With the assimilation of special hospitals into mental health trusts on the way, Charles Kaye and Alan Franey argue that patients' needs would best be served by smaller hospitals with more specialised care
When scandal rocks an institution - as the Fallon report has recently censured Ashworth Hospital's services for personality disorder patients - the reflex response is to demand radical change. A lengthy casualty list of those held responsible and indignant calls for immediate closure are seen as essential ingredients for change. All too often, however, such extreme responses blur the very real dilemmas and difficulties that these controversial institutions face and of which, on behalf of society as a whole, they try to make sense.
Although the three special hospitals, Ashworth, Broadmoor and Rampton, have (under the aegis of the Special Hospitals Service Authority - SHSA - 1989-96) been described as a national service, in fact they represent a series of state improvisations, with facilities to meet needs beyond existing provision.
The 1959 Mental Health Act represented the first real attempt to define the role and purpose of special hospitals - later summarised as designated hospitals for individuals needing 'treatment under conditions of special security on account of their dangerous, violent or criminal propensities' (1977 NHS Act ). The attempt to manage them from the centre by the Department of Health was widely seen as unsuccessful, and the creation of the SHSA was the first and perhaps only time when the service was nationally defined and managed.
Despite some admirable therapeutic endeavours, the hospitals were generally hostile to their patients, professionally isolated and heavily influenced by the activities of a union - the Prison Officers' Association - that was explicitly custodial and industrially aggressive. Above all, the public regarded their work with fear.
A single body or set of managers could not expect to change that situation overnight.
But the SHSA set out to give staff purpose and self-respect and to offer fairness to patients. It was encouraged and motivated by powerful direction from the centre, seeking more humane care but not, of course, the abandonment of essential security; control had always to rest with the staff. That work has been described in detail.1
In part, according to the Fallon team, the SHSA has been found wanting. It could certainly be argued that the SHSA's reign was too brief to allow a stable national service to be established. Our experience during that period was that these hospitals are indeed very difficult to manage. But they are not unmanageable, given the right resources.
The service is today represented by three separate hospitals which are on the verge, given appropriate legislation, of being assimilated into existing mental health trusts. It is assumed that this will help to 'normalise' these institutions, presumably strengthening their staffing and bringing them firmly within the bounds of the NHS.
Society's views and tolerance of risk have altered dramatically in the past decade. This is neatly illustrated in the difference between the two public inquiries into Ashworth Hospital: Blom-Cooper pursued ill-treatment and the championing of patients' rights; Fallon pursued the seizure of power by patients and the abuse and exploitation of their advantages as patients. The tension between 'mad' and 'bad' is clearly illustrated.
The shift in emphasis nationally, reflected in 'get tough on crime' policies, is inevitably influencing forensic psychiatry, where increasingly the clients come from prison, either convicted or on remand.
The government is now contemplating indefinite detention for some offenders. But there will remain many who, whatever their diagnosis, cannot be so consigned in this way and about whom issues of risk and release have to be faced.
The starting point must not be management, fashions or buildings, but an analysis of patients' needs and an evaluation of society's willingness to respond.Within the hospitals, nearly a third of the patients have killed, 10 per cent have committed a sexual offence, 10 per cent have committed arson, and almost everyone else has committed non-fatal but serious personal violence.
Virtually all (93 per cent) have had previous treatment in the mental health services.2
Over the past decade, the population of the special hospitals has dropped from 1,734 (in 1988) to 1,423 (1997), a reduction of over 300 patients (more than 18 per cent).
During the time of the SHSA, this reduction was achieved by applying more stringent admission criteria and investing heavily in transferring patients ready for conditions of lesser security. Some commentators have envisaged that a decline in numbers could be accelerated with the discharge or transfer of the large proportion of patients identified by surveys as no longer needing high security.3
This could be misleading since those estimates are based on the optimism of medical assessments, not the pessimism of 'legal' assessments carried out by the Home Office, which is understandably cautious about release.
But two further factors could point to a declining population: first, the likely reassignment of severe personality disordered individuals towards a prison-type setting; and, second, the initial success of new drug regimes for treating long-term schizophrenia. Yet this reduction has to be set against the existence of unofficial waiting lists for admission to each of the hospitals and significant unmet need in the prison population, which is itself increasing rapidly.
There remain other significant needs: for instance, the ethnic minority population (mainly African Caribbean) is rising both proportionally and in absolute numbers; it now represents 20 per cent of male patients and 13 per cent of female patients. There is an increasing problem of relating to and treating this minority, which feels its very presence in the hospitals represents racial oppression. Indeed, such a need underlies much of the forensic scene, where the comparative dearth of top-quality research hinders a deeper understanding of the relationship between treatment and progress in a way which would inform clinical choice and help better investment of resources.
A clearer understanding would help the development of more specialised treatment for groups of patients: adolescents, adults with alcohol or drug addiction, adults with paedophile behaviour. Treatment needs to be more precisely targeted and more closely monitored for effectiveness.
The hospitals' facilities provide one of their major assets - a very relevant factor for patients detained an average of seven or eight years. The experience of the staff offers a further advantage.
We would support smaller special hospitals offering more specialised services in closer co-operation with other parts of the forensic service. In this connection, a particular barrier which must be removed is multiple assessment of patients, where each staff team starts anew.
A common protocol for assessment and a mutual acceptance of assessment between teams is urgently needed to help the service integrate effectively.
We would envisage a real commitment to training, equipping staff to respond to the most ill and most difficult psychiatric patients in the country.
That training, which should be interdisciplinary, needs national standards and should be obligatory for all staff. Staff should also be recruited more widely - the traditional sources, particularly of registered mental nurses, are drying up and staff shortages at ward level are chronic. A new breed of 'social therapists' with a practical training is required, similar to the model found in the Netherlands. Organisational stability is needed to enable staff to focus on their real job of treatment within detention, instead of being distracted by management upheavals or pilloried by blame-seeking inquiries.
Better selected, properly trained staff working with fewer patients could specialise and demonstrate effectiveness. But even they would still have to take risks because, inevitably, the only way to test progress is to return individuals to society, and assessments and treatments will never be perfect.
That reality should be recognised so that a proper balance between care and security, between the present and the future, can be maintained.