Edited by, and with chapters from, two senior NHS managers involved in the special hospitals, this book provides a fascinating, if partial, view of the management challenges in the often closed world of Broadmoor, Rampton and Ashworth.
The book opens with an perceptive introduction and history of the hospitals, tracking the story from the foundation of Broadmoor in 1863 to the present. Given the archive material available at the hospitals, I found this section a little sketchy.
Later chapters, on culture and the inheritance of the former Special Hospitals Service Authority, provide fuller commentary on the history - particularly the influence of the Prison Officers Association - and the mythology surrounding these institutions. The political realities of running such a service are well described and give the reader a flavour of what challenges managers face in handling the relationship between security and therapy.
A chapter examining the troubled industrial relations at the hospitals does not sit on any fences. It states boldly that 'the POA should no longer be recognised' if real culture change is to occur.
Margaret Orr attempts to describe the hospital patients and trots out the now rather sterile and unhelpful psychiatric terminology, including the term 'psychopathically disordered'. Greater discussion of the weakness of current knowledge would have been useful, as would a specific analysis of the special needs of women patients as well as black people and other minority groups.
Professor Pamela Taylor provides an excellent and useful analysis of the thorny issues of patient relationships, which any forensic mental health service would find valuable. This chapter provides well-researched guidance of a practical nature that is realistic and sensitive.
The book examines the influences of the media coverage of the hospitals and the effects of independent inquiries, of which there have been many. I found it somewhat defensive and depressing on these topics.
The media will always have a legitimate interest in these services, but the book fails to ask whether more open policies might actually help.
The authors accurately plot the negative effects of inquiries and question their role. In truth, the need for independent examination of these hospitals is crucial in an open society, however painful.
The authors courageously accept that 'with hindsight, we would have initiated fewer inquiries, but followed them up more vigorously'.
The book plots the progress made from the inception of the SHSA in 1989, including the elimination of slopping out and the introduction of 24-hour care. It offers candid examination of some of the more extreme mistakes, for example the death of young black men in Broadmoor, a chilling reminder that much still needs to be done.
But this book has a major deficit. It does not include any real contribution from the patients' experience. In any attempt to get a balanced picture of the work of these hospitals, a user perspective, gained from somebody who has actually lived in the system, is essential. The views of one or two former patients would have given a more rounded picture.
The definitive story of these three hospitals may never be written, but this book does attempt to provide an honest, and at times painful, examination of what goes on.
Ray Rowden Visiting professor at York University.
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