A model of forensic mental healthcare where high-security units and special hospitals are integrated with community care has yet to be found, says Nigel Maguire
The English special hospitals appear to have staggered from one crisis to another in recent years. They seem to have been unable to take forward a clinical and therapeutic agenda while maintaining a safe and secure environment. It would be unfair and, indeed, unwise for service commissioners or providers to accept this view uncritically, as there are many examples of innovative good practice in all hospitals. But the perception - not just in the public arena - is one of fear and mistrust.
The desirability of moving away from large institutional high-security hospitals is not questioned by most professional staff in mental health. The experience of the special hospitals management teams can testify to the immense difficulties in effecting real change in such large, highly politicised environments.
Change has occurred, but it appears to swing from one end of the spectrum to the other, from a custodial, authoritarian attitude to an almost laissez- faire approach. The middle ground, where therapeutic care can be achieved in the context of a safe and secure environment has yet to be found.
An alternative model is needed to take things forward - one that recognises the potential strengths of the existing special hospitals and the affordability of closing them down, while recognising that there is a need for radical change in the delivery of forensic mental healthcare in England and Wales.
Until recently it appeared possible, even probable, that radical change was on the cards for the special hospitals. The announcement by health secretary Frank Dobson in the aftermath of the Fallon inquiry into Ashworth Hospital, however, indicated that the special hospitals would not close, as the inquiry team recommended. But Mr Dobson did indicate that change would be needed to ensure a more effective and robust management culture.
This steadier approach will see the gradual downsizing of the special hospitals to around 350 beds each, as the long-stay medium-secure populations are moved to regional medium-secure units.
The question of where and how best to care for and treat patients with a severe personality disorder has only in part been answered - and evidently not to many people's satisfaction. Proposals to include reviewable or renewable periods of detention for offenders with a severe personality disorder, while playing to the public gallery, do not address questions over their treatability and which service or organisation is best placed to treat them.
The National Association for the Care and Resettlement of Offenders report Risks and Rights called for a new service and proposed that 'offenders would be placed in separate accommodation outside the current penal and health systems'.1 A decision on future provision for this group is expected some time this year, and is likely to echo broadly the NACRO proposals. Should this be the case, then this may ultimately reduce the special hospitals to 250 beds.
This reduction, while significant, would still leave the current institutions and their associated problematic behaviours intact. A more manageable figure for these institutions, based on the experience of Scotland's state hospital Carstairs, would appear to be around 150 beds - though this would require serious consideration of alternative and complementary provision.2
Current developments will see the special hospitals being managed by existing specialist mental heath trusts. This structural change is to be welcomed, and is supported by the proposed legislative change. But it must be delivered alongside a model of service provision that affords seamless and more therapeutic care to the patient.
As we move to regional commissioning of the services, there is a need to produce a national framework that sets clear standards within which each of the regions can develop their forensic services.
To complement the slimmed-down, integrated special hospitals, there would be a need for a number of high-security units, also managed by specialist mental health trusts. It would be unwise to develop high-security units in isolation from existing forensic services; this would only perpetuate the mistakes of the past.
What is needed is a clear pathway from the point of entry into a service, through to the point of discharge, incorporating community and mainstream mental health services.
This must include the various potential pathways that the individual may tread, as lack of clarity in the past has contributed to the current crisis of confidence in the system. What is important is the integration of services to ensure that they function as a single provider.
There are significant advantages in this option for the cross-fertilisation of staffing and ideas, and the dissemination of good practice across the spectrum. The diffusion of the culture between medium and high-security environments would help to provide a broader perspective of care, while some of the expertise within high security, especially in relation to safety and security, would enhance practice within the medium-secure setting.
A number of inquiry reports - including, notably, that of the Ashworth inquiry - stressed that one of the major problems in the high-security services was their size, although this was not the only problem.3 A significant recurring theme was their isolation from the rest of the health service, in particular from medium-secure units, and lack of external objective reference points.
It was this lack of external reference that allowed the ethos in some of these hospitals to swing from one extreme of custodialism and its occasional infringement of rights to the other - a libertarian culture of excessive autonomy, without the effective checks and balances which are essential when caring for this patient group.
Ideally, high-security units should be built on existing medium-secure sites, but it is unlikely that public opinion and planning regulations would support such a move. The more realistic option is a move to a greenfield site located on the outskirts of a major area of population where a high- security unit could be built together with the relocation of the existing and other forensic services.
Future forensic healthcare services could then develop as follows:
high and medium-secure acute assessment and treatment services;
high and medium-secure long-stay care provision;
a broad spectrum of inpatient forensic rehabilitation services;
community-based forensic teams;
community-based work facilities;
support staff to provide services to prisons and local hospitals.
The services would cater primarily for adult mentally disordered offenders. Adult learning disabled offenders and adolescent mentally disordered offenders should be cared for by existing or new services, with the potential for a single high-security learning disabilities service. The case for a high- security adolescent service has yet to be made.
Each of the new integrated secure units will have to define clearly the areas of specialist care to ensure that each ward has a particular focus or treatment approach, especially for sex offenders and those with severe and enduring mental illness. A discrete women's service will also be needed, which
perhaps spans the secure spectrum, although there is little empirical evidence that women require
high-security psychiatric provision. The Special Hospital Services Authority's 1994 report, Authority Strategy for Women Requiring Secure Psychiatric Services, found that nearly four-fifths of women in the special hospitals did not require high security and two-fifths of these did not require even medium security.4
These specialist provisions should reflect differing approaches to care - for example, psychosocial interventions, the therapeutic community, cognitive behavioural approaches or dialectical behavioural therapy for women. This degree of specialisation will necessitate a much more rigorous research-based approach to care and the development of specific models that reflect both the clients' needs and the service's goals.
The provision of a single-site high and medium-security service would promote economies of scale and integration. There would be potential for shared services and facilities in the areas of recreation, diversion and off-ward therapeutic activities.
Both the re-shaped special hospitals and new units should have a single management structure, a single management team, a corporate strategy and a therapeutic and proactive clinical agenda. Each ward would have a clear operational philosophy and model of care with defined treatment and research outcomes.
This would ensure that patients were maintained at the level of security they needed, in accordance with the Reed principles, and thus enable varying degrees of independent living in relation to the rehabilitation and pre- discharge services.5
Each site would have significant training and practice development agendas that would incorporate both academic research and competency-based teaching and learning programmes.
The development of a core site for medium and high security with a broad spectrum of clinical services would enable these regional services to recruit and, importantly, retain the highest calibre of staff from across all professions. Staff would be able to work in high security and thereby be given opportunities to develop clinical skills while remaining in a mainstream clinical arena.
In addition, staff could be afforded time out of the extremely stressful area of high-security care, and there would be opportunities for greater transfer of skills and knowledge that would be to the benefit of both high and medium-security services.
There would be an active commitment to recruitment - particularly of occupational therapists, who have traditionally been the most under-represented professional group, and advanced nurse practitioners. These two groups are in an excellent position to provide an external reference to the ward.
Integration into trusts would provide an opportunity to extinguish the unhelpful influence of the non-NHS representative organisations which have laid down the custodial practices from which we must continue to distance ourselves. To be less custodial does not equate to being less secure. Custody is a state of mind that the nurse has towards a patient. It is this which inhibits their practice and biases their attitude towards a patient.
Nurses may need to reconcile the public expectation of the control function of mental health services with their professional assumptions about their therapeutic relationships with patients.6
There will be a need for a clear and robust management culture which would support and guide decisions in the day-to-day management of the service. Clear policies and practices in relation to security and safety are essential and will need to be understood and practised by all staff, not just the nurses who have traditionally accepted this responsibility.
Lines of accountability and responsibility internal to the service and trust will be essential, together with channels through to the regional office, the Department of Health and ministers. This lack of clarity has all too often been evident in the past.
Before we embark on this new venture, more open debate and discussion is needed, not just on the structure but the clinical pathways, models of care for defined patient groups and treatment outcomes. We also need clarity from our political masters about what we, as providers, are expected to deliver.
If we are in the business of rehabilitating mentally disordered offenders, then measured, balanced and calculated risks will need to be taken. This should be backed up by more scientific clinical risk-
assessment tools. In return, services will need to be managerially and politically supported at the top.
What will all this mean for the patient? What we will see is a more integrated service that breaks down the arbitrary barrier between high and medium security, allowing the patient to move seamlessly through the service according to need and presenting risk. The service will focus on delivering a broad range of evidence-based treatment options with highly trained and competent practitioners.
Ministers must take the brave decisions needed to move forensic mental healthcare to a positive, dynamic future so that we, as managers and clinicians, can deliver on this agenda.