Select Committee on Health First Special Report

Provision of NHS Mental Health Care Services (continued)


Government Response and Action

Recommendation GG We do not feel that we received sufficient evidence on the issue of self harm to make a judgement as to whether or not competent patients should be compelled to accept treatment for their own safety, rather than for that of others. We do, however, agree with Professor Richardson that this is a serious moral issue, and one which demands consideration. We are concerned that it was not raised at all in the Green Paper, and ask the Department to ensure that it is discussed publicly, before the future legislation is framed (para 131).

The Government agrees that whether or not to intervene through the use of compulsory powers to prevent a person with mental disorder from harming themselves, where they appear to be capable of understanding the consequences of their actions, raises complex questions. We are currently discussing these with key interests in the field so that we can reach a clear principled conclusion in the proposals which we will be publishing at the end of the year.

Recommendation HH We recognise the danger that a "treatability" criterion, such as that found for psychopathic disorder and mental impairment in the 1983 Act, may be used as an excuse for not seeking to help individuals when resources are stretched, or where clinical opinions are divided. But we believe that if an individual is to be compulsorily treated under mental health legislation, one of the criteria for compulsion must be that they are likely to benefit from that treatment. We note that while the Government endorses this principle, respondents to the Green Paper do not believe that the proposals contained within it will achieve this aim. We therefore recommend that the requirement that a patient is likely to benefit from the treatment being proposed should be made much more explicit in the criteria for compulsion. Taking up Mr. Hutton's point that there must be "clear evidence" that a person will benefit from the treatment programme, we would make a distinction between patients accepting treatment voluntarily and those being treated against their will. We appreciate that how an individual patient is going to respond to treatment can never be predicted with complete certainty, but we would argue that the levels of certainty required if treatment is to be provided compulsorily must be much greater than in cases where treatment is being provided as part of a consensual contract between doctor and patient (para 138).

The current 'treatability' criterion has been interpreted by the courts as setting a very low threshold: the criterion is effectively met in law where a patient is detained in the context of a generally therapeutic environment providing appropriate care. In practice, however, clinicians have tended to apply a much stricter test, often requiring clear evidence that a patient's mental conditions will improve substantially before they regard the criterion as satisfied. This lack of clarity needs to be resolved. Under our proposals, no patient will be subject to compulsory care and treatment unless there is an approved care and treatment plan. The care and treatment plan will only be approved if it includes proposals for interventions from which there is a reasonable expectation that the patient's condition will benefit. However, some interventions, notably those involving psychological therapies, will only work if the patient accepts them and enters willingly into treatment. Where such therapies are part of the care and treatment plan, then all that it is reasonable to expect of the authorities concerned is that they are made available to the patient.

Recommendation II We suggest, that it would be more helpful for the term "health benefit" to be used in any future legislation when referring to benefits of treatment, in order to emphasise the potential breadth of therapeutic interventions which might be appropriate (para 139).

We will consider this helpful recommendation in developing our final proposals. It is certainly our intention that future legislation should define care and treatment widely so as to include a large range of interventions which go beyond conventional psychiatry and which fit modern patterns of care and treatment including the provision of social and psychological care.

Recommendation JJ There are clearly some very serious concerns about the prospect of compulsory treatment in the community. At the same time, we were impressed by some of the arguments put to us, that the principle of community treatment orders accords with the spirit of treating patients closer to home, and that mental health professionals have always had to juggle the possibility of compulsion with the necessity of building a trusting relationship. We believe that if the Government is to introduce some form of community treatment order, it is imperative that the safeguards set out in the Expert Committee's report, particularly those relating to reciprocity, and the right of the user to request an assessment, should be included. We also reiterate our earlier recommendations that the criteria used for determining who is subject to compulsion should in principle include a recognition of capacity and should require clear evidence of health benefit for the patient (para 146).

The Government is glad that the Committee has been impressed by some of the arguments in support of the introduction of community treatment orders. One of the Government's main aims in drawing up proposals for the reform of the Mental Health Act 1983 has been to extend compulsory powers beyond an in-patient setting so that they may be applied in the least restrictive environment that is appropriate to the needs of the individual patient, where this does not compromise the safety of the wider public. We have accepted that where a patient is to be subject to the use of compulsory powers, then there has to be an approved care and treatment plan and that health and social services authorities will have a duty to provide the services that the care plan stipulates. Assessment of capacity is already an important part of the assessment process and it will therefore play an important part in determining the appropriateness of each individual care and treatment plan.

Recommendation KK The question of the burden on tribunals is clearly directly related to the criteria used for entry into compulsion and hence how many people will be potentially liable to being made subject to community treatment orders. We draw the Department's attention again to our recommendations on the use of much tighter entry criteria: as Mind pointed out to us "if the criteria are too wide, the tribunal is no protection at all" (para 148).

We are currently considering the criteria which will have to be met before a patient can be subject to compulsory care and treatment. These will be clearly stated in the White Paper which we will publish before the end of the year. We stated in our evidence that the purpose of the proposals was to modernise the legislative framework so that it reflected modern patterns of care and treatment. The proposals are not intended significantly to change the proportion of people with mental health problems who are subject to compulsory powers.

Recommendation LL We were very struck by the positive response from witnesses on the proposal that there should be a statutory right to advocacy. It was clear from the evidence given to us by users that they see advocacy as something quite separate from an institutional safeguard such as a tribunal, and something which would help to make them more "equal" within the system. We recommend that there should be a statutory right to advocacy, in the sense of access to adequately funded schemes providing advocates for individuals. We also recommend that such schemes should be funded, and be accountable, through a national structure, to enable them to keep the appropriate distance from local statutory authorities (para 151).

The Government recognises the importance of effective advocacy. The NHS Plan sets out our commitment to establish a NHS-wide Patient Advocacy and Liaison Service (PALS) in every trust, beginning with every major hospital by 2002. We also recognise the specific needs of patients with severe mental illness who are subject to the Mental Health Act. In our Green Paper we undertook to commission a study to determine and develop principles of good practice and have recently commissioned the University of Durham to undertake this work. We will consider how that work will be implemented, including how it will link with PALS, once we have the report from that study early next year. We will also keep the case for introducing a statutory right to advocacy under review.

Recommendation MM We very much welcome Mr Boateng's explanation that these proposals are "first and foremost a criminal justice matter". However, we are still concerned at the use of what could be described as a "quasi-medical" definition, which runs the risk of being highly stigmatising for the many people suffering from personality disorder who are not judged by anyone to be dangerous. We are also very unclear how the estimate of around 2,400 individuals has been derived given the very unspecific nature of the definition being used. We recommend that a definition similar to that being used in Scotland , for example, "serious violent and/or sexual offenders who may present a continuing danger to the public" should be used in the English proposals, to make clear that they are concerned with offending behaviour and not mental disorder (para 156).

The Government recognises that the term 'Dangerous and Severe Personality Disorder' is not a clinical or diagnostic term. 'DSPD' has been used as shorthand for the group described in the consultation paper, which made clear that the proposals are aimed at a small minority of the sub-group of those with severe personality disorder "who pose a high risk to other people because of serious anti-social behaviour resulting from their personality disorder". Scottish law in this respect has long been founded on different principles from that in England and Wales, in that it does not acknowledge the concept of psychopathic disorder. It is not therefore possible simply to import the Scottish approach into English law. The Government's proposals are therefore very different from those being considered in Scotland for 'serious violent or sexual offenders who may present a continuing risk to the public' in that our proposals focus on a small group of individuals for whom a link can be made between their offending behaviour and their personality disorder. This is a fundamental part of the Government's approach to this issue. It concerns both the reason for detention and the nature of the services which the Government will be developing in order to enable those detained to manage the consequences of their disorder and to work towards successful re-integration into the community. These proposals form part of a broader range of measures to increase public protection from dangerous offenders. (See Cm 4888 for full response)

Recommendation NN We feel the whole debate around the care of those designated "DSPD" has been fundamentally muddied by the various different meanings attached to the concept of "treatability". We welcome the recognition that services for people with personality disorder have in the past been very patchy, and we urge the Department to take positive action to develop more consistent services, based on the best research evidence available. We are told by the Royal College of Psychiatrists has called for randomised controlled trials into the treatment of anti-social personality disorder and we strongly endorse that proposal (para 159).

The Government is committed to developing a robust research strategy, addressing previous criticisms about methodologies. This will support systematic evaluation of assessment and treatment approaches for people with personality disorders in the high security hospitals and prisons. Whilst randomised controlled trials could be an important component of the spectrum of evidence to be 1 Psychiatric morbidity among prisoners in England and Wales. Office for National Statistics. The Stationery Office 1998. taken into account in the long term development of new approaches to treatment of anti-social personality disorder, they could pose a number of ethical problems. Also, such trials will inevitably take a considerable amount of time and in the meantime it is essential that services continue to be developed on the basis of the best available knowledge. These issues will be addressed in the Government's research strategy, details of which will be included in the White Paper to be published before Christmas. The research strategy will also include pilots of new approaches to treatment (within both the prison service and the NHS) covering a range of psychological, social, educational, occupational and crime/violence reduction interventions. These approaches will offer a much wider range of interventions than is generally available under psychiatric approaches for hospital patients. The aim is to develop partnership arrangements between the prison service and the NHS so that we can bring together the full range of skills and approaches required to safely manage this group - and to increase the capacity of both services to provide dedicated 'treatment' for this group. The Government agrees that the lack of clarity in the past around the concept of 'treatability' has been unhelpful and has neither met the needs of patients nor helped to give the public the protection it needs. This aspect has already been discussed further in the Government's response to Recommendation HH.

Recommendation OO We would also like the Home Office, as a matter of urgency, to clarify whether it sees the "interventions" that it is developing for DSPD individuals as being different in kind from the "interventions" that are currently available, albeit patchily, in the NHS. If these interventions can be described as "treatment" in the very broad sense discussed earlier, and are aimed at individuals with a recognisable mental disorder, then we would argue that they should be provided by the NHS on the basis of mental health legislation. If, on the other hand, they can be distinguished clearly from any "treatment" that the NHS might provide, then we would argue that they should be made available in prisons to convicted offenders, as part of the criminal justice system (para 160).

There are fundamental cultural and organisational differences between the prison service and the NHS which have resulted in differing approaches to the management of people with severe personality disorder. But it is clear that a range of approaches is required to respond to the diverse needs within the DSPD group and to reduce the level of risk they pose to the public and that there is considerable overlap between the treatment options that can be provided in both environments. As part of the evaluation of the pilot projects, we will be seeking to identify the most appropriate environments for treating and managing this group. However, the Government has always made clear that whenever individuals are detained because of their mental disorder - rather than on the basis of an offence which they have committed - they must be detained in a therapeutic environment. This is a fundamental requirement of the European Convention on Human Rights which the Government is committed to uphold and which has been, from 2 October of this year, incorporated into our own legal system, by way of the Human Rights Act 1998.

Recommendation PP As we have indicated above, we would certainly welcome "service enhancement gains" for people suffering from anti-social personality disorder who are currently being excluded from services. However, we do not understand why these service improvements cannot be provided without the sort of legislative change put forward in the Home Office/Department of Health document. We believe that the proposals for reviewable sentences put forward by Peter Fallon QC deserves further consideration.

The Government will be announcing its response to the consultation exercise, including proposals for legislative change, shortly which are needed to address a gap in the law by which, unless a DSPD individual is prepared to co-operate with treatment, he cannot be detained. Whichever legislative option the Government decides upon , new services will be required and it is important that any new assessment processes and treatment interventions are piloted and evaluated. An ambitious programme of service development is therefore already underway and includes increasing the capacity in both the NHS and the prison service to carry out specialised assessments and to provide enhanced 'treatment' services for this group. The first pilot assessment centre at HMP Whitemoor is now open and Rampton Hospital will shortly start piloting the assessment process on its current population of PD patients. The NHS Plan, announced the expansion of provision within the NHS for the DSPD group. 140 additional specialist secure places for the DSPD group will be provided by April 2004. In addition, a further 75 specialist rehabilitation hostel places will be provided which will enable those PD patients being discharged into the community to move out of secure facilities more quickly and receive the most appropriate specialist help and support in the community. In addition, substantial resources have been allocated in the recent Spending Review for service development and pilot projects. Resources from the Home Office Spending Review Allocation will provide for the 100 places in newly built units and 80 places in units converted from existing accommodation to pilot the assessment and treatment of the DSPD group within the High Security Prison Estate. Resources from Department of Health Spending Review allocation will be announced shortly to enable similar work to take place in he NHS High Security Estate. In the Government's view, a long-term and comprehensive response to the challenge of dangerous people with severe personality disorder needs to include powers to detain for care in specialist therapeutic settings both those who are before the courts for sentencing for an offence and those who are not before the courts but who clearly represent a high risk to the public because of their disorder. The idea of a reviewable sentence would therefore only meet part of the need, because it could by definition only apply to convicted offenders. And the need for sentencing to be proportionate to the offence committed would make it very difficult to ensure that the public received adequate protection from an individual who presented a very high risk but who had only been convicted of a less serious offence.

Recommendation QQ It will be clear from our conclusions above that we are unable to support either Option A or Option B in the Home Office/Department of Health discussion document. We repeat our recommendations that research should be initiated on the treatment of anti-social personality disorder, that adequate facilities should be made available within the NHS for those suffering from a recognised disorder who are able to benefit from treatment, and that further thought should be given to the proposal of reviewable sentences to provide those who are deemed a danger to the public but who are genuinely not amenable to treatment in the NHS (para 165).

As set out above, the Government has already initiated a comprehensive programme of work in this area - which includes development of a robust research strategy into the treatment of severe personality disorders, and the resources for additional specialist assessment and treatment facilities within both the prison service and the NHS - which will be required whatever option is chosen for the longer term. But it remains of the view that there is a clear gap in both the law and in service provision in this respect at present, and it is disappointed that the Committee does not share this view. The Government will publish its formal response to the consultation exercise to Parliament in the autumn, and will set out the detail of its proposals in a White Paper to be published before Christmas.

Recommendation RR We find it quite extraordinary that in certain parts of the country 16 and 17 year olds who are not in education can be excluded from both child and adult services, at a time when they may be most vulnerable. We recommend that the Department should consult on the most appropriate age, on average, for transfer to adult services and set that age as a national target for transfer. Local services would then be clear what the normal age for transfer was, but would be able to vary this as appropriate for individual patients. We also recommend that, whatever the age chosen, there should be no possible gap between adolescent and adult services (para 171).

The Government agrees that it is totally unacceptable that young people aged 16 and 17 may find themselves excluded from both child and adult services. The National Service Framework makes clear that local arrangements should be in place to ensure that there is clarity about the handling of referrals of young people in this age group to ensure that no young person's mental health needs remain unmet. The Government welcomes the Committee's appreciation that some flexibility may be required to ensure that young people's mental health needs are met by the service most suited to meet those needs. It nonetheless understands the Committee's view that there should be a national target age for transfer but consultation on this issue is likely to produce a wide range of viewpoints, as was highlighted by those who gave evidence to the Committee. A firm decision taken at national level about a particular age may disrupt some services which are currently working well and present resourcing difficulties to others. Further careful consideration will need to be given to the Committee's proposal to ensure that a single nationally determined solution is preferable to locally determined solutions. Guidance that will be issued on implementing the NHS Plan will, wherever possible, address this issue. For example, early intervention services for young people will involve child and adolescent mental health services and adult mental health services working closely together to help ensure that young people receive timely treatment appropriate to their needs.

Recommendation SS We believe that the current poor relationships between child and adolescent mental health services are highly unsatisfactory. We are aware that the National Service Framework (NSF), although aimed primarily at adults, does touch on interface issues between adolescent and adult services. We recommend that the Department should require local NSF Implementation Groups specifically to consider how working relationships between those two services could be improved, and should ensure that the monitoring of the NSF pays particular attention to this issue (para 173).

 It is assumed that the Committee is referring to the relationships between child and adolescent mental health services and adult services. The Government agrees with the Committee's suggestion that local National Service Framework Implementation Groups should consider how working relationships between these two services can be improved. For example, early intervention teams will target all young people. This will be monitored through performance management arrangements. It is already an important part of the National Service Framework.

Recommendation TT We agreed that one of the most important factors for young people in the services provided for them would be a factor of choice. We also appreciate that a service aimed at young people, whether 14-19, 16-25 or any ages in between, will have its own boundary issues to resolve. We do, however, feel that a "youth service" is an idea worth pursuing. We recommend that the Government should commission research on how such services are working in this country and elsewhere, with a firm commitment to developing them if good models emerge (para 175).

The Government accepts the Committee's view that there is some merit to the idea of a mental health 'youth service' but agrees that such a service would introduce its own boundary issues that would require resolution. We are considering ways of identifying and disseminating good practice, one priority being the interface between services for adolescents and young adults.

Recommendation UU We welcome the Government's policy of increasing the capacity of the NHS to provide secure care on a local basis. We recognise that there has, historically, been a mixed economy of care in the secure services, and we accept that there is likely to remain a role for the independent sector in providing highly specialised "niche" services. However, we would like to see the NHS develop sufficient capacity in secure provision, properly integrated with general mental health services, so that routine reliance on out-of-area placements with the independent sector is no longer necessary (para 180).

The Government has provided extra investment to create almost 500 additional secure beds by April next year. At the same time, Regional Specialised Commissioning Groups which this year took on full responsibility for the commissioning of high and medium secure psychiatric services are providing a more focused mechanism for identifying the needs of their population and developing integrated local services accordingly. The Government outlined in the NHS Plan its intention that the NHS should engage more constructively with the private sector. The problem is that many of the arrangements have hitherto been ad hoc and short term. As the necessary secure services are developed within the NHS, the need to use of out-of-area placements with the independent sector will diminish. As the Committee point out, there may still be a role for the private sector in providing some services, but this would be as part of a properly considered partnership rather than because of a lack of appropriate local provision.

Recommendation VV We feel that the changes in funding mechanisms for medium and high secure services can only be beneficial in improving the links between these services and the general mental health services. We also welcome the needs assessment which is currently taking place in the Special Hospitals. But we were struck both by the apparent lack of firm figures distinguishing the number of medium secure beds from the number of low secure beds, and by the evidence we received on the uncertainties surrounding the best models for long-term medium and low secure care. In these circumstances it is hard to see how anyone can be sure that the appropriate capacity has now been provided, or that it is being provided through the most appropriate models (para 188).
Recommendation WW We recommend that the Department publish firm figures on the number of secure beds which will be available once all the additional beds which have been announced have been created, separately identifying short-term medium secure, long-term medium secure, short term low secure and long-term low secure beds. We also recommend that the Department should commission further research on the best ways of providing medium and low security services for those likely to need this support on a long-term basis, including specialised long-term community support for patients discharged from secure services.

The Government has commissioned a review of medium secure provision and forensic networks of care, which will identify gaps in capacity. The review will also encompass a survey of all types of secure beds, and the results will be shared with the appropriate agencies. The NHS Plan also identifies further developments in medium/low secure care (200 beds) aimed at moving inappropriately placed people out of high secure care. Many of these beds are likely to be long term low secure accommodation and will be funded on a recurring basis rather than for individual placements. A further 140 beds and 75 hostel places are being developed for dangerous people with severe personality disorder. The NHS Plan envisages 335 crisis resolution teams being established over the next 3 years, which should take the pressure off local in-patient beds and consequently prevent the need to transfer patients out of area. If crisis resolution teams do reduce the need for general acute beds further, some local wards could be redesignated to provide low secure accommodation. 50 early intervention teams will be established over the next three years to provide treatment and active support in the community to young people with psychosis, and to assist their families. They will also take the pressure off local in-patient beds. The long term effect of these service developments will be closely monitored.

Recommendation XX We are deeply concerned as to the human rights implications of patients staying far longer than they should in the higher levels of security. It seems quite possible that claims under the Human Rights Act 1998 could place a considerable burden on already over-stretched services. We recommend that the action already being taken to assess individual patients' needs should be completed as speedily as possible, and that if short-term funding is necessary to provide appropriate placements, it should be made available (para 190).

It is Government policy that patients should not be detained in higher levels of security than is strictly necessary. Additional secure beds are being created, and services in the community are being developed to facilitate the movement of patients to the most appropriate forms of care. The Government has made an extra £25 million of recurrent revenue funding available, phased in over a three year period, specifically to address the problem of moving out patients who are inappropriately placed in the high security hospitals. Significant capital funding is also being made available for this purpose over the three years 2001/04. The needs assessment work currently being undertaken will help inform the use of this funding, and we have already decided that women patients should be given high priority.

Recommendation YY We feel that the arguments outlining the benefits of a genuinely regional focus to secure care are overwhelming. The new regional arrangements for commissioning care and the intention of merging the Special Hospitals administratively with other mental health trusts appear to us to represent a poor second best in the attempt to provide that regional focus. We have come to the conclusion that the reform and improvement of the Special Hospitals is probably not workable, despite the millions of pounds committed to them by successive governments, because of their isolation, their difficulties in recruiting and retaining highly professional staff, and the culture which has developed within these institutions. We repeat the recommendation of the Fallon committee, that the three Special Hospitals should be replaced by eight smaller, regional based units, fully integrated with existing medium secure, low secure and general mental health service provision. A decision to retain the existing system would, we believe, be prompted more by political expedience than by any genuine attempt to achieve the most appropriate and most secure provision. We believe that the distinction between high secure and medium secure provision needs to be retained. Clearly, public safety and staff safety in high secure services must be given at least equal weight with therapeutic considerations, and our proposal to replace the existing three Special Hospitals with regionally based units should be understood as a long-term project. We would endorse the approach taken in the Italian reforms of 1978 of introducing a moratorium on admissions to old facilities while capacity is built up in the new facilities. Existing patients would only be transferred to the new services when these had consolidated their working practices and skills. We would also emphasise our belief that smaller, purpose-built units would in fact offer far better security for the public, for patients and for the staff than the existing unwieldy old estates where security is inevitably difficult to manage. Indeed, if we were not satisfied that public safety would actually be increased, we would not be in favour of the proposals outlined above (para 196).

The Government does not agree with the Committee that reform and improvements in the high security hospitals is unworkable. Government policy with regard to the provision of high security psychiatric services is to secure the safety of the public, staff and patients, and to ensure that the best possible services are offered to patients who need to receive their care and treatment in a high security setting. The three high security hospitals provide a unique service for people with the most severe types of mental illness, personality disorder and learning disabilities. We need to maintain these secure facilities, the valuable expertise of their staff in dealing with a very challenging group of patients with complex mental disorders and the opportunities for therapy and activity which can be made available on the existing high security hospital sites, as part of a comprehensive range of secure services. The record of the high security hospitals in terms of protecting the safety of the public by preventing escapes from within the hospitals is good, with the last escape having occurred in 1994. However, there is no room for complacency about security. In 1999, the Department of Health commissioned a review of security at the high security hospitals by a team led by Sir Richard Tilt, the former Director General of the Prison Service. Sir Richard's report, published earlier this year, made a number of recommendations for improvements to the perimeter and internal security of the hospitals, all of which we have accepted. We have made the necessary funding available and work is currently under way to implement those recommendations. We are making other new resources available to the high security hospitals to improve the services they offer, and responsibility for the commissioning of high and medium secure services now rests very firmly at the regional level. The high security hospitals' professional and geographical isolation has undoubtedly been at the root of many of the difficulties experienced. The integration of each of the hospitals into NHS trusts providing a wider range of mental health services will considerably alleviate the isolation problem, and there are already indications that recruitment difficulties are improving. The distinction between high and medium secure services will be maintained by providing the services on separate sites but with the advantage of having a Trust Board which can take an overview of the provision of the whole range of services. We are also investing a further £25 million in order to move out of high security people who need lesser security. This will enable the high security hospitals to focus on smaller numbers of very difficult to manage patients. The Government are confident that the new investment in the high security hospitals, and the linked modernisation and mainstreaming of the hospitals, will achieve our twin objectives of securing the safety of the public, staff and patients whilst offering a high quality service to people who genuinely require care and treatment in a high security setting.

Recommendation ZZ The reasons for restricting child visitors to male personality disorder units are self-evident. We are, however, very concerned that recommendations made with one patient group in mind have been applied across the board to all patients, including women patients. We strongly recommend that the Government issue separate security Directions for women, reflecting their different needs. In particular, we would recommend that once an assessment has been made that it is safe for a woman to receive child visits, it should be possible for these to be made on an ad-hoc unplanned basis (para 201).

The Visits by Children to Ashworth, Broadmoor and Rampton Hospitals Directions were introduced with effect from 1 September 1999. It was stated at the time that they would be reviewed by the Department of Health after one year from their date of issue. Although the formal review has only recently commenced, the Department has already issued amending Directions and Guidance to allow others to accompany children when no close relative is available or willing to undertake this. Before completing the review the Department will need to take account of a judgement, following a recent judicial review concerning the Directions. The Committee's recommendation about introducing separate Directions for women will be considered in the context of the review. (See Cm 4888 for full response)

Recommendation AAA We agree that the way forward for women's secure services must be a completely separate service. We urge the Department to bring forward and publish a national strategy to achieve this as a matter of urgency (para 203).

The Department of Health commissioned work, supported by an expert group chaired by Dame Rennie Fritchie, to look at strategic issues around women in the high security hospitals. The report of this group has been received and the Department wishes to acknowledge the considerable amount of work, expertise and consultation that has gone into producing it. This report will form the basis for developing a strategy, linked to additional funding, to ensure that priority is given to the discharge and movement out of the high secure hospitals of women patients who have been identified as not requiring the physical security that the three hospitals provide. The ultimate aim will be to provide safe, appropriate, and secure services that meet the needs of women patients. The strategy should be complete within 12 months. However, it is likely that there will remain a very small number of women who present a high risk to the safety of others and who will continue to require a high level of physical security. The longer term needs of these women will be considered further by the National Oversight Group in policy and strategic developments around implementation of Sir Richard Tilt's report; and will also form part of policy considerations between the Department of Health and the Home Office around services for women with dangerous and severe personality disorder and with the Prison Service. Consideration will be given to creating separate dedicated facilities for the small number of women who require high secure care.

Recommendation BBB We hope that the new partnership between the NHS and the Prison Service will encourage developments on the lines of the system we saw at Belmarsh Prison and Oxleas NHS Trust. But we would agree with Sir David Ramsbotham that it is inappropriate to attempt to provide two parallel systems of specialist mental health services, one in prisons and the other in the NHS, especially as those remaining in the prison service do not enjoy the safeguards included within the Mental Health Act 1983. We recommend that all prisoners assessed as needing specialist mental health services should be eligible for transfer to the NHS, if necessary under temporary licence. We also therefore recommend that Dr. Reed's estimate of the number of prisoners involved (approximately 500 at any one time) should be taken into account when planning the number, and type, of secure mental health beds required in the NHS (para 210).

The Government has demonstrated its commitment to improving healthcare services for prisoners by accepting the recommendations in last year's report from the joint Prison Service/NHS Executive working party on the future organisation of prison health care. The working party stated that the most appropriate and practical way to improve prison health care in general, and for mentally disordered prisoners in particular, is through a formal partnership arrangement between the Prison Service and the NHS. There is no intention to develop parallel systems of specialist mental health services in the two settings: the aim is to ensure that health services provided by the Prison Service and the NHS are co-ordinated and in line with the needs of prisoners. The majority of prisoners with mental health problems will not require in-patient treatment for their disorders. For them, care and treatment will be best provided by the development of in-reach services into prisons from community mental health teams. For those prisoners who are so severely ill that they require in-patient treatment in hospital, the objective will be to ensure they are diagnosed, assessed and transferred as quickly as possible, through active management of waiting lists and the effects of Government's other reforms to the commissioning and provision of secure mental health services, which, through the partnership, will be better informed about the needs of prisoners. These arrangements will build on those which exist already, under which some 700 or so remand and convicted prisoners on average are transferred from prison to hospital each year.

Recommendation CCC We recommend that the Expert Committee's recommendation that all prisoners should have a right to a mental health assessment should be accepted. We also urge the Home Office to ensure that the health needs assessments promised for 1997 are completed as a matter of urgency, so that the data can be used to inform planning for capacity in the NHS (para 212).

The Government is not persuaded of the need for legislation on this issue. The National Service Framework for Mental Health sets out requirements to assess the mental health needs of prisoners while they are in custody and in preparation for their release, contributing to their through care, as well as improving their access to appropriate services while in custody. All prisons and the health authorities in which they are situated have been asked, by March 2001, jointly to assess prisoners' health needs and to identify appropriate services to meet them. This exercise should establish the nature and extent of unmet need for mental health services and how existing services within prisons need to be reshaped and refocussed to meet these needs and become better integrated with those in the community. Implementation of improvements through individual prison health improvement plans should begin from April 2001 at latest but will do so earlier in many cases. These joint needs assessments will inform implementation of the relevant elements of the National Service Framework.

Recommendation DDD We recommend that it should be made a requirement that courts liaise with local mental health providers to ensure that all courts are covered by court diversion schemes. We also recommend that the Home Office should commission research on best practice in court diversion schemes, to improve their efficacy in identifying vulnerable offenders (para 213).

The Government fully accepts the value of mental health assessment schemes at magistrates' courts. These are local initiatives designed to enable magistrates' courts to receive speedy medical advice and to ensure that, where appropriate, arrangements are made quickly to admit mentally disordered offenders to hospital, for example, as a condition of bail or on remand to hospital. The Department of Health and Home Office jointly have been carrying out a wide range of initiatives so as to encourage the development of local inter-agency arrangements for ensuring that the health and care needs of mentally disordered offenders are properly met. This includes the issue of advice and guidance and the provision of some limited funding to support some schemes at magistrates' courts. On behalf of the two Departments, the National Association for the Care and Resettlement of Offenders (NACRO) carried out a survey in 1996/97 of inter-agency arrangements for managing the response to mentally disordered offenders. The survey found very considerable inter-agency activity around the country and it identified some 160 court schemes in operation. A follow-up survey is now underway. The lead responsibility for developing assessment arrangements at magistrates' courts rests with local mental health services. We recognise that, to be effective, schemes must also have the local support of those working in the criminal justice system. The findings of the NACRO survey indicated that there is widespread recognition among those services of the need for such arrangements and a willingness to be involved. Against this background, the Government has concluded that there is no justification for placing a requirement on courts as recommended. The Government accepts the recommendation for research into court schemes. The Home Office has already commissioned a study of their performance and effectiveness. The research aims to evaluate how effective this intervention is in terms of addressing mental health needs and preventing re-offending; to provide an analysis of the client group and to define quality criteria for schemes. A final draft of the report is in preparation and the Home Office expects to receive it shortly. Both the Department of Health and the Home Office will consider the report carefully so as to decide how best to disseminate its findings.

Recommendation EEE We are aware that the Department is currently reviewing the formula used for allocating resources to Health Authorities and urge them to pay particular attention to the distortions caused in the local health economy by the existence of one or more large prisons. We also recommend that the Department gives serious consideration to the possibility of extending the authority to pool budgets to the NHS and the prison service (para 216).

There is currently a wide ranging review of the formula used to make allocations to health authorities and Primary Care Groups/Trusts. The aim of the review is to produce a fairer means of allocating resources which supports the Government's wider policies on social exclusion, fairness and reducing health inequalities. The review will cover the whole range of concerns raised about the fairness of the current formula. This includes the area of mental health, including mentally disordered offenders. The review forms part of the Government's programme for reducing inequalities in access to NHS Services set out in the NHS Plan. By 2003 following the review, reducing inequalities will be a key criterion for allocating resources to different parts of the country. The review of the formula is being carried out under the auspices of the Advisory Committee on Resource Allocation which has NHS management, GP and academic members, who will ensure that the allocations formula will take full account of the impact of prison populations as part of the local health economy. The Department will be looking at operational experiences of managing pooling of budgets between health and local authorities to see what lessons can be learned which may contribute to closer working between the NHS and Prison Services. However new primary legislation would be required to make the latter possible.

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