Professor, are you suggesting
that we wait until someone who is suspected of potentially being
a danger to themselves or the public commits a crime before they
are detained?
Q604 Chairman: Could you answer the
question?
Professor McClelland: Yes. The
proposal in hand is that capacity is the criteria on which to
judge whether or not to override a person's freedom.
Q605 Chairman: I am sorry, you have
not answered the direct question directly, you are giving rather
convoluted answers. I understood Dr McClements' answer, it was
a simple "yes", yours is going round and round and round
the mountains of Mourne!
Professor McClelland: The diagnosis
would not play a part in the decision of whether or not to take
away someone's freedom, that is the proposal in the recommendations
coming forward in the legislation.
Q606 Mr Murphy: You would disagree
with that?
Professor McClelland: I would
support that position.
Q607 Chairman: Dr Bownes, do you
have a view on this?
Dr Bownes: Yes. From a purely
practical point of view, we have to deal with people daily. As
I mentioned, 75% of the people with morbidity within prisons suffer
from personality disorder related conditions and behaviours. Quite
frequently I would see individuals who suffer from personality
disorder where the outworkings of the various component parts
of their personality disorder lead them to deteriorate, lead them
to suffer from lowered mood, thoughts of self-harm, poor personal
hygiene, poor interpersonal functioning and those are the sorts
of individuals that I would like to see transferred from the prison.
I am realistic enough to accept that people with severe social
and psychopathic conditions which are untreatable should not be
going to psychiatric hospitals no matter what level of security
there is, but there is this group of individuals where the deterioration
of their mental state, the deterioration of their functioning
for quite often long periods of time, those are the sorts of individuals
I think legislative change could help. Those would be a relatively
small number of individuals which we would not be able to cope
with sufficiently within the prison but would benefit from the
opening of an NHS facility. At present, where we know that the
primary diagnosis is personality disorder, under current mental
health legislation we are precluded from transferring those individuals.
I would like to see that area changed as soon as possible. To
reiterate Roy's point, it is probably easier to change the legislation
in favour of detaining people with personality disorder than it
is to train up and put in place the whole gamut of personality
disorder facilities which would be required. A simple change in
the legislation will not do very much overnight to change the
culture, to change the absence of a culture of treating people
with personality disorder within NHS hospitals. We would also
require secure hospitals, we would require a range of secure facilities
and semi-secure facilities within the community so that individuals
who are treated under mental health legislation, when they are
well or relatively well they could step down into facilities in
the community. It is not just a simple matter of changing the
legislation, sending someone to a psychiatric hospital and all
their difficulties vanish, there has to be structural facilities
stepping down within the community and a range of professionals
who have a good track record of managing these individuals. We
do not necessarily have that within Northern Ireland. We do not
have the culture and we do not have the expertise of managing
people with psychopathic disorder the way we have in England.
We do not have the range of therapeutic communities, secure hostels,
medium secure facilities, higher secure facilities for people
with these conditions and that is a major problem which needs
to be looked at in parallel with any change in the legislation.
Mr Murphy: Thank you, Dr Bownes. You
have also answered my second question, which was what facilities
would you like to see in place. Thank you very much.
Q608 Stephen Pound: If I can ask
a couple of general questions. First of all, is everything you
said so far male sex specific because when you are talking about
two or three people going to Carstairs and you are talking about
34 beds at Shannon, can I get some idea if we are talking exclusively
about male patients and male prisoners? Secondly, less than a
week ago the Secretary of State for Health announced enormous
investment, about £89 million in cognitive behaviour therapy
which, to those of us who know nothing about the subject, sounds
to be almost like a magic bullet to solve all of the woes and
travails of society. Do you think there is a role for cognitive
behaviour therapy within the Prison Service? The final question
is Mitchel McLaughlin and Iris Robinson agreed yesterday, I just
wanted to leave that hanging in the air for a moment! One of the
things they agreed on was they both feel there is a reverse peace
dividend in the field of psychiatric health. Just as suicides
and self-harm in Great Britain increased at the end of the 1939-45
War they both feel, from not just anecdotal evidence but empirical
evidence from their surgeries, that there has been an increase
in the time of peace of particularly suicide and self-harm and
they both feared that this could be on an increase. Do any of
you have any feeling of the way the wind is blowing in that direction?
I am sorry to hit you with all three.
Dr McClements: On the first issue,
I would not be talking gender specific, it is equally appropriate
for female prisoners in Hydebank but the numbers are so small.
The numbers vary between 30 and 40 prisoners at a time. That group
is particularly difficult, and we could go into the issues of
the female population because while they are different as a group,
I think the same messages apply. We do get female prisoners who
have major problems in terms of personality disorder or major
psychiatric illness, but because of the small category of them,
they are not so prominent. In terms of CBT, it is quite interesting
because one of the things we introduced about three years ago
now was an initiative from the South East Belfast Trust, when
it was still in existence, for a CBT service to Hydebank to the
women and that has now been written up and is a very successful
model. CBT—and, again, I will turn to the experts in due
course—seems to be the flavour of the month. The other problem
we have in prison is it has been practically impossible to recruit
and retain clinical psychologists. We cannot get clinical psychologists,
so really we look to CBT as an alternative almost to clinical
psychology. The pilot in Hydebank has been very successful and
I know Maghaberry would like to do the same. In my view CBT is
a useful entity. In terms of Iris Robinson and Mitchel McLaughlin's
views on suicide—again, I know Roy has done a lot of work
and I will turn to him in due course—one of the things I
would put to the Committee which I found quite interesting is
suicide, as we know, particularly in young men and particularly
in North and West Belfast has been a major problem over the past
two or three years in terms of the numbers of young men who commit
suicide. It is a very interesting fact, and I do not want to tempt
providence, but there has not been a male suicide in the part
of Hydebank Wood where the male offenders are in the last seven
years, but many of Hydebank Woods' prisoners come from North and
West Belfast and the areas where suicide is very prevalent. It
is almost as if something happens when you bring those young men
out of their own communities into a prison situation, it protects
them against suicide and self-harm and many when they go out then
revert and may commit suicide. It is something I have said should
be researched because there is almost a protective factor—
Q609 Chairman: Is that the same with
the women?
Dr McClements: I could not answer
the question but the women would be in a different age group from
the young men. The average age in Hydebank would be older for
women than men. The male population for Hydebank by definition
is 17 to 21, so this is the high risk suicide group in the community,
but the last suicide was in either 1999 or 2000 and I am delighted
I find I am asking the reasons why is that.
Q610 Chairman: That is very interesting.
Professor McClelland: The issue
of suicide and the relative rates of suicide in the prison to
that of the community I think are more related to the patterns
across the countries. In other words, the Scottish suicide rate
in the wider community is higher as is the rate in prison. The
rate of suicide in England and Wales is smaller than Northern
Ireland, both in the community and in prisons, and taking our
suicide rate in prisons as a whole, it is intermediate, as is
the community rate. That said, there has been concern in the last
two or three years in particular about the increasing numbers
of young suicides. Again, that said, the situation is complicated
because the pattern of suicide increase is also seen in the South
of Ireland, so a simple explanation in terms of post-Troubles,
unlike the onset of war and terrorism where you do see a downturn,
and that was noted in the Northern Ireland situation, I think
the present concern and reasonable concern over the rise needs
to look at the usual kinds of factors which contribute to suicide.
There is evidence to suggest that these are the factors which
are important: socio-economic factors, social deprivation, single
parent situations, unemployment and mental ill health. Of course
if you go to those areas where these high incidents are being
observed, all of those factors are very prevalent as well. I expect
you need to look at the broader determinants of suicide to understand
something of the relationship between rates. I do think the Review
as a whole is very concerned about the two-sided factor. One is
that Northern Ireland's mental health services have been chronically
under-resourced on the one hand and yet we have evidence that
the prevalence of mental disorder, particularly at the community
level, is about 25% higher. I think that is relevant to some of
these issues in which suicide is the tip of the mental health
morbidity story. The last issue was the issue of CBT and the possible
benefits. I do strongly believe that the evidence is very convincing
among the psychotherapies for the efficacy of CBT. It has subjected
itself to scientific evaluation and has proven itself to be very
effective and also very cost-effective. I think the proposals
being promoted and driven forward by others, including Lord Layard,
are excellent and the investment from an economic perspective
is sound. We need to replicate this in Northern Ireland, and I
am quite certain that the benefits for all groups, including prisoners,
could be experienced with a skilling of workforce to deliver such
therapeutic benefits.
Dr Bownes: I would agree with
all that has gone before. Just to make two points on the gender
specific issue. We do have dedicated places within the Shannon
Clinic for women. There is also provision for dedicated and discrete
provision for women with mental illness problems who are transferred
to psychiatric intensive care units. What we have said regarding
morbidity reads across to the female population but, also, as
well, having regard to that, there is provision within the NHS
facilities to properly nurse and treat women in appropriate and
dedicated settings.
Q611 Stephen Pound: Those beds, bearing
in mind Dr McClements' earlier comment about the difficulty of
finding female doctors, do you feel it is necessary for a woman
doctor to treat a female patient?
Dr Bownes: No.
Q612 Stephen Pound: Forgive me of
my ignorance.
Dr Bownes: The lay person may
think so and certainly there would be a significant number of
women who would prefer a female doctor, but there are some studies
to suggest that at best a mix of male and female doctors attending
a female patient or in some circumstances a male doctor caring
for the female patient, the dynamics of the situation can often
be much more therapeutic, but it does depend on the core difficulty
which the individual may have.
Dr McClements: Relevant to the
gender issue, when I said about the necessity to have a female
doctor, I think the woman should have the choice.
Q613 Stephen Pound: Thank you for
that clarification.
Dr McClements: The position now
is for six months I could not get any form of doctor, male or
female, there was no response to the trawls for somebody to come
and help in the short-term. We now have a situation where we have
an option of a female doctor and two male doctors who are available,
so we can offer women the choice and most women will not say that
they insist on a female or a male, they are quite happy to see
a doctor. We run cervical screening and we run in particular a
gynae clinic for women which we feel should be done ideally by
a female GP.
Dr Bownes: I just want to make
a brief statement about therapy within the prison context. I am
a great fan of the prison using the appropriate social context
with the appropriate provision of therapies and I would welcome
further expansion of CBT within the prison setting. As Roy has
said, there is clear research evidence that this is efficacious.
I would like to point out that it is difficult to argue that you
should have CBT in isolation within the prison without there being
appropriate services outwith the prison so that whenever these
individuals have their therapy kick-started in the prison it can
be continued on using the same therapeutic principles within the
community, otherwise you are going to lose the usefulness of it
and waste that resource.
Q614 Mr Hepburn: What do you view
as a useful purposeful activity in a prison? How would you improve
the provision of purposeful activities in prison? How do you view
it as improving the mental health of prisoners in prisons?
Dr McClements: Again, I am not
an expert in this. At this moment in time almost my entire job
is trying to drive forward the transfer project, but my personal
view is—I am going back to my days as a GP—meaningful
activity in life is so essential. I would feel personally that
if I was confined to prison and did not have activities and was
in my cell for long periods of time, that in itself would be a
trigger factor for mental illness or even more drastic things
to happen, for example intentional suicide. Everybody in the Prison
Service, both sides of the discipline and health agenda are agreed
that suicide prevention is a lot to do not with health and not
with the Health Service side of prison. There was a tendency in
the past for the discipline side to say if it was a suicide issue,
"That's over to health. They deal with suicide". I think
there is now a general acceptance, it is all our business. Some
of the keys things in preventing suicide are about having meaningful
activity, about daily occupations, things to do during the day,
about just having company and having social interaction, all those
things are important factors in preventing suicide but, as I say,
I am not an expert in this.
Professor McClelland: I think
already there is research evidence showing that activity is important
in protection against depression and, secondly, the obverse, when
we looked at the prison situation in the context of our investigation
of non-natural deaths, we were struck by the amount of lock-down,
so one of our recommendations was that there was a much greater
emphasis on the day-time activity of prisoners.
Q615 Chairman: Professor McClelland,
would you like to add anything to what you said in your review
about the six non-natural deaths?
Professor McClelland: As you know,
that report brought forward 30 recommendations. It was not entirely
part of the Bamford Review, but as Deputy Chair of the Bamford
Review at that stage we saw those recommendations sitting very
close to the forensic report part of the Review itself. Recently
I was appointed to the board which is meant to champion the implementation
of the Bamford Review and as part of that I revisited recently
with Dr McClements just what had happened to the recommendations
in the non-natural death's report. I have to say, from quite a
detailed discussion over two meetings I am impressed with the
extent to which a number of the issues have been addressed. There
are a couple of areas where they have not been successfully addressed
and that particularly relates to the enhancement of mental health
services within Maghaberry Prison. This seems to relate to problems
about staff recruitment and issues of staff sickness. There also
has been some delay in moving from what is referred to as the
"Par 1 form" which had not itself been properly implemented
in terms of risk assessment to the form being used in English
prisons. There has been more delay than one might have hoped for
in moving towards that new assessment system. Those are the two
shortcomings out of the 30 recommendations which I have observed
and Dr McClements and I have noted together.
Q616 Chairman: Would you say also
there has been real progress in dealing with the issue of self-harm?
Professor McClelland: That has
been my impression, that the risk assessment arrangements, the
issue in relation to reception and reception assessment, the awareness
and, in particular, staff training and the use of the Par 1 form,
I was impressed with the effort being driven on this by the Director
General and his governors.
Q617 Chairman: Before we conclude
this public session, I want to clarify one point. Dr Bownes, you
were talking about developing special treatment for persons with
personality disorders in the NHS. To what extent would the development
of personality disorder units in prisons, such as the unit in
Maghaberry, be a useful way forward?
Dr Bownes: You are talking about
the REACH Unit?
Q618 Chairman: Yes.
Dr Bownes: I think that is a good
seabed to kick-start the whole thinking process of how you assess
these individuals, how you assess their needs, how you target
the morbidity and how you target the factors which cause them
to have difficulties, cause them to have sub-optimal mental health,
cause them to have behavioural problems and I would like to see
that resourced continuously. As our knowledge and our experience
of this builds up, think about developing a network of contacts
outside the prison, so that individuals who we have assessed,
individuals who we have worked with and treated, if they still
require an in-patient facility outside the prison on completion
of their sentence, they can be moved from the prison to that setting
and, again, then step down within the community.
Q619 Chairman: Bearing in mind the
size of the prison estate in Northern Ireland, even with any additions
following the review of the site which is going on at the moment
at Magilligan, do you think the REACH Unit needs either expanding
in itself or replicating in other prisons?
Professor McClelland: I do not
think there is a requirement to replicate the unit within other
prisons, I think enhancing the diversionary activities and enhancing
the input for assessment of mental disorder within the prisons
would suffice in other settings. The focus should be in one unit
in Maghaberry and our expertise should be poured into that unit.
It is more important to build up a core of expertise in one site.
Q620 Chairman: Gentlemen, would that
be a general view?
Dr McClements: Yes.
Dr Bownes: Absolutely.
Q621 Chairman: Thank you very much.
Is there any colleague who wishes to ask a final public question
before we go into private? No. Can I thank you publicly for the
evidence you have given which will be on the record and will be
publicised with our report and obviously taken carefully into
account as we determine what to recommend in our report. Are there
any points which any of you wish to put on the public record before
I close this session? Are there any points you feel either that
we have not adequately explored or you have not fully described?
Dr McClements: No, Chairman.
Chairman: Thank you very, very much indeed.
In that case, could I declare with grateful thanks the public
session closed.
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