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Lord Bethell: My Lords, I am grateful to the Minister for giving way, but has he considered the effect of what he has just said on the Government's position vis-a-vis the European Convention on Human Rights if those European citizens are not allowed to vote?
Lord Williams of Mostyn: My Lords, of course one considers that. I am giving your Lordships a full account of the conclusion of the Government's review. Your Lordships may wish to return to this matter in Committee and I may then have to expand my answer, but I have given what I hope is sufficient for today's purposes.
I believe that those are the main questions that have been raised, with the single exception of how to deal with various matters if one has multi-Member constituencies. That is the present situation in Northern Ireland and in multi-member local government wards. We believe that the difficulties are more illusory than real.
The noble Earl said: My Lords, my purpose in tabling this Unstarred Question is to ascertain whether the Government can say anything helpful about their attitude towards the future of special hospitals. In recent times, I have inflicted myself on the House often with regard to penal matters, sometimes dogmatically, but I am not withdrawing anything that I have said. Curiously enough, on penal matters I seem to have had the House with me over the years. Anyone who disagrees with me keeps quiet--except, of course, those who are employed otherwise.
I am sorry to say that my much-admired Home Secretary, Mr. Jack Straw, came out yesterday in The Times with an attack on old Labour's attitude to penal affairs. I do not know to whom he was referring, but he would not want me to rebuke him this afternoon. Good Friday is coming and my right honourable friend is a good Christian and will probably spend a lot of time in mortification. When he emerges, he may have a wider attitude, but that is not the subject of today's debate.
We are dealing with the difficult question of special hospitals. Although I am referring today specifically to the 1,500 people in special hospitals, the Minister and others may feel that they want to range rather wider over the whole question of the relationship between mental health and crime.
My connection with special hospitals goes back quite a long way. When I was a don at Oxford, my wife and I had a friend, a charming lady who lost her husband and then went off her head. She killed one of her children and tried to kill herself. She went to Broadmoor and I visited her there. So, I first visited Broadmoor in 1940--some years ago.
However, that was not my last contact with Broadmoor; I have been in touch with it fairly closely ever since. Many years after my first visit, a very gifted young man, Peter Thompson, who had initiated the Pakenham-Thompson Report on the aftercare of prisoners which led to the setting up of NACRO, had a mental breakdown and found himself in Broadmoor for four years. I used to visit him.
He came out of Broadmoor without any help in the world absolutely discredited, isolated and penniless. He started the Matthew Trust which flourishes today. The Matthew Trust is particularly concerned with mental offenders but is also involved very much with those who
Time has moved on. I am honoured today to be the president of the Matthew Trust. I suppose that I should declare an interest. I do not believe that even in these days of alleged sleaze people will accuse me of being paid by the Matthew Trust. At any rate I am president of that body and come before the House in that capacity. The Matthew Trust has helped 8,500 people over the years and has raised £1 million without any help from this or the previous government. Peter has been an honorary guest at Broadmoor and has preached in the chapel. He is an old Broadmoor boy made good, and may there be many of them. Of course, that is not the ordinary experience of those who have been in Broadmoor. The friend I referred to earlier and Peter are the success stories. I have visited others over the years in Ashworth, Rampton and Broadmoor. In some cases I have been closely associated with those who have committed rather horrifying murders. One of them is now dead and perhaps the other two will never come out. One is dealing with every kind of person when one speaks about the 1,500 people who are in Broadmoor. Some will be coming out very soon and will lead good and useful lives; others may be stuck there forever. That is what we are talking about in the special hospitals.
What are we to do about the special hospitals? I realise that the Government cannot be expected to come out with a clear, positive and ineluctable pronouncement today. Whatever the Minister says will be acceptable and many allowances will be made. However, I hope that she will be able to give the House some idea of government thinking on the matter. I should like to put three questions to my noble friend. Do the Government agree that the present special hospitals should continue with the 1,500 people who are already there? Do they believe that three hospitals of that magnitude should be maintained, or do they have some other idea? If they believe that smaller units should be maintained what is the alternative to the treatment of the 1,500 people who are now in these hospitals?
Obviously, high-minded people with a great deal of knowledge can have very different views. Officially, the Matthew Trust has very strong belief in special hospitals on the Broadmoor model. I shall refrain from commenting directly on Rampton and Ashworth, but the trust would like the three hospitals to be on the Broadmoor model; in other words, one would not have five instead of three but three hospitals on the Broadmoor model. That is the official attitude of the Matthew Trust. Smaller units may have advantages, but it believes that the facts tell rather in favour of the larger hospitals. It appears that the record of those who are released from the larger hospitals is rather better than that of those from the smaller ones. Its official view is that three hospitals on the Broadmoor model is the right answer.
I have quoted the example to the House of the Matthew Trust and Peter Thompson. He was in Broadmoor many years ago now. I should like to quote one other view. I have a friend, someone I visited for 12 years, and it is in fact 12 years since he was sent to a special hospital, Rampton. He has been in special hospitals and smaller units ever since. His opinion is worth listening to, of course. He had a mental breakdown at one point, but before that he was an intelligent man and well educated: he went to university. His opinion, if you like, has to be accepted as one opinion among many because he has been in both special hospitals and in small units, including Rampton. Peter Thompson had been in Broadmoor; so in each case you have an opinion from an inmate in favour of the larger unit. My friend is still in a secure mental hospital but he found that in Rampton there was a stronger community spirit with a better quality of life. People were protected from dangerous people and so, taking it all round, there is the opinion that there is a better opportunity of life in the larger units, in the opinion of those who have been in both. I therefore ask the Government, although I am not expecting them to be too positive today, whether they can give any indication at all as to the lines upon which they are thinking.
We are approaching Easter. I am sorry to think that the Home Secretary has recently expressed some very sharp ideas about old Labour in relation to penal matters, but I know that he is a good Christian and may in due course come to wiser counsels. Leaving that aside for today, and looking beyond Good Friday, is there any hope for people in special hospitals? I believe that Peter Thompson, a man who went to Broadmoor and who has since devoted himself to those who have come out from such places and other mental hospitals, gives us a message of hope and a hell of an example.
Lord Dholakia: My Lords, I am delighted to contribute on this particular subject. I cannot profess to have either the age or the experience of the noble Earl, but he does raise some very important issues.
As part of my study of this subject, I decided to look at headlines in newspapers over about a 12-month span and I found some disturbing facts. For example, there was the Sunday Times talking about Broadmoor being used for drug tests; the Guardian talking about secure hospitals being out of control; Rampton and Broadmoor facing closure.
I also picked up an editorial printed in the British Medical Journal of May 1997. It talked about the Ashford Hospital inquiry which investigated the circumstances surrounding four specimen untoward incidents: a patient's sudden death; an alleged sexual
It would be wrong for me to be critical, but we need some specific answers from the Minister. I do not profess to have detailed knowledge of this matter, but when I was appointed to the committee reviewing the parole system, chaired by the noble Lord, Lord Carlisle, I had the opportunity to visit special hospitals and to listen to the deliberations of the Mental Health Review Tribunal.
I want to pay tribute to the hard-working members of that tribunal and the delicate nature of the task that they perform. It is not easy to balance the needs of the individual against the safeguards society expects from the tribunal's decisions. One error of judgment could have a drastic effect on the way society deals with offenders committed to special hospitals. During the past few weeks I have had the opportunity to talk to a number of practitioners, and my contribution will reflect much that I gained from people deeply involved in some of those institutions.
There is a general acceptance that the best of the work in the special hospitals has been of a high standard. There are many staff committed to doing a difficult job, but, at the same time, we must accept that they are dealing with the least attractive members of the offender population. The worst of what happens in that setting is at least as bad as has been demonstrated by Boynton, Blom-Cooper and others.
I said earlier that we need to balance the conflicting expectations of society and the offender. That is not an easy task. There are bound to be occasions in the future when we will question whether our approach has been the right one. However, any proposals for fundamental change in the way maximum secure services for mentally disordered offenders are currently provided need to take into account a number of general issues.
Let me see whether I can specify what those issues are. Any proposed changes need to be undertaken in parallel with the new Mental Health Act. Not all of the patients held in the special hospitals are there as a result of criminal offences. Some of those with learning disabilities come under the civil sections of the Mental Health Act 1983. It would be helpful to know from the Minister the numbers of such patients. A few patients with severe mental impairment are considered by their families to be appropriately held in an institution--for example, Rampton--with high levels of caring staff. That is an arrangement which, for all its stigma, ensures the safe and satisfactory custody of their loved ones. However much we dislike it, that is the preferred choice of the parents.
In addition to the mentally impaired and the learning disabled, there are two further distinct groups of patients--those with mental illness in all its forms and the psychopathically disordered patients. The former group includes the Asian and Afro-Caribbeans, with their particular needs. That must be examined in terms of the publicity that has been generated over the past few years. The latter group, the personality disorder group, present a range of problems which the special hospitals are trying to deal with. However, the phenomenon needs to be better understood, with a wider range of responses tailored to meet the understandings which seem to be evolving.
Here one can talk about distinct approaches to women identified as being psychopathic, and applications of the experience that must have been accrued at HMP Grendon Underwood and elsewhere, as well as the visions of psychopathy as a product of post-traumatic stress disorder. Here one must look at Ashworth. The fiasco there is unlikely to be the last of its kind. Things of this nature may recur again and again. That is where I think the noble Earl is absolutely right to question the future of such hospitals.
Is there merit in the view that all personality/ psychopathically disordered offenders warranting detention should be sentenced to imprisonment and then transferred to hospital if they seem to be treatable thereafter? Some of the most recent publicity has been about the closure of existing provision and dispersal of the population of these units to other sites. It may be that the present locations are so dishonoured or discredited that only closure is feasible as a means of dealing with them. Whether or not that is the case, and only the Minister can enlighten us on that, smaller units are clearly envisaged. I consider that these units need to take account of the lessons learned from the RSUs created after Butler and Glancy.
Size is not everything. If units are to be smaller, they should be closer to the areas of the patient's origin. That approach will make the process of restoration to the community, where possible, easier and less costly. It will go some way towards maintaining those links with families which are, in any event, tenuous enough where they exist but are often the wish of the family as well as the detained patient. This strategy will do more to confront local health authorities and trusts with their responsibility for the long-term care of such patients.
Staffing levels and patient-staff interaction are significant aspects of the security of the regime--it is not always about bolts and bars. Some patients who no longer require the high levels of security provided by the special hospitals will nevertheless need to be detained in a medium secure hospital for longer than the 18 months to two years that RSUs currently see themselves providing. This may be especially true of some patients with learning disabilities whose perceived capacity to cope in the community is ill-informed and overstated.
The regimes in most RSUs are less costly than the special hospital setting on a per capita basis--which I am sure the Minister can confirm. The result is that many patients find the setting under-stimulating and
If the envisaged smaller units are to offer a service of the present quality and more, they will need to continue the range of opportunities. The key to that will probably be a critical mass which allows for levels of expenditure on treatment and rehabilitation which are not totally beyond acceptable levels. Thus "local" and "small" will be relative concepts only in this instance. In summary, smaller maximum secure units, closer to home and family, good staffing ratios, adequate treatment and rehabilitation resources.
Over the years, various lobbies have argued that a number of special hospital patients do not need to be there. Indeed, the recent report of the commissioning board makes similar claims. That may give an impression that there is some kind of conspiracy to prevent the discharge of patients. I do not believe that is so. I am told that from time to time there are individuals who are granted a conditional discharge whose discharge has been held up because the facilities required were non-existent or the receiving authority was reluctant to supervise because of his or her dangerous propensities.
Let me add that each patient has the opportunity to make an application to a mental health review tribunal each year for a review of his or her detention. There is therefore already in place, however imperfect, a system for patients' circumstances to be discussed by an independent body. We must accept that there will always be a need to provide for people who offend while being mentally disordered. The current number clearly demonstrates that it is not a vast problem but that during the past few years it has remained static.
I am of course interested in the future of Ashworth Hospital and the current inquiry there. Is closure an option that is being considered? If so, this may allow for two units geared to the longer term needs of ex-patients, allowing for the development of an organisation with a benign culture, as well as allowing patients to reside in a hospital nearer to their home.
In the final analysis, there needs to be a spectrum of secure services graded to meet the needs of those requiring high or utmost security in circumstances where high grade therapeutic treatment is matched with high grade education and training, and rewarding employment where possible, ultimately tapering to medium security and eventual conditional discharge into the real world under supervision.
Earl Howe: My Lords, the House will be grateful to the noble Earl, Lord Longford, for introducing the debate and for his authoritative remarks on a subject about which he has a deep and intimate knowledge. As he indicated, this is a timely debate, coinciding with the Government's all-embracing review of mental health policy. That review has yet to reach conclusions. For that reason, the Minister may be unable to provide the House with definite answers today. However, I hope that she will feel that the occasion has been no less valuable for that.
As I sat down to contemplate the subject of special hospitals, my first thought was that it is all too easy to follow the predictable route and point to what is wrong with them rather than to take time to consider what is right with them. From the point view of the citizen, Broadmoor, Rampton and Ashworth hospitals have the merit of being extremely secure institutions where some of the most dangerous members of our society are housed without posing a risk to the general public.
If from a different perspective we look at their function as therapeutic environments for the care of the mentally ill, the special hospitals can boast of having a highly skilled complement of specialist staff to whom we owe a great debt for the difficult and stressful work that they carry out. Furthermore, they can boast of a culture which during recent years has been transformed from one which was fundamentally punitive and in many sense inhumane to one which most of us would more readily associate with that of a hospital. Indeed, each of the three special hospitals is now a discrete authority within the National Health Service; in other words, no longer under the aegis and influence of the Home Office.
That is not simply a formal change; it reflects a cultural change of considerable substance. For that, tribute is due to the chief executives, senior management and staff of the special hospitals for the dedication and commitment that they have shown in bringing it about.
At the same time, there is much which should concern us. Of the 1,500 or so patients within the special hospitals, there is general agreement that about half, perhaps more, need not be there at all. Many of those individuals need neither the degree of security nor the specialist mental health care which the special hospitals are designed to provide. They would be more appropriately detained in medium-secure psychiatric units. They cannot go there because that tier of the system is itself clogged up. That has the regrettable consequence that a large proportion of those who are confined in special hospitals remain there for much longer than might otherwise be the case. I believe that the average length of stay in Broadmoor is around eight years. If the cost of detaining a patient in a secure hospital is between £90,000 and £100,000 a year, that represents a huge and unnecessary cost to the public purse, quite apart from the cost to the individual themselves. That human cost is considerable and can be measured in a number of ways.
For example, it is commonly supposed that all those detained in special hospitals have committed a serious crime. But, as the noble Lord, Lord Dholakia, reminded us, that is by no means the case. Special hospitals do indeed contain some extremely dangerous people who have committed rape, murder and other serious offences. But alongside them are others who have not committed any crime at all and others again who have committed relatively minor criminal offences. For the latter two categories of patient, that cannot be a healthy therapeutic environment either psychologically or in terms of the risks they run of suffering violence or abuse from disturbed and dangerous fellow inmates.
We cannot speak of special hospitals and not be mindful of the recurrent scandals over many decades which have tarnished their reputation and triggered a succession of official inquiries. Judge Fallon is currently pursuing the latest of those into conditions at Ashworth Hospital. If the evidence he has heard is as reported in the press, it represents a serious breach of security and supervision in that hospital.
At Broadmoor the management apparently exercise a much tighter disciplinary grip. But the problems there have been of a quite different kind--a consequence of acute shortages of trained staff and of what has been described in the press as a climate of intimidation and victimisation of nursing staff engendered by certain members of the dominant union, the Prison Officers' Association. Indeed, there are those who feel strongly that the POA played a fundamentally negative and destructive role in the struggle to turn the special hospitals into therapeutic institutions. Even if that view is overstated, it is not hard to see why recruitment of skilled nursing staff and ward orderlies at Broadmoor has proved so difficult and why, over a considerable period, overtime rates there were running at levels which, in any other context, would be considered completely unacceptable.
The effect of all that on staff morale needs no stating. But, taking a wider view, it is not hard to see why Sir Louis Blom-Cooper, in his report on Ashworth in 1992, described special hospitals as "inherently unmanageable". Judge Fallon will no doubt be addressing that very point in his inquiry, as will the High Security Commissioning Board in its forthcoming review. My view, for what it is worth, is that the whole rationale for special hospitals in their current form merits a fundamental reappraisal.
Much has been made recently of an alternative model referred to today which would involve a larger number of smaller secure sites throughout the country. If smaller units are inherently more manageable, as one suspects they should be, that is an option with immediate attractions. However, there would need to be two preconditions attached to them. They would have to deal effectively with a relatively small number of patients who need to be detained for a long time, some indefinitely. They would need to ensure that the specialist skills developed in the existing special hospital service are retained and built upon. In other words, the units would need to be quite distinct in character from the present medium-secure facilities but because, as I said, the patients within special hospitals are far from homogenous, there is little point in going down an alternative route of this kind unless we ensure that the different needs and challenges of patients are properly catered for: for example, that serious sex offenders and those with psychopathic disorders can avail themselves of the specific therapeutic regime they require. For others, there is a need for much shorter periods of detention with different care and treatment regimes, and that group equally should be catered for.
The practical difficulties of such an approach are perhaps obvious. Where would such units be located? How could one ensure that a sufficient level of security is in place in a small unit? What would be the financial
It seems to me that the eventual choice for the Government will be between changing the special hospitals or closing them. I doubt whether the status quo will be seen as an option beyond the short term. Attempting to reform the system merely by changing the management is unlikely to rid these institutions of the problems which have dogged them so consistently over many years. Whichever route is chosen, there will be financial implications. If the Government decide that it is right to spend in order to save and in order to improve, we from these Benches will warmly support them.
Baroness Ramsay of Cartvale: My Lords, like other noble Lords who have spoken today, I am grateful to my noble friend Lord Longford for providing us with the opportunity to air views on such an important subject. It is also a privilege to respond to my noble friend who has such a distinguished record of active concern in this whole area. Indeed, I welcome the opportunity that he has given me to respond to the questions that he has raised. I am also grateful to the noble Lord, Lord Dholakia, and the noble Earl, Lord Howe, for their thoughtful and valuable contributions. I shall endeavour to cover the various points that they made.
In relation to the need for high security psychiatric services, the Government place a very high priority on public safety. We recognise that, as part of a comprehensive range of mental health services, there will always be a need to provide places in conditions of high security for the small minority of mentally disordered people who pose a grave risk to the public. Patients in high security hospitals should have access to the same high quality therapeutic care that we expect to be provided in any other part of the NHS.
The structure of the high security psychiatric services, and their relationship with other services for mentally disordered offenders, have been extensively analysed in recent years--notably in the reports of the Department of Health and the Home Office on the review of services for mentally disordered offenders in 1992, and in the subsequent report in 1994 of the Working Group on High Security and Related Psychiatric Provision. Both these reviews were chaired by Dr. John Reed, a distinguished forensic psychiatrist, who was then at the Department of Health.
My noble friend Lord Longford is right in stating that the three high security hospitals, Ashworth, Broadmoor and Rampton, currently accommodate a total of about 1,500 patients. Recent research and needs assessment has shown that at least 30 per cent. of these 1,500 patients no longer require detention in such high levels of security. I do not have the specific answer to the question of the noble Lord, Lord Dholakia, who asked me how many people were detained under the section of the Mental Health Act he mentioned, but I shall write to the noble Lord on that point and send a copy of the letter to other noble Lords who have participated in the debate.
Both the noble Lord, Lord Dholakia, and the noble Earl, Lord Howe, pointed out a key gap in provision for patients requiring care and treatment in a medium secure setting for an extended period, longer than the 18 months to two years which the existing medium secure units cater for. The NHS Executive is working in partnership with the high security hospitals to modernise existing high security services, and with other NHS providers, in areas of greatest need, to develop longer term medium secure facilities which are intended, after evaluation, to act as a model for further long-term facilities. It is anticipated that the first of these facilities will open in the early part of next year.
Collaborative international research has a significant part to play in investigating and evaluating effective treatments for this comparatively small but very complex group of patients. We have initiated a major research initiative using information technology to create the "virtual institute", bringing together 11 academic units, and comprising a number of disciplines and professional groups. Discussions are going on with the Medical Research Council, the European Social Research Council and European partners with reference to this programme.
We have already initiated work in four priority areas, developing appropriate services for people with learning disabilities who require secure services; people with enduring mental illness who require long-term secure placements; women who require secure placements; and people with personality disorders. These initiatives involve designing new services, staff training
I would like to mention specifically work in hand in relation to two of these four groups of patients. As regards services for women, there are currently many vulnerable women patients accommodated in the high security hospitals, and in other mental health services and prisons who must be treated in more appropriate settings by specialist staff. There are now research studies and staff training strategies being developed to refine this component of service. The research is already beginning to identify more effective ways of managing and treating this patient group, improving their quality of life.
I also wish to mention services for people with personality disorder. The management of high security services is greatly complicated by the difficulty presented by patients with severe personality disorder. This is not only a matter of service provision but also relates to the form of the present legislation. Department of Health officials are working with colleagues in the Home Office on a separate review of policy in this area. A service model using social therapists is being established and evaluated and therapeutic communities are being developed at Ashworth and Rampton. There is already one at Broadmoor.
The existing hospitals do benefit in some ways from economies of scale but they also have disadvantages. Noble Lords have enumerated some of them. In considering the way in which services should be developed and modernised we are carefully evaluating the evidence and arguments taking into account a range of views, including those of the Matthew Trust--of which my noble friend Lord Longford is president, and about which he has spoken today--and will be giving utmost priority to ensuring the safety of the public, hospital staff and patients themselves.
The high security hospitals in their present form suffer from both geographical and professional isolation. Historically they have been seen to represent a custodial rather than a therapeutic culture and this has, despite sustained efforts in recent years, impeded the pace of change, integration and service development. Largely as a result of their isolation, the hospitals have experienced problems in recruiting and retaining staff in sufficient numbers and the wider NHS has not benefited from the sharing of the specialist expertise and experience that exists within the high security hospitals. Consequently patients may not always get the most suitable care, and community mental health services may not get the specialist support and backing they need in managing difficult and potentially dangerous patients. Partnerships and integrated service development with the wider NHS, other statutory and voluntary agencies, are priorities for a modern high security service.
The present funding arrangements present a perverse financial incentive to the movement of patients from high security to medium or lower security services, because health authorities do not have to meet costs for those in high security hospitals in the same direct way that they do for other mental health services. The Government's White Paper The New NHS sets out the policy and the timescale for commissioning health services and we intend, in common with the rest of the NHS, that the specialist commissioning of high security psychiatric services will be addressed within the implementation of the White Paper.
There has been a good deal of speculation in the media recently--the noble Lord, Lord Dholakia, the noble Earl, Lord Howe, and my noble friend Lord Longford mentioned it--that the existing high security hospitals might be closed. I can assure noble Lords that no such decision has been taken. It is not appropriate to look at high security psychiatric provision in isolation and consideration of the way forward is therefore being undertaken in the context of a long, hard look at the whole of mental health policy.
I make no apology for the fact that this has taken, and will continue to take, some time. It would be quite wrong to make any changes precipitately. But high security psychiatric services have been neglected for far too long. The scandals must end and dangerous patients must be held in therapeutic environments where security is the first priority. While there are many examples of very good therapeutic work being done in the high security hospitals, their isolation from other mental health services means that there are limitations in the care, treatment and rehabilitation pathways that the existing high security hospitals are able to offer. We intend to develop and integrate high security services to address what are blocks and barriers to effective treatment and rehabilitation.
The Earl of Longford: My Lords, before the Minister sits down, while I thank her for the high quality reply we expected, perhaps I may ask her whether she can tell us when we may expect the report of the inquiry into certain allegedly frightening aspects of what is taking place in Ashworth.
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