Excitable media coverage means the public is in fear of mental health service users. Should a very low level of security be accepted or should the emphasis shift towards public safety? By Charlotte Santry

The story of Darren Harkin, who earlier this month was convicted of raping a 14-year-old girl after escaping from a low secure hospital, provoked fury among health managers. This was not just because it was a shocking case, but because it was used by the national media to boost findings revealing there were 94 escapes from low and medium secure NHS units last year.

As well as proving the public is still quick to link mental illness with the threat of violence, the issue went to the heart of mental healthcare’s dilemma over how to strike the right balance between protecting the public and providing the best care for patients. Should providers perpetually lock up patients displaying even the slightest propensity for violence? Or does the public simply have to accept that in a humane health service patients need to access the outside world, albeit in a controlled way, and that tragedies will happen?

National mental health director Louis Appleby wants managers to be more honest. “There are risks associated with mental illness. Sometimes we’re rather too defensive about that,” he says. “There are a lot of good clinicians, who are well intentioned, whose aim is to play down the risks.

Public reassurance

“The public aren’t stupid. They want reassurance. If our line is just that [violent incidents] are very rare and we mustn’t stigmatise, we will not win the trust of the public. In the end the stigma we’re concerned about will get worse.”

But the difficulty of Professor Appleby’s argument is demonstrated by his response when asked about the quality of low secure services, in light of the Harkin case. “There was just a problem in that unit - quite an unusual unit - run by the National Autistic Society. You’re in danger of drawing a broad conclusion about low secure care on the basis of that very unusual case,” he says.

It is also important to keep perspective. None of the escaped patients mentioned in the investigation are known to have committed criminal offences, and the figures include those who ran away on escorted leave and may have returned within half an hour.

The number of killings by mental health patients has remained stable over the past decade despite many more people being treated in the community, and there have been no escapes from the three high security hospitals - Ashworth, Broadmoor and Rampton - for 10 years. All the available statistics show the vast majority of people with mental illnesses pose no threat to the public. But it will take work to convince the public that psychotic axe-murderers are not roaming the streets.

A number of people contacted by HSJ for this article, including Professor Appleby, claim there has been a public backlash against the way the issue had been reported on the BBC’s Today programme, resulting in scores of complaints. This does not appear to be the case.

Only seven complaints were registered with the broadcaster, out of a weekly audience of more than 6 million. Emails received were “mostly praising the report”, according to a spokeswoman, although four were critical.

Defining care

A matter on which there is broad consensus is the need to better define low secure services. In general, they offer long term rehabilitation and are often based near general psychiatric wards, but services have evolved ad hoc and vary considerably across the country.

Medium secure services usually contain locked wards for challenging patients with a criminal background. High profile cases such as Mr Harkin - who was in a low secure unit in Hayes despite the fact that he killed his baby brother at the age of 12 and had absconded before - prompt questions as to whether patients are receiving the right care.

The Department of Health is drafting a set of low secure standards, following the publication of specifications for medium secure services last year. In addition to making it clear to patients why they are having treatment, it is hoped a clearer framework will help clinicians decide where to place patients and aid commissioners, who have said their performance management role is difficult. “It’s maintained it’s been very difficult to assess services in a systematic way and make judgements about low secure,” says Healthcare Commission mental health strategy lead Anthony Deery.

“I’m not sure there’s any clarity as to what the service should look like.”

Commissioners have been repeatedly warned to keep a closer eye on the quality of mental health providers, particularly those in the independent sector. But an HSJ investigation revealed few had heeded the call. Of 47 primary care trusts surveyed, only three could prove they had inspected private mental health providers in the previous two years.

In addition to the specifications, better data across the independent sector and NHS would make it easier to ensure people were placed in appropriate settings, Mr Deery says.

Responsibility for secure services is transferring from PCTs to specialist commissioning groups, which it is hoped will help make standards, including levels of security, more consistent.

Security standards

Some strategic health authorities have carried out their own consultations on low secure standards ahead of the DH paper. HSJ has been told by several providers that these appear to promote what one called an “overly oppressive” regime.

Is the NHS trying to impose excessive restrictions on patients in response to public fears? Professor Appleby denies this. But independent consultant and former mental health manager Brendan Ward confirms he has picked up on “pressure about security coming from SHAs”.

He claims mental health teams are being forced, against their will, to focus “much more on the containment of people and less on their care and rehabilitation”.

Sainsbury Centre for Mental Health chief executive Angela Greatley is unaware of pressure being placed on providers to tighten security. However, she feels that when services are standardised “it’s probable that will mean some services that have been described as low secure will become more secure”.

NHS Confederation mental health director Steve Shrubb does not think the new specification will increase security, and feels this is right. “It’s inappropriate to design a low secure hospital as if it’s a prison. We’re not talking about hospitals where people can walk out willy-nilly. In the main, trusts get the balance right.”

Escape bid

Instead of placing bars on windows and building tall fences, improving the environment of mental health wards could discourage patients from wanting to escape in the first place.

As Priory Group hospital director Mandy Stevens explains, the vast majority of patients who try to break free are not motivated by violence but the desire to get away from a psychiatric ward. “You’re in a hospital you don’t want to be in. You don’t think you’re ill. You’re with nine blokes you don’t like. Some are trying to steal from you, some are trying to have sex with you, some are violent.”

The quality of therapy on offer in units is also a vital factor in the willingness of patients to stay put, she adds.

Keeping people in expensive medium secure units unnecessarily is not an option likely to appeal to commissioners, given that enhanced medium secure beds cost£300-400 more per day than low secure beds. But “no-one would ever make a decision based on cost”, Ms Stevens stresses. “There’s never any pressure, because the risk is phenomenal.”

Paul Stanton of Northumbria University warns against an overly risk-averse attitude. “The duty of mental health is to meet the needs of patients without putting others at risk,” he says. “If we become more risk averse we will never rehabilitate people.” He claims other sectors do not always understand the challenges mental health managers face, but praises proposals at one mental health trust to take council overview and scrutiny committees into confidence on tricky decisions.

Corporate manslaughter

But can mental health ever get it right, or will tensions between treatment and security become even more troubling in future? Charities fear last year’s Mental Health Act, by bringing in community treatment orders, will tip the balance away from good care towards public safety by imposing treatments for long periods of time. Advocates of the orders say they allow people to be treated away from hospitals.

The Corporate Manslaughter Act places greater pressure on managers to protect staff and patients from harm and has particular relevance for mental health employers.

April’s NHS staff survey shows 22 per cent of mental health trust staff had experienced physical violence from patients or their relatives in the previous 12 months - surpassed only by ambulance workers, for whom the figure was 29 per cent.

An added threat is the growing trend for coroners to refer to failures and shortcomings when making verdicts, when traditionally they have avoided apportioning blame, according to Capsticks Solicitors partner Ashley Irons, speaking at HSJ’s Mental Health Forum in Manchester three weeks ago. This can provide a strong basis for compensation claims, he said.

Risk management

Although risk management is important across the NHS, Professor Stanton maintains “there’s no more risk-rich environment than mental health”. Assessing risk is “like reading the bleeps on an invisible radar screen”. The burden on clinicians is particularly weighty when it comes to deciding whether patients are ready to move from medium to low secure or from secure services out to the community, and the need to improve transitions and medicines management is well known.

Independent inquiries carried out after mental health patients commit murder or manslaughter are unsympathetic to the fact psychiatric staff cannot always get it right, argues Barnet, Enfield and Haringey mental health trust medical director Pete Sudbury. “Badly conducted inquiries wreck psychiatry services… leaving people feeling scapegoated and degraded.”

Ultimately it is impossible to predict how accurately individuals will react in a less secure environment, he says. “The government thinks we can predict people’s behaviour, but we can’t.”

THE FACTS

  • Thirty-four per cent of people in England think people with a mental illness are likely to be violent (Attitudes towards mental illness survey, DH, 2007).

  • Around 50 of the 600 homicides a year in England and Wales are carried out by someone with a history of mental illness, but that is not always a factor (National Confidential Inquiry, 2006).

  • Five per cent of violent crimes are committed by people with serious psychiatric disorders (Oxford University/Karolinska Institute, 2006)

See Adult mental health spend stays patchy