Examination of Witnesses (Questions 600
THURSDAY 18 MAY 2000
600. It is obviously all his fault, as you can
see. My perspective, looking at it from the outside, is that until
recently the two government departments responsible for this area
frankly barely spoke to each other on how we resolve some of these
issues. Sir David, Dr Reed, you are both nodding. Is that a fair
perception? I accept there is movement now, we have got some progress,
possibly not as much as we want. Is that a fair perception of
why we have the current situation?
(Sir David Ramsbotham) Yes.
601. Sir David, Dr Reed, in the evidence you
have sent in advance and also that you have reinforced today in
answers to questions, you have fairly and squarely damned the
service as being a disgrace and appalling and in that respect
I certainly do not disagree with you in any way in that I fear
that if the level of health care, both general health care and
for mental patients, were at the level of that provided in our
prisons nationally outside our prisons then Members of Parliament
would be inundated day after day by aggrieved and angry constituents.
It is a sad reflection on the society we live in and governments
of all political parties, to be fair, that we are prepared to
tolerate this and have been prepared to do so. What I have just
said has been pointed out by many people over many years with
boring and rather tragic repetition but nothing has been done.
Why do you think that things do not improve and that we have tolerated
this and it has dragged on and on?
(Sir David Ramsbotham) I cannot comment on why it
has dragged on and on because I only came into this scene in 1995
and I have to say that in my second week in office I inspected
Holloway which immediately set me off down this trail because
I was totally appalled by what I found. Frankly, what I think
is one of the barriers to it has been the barrier between ministries
in Whitehall and the Department of Health and the Home Office
and others have been going down their individual routes. I remember
this in the Ministry of Defence, we were not very good at liaising
with other people or other people with us. That is a simplistic
answer but I did find it absolutely fascinating that the moment
we suggested that the way out of this particular morass was to
go down the NHS route, because the NHS was the responsible organisation
in the country, and then discovered that only prisons in this
country were excluded from it, there were quite a lot of squeals
about "oh, you cannot afford it" to which I said "have
you actually looked at it?" because what in fact the Prison
Service had been having to do was to duplicate what was already
available if they had functioned as outreaches of the NHS. Therefore,
what you had was a small service functioning on its own isolated
from the mainstream of development, as indeed were its staff,
which was one of the things that worried us. At one time we discovered
that only 10 per cent of the senior medical officers in prisons
were qualified to function as GPs in the NHS. That is something
which should never have been tolerated frankly, nor should it
now do we believe.
602. How far back was that, Sir David?
(Dr Reed) 1996-97.
(Sir David Ramsbotham) Three years.
603. Quite recently.
(Sir David Ramsbotham) Very recently. I personally
think that it is not all that productive to go on looking back
because what has happened is that now there are recommendations
in our paper for the patient or prisoner saying "for heaven's
sake consider this", followed by the working party to which
Dr John Reed referred, followed now by the task force, followed
by the arrangements which you are going to see at Belmarsh which
include the contracting out of primary and secondary mental health
care from prisons into the regional authorities bringing in the
clinical governance, and that has started a process. I think we
ought to concentrate on the starting of the process and in particular
encouraging the many good staff there who are trying to do a job
against the odds. You can waste a lot of time worrying about the
blame factor in this.
604. That is very interesting. You also said
earlier in your response that you felt that government departments
did not talk to each other. I certainly got the impression, particularly
at the back end of 1996/97, that certainly the Department of Health
did not want to talk to the Home Office. I believe the Home Office
would have been more than happy to transfer the Prison Health
Service to the NHS because it then would not come out of their
budget and I certainly know for a fact that the Department of
Health did not want to touch that hot potato with a barge pole
because there were enough pressures on the NHS budget in the far
more politically sensitive area of health care for the general
public outside prison without wanting to take on the additional
burden, a burden that, notwithstanding some of the savings you
may make because of duplication, was far outweighed by the additional
burden of not only financing the Prison Health Service but also
the initial investment that would have to be put into it to bring
it from a kind of Third World Health Service to a state of the
art NHS on a par with the health care outside prisons in this
country. Given that, and notwithstanding the good practice that
you have highlighted which may be the beginning of a new dawn
that develops throughout the country, but it may not, how confident
are you that it will move forward and will radically improve and
enhance health care?
(Sir David Ramsbotham) I am an optimist and, as I
said right at the beginning, one of the things that makes me optimistic
about it is that inquiries such as this, and such as the work
of the task force, are now bringing in all the people who should
have been brought in.
(Sir David Ramsbotham) The obstacle, as you quite
rightly point out, is money. It seems to me, and this is being
idealistic, that the problem is that everyone thinks of the money
first and then the solution second. For heaven's sake, let us
think of the solution and then look and see how much of that can
be afforded and, if so, from where. We go about it the wrong way
round if we do not analyse where the problem is. For example,
some prisons do not need more than a good nurse practitioner running
a minor injuries unit, they do not need a massive health care
centre and all that goes with it. When you actually look at what
the needs are in each of the prisons then I believe you will come
up with the cost which has to be looked at. The Prison Service
demanded that every prison should have completed a needs assessment
by July 1997. To date not a single prison has completed it, nor
did the Prison Service demand it. The needs assessments are now
currently being produced. Hopefully they will include mental health
needs as well. Once that is there and once you have got a description
of what the problem actually is then I believe you can tackle
it, you can start putting the money to it. If you start putting
the money to it before you analyse the problem, you are going
to confuse any solution you come up with.
606. In the light of that example, do you think
that maybe your optimism might in the end prove to be misplaced
because it is a sad fact of life that there are not many votes
in prison and health care, particularly as the client base does
not even have a vote?
(Sir David Ramsbotham) If I am cynical, the moment
litigation starts under the European Convention on Human Rights,
because of the way people have been misplaced, the financial penalties
on people will be such that I think it will wake them up to what
has been done.
(Dr Reed) Could I go back to one of the Chairman's
original questions to me about how did I feel about progress that
has been made since the Mentally Disordered Offenders Review at
the beginning of the 1990s. I hope I came over as being fairly
positive about the development. At that time, when we published
the report, we costed what costs would be to implement it all
over and we came up with the extraordinarily alarming figure of
£100 million. I have to say that is something that civil
servants kept to themselves. It is important not to be frightened
by sums like that, it may cost more to develop good quality health
care services in prisons, that is something that needs to be examined.
But, there is no big bang solution to this. If it does cost money
it is going to be money over a considerable period of time because
the limiting factor for the mentally disorder offenders' work
was training additional staff, more psychiatrists, more mental
health nurses, and you cannot do that quickly. It takes a minimum
of 10 years to train a doctor. If you work out costs and they
come up to something rather startling, you have to think of that
as £100 million over 10 years, £10 million a year, which
is quite a different prospect. If one is to succeed in that it
does depend then on people continuing to see this as an important
area and Committees like your own continuing to keep it on the
agenda, otherwise it will slip back. Can I just make one point.
You say "Right, there are not too many votes in mental health
care for offenders", well maybe as we learn more about this
people will realise that these are important things, not just
for prisoners but for them. I have recently made some inquiries
about a recent series of post homicide inquiry reports, the inquiries
that are run by the NHS when a mental disordered person has committed
homicide. I asked someone who has been involved in a great number
of these how many of these people who went on to kill had been
in prison in the year beforehand? Without pausing the answer was
"Well, the last five anyway". There are important public
safety issues as well as important personal health issues.
(Sir David Ramsbotham) If I could just endorse that.
This comes up in prison after prison after prison. At the last
prison we were inspecting last week, a young offenders' establishment,
the staff told me they were extremely concerned last year about
a boy who quite clearly had homicidal tendencies. They reported
this to the local authorities, they reported it to the police,
they warned everyone, nothing could happen and out he went. Sure
enough three months' later he chopped someone's head off. They
were at that moment very worried about a boy who was openly saying
he was going to kill. They simply did not know who was going to
listen to their cry saying "This is what is going to happen
unless you listen to us". Again, it is desperately important
that all involved establish this dialogue and listen to each other.
607. Can I address the issue of transfer between
those who might need some care in a different kind of Prison Service
from the NHS. Can I ask, first of all, Mr Boyle. I am not sure
so far, Mr Boyle, from what you have been able to say what it
is you are able to say to the Committee. I would be grateful if
you could say something about this. We have been given evidence
that transfers are slow. How can you speed up the system? What
is the Home Office thinking on speeding up the system of transfers?
(Mr Boyle) Can I just be clear, are you talking about
transfers of people from prison to hospital?
(Mr Boyle) Rather than transfers within the hospital
(Mr Boyle) I just ask because we have responsibility
to give consent at both ends of the system.
(Mr Boyle) As far as transfers out of prisons into
hospital are concerned, our narrow responsibility is in effect
to look after the mechanicswe have to give the formal authority
rather than making the actual arrangements. In that respect we
think that in my unit we are offering quite a good service. From
a figure of under 200 prisoners transferred to hospitals per year
in the late 1980s, the figure has increased, largely as a result
of extra capacity in the health system I suspect, to a level of
750 transfers a year. One of our targets, which we virtually without
exception achieve, is to process all the necessary paperwork to
provide the authority for the transfer within 24 hours of being
informed that a bed is available for the prisoner. At that level
the system works. The issue is elsewhere in the system and I think
it is related, first of all, because I think there is a theme
that has emerged from the previous discussion, to identifying
the fact that the prisoner actually is suffering from a mental
disorder that is so serious as to warrant specialist treatment
in hospital and then, secondly, identifying the right place in
the hospital system for them to go to. Perhaps I should just add
that is not just a question of bed availability in the very high
security hospitals because last year out of the 742 people we
transferred to hospital, actually less than ten per cent went
to high security, the great majority went to either NHS or private
sector medium security and quite a good proportion to low security
as well. It is a question of capacity throughout the system. The
final thing I would just say in relation to our role in the system
is that we do encourage prison doctors both to use the existing
arrangements that have been set up by which if they are having
problems identifying an appropriate placement for a prisoner they
go through the regional specialised commissioning units to see
if they can resolve the problems and clear blockages at that level,
but also to make sure that they let us know if they are having
real problems in that respect because we do have a reserve power
to direct the admission of a prisoner to hospital. Even if the
hospital says "we are full, we have not got the room",
if our assessment is that the situation is so serious that the
prisoner has to be directed to that hospital, we have that power.
It is one that we use very sparingly, we only used it four times
last year, but it is there in cases of real need and we are willing
to use it if we need to.
611. Dr Reed, I am given to understand that
in a recent BMJ article you spoke about prisoners who might
just need 24 hour nursed care who would not necessarily be detained
or diagnosed under a Mental Health Act diagnosis and those might
be helped by temporary licence transfers. Can you say a bit more
about that, particularly in the light of what Mr Boyle has said?
(Dr Reed) The second paper you have looked at the
care of people who are inpatients in health care centres. They
divide them into broadly three groups. There are ones who I think
you could call proper sick bay cases, people who are getting over
the flu or have broken their wrist and they need to be protected
from the rest of the world for a while. That is about a third.
There are a third who have difficulty in coping with life in prison
and who get upset, and that is a group that is not particularly
relevant to your discussions here. There is this third group of
people with serious mental illness who if, instead of looking
at what you have to do pragmatically, you look at what their clinical
needs are, these are people who need to be in the NHS psychiatric
service. The great majority of them need to be in medium secure
care. A small proportion, a single figure percentage, need to
be in the high secure or in the general psychiatric service. The
great number need to go into medium security. You can project
from the study that we didand we commissioned some work
in the West Midlands Forensic Service looking at two whole NHS
regions and the prisons in thosethat there are probably
at any one time 500 seriously mentally ill people in prison health
care centres who really, if their clinical needs are to be met,
ought to be in NHS secure care. There are, of course, others who
are out on the wings who I spoke about earlier who we do not know
about, but that is a clearly identified group. Now, at present,
it is the almost universal experience that it is an extremely
slow process to transfer mentally ill people from prison to the
NHS. To a certain extent this is because of disputes about the
proper level of security that they need, whether they should have
high security or medium security. To a much lesser extent nowadays
there are disputes about funding, who should pay. The big problem
from the prison perspective is simply unavailability of beds for
them to go to. Particularly this is true of the longest waits
of people transferring to the special hospitals. Certainly I have
been in prisons where people have waited well over a year before
a bed becomes available in the special hospitals. Meanwhile, the
prisons, with their limited and not very adequate resources, have
to do the best they can. There is also a problem of medium security
though the length of wait there is not so long and it varies very
much from place to place. For instance, at Liverpool Prison there
was no problem, the local forensic psychiatric service took people
out and if they waited a week it was viewed as a failure. They
managed it very rapidly. I think there is scope for study as to
why they are so successful and others are not. There are serious
blockages in the system. This is particularly difficult for people
who are in prison on remand because at any moment they may go
back to court and the court may make a non custodial disposal
while you are trying to transfer them to secure psychiatric care
and they are lost in the system.
(Dr Snowden) I think it is fair to say that there
are some secure units, like in Merseyside, which are able to transfer
individuals from prison to hospital fairly rapidly and that may
be something about the number of beds that unit has for the geographical
area that it is responsible for. I think it is fair to say on
the whole on any one day, let us take today, it is unlikely that
there will be a single medium secure unit bed available in the
NHS, it is unlikely that there will be a single high security
bed available in the NHS. There is no spare capacity and that
no spare capacity has been caused by the long stay patients with
secure needs who have silted up the system and usually gravitated
to the highest level of security, but there are some in medium
secure services. I agree with Mr Boyle that there has been an
increase, and I am sure there will continue to be an increase,
in prison transfers from prison to the health care settings but
it is increasingly difficult and many end up going into independent
sector secure provision. The problem with that is that when they
are deemed well enough to move to the NHS there is a discontinuity
of care. Someone else takes them over, has to relearn their case
and in terms of risk assessment of these, at times, very difficult
individuals I think that is problematic for the community. I think
apart from capacity there are process issues. For example, we
have discussed already the identification of individuals with
severe mental illness but the assessment process can be very time
consuming. If I have a Manchester resident who ends up in a prison
on the Isle of Wight it could take a day or a day and a half to
go down with a multi-disciplinary team, do a proper assessment,
come back, do the report, etc., because the Prison Service is
unable in most cases to get its head around transferring the prisoner
close to the health care service which is supposed to be providing
the care. Fortunately, again there may be other areas of good
practice but I am aware in Manchester the Governor there is able
to organise a spare bed or two within the health care centre to
allow prisoners to be transferred from further afield to Manchester
so we can organise a fairly urgent assessment. There are a number
of process issues about but I think the bottom line is capacity.
612. It is nice to have the opportunity to visit
the Isle of Wight. It is very interesting. We have been told that
the Prison Service is the method of managing waiting lists, basically,
for NHS provision. Dr Reed, I think you gave a figure of 500 beds.
(Dr Reed) Yes.
613. Your assessment being noted.
(Dr Reed) Yes.
614. We have been told by the Department they
are planning almost 500 new medium and low secure units but that
presumably does not take into account the other end of the logjam
which is the special hospital to make more space available there.
Is the total figure of 500 an appropriate figure? Is that a Prison
Service derived figure? Has it taken into account the need which
we discussed earlier of the special hospitals to move on the 20
to 30 per cent of people that they have got who could be placed
(Mrs Foley) The 500 that John has talked about are
the 500 that are sitting in the Prison Service.
(Dr Reed) Purely in prison.
615. Can you give us the total figure? From
your experience of the special hospitals, how many beds in medium
and low secure units do you need to complete this jigsaw?
(Mrs Foley) I think, as we heard right at the very
beginning of this from the Chairman, there is a general acknowledgement
that between 25 and 30 per cent of patients who are in high security
at the moment do not need that.
616. We are talking about another 400?
(Mrs Foley) Yes.
Dr Brand: That is very helpful. Has anyone done
any costings of what it costs to keep someone in a prison, someone
in a secure unit? It would be helpful if somebody could give us
Chairman: Perhaps you could write in. I am sure
you have these figures.
617. I am sure it will be very helpful in our
final report. The last question I would just like to ask Sir David
or Dr Reed. Sir David is quite right in saying that we have to
think about patterns that meet the problem rather than look at
the funding, but do you believe that the current funding for,
say, secondary care for prisoners, which is based on a capitation
system, is adequate? Certainly my health authority is very much
out of pocket in providing hospital care for prisoners in our
three prisons because the capitation based system does not take
into account the higher rate that group costs. That makes them
very reluctant to start volunteering imaginative schemes of increasing
the NHS involvement.
(Sir David Ramsbotham) I bow to Dr Reed.
(Dr Reed) That is more an answer for my colleague
from the Department of Health. My understanding is they have been
looking at funding in that light, as you say. The Isle of Wight
is the crucial case.
618. I always think so.
(Dr Reed) Three big prisons. I understand they are
looking at that. It is something you will have to ask them. Just
on the money issue, okay I say there are 500 people currently
in prison health care centres who ought to be in the NHS, the
corollary of that is there are 500 beds in the Prison Service
which could be closed.
Dr Brand: Unfortunately, I think they will probably
be filled up.
619. I just want to make a quick point. When
we visited Broadmoor last week they said there were no women on
a waiting list to come into Broadmoor but there were 20 men on
this waiting list. As you have already said, there can be a lengthy
wait. Presumably you would agree that these men on the waiting
list, their outcome is poorer so they are not receiving the treatment
they really need.
(Sir David Ramsbotham) Yes, that is absolutely right.
Chairman: I think we are going to move into
areas away from directly the prison environment with Mr Gunnell.
Can I make a brief point, perhaps on a lighter note. We are looking
at concerns over medical provisions within the prison system.
I received a letter yesterday from a GP in my constituency on
behalf of a patient, who was a prison officer, expressing concern
that the prison officer with a particular condition was getting
a poorer service on the outside than the prisoners that he knew
of within the prison in which he worked.