Behind locked doors

On a hazy, spring day wooded hills gently unfurl over the countryside. You can see as far as Hampshire from here, a hilltop spot known as the Terrace that, in season, affords good bird watching opportunities and a prime viewing spot for the Farnborough Airshow.

But the bucolic scene is marred by a high razor wire fence and brick wall in the foreground. Turn your back on the view and a very different sight greets you: a series of three-story Victorian brick buildings with bars on the windows and doors.

This is the maximum-security Broadmoor Hospital, run by West London Mental Health trust. Despite the common misconception sparked by its name, Broadmoor is not situated on a spooky windswept moor. It is in a rather select part of Berkshire, near the village of Crowthorne and the public school Wellington College.

The area's original planners had to decide whether the hospital, then the country's first asylum for the criminally insane, or the proposed school, would get the hilltop position. Due to the belief that an asylum should provide patients with space, peace and an escape from the rest of the world, the hospital got the prime location and the view.

Of the three former high security hospitals, Broadmoor is the most notorious. Its name alone inspires fear, suspicion and loathing. It struggles with a reputation as a place housing some of Britain's most infamous and dangerous people. Tabloid headlines scream of the killers living behind its bars.

Yet it is home to almost 300 people. In the words of a patient interviewed in 2004 on Radio 4's All in the Mind, it is home to' damaged people who have damaged other people'.

The high-security conditions at the hospital would shock anyone who has never visited a prison or another of the former special hospitals, Ashworth and Rampton, before. Security levels, informed by the Department of Health's national security directions, have been comparable with a category B prison since the 2000 Tilt report into special hospitals.

In addition to the fence and wall and a seemingly endless series of locked doors, all visitors are patted down by security staff and the back of watches are checked while coats and anything you can carry in are subjected to an airport-style scan. There is a long list of items that cannot be taken into the hospital.

Patient movements

Unless patients have permission to go outside their ward on ground leave, they cannot go anywhere unescorted, leading to problems around access to fresh air and exercise. Having male and female patients separated at all times, a procedure instigated around 2003 following allegations that women patients were at risk of sexual abuse, has also limited patient movement.

Patients on wards that are on first or second floors have access to garden areas but again this usually has to be under escort. No visitors are allowed on the site unescorted and in some areas where patients are under particularly high levels of supervision, they must never be more than an arm's length away from a member of staff.

None of this distracts from the widely held public belief that Broadmoor is actually a prison, not a hospital. But at the same time, patients are there because of the risk they pose to themselves and others.

Campaigners say there are exceptions, patients who pose no risk and should have been re-housed long ago, and there have been terrible cases: in 2003 a 94-year-old woman was discharged after 40 years, in a state of extreme frailty. But levels of risk remain key. Most of the patients have arrived there via the criminal justice system, although a few are there purely because of their mental health problems. All pose a risk to themselves or others.

At present conditions make these risks harder to manage. Services are provided in settings similar to those which have all but disappeared from the mental health scene.

With original buildings that were built in 1863 to a design by Sir Joshua Jebb, much of the accommodation is shockingly out of date.

The case for change

HSJ visited the site to be shown why West London Mental Health trust, not to mention patients, staff and carers, want things to change. Extensive redevelopment of the site is currently planned. Of the two wards that HSJ is shown around, the first is in Kent House, one of the original 1863 buildings that leads off the large central hall, where social events used to be held.

Bars on the windows do little to dissipate Broadmoor's reputation but Jude Deacon, service director of the hospital's south of England directorate, explains that the bars cannot be removed as they are built into the fabric of the building. If they were removed the building could fall apart. Certain parts look as if they are heading that way already. The only block that has en-suite bathrooms is an assertive rehabilitation ward from where patients are usually intended to be discharged into medium-care services.

High ceilings ensure the ward is light and airy and although decorated with personal photos and pictures by patients, the rooms are very small. The narrowness of the main ward corridor and a shorter one that leads off to a communal bathroom and toilet contribute to the ward being totally unfit for modern care. The number of blind spots mean no patient or staff member can safely be allowed along the shorter corridor.

The facilities look shabby and tired, despite the personal touches in the bedrooms and efforts of a patient tidying the dining area. Yet the atmosphere is peaceful and relatively relaxed, certainly more so than on an average mental health inpatient ward.

If the age of the Victorian blocks contributes to their unsuitability, it is shocking to discover that more recently built accommodation is little better or perhaps worse.

Broadmoor's eight-bed intensive care ward, Isis, is part of a block built in the 1980s. Situated in a slight dip, it does not enjoy the view the older blocks have and does not have open space nearby.

Although no longer new, it might be expected that a building constructed only 20-odd years ago might be more fit for purpose. But the moulded units that made up the bedrooms have deteriorated over time under the harsh treatment they receive.

The walls are cracked and beds can be broken if a patient becomes violent. Only a narrow slot is available for staff to observe patients in their bedrooms and if a patient has been isolated in their room, another slot forms the only way for the patient to receive food, via the bathroom area.

There are no bars on the toughened glass windows but limited ventilation also makes the unit, especially the bedrooms and the small ward office, warm and stuffy. Open doors to a small garden provide for an outdoor social area. A patient on Isis ward points out that Banbury ward, the high-dependency unit above Isis, does not even have that.

However, it is not a generous space and only having one social area can lead to difficulties. Unit and clinical nurse manager Mick Robson says it is often necessary to keep patients apart if they threaten each other. But the only form of separation is to confine one of the patients in question to their room. Other design faults include having a patient toilet next to the nursing station.

'When this unit was built no-one asked the staff what would have worked,' says Mr Robson. 'Now we have a chance to have our say on what the new building will look like and how it will work.'

Call to action

Plans to redevelop Broadmoor gathered pace following the publication of a 2004 Commission for Health Improvement clinical governance review of the trust's forensic services. The report unequivocally described the hospital as unfit for purpose.

An outline strategic case for developing the site was introduced as far back as 1999 and by November 2005 the trust had approved the outline plan's case for a£190m redevelopment to provide new ward and therapy accommodation.

'We are now looking at a shortlist of options,' says redevelopment project director Nigel Leonard.' Broadly speaking we will either: develop to the south of the existing site, where The Paddock [a recently built unit for people with dangerous and severe personality disorder] is, develop a new area within the existing security perimeter, or develop elsewhere on site and sell the land that the current buildings are on. We own a lot of land on this site and all options are up for discussion.'

By the end of 2007 it is hoped that an outline business case will be ready for submission to the DoH. A decision will then be taken internally on what procurement process will be used. A private finance initiative is an option but Mr Leonard believes the scale and complexity of the scheme means Treasury capital funding is more likely. Plans to redevelop the Scottish high-secure hospital Carstairs under a PFI scheme recently fell through. 'This funding is long overdue,' says Mr Leonard. 'Continued use of current buildings for wards is not an option.'

Deputy director of nursing Jimmy Noak says,'we've done the best we can with what we have but this site does not lend itself to caring for patients. Even the newer wards are not built for purpose. Since this hospital opened technological advances have passed this place by and even the basics such as heating and lighting are not right.'

Sizing up the options

Numerous inquiries and campaigners have long suggested that the high-security hospital be closed and replaced with a number of smaller units. All plans for the redevelopment of Broadmoor involve a similar number of people being rehoused on the same site: 266 men from London and the South of England.

The 76 female patients currently at Broadmoor stay in an original Victorian block. Most are to be rehoused in an enhanced medium-secure setting at the trust's Ealing site and those felt to be in need of high-security care will move to a national high-secure service for women at Rampton Hospital.

'There is a debate about the size wards should be, taking in cost and therapeutic benefit to patients. We have been asked by commissioners to work on the principle of 15 beds per ward,' says Dr Ed Petch, a consultant psychiatrist and consultant lead on the redevelopment. Most of the wards currently have 20 beds.

The clinical model of care provision, in which work is already being implemented, is key to the proposals. Four types of care are provided at Broadmoor: admission, intensive care, high dependency and assertive rehabilitation.

'We want safe and secure therapeutic environments,' says Dr Petch.' Mental and physical health restoration is key - mental health comes first - as are educational and occupational opportunities. Many of our patients have lacked both.' Security will remain a key issue.

'Risk reduction, both clinical and criminogenic [likely to cause criminal behaviour], is our key business. There is a balance between clinical needs and security, allowing us to do what we do in a safe way. Security is integrated with patient-centred care,' continues Dr Petch. 'Many of our patients have had criminal lifestyles in addition to their diagnostic mental health issues. Due to the size of Broadmoor, moving through different levels of care has led to patients changing care teams and lacking care co-ordinators.

'There has been a lack of strategic overview of continuity of care but we are working to improve this and to better inform our medium secure partners. The effectiveness of interventions will be monitored and also shared with medium-secure partners.'

Further improvements such as developing therapeutic treatments for patients are intended. In common with life on other inpatient units, patients have a lack of activities to do. It is hoped a range of morning, afternoon and evening evidence-led interventions will be provided seven days a week in an off-ward treatment area.

In comparison with the current need for patients to be constantly escorted, where possible, they will be unescorted or provided with more on-ward activities.

All the clinical model plans were created by a group of clinicians. Still undergoing consultation, they are being developed with staff groups, parents and carers. Broadmoor has a strong and active carer group. The clinical model aims to reduce length of stay for patients and improve care and treatment with a focus on discharge. Staff mix and training is also vital. The former special hospitals have suffered from having a large contingent of staff with a security rather than care focus.

'Workforce will be based on skills, with fewer traditional roles and more can-do roles,' says Mr Noak. 'Work will focus on relapse prevention and coping with being back in the community when that happens. We have to provide the right treatment at the right time, you do not send someone to an advanced stage of care if they do not think they are ill, for example.

'Ending up in Broadmoor is the end of a long journey. It is about providing a positive approach to how patients got in here and how they can move on.'

Consultation with other high-secure mental health facilities, here and overseas, is needed so that 'we do not end up creating something that cannot be replicated. We want to push this model forward,' says trust director of forensic services Sean Payne. 'This is a national service and we cannot have variance in that level of service.'

Detailed ideas about what the interior of the development will look like are some way off completion but the project team knows what it wants to achieve.

Mr Leonard uses a picture of the Broadmoor gatehouse, where patients once arrived at the hospital, although it is now a staff training centre behind a security fence, to show what the trust wants to leave behind.

'We want to move to this,' he says, showing a picture of a central social area in a high-security hospital in Baltimore. It is modern, bright and well lit, with tiled floors and potted plants. It looks like a 'street' area in a shopping centre, and will have a library to one side.

Slow progress

Construction work on the redevelopment is not expected to begin until 2009 or 2010 and the earliest possible date for completion of the site is not likely to be before 2014.

As Mr Leonard notes dryly, most of the current staff and patients are likely to be gone by then. Despite Broadmoor's reputation for housing 'lifers' the average length of stay is five to seven years. Most current patients will also have left Broadmoor by the time plans are actioned.

'The quickest new-build options will take around four years to construct, for completion around 2014, but some could take up to three years longer. With care levels ranging from high dependency to assertive rehabilitation we have to be confident of having a range of accommodation provision that is flexible for use,' says Mr Leonard. The trust is adamant that the original 1863 accommodation will cease to be used for patient care. As they are listed buildings the blocks might not be demolished but could be converted for other non-clinical uses.

Financing the scheme is a delicate issue as initial plans are for the NHS funds to build an entirely new ward and therapy accommodation without further use of the Victorian buildings. Other tactful negotiations that will have to be undertaken by Mr Leonard and the development team involve building on a rather attractive greenfield site in close proximity to a wildlife protection area.

Meanwhile, all patients and carers so far consulted have said the view from the Terrace must be maintained with any new premises.

Key points:

• The maximum-security Broadmoor Hospital is home to around 300 'damaged people'.
• The hospital has been unequivocally declared unfit for purpose, but plans to demolish it could take until 2014.
• The average length of stay is five to seven years - so care should be focused on rehabilitation.