Examination of Witnesses (Questions 620
- 637)
THURSDAY 18 MAY 2000
MRS SHEILA
FOLEY, DR
PETER SNOWDEN,
SIR DAVID
RAMSBOTHAM, DR
JOHN REED,
MR MIKE
BOYLE AND
MS LIZ
MAYNE
Mr Gunnell
620. Just a quick question very much, first
of all, for Mr Boyle. In both Ashworth and Broadmoor we found
there were problems which existed over the restricted patients
where you may have a clinical view that the patient can move on
but the Home Office will not permit it and where the release of
some prisoners, or even the movement of some prisoners, would
be regarded as politically impossible. How do you respond to such
concerns and do you accept they create serious problems for the
secure psychiatric services where they are?
(Mr Boyle) I think you need to understand our function
in the system is totally different from that of the care teams
in hospitals. As I said at the beginning of the session, we are
quite clear that our role is not one of second guessing clinical
judgments, so we are perfectly content to accept the judgment
of the care teams as to the state of the prisoner, the treatment
that is needed and their judgment as to the likely prognosis.
Our function is purely that of safeguarding the public interest
in the risk dimension and that is why the system has us deliberately
set apart from the care teams, so that we are able to exercise
an objective and discretionary judgment without the danger of
becoming too close to the individual and losing track of some
factors that may still be quite prominent in the individual case
which the care team may lose sight of. That said, we have no interest
whatever in keeping people in hospital any longer than they need
to be on the basis of the combination of their own state of health
and the risk to the public they represent. Those two factors are
obviously intertwined. Very often what we do find is that we struggle
to get the full range of information that we need in order to
be able to exercise our functions. The discussion today is focused
on the high security and medium security hospital prisons. It
is perhaps worth mentioning that our restricted patient population
is spread across 600 hospitals across the UK. We are dealing with
1,200 doctors who are responsible to us. It is very important
that they should be aware of the factors we take into account
when considering cases. We have issued to all of those doctors
copies of our risk assessment check list, a 36 point list, so
they are all aware. We reissue it every year and encourage them
to make sure that all members of the care team are aware of it.
They have, or they should have, a very good awareness of exactly
what we need to have covered when they put proposals to us. If
those areas are covered we are very, very keen to take a decision
quickly. It is not in our interest to have our offices clogged
up with files as well, just taking the very narrow perception.
We do find that we have repeated rounds of correspondence. In
the main, the forensic specialists we deal with, who understand
our role, appreciate we have something extra to contribute and
do not begrudge us our involvement in the process at all. I think
that would apply certainly to people from the high security hospitals.
We have an issue more generally with some general psychiatrists
who perhaps feel we should not feel our role necessarily involves
challenging their clinical judgment and do not understand it.
In some cases they begrudge us that role.
621. In Broadmoor the particular patient that
I asked about was a person who knew, and had been told, that he
would never, ever leave the place. That is something which I understand
on the community basis. How many such patients do you have? When
you talk about 600, you do not have 600 patients who would know,
know as of now, that they will never leave the prison establishment.
(Mr Boyle) I am not aware of any patient that on the
strength of anything that we have said from the Home Office has
been told that they are never going to be discharged. There may
be some, I am sure we can all imagine some particularly high profile
patients who we consider, if only for their own safety, it is
going to be very difficult to imagine them being able to return
to the community. We deal with specific applications for consent
to grant leave to transfer or discharge as we receive them. In
responding to that application we will never say "no, not
ever". What we might say in respect of a particular application
is "not now" but we will never say "not ever".
If that message has got back to a patient it has not emerged from
the Home Office.
Dr Brand: Probably, Chairman, through The
Daily Mirror or The Sun.
Mr Gunnell
622. I do not think in this patient's case it
has ever been suggested that the patient will be released, undoubtedly
The Daily Mirror and The Sun would have an interest
in it. There are certain others who have had more recent publicity
in The Daily Mirror and The Sun who are in that
position. You do not think the numbers of such prisoners in any
way clog up the system? There are not sufficient numbers of these
people who are high profile cases or who have in their time been
high profile public cases?
(Mr Boyle) I think all I can say, again, is we will
not take a judgment purely on the basis of the profile the case
may have had. We accept that if a patient is given a hospital
order with restrictions that is not a punitive disposal. It is
not our function, in a sense, to apply a secondary punitive element
to it by refusing to consent to the transfer or discharge where
that is otherwise justified on the basis of the patient's mental
health and the risk to the public. If those two factors are satisfied
then we will never prevent the patient from leaving. In a sense,
to ask me about how many people there are in that category is
a question I cannot answer because it is not a way we address
the issue.
Mr Austin
623. Can I just make a comment. As the Member
of Parliament for Belmarsh who has visited it over a long period
of time and who has therefore seen the transformation, I endorse
Sir David's comment that those of us who are visiting next week
to see the transformed service perhaps ought to see one that has
not undergone that change. Can I say also in commenting on the
Chairman's remark about the prison officer and the prisoner, as
the local Member of Parliament for Belmarsh I do see some merit
in sharing the same primary care provider in terms of GP practice
as the prison I represent. There is some merit. The issue was
raised earlier about gender and the inappropriateness of the way
in which care was delivered or the appropriateness of the care
itself or, indeed, the appropriateness of the placement of women
in particular units. I think to an extent that Dr Snowden was
almost implying some units had to carry a health warning that
these units can seriously damage your mental health. I want to
draw a parallel with race and ethnicity because it does seem to
me there is a disproportionate number of black and other ethnic
minorities in all of the units we have seen. Whether this is because
of the inappropriateness of provision or whether it is because
of issues around diagnosis, the fact is that there are large numbers
of black people in our prisons, in our special units, etc. I would
like to ask all of our witnesses whether they feel the kind of
care which is being provided is appropriate, whether the services
delivered are culturally sensitive, and also whether enough is
being done within the prison to combat racism itself?
(Mrs Foley) If I can respond by saying 26 per cent
of patients who are in Rampton Hospital at the moment are from
an ethnic background, so you are quite right they do appear to
be over represented. In terms of do I think they are in the right
place and they are getting the right treatment, I certainly believe
they are getting the right treatment but it would be remiss of
me not to say in terms of the culture that we are delivering that
we have got some work to do. You can never forget that basically
we are working with a very diverse group of people who have got
very different needs. Just lumping them together and saying they
are ethnic does not help you. It is sub-divided down and their
needs are very different within that. We are very conscious that
we need to do a lot more and we have got an equal opportunities
group within the hospital which I chair and we are encouraging
patients, if they have got concerns, to raise them. As part of
that I am coming to London to hold a meeting with black patients'
relatives because it is difficult for them to get up to the hospital
and see me when I am there and as a group, so we are working on
that.
(Dr Snowden) If I was to look at medium secure provision,
I would have to say that it has to be the responsibility of services
who work with individuals who come from an ethnic minority background
to make certain that their services are culturally sensitive and
to make sure these individuals are not too disengaged from their
local community. I work in Manchester and my patch is Central
Manchester and Moss Side and many of my patients come from Afro-Caribbean/African
backgrounds and the way that we have tried to deal with their
needs is to open our secure unit up to the community and to invite
in the Afro-Caribbean mental health service. It is a voluntary
project which receives funding from various sources and they have
care workers who come in and attend ward rounds and provide out
in the community some diversion, some meeting places that are
appropriate. I am not sure if all the units provide that sort
of sensitive service. I agree that there are a number of individuals
in medium security who are black, and particularly young black
and male, who should not be there, and I feel that very strongly,
but also by the time they get to an assessment by the forensic
service they have probably failed a number of hurdles and missed
a number of contacts that might have diverted them, from general
practitioners right the way through to the forensic mental health
system.
624. So the system has actually damaged their
mental health?
(Dr Snowden) It is often the case my service picks
up someone who has been damaged because they have not been appropriately
connected with the health system at earlier layers and we have
to do our best once they come to us. But often I would have to
say these are individuals who have been failed by the system.
Chairman
625. Dr Reed, have you any quick points on this
issue?
(Dr Reed) I think all the difficulties and disadvantages
that apply to health care broadly apply to those from ethnic minorities
and there is obviously more that can be done. We have remarkably
little information about prison health care and ethnicity, at
least I have not found any. The only bit I have got is something
that came up from the West Midlands Forensic Service survey we
commissioned of inpatients in prisons which showed that the white/non-white
breakdown in patients was roughly the same as for the whole prison
population, which I thought was very interesting.
(Sir David Ramsbotham) All I would add is this is
something we will be going into during the course of this year
because I will be doing a study of racism in the Prison Service
anyway and this is one of the areas we will look at. As John said,
I do not think we have any information at present.
(Mr Boyle) To complete the picture in relation to
the work we are doing on developing new systems and services for
dangerous people with severe personality disorder, we are acutely
aware that as we are developing a new type of system for these
people that we need to build in appropriate mechanisms to ensure
that we meet the needs of people from a whole range of culturally
diverse backgrounds. That is something we are building into the
work right from the start. On the gender issue, because we recognise
that the number of women who are likely to be affected by these
proposals is very small indeed, that presents a huge challenge
in terms of the designing of services. In the joint service development
team we have set up jointly chaired between the Prison Service
and Department of Health, to design and develop the new services,
we are setting up a specific sub-group on women's issues to take
a particular look at exactly the nature of the service we should
be designing for women and ensure we meet their needs in a particular
way.
Mr Austin
626. Dr Snowden was talking about integrating
the unit within the community. That is all very well if you are
talking about a service that is related to the community it serves
but when we are talking about special hospitals we are talking
about a number of people being divorced a long way from their
communities and communities where they are being accommodated
wholly unreflective of the areas they came from. Is that something
for the staff?
(Dr Snowden) It would be difficult to counteract that
whilst we still have three high security hospitals. There have
been arguments that there should be more than three and that they
should be smaller and that they should be more connected to local
services.
627. Was that not one of the recommendations
which was not accepted by the Government?
(Dr Snowden) Yes, so far.
Dr Stoate
628. Can I briefly go on to dangerous severe
personality disorders which you have already mentioned. How can
we ensure that the proposals being put forward are going to tackle
the right people and how can we have any method of assessing whether
we are getting to the right group of people? We have already heard
from Sir David this morning about a young man who was clearly
known to be homicidal but the Service had to wait until he had
killed somebody before taking any action. So, Mr Boyle, what is
is the new service going to look like?
(Mr Boyle) I cannot say what it is going to look like
in total because, as you know, we are still considering the outcome
of the consultation process which gave two broad options for what
the system might be for the future. The common element of them,
whichever of the two options Ministers decide to go for, clearly
will be dedicated treatment facilities and new specialist in-depth
assessment processes. The key to making this system work, as you
identified, is getting the right people into it, identifying who
should be either exposed to a liability to detention or given
the opportunity of the new innovative treatments which we want
to devise. Getting the assessment right is crucial. While the
consultation process was underway we had a range of specialist
groups of experts working to devise a battery of tools and a process
that would enable us to put the assessment procedures in place
and on the back of that work we are already beginning to set up
the first pilot assessment centre to test out what will amount
to the most intensive and long term of the range of processes
that an individual will need to go through coming into this system.
If I can take it in a sense from back to front, what we are now
beginning to pilot will take place at Whitemoor Prison and the
arrangements are already being put in place and we hope the first
assessments will begin there in September. That will involve an
in-depth multi-disciplinary assessment over a period of about
12 or 13 weeks of individuals looking at a whole range of factors,
applying the battery of existing psychological tools and building
on other aspects as well. The work on refining exactly what that
tool will be is underway.
629. The question is how will we be able to
justify the detention of somebody, even after your 12 or 13 week
period, who has not actually committed a crime? Will that contravene
human rights legislation?
(Mr Boyle) In a sense it is a similar justification
to civil detention under the Mental Health Act at the moment.
It is a justification based not on the need for a punitive reaction
to an action that somebody has actually taken but it is a reaction
to an assessment of their mental state linked to the risk that
they present to the public.
630. The difference between the current legislation
on mental health is that that is related to treatment. The idea
is you are compulsorily admitting somebody for treatment. If we
are talking about dangerous personality disorders, we are, by
definition, saying these people are not amenable to treatment
so you are then compulsorily detaining somebody not for the prospect
of treatment because that is not available but purely for the
prospect of locking somebody up. How will that fit in with human
rights legislation?
(Mr Boyle) I could not accept the statement that by
definition these people are untreatable.
631. If they were treatable they would come
under the Mental Health Act as it currently stands.
(Mr Boyle) What we are talking about is creating a
specialist system. It may be if Ministers opt for option A in
the consultation document the people who would come in through
this system would be in the NHS anyway.
632. Michael Stone, a classic example, was turned
down by the psychiatric service because he was untreatable. He
then went and killed two people and that of course brought many
of the issues to the fore. The fact is if somebody is treatable
under the current system they do not need this new system at all,
they simply detain them under the current legislation. So this
new proposal is specifically designed, surely, to detain people
who currently do not come under the Mental Health Act and by definition
have not committed a crime so how do we justify their detention?
(Mr Boyle) I will not be drawn into the Michael Stone
issue because there are all sorts of separate issues on that,
but I do take the general point. The issue of treatability, whether
an individual is treatable or not, has become the key issue as
to whether there is any means whereby the public can be protected
from somebody who by common consent represents high degrees of
risk to the public. I know that there is great concern amongst
psychiatrists that they are already under pressure to take into
secure hospitals individuals that they feel they can do nothing
for in order to serve a different end of public policy—protecting
the public. That is, I think, largely because for a whole host
of reasons we have to some extent gone down a blind alley on the
question of what treatment can be given for personality disorder.
There has not been proper resourcing or proper research so fundamentally
while there is—and clinical colleagues are better placed
to comment on this than I am—still a considerable debate
going on among not just psychiatry but within psychology as well
as to how far individuals with personality disorders can or cannot
be treated, if you look at the Report of the Royal College of
Psychiatrists published last year there are some good indicators
there of useful things that can be done.
633. I am sorry to interrupt you but you are
dodging my question. My question is if you can persuade a psychiatrist
that these things are treatable, they are covered by the Mental
Health Act and we do not need to worry about new legislation.
The whole point of this is if somebody can be deemed treatable
by the psychiatrist, that is fine, no problem under the current
rules. We are talking about people who cannot be defined under
the current rules otherwise we would not need the new rules. You
still have not answered my question on the human rights issue.
If we are to detain somebody who has not committed a crime, who
was not deemed to be treatable by current medical opinion, what
are the human rights implications of doing that?
(Mr Boyle) To take it at its most basic, the European
Convention on Human Rights provides two relevant articles by which
you can justify detention for this group. Article 5.1.a allows
for detention following conviction by a court following the committing
of an offence. That is clearly not necessarily relevant to this.
The provision which we would be relying upon for this system is
Article 5.1.e which provides for detention on the basis of "unsound
mind". The existence of unsound mind itself is sufficient
basis to justify detention. There is no requirement on the face
of the ECHR that that should be linked to any issues of treatment
or the provision of treatment, but we are not saying that is what
we want to do. The proposals are very clearly not about identifying
people who are so severely disordered as to meet the threshold
of unsound mind, identifying them as high risk and then simply
locking them away and losing them in the system. The intention
is to very specifically ride on the back of the ECHR's implications
and not just using the skills psychiatrists have now and perhaps
not using anything that we are aware of now, but looking at a
whole range of inputs that could be made from across psychology,
psychotherapy and so on.
634. Again, you are hiding behind this idea
of treatability because you are now saying we can find new treatments
for them. I am talking about people who have, by definition, been
deemed untreatable otherwise they would not be subject to this
new proposal. It will not do to say we will find some psychologist
who says they have got something up their sleeve that might be
able to help them. I am specifically talking about people who
are not treatable otherwise they would not be in this position.
(Mr Boyle) The bottom line has to be that we think
we can do an awful lot better than we currently do in identifying
new treatments and providing those treatments so that individuals
who currently receive totally inadequate management across the
system can be helped to make the changes in their behaviour, if
not in their personalities, that will let them return to the community
safely. We are reasonably confident and we certainly feel an obligation
to put much greater effort into investigating that possibility
but we do recognise there will be individuals who will be drawn
into the system who will be not be amenable to any kind of intervention
of that kind and who may end up spending the rest of their lives
in that system. The key point there is to recognise that those
individuals currently are damaged individuals. They are suffering
and they cause great suffering in the communities of which they
are a part.
635. I understand that. I understand there is
a need for some people to be removed from society for all sorts
of reasons. What I am asking for is justification under human
rights issues to be able to do to that. It is really as simple
as that.
(Mr Boyle) The justification is that at the moment
they are not—I would almost want to argue the question in
reverse. If you look at the position as it applies at the moment
where you have damaged, disordered individuals who are not receiving
adequate services either from the Prison Service or from the NHS,
who are distressed themselves, cause distress to their families
and communities around them, and we are saying in effect there
is no response to that, that seems to me to be an infringement
not only of their human rights but of the human rights of the
rest of society.
Dr Stoate: This is designed to lock people up,
not to treat them, that is the difference. We are not producing
a service to treat people, we are producing a service to lock
them up out of society. That is not the same thing and that is
why I feel the human rights issue has not been addressed.
Chairman: Can I bring Simon Burns in.
Mr Burns
636. Would you accept that with people who are
untreatable but who were in the considered opinion of a number
of people qualified to take the judgment like psychiatrists, social
workers, the police, etcetera that they pose a threat to society,
that yes of course they have human rights, but also it is the
state's duty to protect the human rights of members of the public
who might potentially suffer at their hands?
(Mr Boyle) I think that is absolutely so and that
is a part of the process. There is a balance here. In fact, the
Convention does impose upon states an obligation to protect the
public from predictable dangers that individuals may cause. I
understand Dr Stoate's point of view in relation to the human
rights of the individuals concerned, but I think I would come
back to the point that these proposals are not designed in order
to lock people up. The detention is a by-product of the conclusion
that with these individuals the need to protect the public requires
that they be detained and also the detention provides the best
possible opportunities to expose them to a range of therapeutic
interventions against the possibility that they may be found to
be amenable to some kind of intervention beyond that which is
offered by traditional psychiatrists up to now.
Chairman
637. I would like to spend time exploring subtle
differences between the witnesses on this area but we did say
we would try and conclude by 12.30. Do any of the witnesses have
a burning point to make very briefly please?
(Ms Mayne) Very briefly, if I could take the opportunity
of requesting the Select Committee when you meet with John Hutton
24 May, if you could specifically ask him what his intention is
regarding the draft national women's strategy which is in his
in-tray.
Chairman: I think Eileen Gordon has made a note
of that. If there are no further questions, can I thank you all
for a very helpful session. We are most grateful for your willingness
to come and help us.
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