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Baroness Hayman: My Lords, I am grateful to both noble Lords who have spoken from the Front Benches for their considered responses to the Statement. As the noble Lord, Lord Clement-Jones, rightly said, it was a shocking document. It is a situation that I think we all find devastating regarding the events that have been described.
If I may deal with some of the points that have been raised, I think we are right to put emphasis on the need to make sure that special hospitals will continue to have the main responsibility for providing high security services. However, we recognise that the cultural difficulties are perhaps the most difficult, indeed the most important to address, to provide absolute confidence that these sorts of events will not be allowed to recur.
Perhaps the most important thing in all this is to end the isolation of these institutions. These sorts of events take place when institutions of whatever size are isolated from the rest of the therapeutic health and even prison communities, with which they are meant to interface. I believe that our proposals for ending special health authority status, for making these hospitals into trusts and for ensuring that they have relationships, professional and otherwise, with other NHS bodies will be crucial in all this.
In terms of issues like the rotation of staff, to which the noble Lord, Lord Clement-Jones, referred, these will be made possible by relationships of that type in the future. Likewise, I think that the recruitment of staff, which is always a problem, will be eased by its being part of a wider professional network. There is some evidence that at Rampton, which is beginning to develop these relationships with neighbouring psychiatric and health institutions, they are actually having more success in recruiting staff.
Referring to the matter of staff shortages, the NHS executive and the three special hospitals are undertaking a comprehensive review of workforce issues, and will consider any of the issues raised in the Fallon Report about staffing. There have been, and still are, difficulties about recruiting sufficient staff of the right calibre but, as I say, we expect that position to improve as a consequence of the partnership arrangements between high security services and the providers of other secure services.
The noble Earl, Lord Howe, asked about the transparency of accountability relationships. I set out in the Statement how we are taking action to ensure that those will be effective and transparent. There are very clear personal responsibilities which are outlined in the Statement for all to see. I agree that it does place an awesome responsibility on the shoulders of the Secretary of State. That is correct, but I think that in taking the steps he has to ensure that until we have the new arrangements in place those people who have been named in the Statement will be responsible to him for the changes which have to be implemented, he is very clearly taking that responsibility on board.
With regard to the issue of whether or not we should contemplate the closure of Ashworth at some time in the future, which was raised by the noble Lord, Lord Clement-Jones, I think one has to look at the reasons behind the recommendations for closure. It was not a matter of closure for its own sake but it was because of the problems of size, isolation and security. We need to take action on all those fronts.
The noble Lord asked how we were going to ensure that only appropriate patients were admitted to Ashworth. I believe this is a major issue because it contributes to the size and therefore the difficulty of management and the creation of a possible "isolation culture" within the institution. We have in hand action to try to deal with this. There are, for example, roughly one-third of patients at Ashworth who do not need high security provision: they need medium security provision. We are taking action to ensure that such provision is available. Again, we have to look very carefully at the people with learning disabilities who are admitted to special hospitals. We also have to look at the position of women in special hospitals. There is evidence, again, that if we provide dedicated services, sometimes they will need security but it may be medium security and not high security for a small number of patients. We hope it may be possible in some way to deal with the problem by breaking up the larger units into smaller ones.
So far as the commission for health improvement is concerned, I would ask noble Lords to await the publication of the Bill to see the exact powers it contains. It will be important that the quality and management of the regime, the delivery of clinical governance, is inspected. Also important is the delivery of the national service framework for mental health in which high security services will have a part to play.
That is not a simple task. It is a complex matter which will involve a large amount of work. There are interrelationships with healthcare and with the Prison Service to which the noble Lord, Lord Clement-Jones, referred. It is important that we recognise that these are health service establishments. We have to be aware that perhaps a third of the patients within them do not have custodial sentences. I believe that the right direction is to integrate these services into the NHS.
Finally, perhaps I may confirm to the noble Earl, Lord Howe, that officials and hence Ministers at the Department of Health were unaware of the serious nature of the events. As the Statement says, events and reports were not reported to senior officials of the NHS or the Department of Health. Reports of serious incidents were suppressed. As soon as they became aware and there was evidence, there was action at the Department of Health, although some of the events have been finally explained only with the publication of this report.
4.41 p.m.
Lord Sheppard of Liverpool: My Lords, perhaps I may press the Minister to say a little more about the issue of scale. If I heard the Statement correctly, it stated that that could involve breaking up the hospital into smaller units. In order to help me understand the size, how many patients are in the personality disorder unit?
I share the dismay of your Lordships' House at this disturbing and deeply disappointing report. Among several visits to Ashworth I visited on the day that Louis Blom-Cooper arrived to start the inquiry. Part of our dismay relates to the swing between what the report describes as an over-custodial approach and what is now seen to have been, in some instances at least, a very lax approach. It is difficult to say it in this context, but during my visits I have no doubt that I saw some extremely devoted and skilful staff. I know that morale has been at rock bottom over many years. The task before management today is very great.
The point has been made that there are fine buildings with wonderful facilities. A large institution makes it possible for a wide range of facilities for long-stay inmates. Does the Minister feel able to expand on the break-up of the hospital into smaller units?
Baroness Hayman: My Lords, the detail of how that might be achieved has to be an issue for the senior management within the hospital. About a third of patients in high security hospitals have a primary diagnosis of severe personality disorder. Currently there are 97 in the personality disorder unit at Ashworth.
If we look at the potential for moving into such units patients who could be managed in medium secure units and the development of specialist programmes related to the new form of reviewable detention, those provide possibilities for reducing the numbers in the personality disorder unit. There are also difficulties of size with regard to the type of people about whom we are talking. They are often highly intelligent and highly manipulative. There are self-evident difficulties about managing this specific large group of patients.
My noble friend rightly points out that within the hospital as a whole there are groups of patients other than personality disordered ones. I believe that there is potential for scaling down the size of the operation by making sure that those who need medium secure accommodation are moved into such accommodation. Equally, I believe that services for women and those with learning disabilities give the opportunity for separate management off site.
Lord Campbell of Alloway: My Lords, will the Minister accept the suggestion of the noble Lord, Lord Clement-Jones, in his remarkable speech? Perhaps I may support his view that this is a matter which should be dealt with on an all-party basis. Does the noble Baroness accept that the essence of making the system work in the future is the inspectorate?
I speak with some experience. I spent quite a bit of my life in high security institutions. It makes no difference whether it is a prison or a hospital. Each inevitably develops its own sub-culture. It is not just a question of management. In our present system management is often totally subservient to staff but it should be impossible for a situation to arise in future about which the ministry does not know. I wholly accept that officials did not know, but they should have known. It was their job to know: it was their duty to know; and if they had known they would have acted.
The only way to achieve that aim is by snap, unauthorised inspections on the spot. I have seen it happen in prison camps; and even that did not always work, but at least such a system stands the chance of working.
Baroness Hayman: My Lords, I am grateful for the noble Lord's bipartisan approach on this issue. I agree that the quality of the inspectorate and the task that it performs is a vital component in ensuring that we do not have to consider such a report again. However, this is one strand, an important strand. I believe that the accountability arrangements are important too. No inspectorate can be present for 24 hours a day. We have to ensure that management all the way up the line is held accountable; and that the systems for both clinical governance and, I believe importantly, for the regional commissioning of high security services--at regional level they will be another check on the quality of the service delivered--are part of a framework which ensures that a culture is not allowed to develop which takes the institution out of the mainstream.
I agree with the noble Lord that the commission for health improvement and other means of inspection are tremendously important but they are one weapon, and not the only weapon, in achieving what we both believe needs to be done.
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